Columbia University Mailman School of Public Health

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Florida Strategies

IECMH for Vulnerable Children with Dyadic Treatment: Early Childhood Courts

For infants and toddlers involved in the child welfare system, Florida’s Early Childhood Courts (ECC) program aims to improve child safety and well-being, address trauma, support positive parent-child relationships, and promote permanent home placement. The program’s nonadversarial, multidisciplinary approach builds connections between the court system and other systems—including mental health, early care and education, and home visiting—to support the needs of families. ECC’s design reflects the components of the Safe Babies Court Team™ (SBCT) approach developed by ZERO TO THREE. Following the implementation of two pilot sites, the ECC program was formally established in 2015, and now serves 24 courts across the state. State-level partners include the Florida Department of Children and Families, Office of Child Welfare; the state’s Office of Court Improvement; and the Florida State University, Center for Prevention and Early Intervention Policy.

The ECC program is guided by Early Childhood Court Best Practice Standards approved by the Florida Supreme Court. The 15 components that comprise the ECC approach are described in the program manual. The manual is currently being updated, and a revised version will be released by October 1, 2020. The components include a multidisciplinary team that implements the program (e.g., a local judge committed to the ECC approach model, a community coordinator, and an infant mental health clinician); trauma screening and services; a range of other behavioral health, family support, parenting, developmental and early education services; concurrent planning for a permanent placement for the child; and training and workforce development for ECC team members.

At the core of each ECC is a local trauma-informed judge committed to and trained in the ECC approach. A judge will typically hold status hearings on a case every month. All ECCs have one or more mental health clinicians qualified to provide Child-Parent Psychotherapy (CPP), an evidence-based dyadic treatment model (see Dyadic Treatment research summary for more information on CPP). The ECC approach calls for all families to receive evidence-based child-parent therapy, such as CPP, but families not yet ready to participate in CPP may be offered Circle of Security-Parenting (COS-P) or other appropriate interventions. The clinician assesses parent-child interactions, works with parents to provide nurturing care through CPP treatment, makes recommendations to the court about visitation and progress toward reunification, and helps families address the implications of the court’s reunification decisions about whether children are reunified with biological parents or not.

Every site also has a community coordinator. This full-time role is held by an individual with expertise in child development who works with the judge to oversee the ECC on a day-to-day basis. The community coordinator helps to identify services for children and families, facilitate stakeholder and family team meetings, participate in court hearings, collect data, and identify training opportunities for the court team and stakeholders.

Families may need additional services to address issues related to mental health, substance abuse, domestic violence, and trauma. The ECC team works with community service providers to build the capacity to deliver evidence-based behavioral health services. Services that support child development, early learning, and parenting also comprise a critical part of the approach. Florida’s ECCs work to ensure that children have access to high-quality early care and education services and are referred to Part C early intervention for screening and, if eligible, services. ECCs also help parents gain access to evidence-based home visiting (such as Early Head Start, Healthy Families, Nurse Family Partnership, and other MIECHV home visiting programs) and parenting programs, such as COS-P (see Parenting Programs research summary for more information on COS-P).

The ECC court team follows best practices in concurrent planning for a permanent placement, which involves planning for both reunification and another permanent option in the event that reunification is not possible. Several other aspects of the approach support this strategy. The ECC approach calls for both the biological and foster parents to be involved and engaged in the child’s life, and supports daily contact between biological parents and children. This contact may take the form of in-person meetings, phone calls, and Skype. ECCs help to address transportation barriers to make it easier for families to participate in these visits. In addition, monthly family team meetings are held with the community coordinator, biological and foster parents, the team of service providers, and extended family to assess progress toward permanency and to identify and address ongoing needs.

Supports for Implementation

Florida’s ECCs have developed training, resources, and methods to support implementation at ECC program sites. In 2019, Florida’s Supreme Court adopted best practices standards that specify services and supports for families and other components of the program. One standard recommends close monitoring to ensure fidelity if a community coordinator’s caseload rises to 20 families. The standards will eventually be used to certify ECC sites that are implementing best practices, which are based on the 15 components in the ECC approach. The standards also help ECCs in the early stages of implementation to assess their status and guide growth.

