Home Is Where Care Belongs

There’s no place like home. That adage is a guiding principle for the mental health professionals who work to keep families safely together. With this in mind, the Yale Child Study Center (CSC) offers an array of services that take place not in an office, but in the home.

The philosophy is simple but also pragmatic: People are more open and comfortable in their own space, which allows clinicians to gain a more authentic picture of their daily lives than may be possible in other professional settings.

“The biggest benefit is the level of intimacy you gain from being in someone’s home. It brings you to the heart of the matter much more quickly,” says Judith Eisenberg, LCSW, program coordinator for the CSC’s Intensive Family Preservation Program (IFP). Karen Hanson, LCSW, coordinator for Family-Based Recovery Services (FBR), agrees. “In-home work allows us to see the goodness of fit between family members, and the family and their environment,” she says. “We see many things that the family members might not think to share in an office-based visit.”

Home-based services for families aren’t new, but they are growing in popularity and gaining acceptance. They can help fill a gap when treatment in a clinic or office setting is not meeting the needs of the child and family. For some here in Connecticut, a home-based care plan begins with a referral from the Department of Children and Families (DCF) in hopes that the family will participate voluntarily. The aim is to help families heal and grow stronger together.

“Children need to grow up with adults who care for them, keep them safe, and help them feel that they are special,” says Jean Adnopoz, MPH, director of In-Home Clinical Services and a clinical professor in the Child Study Center. “The relationship between child and parent should be protected and supported. Any disruptions, including placement in foster care, is usually not a good thing. The idea of having been neglected, unwanted, or abandoned reverberates throughout the child’s life.”

With that in mind, the Child Study Center offers several in-home programs in which teams of trained staff members work with parents and children in their own homes to develop treatment plans that can range from mental health and substance use counseling (for children and adults) to family counseling to parenting education and support.

IICAPS is designed for children with serious emotional disturbances who are returning home from a psychiatric hospital—or who need intervention to prevent hospitalization. For these kids, traditional, community-based services aren’t enough to keep them safe, Adnopoz explains.  

The term “serious emotional disturbance” means that a child has at least one psychiatric diagnosis and that he or she has problems in school, at home, or in the community. “The problem could be anxiety, depression, adjustment disorder, psychosis—anything,” explains Virginia Zecchini, MSc, program coordinator for IICAPS. “Although children with a diagnosis of autism alone are not eligible for IICAPS Services, children with a psychiatric diagnosis and autism are among those for whom we provide treatment.”

A team of two (a clinician and a mental health counselor) provides treatment under the supervision of an experienced clinician and a child psychiatrist. The program, which serves children from ages 4 to 18, runs for six months. Clinicians visit the home three times each week: once with the parent(s) and the child individually, and once with the family together. IICAPS staff provides around-the-clock emergency crisis response.

“We are a higher level of care. We are usually not the first program that someone tries,” says Zecchini, noting many families have sought outpatient or emergency department care previously.

IICAPS, she explains, focuses on relationship building. “IICAPS teams go into a family’s home and really get to know them well,” says Zecchini, who is also an assistant clinical professor in the Child Study Center. “You might have a single parent with a difficult work schedule, and by meeting in the home at a time that works for the family, the child doesn’t have to leave school, and the parent doesn’t have to leave work to make the appointment.”

A large part of the work, she adds, is helping parents understand what their children need. “We had a case with a teenaged girl whose guardian kept saying how defiant she was,” Zecchini says. “But as we started working with the family and the school, we learned that she had a low IQ. Her processing ability was different. So, we worked with the guardian, helping her to communicate in steps and not to tell the girl five things at once. It made a huge difference.”

There are 19 IICAPS sites in Connecticut; more than 2,000 IICAPS cases are active each year. Referrals come from psychiatric hospitals, child guidance clinics, schools, community providers, and DCF.

Family-Based Recovery is an in-home program for parents who have used illicit substances or alcohol within four weeks of referral and who are actively parenting a child up to age 3. The program was designed to promote positive, healthy relationships between parents and children and to prevent familial disruption caused by placing a child outside of the home. This is notable because children living with parents who use illegal substances are more likely to be placed in foster care. FBR clinical teams work to reduce the risk of parental substance use while the parent enters recovery. This requires constant attention to issues of trust, engagement, and collaboration with Child Protective Services (CPS) and systems.

