The Journal for Nurse Practitioners
Volume 2, Issue 9 , Pages 593-598, October 2006

Using a System of Care Framework for the Mental Health Treatment of Children and Adolescents

  • Robin Bartlett

      Affiliations

    • Robin Bartlett, PhD, RN, BC, is assistant professor in the School of Nursing at the University of North Carolina at Greensboro.
    • ,
  • Charlotte A. Herrick

      Affiliations

    • Charlotte A. Herrick, PhD, RN, is professor emeritus in the School of Nursing at the University of North Carolina at Greensboro.
    • ,
  • Linda Greninger

      Affiliations

    • Linda Greninger, APRN, BC, works at The Guilford Center (County Mental Health Center), Greensboro, North Carolina. None of the authors has financial relationships with any business or industry to disclose.

Article Outline

Abstract 

Advanced practice psychiatric and mental health nurses recognize the need to provide holistic, culturally competent and family-involved care to children with mental health problems. Yet frequently, other key aspects of the best care are overlooked. System of Care not only promotes holistic, culturally competent, child- and family-centered, and community-based care, but also promotes comprehensive “wraparound” services to families. Further, System of Care encourages individualized care provided in the least restrictive setting by an interdisciplinary group. This article presents key principles of System of Care, and the rationale for their use in all mental health care for children. It also includes examples of how the model has resulted in positive outcomes with clients and their families.

Keywords:  Adolescents , children , community-based care , family-centered care , System of Care

 

Advanced practice nurses and other primary providers of mental health services for children and adolescents have long recognized the need to involve the families of these children and to provide them with culturally competent care. However, according to a 1999 US Department of Health and Human Services Report,1 these elements are insufficient for the provision of the best mental health services to children. The System of Care philosophy mandates that care be child and family centered, community based, and culturally competent.2 The individual elements of the System of Care are not new; however, comprehensive application of these elements can breathe new life into mental health practices. Indeed, the US Department of Health and Human Services holds up System of Care as the practice standard for children with complex mental health concerns and their families.1 This article summarizes System of Care principles as a framework for advanced practice psychiatric and mental health nurses working with children and provides recommendations for putting these principles into practice.

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Family-Centered Care in the Community 

At times in the past, mentally ill children were isolated from family while in treatment. Then oftentimes, when the child was returned to the family, treatment gains were lost, and all parties were frustrated with the outcomes.3 Indeed, according to Knitzer,4 the separation of emotionally disturbed children from their families and communities and the overuse of restrictions in children's mental health treatment, usually in residential settings, were the catalysts for the System of Care movement in children's mental health.

Continuing barriers to the provision of family-centered care include that traditional health care systems are still focused on the individual “patient” and not the family, the treatment is usually provided in inpatient settings, and the systems themselves are often paternalistic in nature. Also, community mental health services are often underfunded, particularly for children. Although government funding for public mental health services has risen sharply in recent decades, much of this funding goes to inpatient and other residential care providers.1, 5

According to System of Care philosophy, mental health services for children must be both child- and family-centered, community-based, and culturally competent. Prevention of mental health problems and early identification of a child manifesting problems within the child's natural setting are basic.6 In addition, the care must be individualized and provided in the least restrictive setting for the child by a team of interdisciplinary professionals who collaborate to see that services are wrapped around the child and family as needed. Finally, care should be coordinated by a care coordinator or case manager who is the child's advocate and ensures that the care is comprehensive.7

Family-centered care focuses not only on the child but also on the family.8 The goal is to make parents part of the treatment team. The care ideally takes place in the home and always in the least restrictive environment. Parents of the child are considered the experts about their child and are full and equal partners in the team working with their child.9

Family-centered mental health care also teaches parents to assume the role of caretaker and decision maker, so that parents can actively take part in their child's care, whether in the hospital or the home. Families partner with advanced practice registered nurses (APRNs) and other professionals to plan, implement, and evaluate the care. The APRN also assists the family in finding support among family and community resources and other natural support systems to help meet their needs.

Partnering with the family not only brings the expertise of the family into the care, but it also brings other benefits, including increased adherence to treatment plans and more rapid improvements in the health and well-being of the child.3 Thus, this partnering makes sense on many fronts.

Care is provided in the community where the child, family, and their support system reside. The least restrictive setting in the community is the optimal location for care of the mentally ill child. Venues for such care include public health departments in traditional social service agencies, schools,10 and rural community mental health centers. Nurses employed by congregations or parishes provide community-based treatment options for children with mental health problems and their families. Before the establishment of System of Care programs, parents were excluded from the decision-making process about their child's care and often overwhelmed by the separation from their children, who were frequently treated in residential settings. They felt helpless to change the system in which they had to relinquish custody of their children to access care. Pumariega et al5 cite several studies showing that by using a System of Care model in the community there are fewer negative behaviors that result in out-of-home placements, fewer actual out-of-home placements, better access to services, and greater consumer satisfaction.

