Therapeutic Behavioral Services (TBS) is a highly specialized mental health children's service delivery model making a significant difference for thousands of children and families throughout California. TBS is designed to assist clients and caregivers in developing and acquiring the behavior management strategies and skills needed to maintain the client's current placement level or successfully transition the client to a lower level of care. TBS is unique because of the parent's or caregiver's intensive involvement and active participation. This increases the likelihood of sustainable and successful change for both the client and family.
Designed to provide short-term (three-month average) intensive in-home or community behavioral support, TBS is suitable for children (0 to 12 years old), adolescents (13 to 15), and transitional age youth (16 to 21) who exhibit moderate to severe behavioral problems and, as a result, are at risk of losing their current placement or moving to a more restrictive level of care. The current placement may be a family or foster home, adoptive home, shelter, group home, or residential facility. Clients referred for TBS generally present a broad range of psychiatric-medical, psychological, emotional, and behavioral diagnoses. The most common of these are bipolar disorder, ADHD, oppositional defiant disorder, PTSD, and depressive disorder.
The TBS concept and model is based on the common-sense approach of community-based service initiated by the 1997 Emily Q. v. Bontá case. At the time, Emily Q. was an 18-year-old Latina who had been placed in a variety of mental health institutions throughout her childhood, moving from one facility to another after state employees deemed her violent, self-abusive, and not amenable to treatment. She often was placed in seclusion rooms and restraints and frequently was overmedicated. Emily Q. later explained that her behavior was a result of fear and desperation.
Advocates for Emily Q. filed a lawsuit against the state, maintaining that children in mental institutions and group homes, as well as those with multiple out-of-state placements, could be served better with one-on-one behavior “coaches” in their own homes or communities. The lawsuit's underlying premise was that services in California were inadequate to enable children to successfully reside in homes and communities instead of institutions, where their behavior often deteriorated.
In 2001, a federal court judged in favor of children (i.e., Emily Q.) and ordered the state and counties to offer a new “full scope” Medi-Cal mental health service: TBS. Interestingly, that same year a report by the University of California, San Francisco, found that local organizations offering services for children with severe emotional disturbances saved $5 in state and federal funds for every $1 invested.
Compared to other rehabilitative mental health services, TBS is distinctive because it delivers one-on-one services in the client's natural environment. Other distinct features include its intensity and frequency. After a thorough behavioral assessment identifies days and times of behavioral difficulty, a behavioral coach is placed in the environment during these periods. The coach's presence allows for immediate intervention and modeling of behavior management skills. Service hours vary and are individualized to address each client's specific needs.
To qualify for TBS, a child must be a full scope Medi-Cal beneficiary that meets medical necessity and additional criteria in accord with California Department of Mental Health regulations. The youth's long-term mental health needs are addressed by a specialty mental health provider who becomes an active member of the TBS treatment team.
After meeting eligibility requirements, the youth is referred to the most appropriate TBS case manager based on considerations, including family needs, culture, gender, language, and clinical needs. The case manager immediately contacts the family, caretaker, or placement staff and conducts a comprehensive clinical and functional behavioral assessment to identify the most problematic behaviors.
A tailored approach
TBS focuses on the behaviors that jeopardize a child's current or transitional placement. TBS programs use a combination of behavioral modeling, structure, consistency, creativity, and other interventions that build on the strengths of each individual and his/her family or caretaker. Program models identify specific risk behaviors and develop an individualized treatment plan implemented via a team approach. The team consists of the client, caregiver, specialty mental health provider, case manager, and coach. All work together to develop the client's concrete and measurable plan.
Target behaviors are identified by duration, intensity, and frequency. Specific interventions are designed to modify or change the target behaviors, and a specially trained TBS coach provides one-on-one behavioral coaching within the home and/or community. Coaching and interventions may include:
Reinforcement schedules, such as rewards and consequences
Behavioral modeling by TBS coaches
Behavioral shaping of desired responses, including “planned ignoring” (not responding to acting out behavior as a means of extinguishing the behavior)
Redirecting to more appropriate behaviors
Positive reframing of behaviors
Removing antecedents to behaviors
Normalizing certain behaviors
Teaching parents or caregivers age-appropriate behaviors