The Florida State University, Center for Prevention and Early Intervention Policy (CPEIP) and the state’s Office of Court Improvement (OCI) partner to provide training and technical assistance to ECC teams and their community partners. Examples of training and technical assistance provided through the CPEIP-OCI partnership include coordinating CPP training cohorts and providing training to ECC teams and their partners on infant mental health, the ECC approach, and trauma-informed care. OCI also supports a statewide all-sites meeting every other year that provides professional development sessions targeted to the ECC teams and stakeholders, including judges, community coordinators, attorneys, child welfare professionals, court staff, caregivers, and clinicians.

Florida participates as a state in the national Infant Toddler Court Program funded by the federal Health Resources and Services Administration (HRSA) and uses that funding to support the state-wide work that continues in Florida. The National Resource Center for the Infant Toddler Court Program at ZERO TO THREE (National Resource Center), also funded by HRSA, provides implementation support for the Florida sites as part of this project.

New community coordinators receive training at an annual three-day national Safe Babies Court TeamTM (SBCT) academy convened by the National Resource Center. If community coordinators begin work before attending the training academy, ZTT also offers support for those coordinators through a weekly Community of Practice call for all coordinators in the country implementing the SBCT approach, as well as additional trainings held at the request of the state. Florida also asks experienced community coordinators in the state to provide peer mentoring. Additional opportunities for new community coordinators include one-on-one technical assistance on data collection and cross training with other ECC sites (including in-person visits). A Florida community coordinator network offers monthly networking calls, an annual in-person retreat, and quarterly statewide calls for anyone involved in ECCs; currently over 250 are invited. The National Resource Center hosts an annual national Infant Toddler Court Program Cross-Sites meeting, which has more than 400 participants attending from 29 states. These meetings support communities implementing the SBCT approach, provide presentations from national experts, networking, and strategic planning sessions and provide tailored sessions for community coordinators and infant mental health specialists.

Workforce Development

Workforce development has been critical to the provision of two evidence-based models in ECCs: Child-Parent Psychotherapy (CPP) and Circle of Security-Parenting (COS-P). The Florida State University (FSU) Center for Prevention and Early Intervention Policy, and the Florida Association of Infant Mental Health (FAIMH) have been building capacity in the state since 2002 through FSU’s Harris Infant Mental Health Training Institute. The Irving Harris Foundation has a national professional development network composed of leaders in infant mental health that Florida has accessed to provide guidance and training since the FSU Institute’s inception. More than 400 CPP therapists have been trained in the state, which has been critical to the startup and rapid expansion of Florida’s ECCs. Recent work to map the distribution of clinicians across the state allowed targeting of underserved areas, especially for ECCs that wanted to expand capacity. FSU partnered with Sunshine Health (a Medicaid health plan) and the Barancik Foundation in 2019 to provide scholarships and leverage funding for four regional CPP trainings that will train 89 new CPP clinicians over an 18-month period. Many, though not all, of the CPP-trained clinicians will serve ECCs. FSU has also helped to arrange CPP train-the-trainer certification for four trainers, which will further build the state’s CPP capacity. The state’s Office of Court Improvement is funding reflective practice and consultation opportunities for CPP clinicians and ECC teams.

FSU and FAIMH have also partnered over the past decade to build capacity for COS-P, which is now widely available for ECCs. FSU has provided scholarships and FAIMH members have received discounts for COS-P training. A COS-P trainer facilitated training and provided consultation to ECCs about using COS-P. After COS-P was highlighted at a statewide all-sites meeting, individual ECCs began coordinating and funding training opportunities. The Florida State University, Center for Prevention and Early Intervention Policy, maintains a statewide provider directory with more than 350 CPP and 100 COS-P providers.

Financing

Financing for services varies across ECC sites. The most common and largest source of funding for community coordinators is federal Title IV-E Foster Care waiver funds provided by the state Florida Department of Children and Families to local community-base care (CBC) lead agencies. CBCs are contracted to provide child welfare services at the local level. Other local agencies, such as behavioral health agencies and county Children’s Services Councils (CSCs) also provide funding for community coordinators in some ECCs. Florida CSCs are county-level, voter-established agencies that allocate local public funds to research-informed children’s services. The current state budget, which is awaiting the governor’s signature, includes a state appropriation to the court system to fund community coordinators.