FBR is for families with young children who aren’t yet in the school system and “are invisible” to the community, Hanson says. The majority of referrals come from DCF. According to Hanson, an assistant clinical professor of social work at the Child Study Center, prior to the FBR program, DCF’s protocol was to remove an infant if the mother tested positive for an illicit substance at delivery. Now, families may get involved with FBR at delivery or when members of DCF, who are already working with a family, determine that substance use is affecting the well-being of a child. While strongly encouraged to engage in FBR, families voluntarily enter treatment, explains Hanson.

This in-home treatment option motivates the parent to be more deeply invested in recovery. The alternative of having a child taken away may only worsen the substance use problem. “A mother would say, ‘If I don’t have my child, I’ll just go use,’” Hanson says. “Data suggest that binge drinking and heavy marijuana use decrease during pregnancy, and then slowly go back up. And when a child is removed, parents often relapse. It’s their coping mechanism.”

Having a new child in the home can be a window for change, Hanson adds. FBR takes advantage of this period of time and brings psychotherapy, substance use treatment, and parent-child dyadic therapy into the home. The focus is on talking to parents about how they would like to raise their children—with special attention to how substance use affects their parenting.

“Studies show that the brains of mothers who use substances do not respond to their child’s needs in the same way as mothers who do not use. We help them to understand their child’s cues,” Hanson says, sharing the story of one mother whose daughter threw a temper tantrum every time the mother went into the bathroom.

“The mom would go into the bathroom to use substances. When she came out, she was not the same, and her child knew that—even though the mother did not,” Hanson says. The clinical team worked with the mother to see how her child’s reaction was in response to her past behavior and to provide an alternative experience for the child now that the mother was in recovery. “FBR works to increase the reflective capacity in parents, focusing on positive reinforcement for their efforts and successes. We work with parents on how to deal with psychological issues. Many parents have trauma histories. They use substances to numb pain, not to get high.”

FBR provides three visits a week from a team of three—two clinicians and a family support specialist for up to twelve months. “We are the only program of this kind in Connecticut, and we have 11 teams throughout the state,” Hanson says.

In 2017, FBR received an $11.2 million Pay for Success grant to expand services in Connecticut. “It’s a five-year project. We are conducting a randomized controlled trial, with the goal of rooting this model in evidence-based data so it can be adopted more widely,” Hanson says.

Intensive Family Preservation is an in-home program for vulnerable children and families in need of additional support to ensure that children are maintained safely in their homes and communities. Funded by DCF, the Child Study Center’s IFP program works with families involved with CPS due to challenges with abuse or neglect of their children. Caregivers referred for IFP services are often struggling with mental illness, substance abuse, serious physical illness, poverty, and hopelessness. Some cases are voluntary, but others, that are more severe, are court-mandated.

For the latter group, “there is a higher level of scrutiny and a timeframe that may lead to removal if conditions do not improve,” Eisenberg says. “Grounds for removal are stipulated by law and must be upheld in court. Lack of adherence to IFP by itself would typically not result in removal; there would need to be significant documented safety concerns over a period of time, despite multiple interventions.”

Services typically last four to six months and entail two visits per week from a single clinician. “Our focus is on the adult in support of the child or children,” Eisenberg explains. “We want to engage with the caregiver so that we can optimize their parental functioning and help them manage their own needs more successfully.”  

The goal, Eisenberg says, is to create a service plan together that becomes the road map for family change. “In addition to relationship work, we may help them improve their means of transportation, go with them to court … it’s very hands-on,” she says. “We address the environment and daily living skills to help effect change and increase safety. We look at the kitchen, for example. Does the family eat together? Are there cleanliness issues? We ask where sharp objects and cleaning supplies are stored. What about weapons? Are precautions in place? Do family members have beds to sleep in? These are the kinds of things we’ll see and address in the home.”

Despite the difficult conversations, relationships develop between the clinicians and the families. “Coloring and playing with families is much more intimate in their home than in the office,” says Eisenberg, also an assistant clinical professor in the Child Study Center. “We hope the warmth of those connections lingers when we end the case.”

What’s more, the programs are successful. “Treating families in their own home has helped to maintain the family unit, improve stability, and decrease the need for out-of-home placement,” says Adnopoz.

Whatever problems children and their families face, these programs through the Child Study Center are dedicated to working with families and keeping them together safely where they are likeliest to thrive—in their own homes.

To learn more about the Child Study Center, click here.