Roxanne Lieb, Mason Burley - May 2011

In response to a 2010 legislative direction, the Institute and DSHS are investigating options regarding the use of mental health assessment tools for two DSHS reports to the courts:

- Competency to stand trial assessments of criminal defendants whose competency is in question, and

- The Secretary’s recommendations to the courts concerning the potential conditional release of criminally insane patients from inpatient treatment.

This document summarizes results of an October 2010 survey of state forensic evaluators concerning their use of assessment instruments. Thirty-one (of the 35) mental health experts who conduct forensic evaluations for the three state psychiatric hospitals (Western State, Eastern State, and Child Study and Treatment Center) responded to the online survey; this represents an 89 percent response rate.

We present three options for assessment strategies and instruments, with advantages and disadvantages of each option. A detailed comparison of instruments is included.

Marna Miller - May 2011

In 2008, an Institute study found that American Indian, Black, and Latino children were more likely to have referrals to Washington’s Child Protective Services (CPS) than White children. Following referrals to CPS, American Indian and Black children (but not Asian or Latino children) were more likely to be placed and remain in foster care significantly longer than White children. In 2009, the Washington State Legislature directed the Institute to examine whether DSHS’s recent adoption of the Structured Decision Making (SDM) risk assessment tool affected racial disproportionality in the foster care system. SDM is used as part of CPS investigations to classify families on their risk of further child maltreatment.

Our analysis took advantage of the fact that DSHS began using SDM statewide in October 2007. We compare rates of placement and re-referral to CPS for children with referrals in 2008 to children with referrals before SDM was implemented.

Disproportionality after CPS referral varied markedly from year to year for Black children. Some of the variation can be explained by annual differences in rates of referral. However, analyses that controlled for referral rates still revealed year-to-year differences in rates of out-of-home placement for Black children. We are unable to explain these yearly fluctuations.

When our analysis combined children of all races, we observed no effect of SDM on out-of-home placements or new referrals to CPS. We also analyzed outcomes for each race separately. For White, American Indian, Asian, and Latino children, we found no effect of SDM on placements or new CPS referrals. For Black children—but not for any other race/ethnicity—we observed a significant increase in the rate of out-of-home placements in 2008. We cannot be certain that the SDM risk assessment was the cause of the differences in 2008; differences may also be the product of the largely unexplained year-to-year fluctuations in disproportionality for Black children.

As implemented in Washington State, the SDM risk assessment did not reduce disproportionality after CPS referral for either Black or American Indian children.

Jim Mayfield - May 2011

In 2006, the Washington State Department of Social and Health Services established two pilot sites for the Integrated Crisis Response Program. At these sites, Designated Crisis Responders (DCR) investigate and have authority to detain individuals with serious mental illness or substance abuse problems. Elsewhere in the state, this function is conducted separately by mental health professionals and chemical dependency specialists. The pilots also created secure detox facilities to hold involuntarily detained individuals. This report describes the 18-mounth outcomes of nearly 1,000 individuals admitted to these secure detox facilities from May 2006 through October 2007. Outcomes examined include psychiatric hospitalization, substance abuse treatment, emergency department utilization, employment, arrests, and mortality.

Annie Pennucci - April 2011

The research literature reveals a relatively small, positive impact on student outcomes resulting from a longer school year. When benefits are measured in terms of the labor market earnings gained from improved test scores, we find that increases to instructional time outweigh the cost of providing that instruction.

Brian Bruen, Richard Jensen, Patricia Riley, Anthony Lara, Xiaoxiao Lu - April 2011

The 2010 Washington State Legislature funded a study to examine options to contain costs in the state Medicaid program. Following a competitive bid, George Washington University was selected as the contractor. They found that small numbers of users account for most fee-for-service spending for inpatient and outpatient services. Options to reduce short-term costs include reducing reimbursement, placing restrictions on benefits, and instituting cost-sharing for beneficiaries. Long-term solutions require concentrated, coordinated care management for high-use, high-cost Medicaid beneficiaries and strategic approaches to reform the service delivery system, with accompanying payment reform to incentivize change.

