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Youth program offers alternative to residential treatment

November 15, 2011
by Martha M. Dore, PhD and Borja Alvarez DeToledo, MEd
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Program's success shows wisdom of wraparound services concept
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“Kevin” is a handsome young man of 14 with a 100 kilowatt smile and mischievous brown eyes who loves playing video games and roughhousing with his dog, Milo. Tragically, Kevin was brutally abused as a toddler by his mother's boyfriend, the same boyfriend who murdered his mother before his eyes when he was just four years old.

After subsequent placement in a foster home, Kevin alternatively lashed out violently at his foster parents and other foster children and withdrew into a sullen, silent shell. At age 8, he was hospitalized in a psychiatric facility after trying to drink bleach, saying he wanted to be with his mom. From there, Kevin was sent to a children's residential facility in South Carolina, his home state, where he remained for two years.

At age 10, Kevin went to live with an aunt and uncle in Somerville, Mass. Kevin's aunt, “Elie Gooding,” who was his mother's older half sister, had contacted the South Carolina child welfare agency to inquire about her nephew and was told that he was scheduled to leave residential care soon.

Elie and her husband “Thomas” applied to become Kevin's kinship foster parents, unsure what they were getting themselves into but knowing that they could not abandon Kevin to an unknown, uncertain future. Because of Kevin's continuing serious emotional difficulties, the Goodings were referred to the Massachusetts Department of Mental Health (DMH) for support and direction regarding his care.

A new beginning

The Goodings were referred to an unusual community program designed to help families keep a child with serious emotional disturbance (SED) at home and prevent further out-of-home placement. This program, the Family Advocacy, Stabilization and Support Team (FASST), was developed in the mid-1990s by the Guidance Center, a children's community mental health agency that is now a part of Riverside Community Care, Inc.

The FASST concept was born in the early 1990s when Joan Mikula, Assistant Commissioner of Child and Adolescent Services at DMH attended a national conference presentation on “wraparound” services that could prevent the need for long-term residential treatment of children and youth with SED. This concept literally “wrapped” an array of services around a child and family to support the family's ongoing care and the stability of the child in the home.

In Massachusetts at the time, there were few community-based alternatives to residential placement of a child with SED. Plus, DMH was spending significant funds to maintain residential beds. So, thought Commissioner Mikula, what if the state redirected the funding needed for a few residential beds into a community-based wraparound services program?

In response to DMH's RFP for a “community residential program without beds,” the Guidance Center developed the FASST program under the direction of Borja Alvarez de Toledo, M.Ed.

The FASST model

The use of FASST marked a major innovation in treatment for the most severely disturbed youngsters because, for the first time, the FASST model offered inpatient and residential care as one element in an array of wraparound services, rather than as the primary mode of treatment for children with SED.

FASST is designed for children and youth, ages 3 to 19, and their families. It delivers services built around family strengths, driven by family-identified goals, and sensitive to cultural differences from an ethnically, racially and linguistically diverse staff.

Encouraging and supporting the family's voice in treatment planning is a key element in the FASST model. Wraparound services range in intensity from normative community resources such as Boys and Girls Clubs, YMCA and YWCAs, and local religious institutions, to the purchase of brief residential and respite placements facilitated by contract providers. FASST staff also provides concrete goods using DMH flexible funds, including transportation vouchers, food vouchers, medical supplies, educational materials, and home appliances.

These goods are included as part of a comprehensive package designed to address the needs of any family member whose functioning may affect the child or youth with SED. This array of goods and services is continually adjusted to build an individualized system of care that can sustain the child in the family and community over time.

When a child is referred for FASST services, there is usually consensus among those involved that the next stop for that child is long-term residential placement. Most of these children have extensive psychiatric histories.

If a youth is in a residential treatment center (RTC) or a short-term assessment unit when referred to FASST, the initial phase of the intervention focuses on family reunification. This involves working with the family from 4 to 6 weeks prior to the child's return home to insure that necessary services and supports are in place, as well as working closely with hospital or RTC staff and the youth to prepare the child for discharge. During this time, the family is engaged in family therapy with the FASST clinicians, child and staff at the residential facility.

Crisis management in FASST

Because of the often fragile and volatile psychosocial functioning of the children and youth served by FASST and the program's goal of preventing crisis-driven psychiatric hospitalizations, the model provides 24/7 response to families, 365 days a year.

When possible, triage by telephone is first carried out to assess the nature of the crisis, de-escalate the child or family members and determine the need for face-to-face contact. When placement becomes necessary, the FASST team can directly purchase various forms of brief, more intensive care, such as:

  • in-home or out-of-home respite for the family,