Appendix 2:
Standards of Care for Children, Adolescents, and their Families

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Clinical standards of care provide context to the Office of Mental Health regulations that define appropriate access to services and quality of care for children and adolescents treated in Clinics licensed by the New York State Office of Mental Health. These standards should be incorporated by all Clinic programs serving children, adolescents and their families as the basic operating framework within which care is provided.

1. Engagement, Assessment and Treatment
1. Engagement
   Engagement of the child or adolescent and their family in treatment is the first step in offering family-driven care and is a crucial element for treatment success. The process of building this connection starts with the first contact, whether by phone or in person. There are a variety of ways that engagement can occur, including the use of Parent Advisors and/or staff that have particular skill in building initial rapport with children and families; the development and dissemination of fact sheets, pamphlets and brochures; through follow-up and confirmation telephone calls used to motivate and engage families; and ensuring that the Clinic maintains cultural relevance within the community that it serves. A variety of approaches to family engagement should be used throughout the assessment and treatment process to maintain involvement and promote successful outcomes for the family.
2. Assessment
   All clients shall have a single clinician designated to ensure that an assessment is completed in a timely manner. The assessment process should begin with the child or adolescent and his/her family or guardian in the child is in foster care. Clinicians should be respectful of who the family invites to be part of the assessment process (distant relatives and close friends, in some cultures, for instance, may provide comfort, for example). Additional sources of information, such as school personnel, current and previous therapists, medical providers, and social service and juvenile justice personnel should be sought to help define the concern(s) that brings the child into the clinic for treatment as well as the child and family's strengths. The assessment should include:
• A thorough mental status evaluation, including interview or interactive session with the child or adolescent, as appropriate. Individual clinical judgment will guide whether or not the child or adolescent should be interviewed alone and/or in the company of his/her parents. Parents or guardians should be interviewed, unless there is a strong clinical or legal reason to exclude their input.
• A review of developmental, mental health, and educational history and symptoms, including prior treatments, medications, and response to treatment.
• An assessment of the family, social circumstances, school performance, peer interactions, social networks. Current and previous life-stressors should be assessed.
• Past medical history and treatment should be obtained. Information from the current medical provider should be sought.
• Family history, including mental illness in family members and particular life circumstances or stressors likely to impact the child or adolescent.
• An initial risk assessment, including the child's risk to self and others.
• A comprehensive diagnostic evaluation using the five axes of the current Diagnostic and Statistical Manual of Mental Disorders (DSM) classification.
3. Care Plan (Treatment Plan)
   Every child and adolescent admitted for treatment is required to have a comprehensive treatment plan that is developed in a timely manner, driven by the needs and strengths of the child and their family (demonstrated with the appropriate signature on the document) and signed by all clinicians participating in the plan and the supervising physician. The treatment plan should be:
• Clear about the needs, strengths, hopes and expectations of the child or adolescent.
• Specific in regard to the treatments to be employed in the attempt to reach those goals.
• Identify how others in the child's life, including teachers, friends, community resources will be involved in treatment and/or consulted with regarding treatment results.
• Responsive to the child or adolescent's unique developmental needs.
• Responsive to the family's social, cultural, and linguistic needs.
• Developed and written with the child (as appropriate) and parents or guardians.
• Updated according to the child or adolescent's needs, progress, and regulatory requirements
4. Ongoing Care (Treatment)
1. Primary Clinician (Therapist)
   A primary clinician (therapist) should be established in a timely manner for each child or adolescent treated in the clinic. This person must be available to family members on a regular basis, in a culturally respectful manner.
2. Continued Engagement in Treatment
   It is the primary clinician's responsibility to ensure that each child and his/her family remain engaged in treatment and are making progress that is consistent with the treatment plan and with the family's expectation of outcomes. Clinicians should feel free to openly discuss issues of motivation and adapt the treatment plan accordingly. Clinicians should be well versed in local Family Support resources and readily refer families.
3. Youth and Family-Driven Care
   Clinicians should listen carefully to discover what youth and their families hope to achieve from treatment and this should be reflected in the treatment plan. Ideally, treatment planning is a collaborative process among a young person, parent, clinician, and other supports, as determined by the family. The mental health treatment goals should be realistic and relevant. Young people and their families should be encouraged to ask questions about treatment goals or to share concerns with what they feel is not working.
4. Collaboration within the child's community
   Active collaboration with others involved with a child or a family can be an important aspect of treatment. Clinics shall develop a plan for each child to assure continuity and integration of care within the mental health system and with other systems of care. A clinician should be familiar with various care systems and the personnel who are serving the child and/or family. For instance, if a particular youngster routinely gets into trouble in school, the clinician should obtain a release from the parent or guardian to be able to speak with the child's school social worker, teacher, or principal. This will ensure that the clinician is obtaining accurate and relevant information and is able to fully understand the scope of the presenting problem. This will allow the clinician, family and teacher to devise treatment solutions that meet the child's unique needs in a timely and respectful manner.