Jim Mayfield - April 2011

In 2007, the Washington State Department of Social and Health Services established the Thurston-Mason Children’s Mental Health Evidence-Based Practice Pilot Project (Pilot) to provide mental health services to children. The first evidence-based practice selected by the Pilot was Multisystemic Therapy (MST), an intensive family- and community-based treatment program for youth. Over a one-year follow-up period, the Institute examined criminal convictions of youth enrolled in the Pilot’s MST program. Compared to youth with similar criminal histories and demographic characteristics, MST youth were convicted of fewer crimes on average. Due to sample size, statistical significance was not attained in this evaluation of MST outcomes. The effect sizes observed, however, are within the expected range for MST according to other rigorous studies of that intervention and would likely return a net economic benefit to tax payers and crime victims.

Marna Miller - March 2011

Washington’s Children’s Administration uses Family Team Decision Making (FTDM) meetings to involve parents and other family members, the child (when appropriate), friends, foster parents, caseworkers, and other professionals. Ideally, FTDM meetings are held for all decisions involving child removal, change of placement, and reunification or other permanency plan. In 2008, DSHS convened 6,600 FTDM meetings regarding nearly 8,000 children.

An earlier Institute study demonstrated over-representation of Indian, Black and Latino children in Washington’s child welfare system. Following referrals to Child Protective Services (CPS), Indian and Black children (but not Asian or Latino children) were more likely to be placed in foster care, and to remain in care significantly longer than White children. In 2009, the Legislature directed the Institute to study the effects of the implementation of FTDM on racial disproportionality.

When we studied outcomes for the child welfare caseload statewide, we found that FTDM had no effect on out-of-home placement, time to permanency, or new referrals to CPS.

When we examined outcomes by racial groups, however, we found three positive results for FTDM. 1) Latino children experienced decreased rates of placement. 2) Asian children achieved permanency more quickly than those in non-FTDM offices. 3) Black children exiting to permanency were less likely to be the alleged victims of new accepted CPS referrals.

With the exception of these three favorable results, FTDM as implemented in Washington did not affect disproportionality for Indian or Black children with respect to placement in foster care or time to permanency.

Marna Miller - February 2011

Temporary Assistance for Needy Families (TANF) is a federal/state program providing cash assistance to families with children. In Washington, the TANF program is administered by the Department of Social and Health Services (DSHS). The 2007 Legislature directed the Institute to study the prevalence of depression among women receiving TANF and to evaluate the effectiveness of current screening methods used by the DSHS.

A random sample of 707 women receiving TANF in February 2008 was interviewed by telephone using a well-validated survey instrument to diagnose major depressive disorder (MDD). Compared with a national sample of depressed women with children, we found that women receiving TANF were more likely to be depressed and their depression was twice as likely to be categorized as severe. Depressed TANF clients were also significantly more likely to receive professional treatment for their condition.

Compared with non-depressed TANF clients, those with MDD were employed less and received TANF longer in the nine-month follow-up period. Depression was not associated with TANF sanction, either at the time of sampling or during the follow-up period.

DSHS has implemented screening procedures that identify a substantial portion of depressed TANF clients. To the extent the state wishes to increase treatment rates, DSHS could modify its Comprehensive Evaluation to include one of several brief, freely available mental health screening instruments.

Elizabeth Drake - January 2011

In this report, we examine recidivism rates for close to 70,000 adult offenders who released from prison in Washington State over a 17-year-period. Our analysis reveals quite notable and favorable recidivism trends.

Mason Burley - January 2011

In Washington State, specialized investigators, called Designated Mental Health Professionals (DMHPs), are responsible for determining if individuals can be committed for 72 hours under the state’s Involuntary Treatment Act (ITA). The criteria established under the ITA statute (RCW 71.05) allow individuals to be involuntary detained to a psychiatric facility if, as a result of a mental disorder, the individual is gravely disabled or presents a substantial risk of serious harm to him or herself or others.

A DMHP relies on both professional judgment and historical case records to determine the extent to which an individual may pose a risk. While protocols have been adopted for ITA investigations, at present, DMHPs do not use a standardized risk assessment instrument to determine the level of danger an individual may pose.

This report reviews both mental health and risk assessment instruments that potentially could be utilized in an ITA investigation. None of the risk instruments discussed here, however, have been validated for use within the general population. While we could not identify suitable instruments for ITA investigations within the research literature, other measures are discussed which may assist a DMHP in the investigation process. These options include expanded access to criminal records and centralized access to previous mental health investigation and commitment data.