  • View full-size image.

  • The APRN can coordinate the complex care needed by children with severe emotional disturbances and their families and ensure that the holistic care addresses the issues related to mind, body, and spirit.

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Cultural Competence 

In providing culturally competent care, the nurse constantly strives to work within the cultural context of an individual or community.11 For example, if the nurse is working with a Native American family that values traditional healers, the nurse would help incorporate the healer into the plan of care or arrange for a competent interpreter to translate when working with a non–English-speaking family member.12

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Coordinated, Comprehensive Mental Health Care for Children 

The System of Care framework requires that mental health services provided to children be comprehensive and coordinated between agencies and facilitated by a case manager.5, 13 Services should be provided at any point across the health care continuum, when and wherever the child needs the care,14 starting with the least restrictive setting such as a school, faith-based organization, or recreational and other setting in the community where the focus is on prevention. Nurses can teach children and their families the skills to promote wellness. Further along the continuum are community-based systems such as children's health services, social services, public health clinics, outpatient clinics, community mental health centers, school-based clinics, special education programs, after-school programs, hospital-based outpatient programs, and day care for severely emotionally disturbed or physically disabled children. The goal of all these programs is to keep children and their families at their maximum level of functioning.3 More restrictive settings that provide both acute and chronic care include acute care hospitals and residential treatment centers for children who are severely and persistently mentally ill.

Children and their families should be provided services that meet not only their mental health needs but also their physical, educational, developmental, and social needs. Vocational and rehabilitation services may be necessary for children because of a mental or physical handicap. Alternative educational opportunities may be needed for children who are unable to remain in a traditional school setting.3

Care should be provided, as much as possible, in an environment that supports the family's lifestyle and in a setting that is familiar yet therapeutic.15 Advanced practice psychiatric and mental health nurses and nurse case managers or care coordinators can work with teachers, school nurses, and public health nurses to help normalize services for children with complex physical and mental health needs. The APRN, nurse case manager, or care coordinator can use available community resources so that the child can remain at home and in the community. System of Care philosophy stresses the importance of also integrating natural and nontraditional support services found in the community.16 The APRN can coordinate the complex care needed by children with severe emotional disturbances and their families and ensure that the holistic care addresses the issues related to mind, body, and spirit.

For a child in need of care, the primary care provider, often an APRN, should, in collaboration with the family and other team members, select the health care setting that will best meet the child's needs, based on the acuity of the child's symptoms and the needs of the family; inform the parents about the various treatment options; and develop a treatment plan. Whenever possible, children should be cared for in their homes and communities by their families or surrogate families with the assistance of nurses and other health care providers.8, 17 When out-of-home placement is deemed necessary, family contact and involvement must be promoted, not contingent on the behavior of the child, parent, or community group. Unfortunately, Robinson et al18 found that, despite the abundance of literature on the benefits of parental involvement with children in out-of-home placements, restrictions on parent–child interactions in these settings remain the norm.

Having the team of professionals, family members, and other care providers come together with the APRN to discuss the care of the client has important benefits for clients. When, for example, care providers describe problem behaviors for which they seek medications for a client, the psychologist and other team members can help the APRN sort what symptoms require medication and what are behavioral symptoms that may be a result of environmental events. Then the team can work together to determine what changes can be made in the environment and what behavioral strategies to use with the client to help in the management of the problems.

Services should be integrated across the health care continuum, with linkages between programs and coordination around the child's and family's needs.3 For families who have complex needs, collaborative relations among agencies are extremely important.8 The goal is to provide continuity of care, prevent duplication of services, and reduce fragmentation.19 When children age from one set of services and need transition to other services (eg, child-based services to adult-based services), coordination efforts by agencies and systems should make the transition smooth.13, 20

In deciding on appropriate treatment, the APRN should assist the child and family to examine where the child's strengths are and what resources the family and community have. Children and their families must be at the center of all care, and APRNs must respect the decisions made by families.21 If a child is to feel cared for and understood, the APRN must respect the child as a person, be nonjudgmental, and convey empathy in all interactions.22 Whenever possible, the child should be an active partner with the team, from problem identification to development and implementation of the plan of care.9

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Seamless Interdisciplinary Care 

Collaborative models are increasingly viewed as the most effective way to deliver seamless mental health care to children across the health care continuum.23 Members of each discipline contribute their perspective in developing the plan of care, and the responsibilities of each team member are documented. Family members help develop the plan of care and are also equal partners in its implementation.3 Because the APRN has the unique skill set to address both physical and mental health symptoms, he or she is the logical team member to coordinate the child and family's care. With their close working relationships with the child and family, APRNs also often serve as child and family advocates.

A seamless System of Care requires collaborative relationships among both professionals and agencies,24 or wrap-around programs. Wrap-around programs are needs driven and comprehensive, seek to promote normalcy within the family, and ensure continuity of care during transitions.25 They also include a crisis plan for the family in case of need.26 According to Tolan and Dodge,9 when services recognize and pay homage to the various systems in play in a child's life (eg, social, developmental), not only will the child and family benefit, but also society in general will have a greater acceptance of and willingness to use mental health services for children.