   Additionally, this will allow the clinician to recommend and refer the child to complementary community based treatment services, to maximize therapeutic gains for the child. Using our example, the clinician might choose to advocate for additional services for the child by making a referral to a case management service provider while simultaneously referring the child's parents to a parental support group.

5. Client & Family Safety
   Many children and adolescents are referred to clinic treatment because they have engaged in high risk behaviors that pose some danger to themselves or others. Other youth come to the attention of clinic providers because their statements or behaviors suggest they have considered or might engage in high risk behaviors. Therefore the issues of “risk” and “risk assessment” are necessary parts of the assessment and are ongoing aspects of the clinician's role during treatment. Parents should be instructed in how to make appropriate risk assessments of the child or adolescent's statements or behaviors and appropriate steps to take if safety continues to be a concern.

   The primary therapist should ensure that appropriate and ongoing assessments of progress in treatment are made, a part of which will include safety assessments as noted above. If there is concern about imminent danger to self or others, appropriate and timely contacts with parents and/or other care givers or agencies is important. All attempts must be made to ensure the safety of the child or adolescent and others. Children and adolescents who are the focus of treatment and their families should have information necessary to contact treatment providers for both routine follow-up and immediate access during periods of crisis.

6. Lack of Progress in the Treatment Process.
   It can be scary and upsetting for parents when they first bring a child to a mental health clinic for evaluation or treatment, but most do so with the intention to work as a member of the team to help their child make meaningful progress. In some situations, life circumstances or personal challenges are too great, and treatment goals are not reached.

   When children, adolescents, or parents do not progress in treatment or do not actively participate in the treatment process this should be addressed in therapy and by members of the treatment team, and collaborating providers and agencies should be notified. A review of the child or adolescent's history, treatment progress, and assessment of risk to self or others should be made. The treatment plan should be re-evaluated to find different approaches that might be more successful. For particularly challenging situations, clinics should consider expert consultation through contract or by utilizing telepsychiatry. Attempts to re-engage the child, adolescent, parents should be made whenever feasible.

   In very rare instances in which parental action or inaction rises to the level of medical neglect, appropriate contacts with social service agencies may be needed to ensure access to treatment if there is a lack of capacity or willingness of the parent or caregiver to engage in or to follow through with treatment recommendations. Of course, mandated reporter protocol should always be observed.

2. Clinical Administration
1. Caseloads: The clinic supervisor or director is responsible for ensuring that complex, time-intensive cases are evenly distributed and considered for more experienced clinicians, and that the number of clients assigned to a clinician permits appropriate delivery of services.
2. Supervision: Clinic leadership should provide regular clinical guidance and oversight for staff, particularly new staff, with attention to ongoing treatment needs as well as emerging problems or crises the child or adolescent (or family) may have.
3. Integration: When children or adolescents receive multiple services, the Clinic is responsible for ensuring that all of the adults and services involved have a shared understanding of the youth's treatment goals and progress. The Clinician should also be committed to ensuring that any and all plans for the family are integrated and complementary. This should be reflected in the clinical record.
4. Communication: Complex care requires that case managers and clinicians from multiple disciplines provide concurrent services within one agency or among multiple agencies. It is imperative that these individuals have ready access to one another and share appropriate information at regular intervals, and when there is evidence of emerging instability and during periods of crisis. While receiving appropriate consent from parents or guardians is good practice and usually advised, mental health providers are authorized under both State and Federal law to share clinical or identifying information with other treating mental health providers, without consent.