Child-Parent Psychotherapy (CPP) services are billed to Medicaid. Clinicians’ non-CPP work, such as court hearings and family team meetings, are often covered by CBCs. The state Medicaid office, FSU, and the Sunshine Health Child Welfare Specialty Plan have partnered with two pilot ECC sites to authorize use of existing Medicaid codes to allow billing for family team meetings and court hearings through a new “in lieu of” services benefit (CPT 99366, 99367, 99368). The pilot also includes an incentive-based reimbursement for six or more well child visits in the child’s first 15 months of life.

Costs of Circle of Security-Parenting (COS-P) classes are typically covered by Medicaid or CBCs.

Support for preservice and ongoing training for community coordinators comes mainly from federal Court Improvement Program (CIP) funds to the state’s Office of Court Improvement. State-level coordination is also provided through CIP funds.

Monitoring and Evaluation

The statewide ECC leadership team helped design a data tracking system that includes results of parent-child relationship assessments and developmental screenings, as well as information about CPP sessions and the provision of other services. Through a data-sharing agreement with the state child welfare agency, information about cases and outcomes such as length of time to permanency, permanency outcomes, and recurrence of maltreatment is collected. ECCs receive site-specific data in quarterly snapshot reports, which are used for quality improvement. A 2018 analysis of court administrative data that compared ECC children with comparable child welfare-involved non-ECC children found significant positive outcomes for average time to reunification (259 days more quickly) as well as permanency overall (143 days more quickly).

In 2018, an evaluation1 of the implementation and outcomes in the state program, as well as of selected individual county-level ECCs, was conducted by the Florida Institute for Child Welfare. The evaluation found that most of the 15 ECCs were successfully meeting 40-60 percent of the ECC Best Practice Standards. Most ECC teams conducted required assessments, including infant mental health (77 percent); parent mental health (77 percent); child trauma (72 percent); parent trauma (70 percent); and the parent-child relationship (84 percent). Additional supports arranged or provided by ECC teams included home visiting (71 percent of ECCs arranged or supported), early care and education (64 percent), and early intervention (70 percent). Common challenges for ECC teams included difficulty addressing child trauma, accessing community resources such as housing and transportation, and maintaining funding.

A cost-benefit analysis conducted as part of the evaluation found that while average monthly costs per case were higher for ECCs ($1,012 versus $990), the total costs per case were lower overall ($18,422 versus $22,561), because cases reached permanency more quickly in ECCs (18.2 months versus 22.8 months for traditional courts).

Additionally, in 2014-2015, five counties in Florida were selected as demonstration sites for the Quality Improvement Center for Research-Based Infant-Toddler Court Teams (QIC-CT) led by ZERO TO THREE, which lasted through September 2018. The QIC-CT provided intensive training and technical assistance to participating sites to build capacity and enhance quality, and also conducted a comprehensive, multimethod evaluation. While most of the findings are aggregated for all QIC-CT demonstration sites across the country, there are some findings presented for individual sites, including four of the five Florida sites. Among Florida children, for example, this evaluation found that 89 percent were identified as having a need for CPP, and of those children, 94 percent received CPP services. Since beginning ECC services, 56 percent of children had only one out-of-home placement. Among closed cases, 100 percent of the children in out-of-home care had achieved permanency in 12 months, and among open cases, 67 percent of the children in out-of-home care were expected to achieve permanency in 12 months.

The QIC-CT is now the National Resource Center for the Infant-Toddler Court Program at ZERO TO THREE. Pinellas County, Broward County and West Palm Beach County are all evaluation sites for that program and contribute data for an independent research project being conducted by RTI International.

Special thanks to the following individuals for providing information for and reviewing this profile: Carrie Toy, Florida Office of the State Courts Administrator; Mimi Graham, Director, Florida State University, Center for Prevention and Early Intervention Policy; Janie Huddleston, Director, National Infant-Toddler Court Program (ITCP), Zero to Three; Darneshia Bell, Senior Technical Specialist, Zero to Three; and Leigh Merritt, Senior Court Analyst, Florida Supreme Court.

References

  1. Qualitative findings have also been published in a peer-reviewed journal article: Mackie, J. F., Foti, T. R., Agu, N., Langenderfer-Magruder, L., & Marshall, J. (2020). Child Abuse & Neglect, 104, Article 104476.