A 19-year-old female client with a history of mental retardation and bipolar disorder had lived her lifetime with her mother and had been in mental health treatment for much of her life. She was transitioned from child mental health services to adult services, maintaining her case manager from one system to the other (seamless care). When the woman's mother died, she became suicidal and required inpatient hospitalization. Then with the assistance of the team, including the woman, her sister, the APRN, and the case manager, it was determined that the woman would prefer to remain living in her home, but she would need assistance to do so. Direct care providers were assigned to assist the woman in this quest, and a roommate was agreed on by the woman so that the financial resources to provide the care were available. The client has been able to remain safely in her home with her roommate.

The case manager has been described by Winters and Terrell27 as the “lynchpin of community-based systems of care,” helping the child and family move seamlessly from service to service to meet their needs.28, 29 The case manager coordinates and integrates care across agencies and disciplines, facilitates interagency team and family meetings to conduct strength-based assessments, plans interventions, implements care plans, monitors and evaluates progress, changes the plan of care as needed, and evaluates the effectiveness of the strategies implemented.3, 28

An example of how important the case manager is to both the APRN and the client is shown by the following case. A 25-year-old female client with a history of mild mental retardation, bipolar disorder, and substance abuse gave birth to a child. A case manager was assigned to assist in identifying and meeting their needs. The case manager coordinated with a social service agency to place the baby in temporary foster care when the mother was unstable with her bipolar symptoms after being off psychotropic medications during her pregnancy. The case manager helped the client establish and maintain a relationship with the baby while the baby was in foster care. The case manager also arranged for parenting classes for the mother and kept regular contact with her to monitor her skills development. Gradually, the baby was returned to the custody of the mother, yet the case manager still maintained close contact with the dyad to help coordinate care when issues arose. The case manager also arranged for some respite care for the baby and some in-home services as further support for the mother. With this help the mother was working 20 hours per week, stable on her medications, free from unprescribed substance use, and providing appropriate care for her child.

System of Care Key Principles 

To implement System of Care values,3, 13, 20, 25, 30, 31 APRNs and other mental health care providers for children should

•Recognize that the family is a constant stabilizing force in a child's life.

•Honor the family's cultural and ethnic values and beliefs.

•Communicate openly and honestly with all persons involved in the child's care, including the family.

•Help to provide prevention and early identification services to children and families.

•Provide complete information to the family, including options for the least restrictive treatment, evidence-based practice, risks, and potential outcomes.

•Relinquish decision-making to the family or those legally responsible for the care of the child.

•Respect the family's decisions, setting aside personal biases.

•Provide emotional support to family members so that they can nurture each other, survive periods of crisis, and flourish.

•Help the child and family identify their interests and then support them in developing these interests.

•Promote the development of skills in self-care in the child and family.

•Wrap needed comprehensive, individualized, community-based services seamlessly around the child and family; facilitate the coordination of these services.

•Be accountable for providing care that is best practice.

•Facilitate holistic care for children and their families.

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Conclusions 

APRNs should provide care with the child and family rather than for them, enable children and families to select their own goals and priorities, provide information about possible options, and assist them to make their own decisions and assume responsibility for themselves.28 The psychiatric and mental health APRN who integrates all of the elements of System of Care into practice provides holistic, empowering, and compassionate care to children and their families. This is the new standard for children's mental health care. Not only should these System of Care values and principles guide all care provided to children and their families, but they should also be the standard by which care is measured. The following case shows many of the System of Care principles and how their consistent application can result in improved outcomes, not only for the child but for an adult as well.

A 4-year-old child with severe behavior problems whose father had clinical depression received a case manager to aid in their care. An APRN was the primary mental health care provider for both the child and the father and made the referral to secure a case manager. The marriage between the man and his wife was in jeopardy, largely because of the strains associated with managing their child's behaviors. On the basis of a meeting of the entire team (parents, APRN, case manager, psychologist, and child's day care provider) a plan was made to provide medication for the child and the father, enlist the help of social services to provide in-home services for the parents to help them improve their parenting skills, and provide respite for the parents to have some time away from the child. The family has remained intact, the child is much more manageable, and plans are under way for him to begin a structured preschool program for emotionally and behaviorally disturbed children. The case manager continues to monitor the family for additional needs and reports her findings to the interdisciplinary team monthly. When the APRN applies the principles of System of Care, the ultimate goal of keeping families together and at home is enhanced.

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Acknowledgment 

We thank Elizabeth Tornquist for her review and helpful comments on a draft of this manuscript.

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References 

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PII: S1555-4155(06)00528-9

doi:10.1016/j.nurpra.2006.06.015

The Journal for Nurse Practitioners
Volume 2, Issue 9 , Pages 593-598, October 2006

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