CFSS is a behavioural health services provider agency in Arizona that provides supportive services for children, adolescents, young adults and families.

1. Winter 2008, Vol. 22, No. 1
Direct Support Services in
Children’s Mental Health
T he system of care approach
has taken hold in the field
of children’s mental health
become busy with
activities and the
aspects of life. This helps
recent years, causing many com- attention on con-
munities around the nation can make in their
rethink and reorganize the homes and communities.
vices and supports they offer relatively common
children and their families. This developmental dis-
shift is perhaps most obvious special education,
children with complex needs services are not
who might previously have been understood, appreci-
placed in residential treatment ely utilized in chil-
facilities or hospitals. The system ’ health. Centering
of care approach focuses instead activities rather than
on developing care and suppor “fix” bad behavior,
strategies that enable children services are differ-
to live in community settings more-typical “behavior
and to participate fully in fam- model, where atten-
ily and community life. Direct ually drawn to the
support services [see article on undesired behavior in an effort to
page 8] are compatible with—and worker’s repertoire. As a result, this extinguish or replace it. Instead,
in many cases essential for—mak- approach often requires clinicians to direct support services work within
ing this approach work for children work in new ways. This approach the environment of the family’s cul-
with complex needs and/or difficult also requires new roles, like that of ture and use a positive approach to
behavior. Direct support services the direct support worker, so that in- focus on what the person wants to do
are flexible, home- and community- home and in-community support can rather than simply what others want
based services that build on and de- be provided in ways that are consis- the person to stop doing.
velop child and family strengths and tent with the child and family’s plan. This approach is particularly help-
capacities, and that focus on helping ful for individuals and families for
the child and family live successfully Direct Support Services whom traditional mental health ser-
in the community. In the traditional Differentiated vices have not been successful in the
medical model of mental health, ex- past, including those with very com-
perts identify a problem and apply Direct support services are provid- plex needs. A common misperception
treatment in order to fix the trouble. ed in the homes of families and in the is to see direct support as a “lower lev-
Within a system of care, on the other community rather than in an office el” of service that is put in place only
hand, treatment and care approaches setting. They involve a philosophy of as a precursor to traditional clinical
are identified by partnering with fam- “treatment by participation,” focus- services such as counseling and medi-
ilies, first to discover their underly- ing on helping a child get involved in cation management. In reality, direct
ing needs and then to design a plan the community, develop a respected support services in and of themselves,
that uses their strengths, capacities, role and positive reputation, practice or in combination with traditional
and resources to reach the goals they life skills, make choices, and experi- clinical services, are often the inter-
consider most important. Making ence enhanced quality of life. Less ventions that are most successful for
this sort of approach work requires focus is placed on talking and more is youth with challenging needs. This is
skills for partnering with youth and placed on doing. Rather than dwell- due in large part to the good fit be-
families, and such skills are often not ing on diagnoses and limitations, the tween community-based support ser-
part of the traditional mental health philosophy of direct support encour- vices and the interests and needs of
focal point 5

2. Winter 2008, Vol. 22, No. 1
children and families. Additionally, di- fair play. most complex youth live successfully
rect support services are often a good • Linda needed to have a positive in their community and overcome sig-
match for children who are either too identity. She had been cutting on nificant challenges and risk factors.
early in their development or too con- her legs when she felt stressed and On the other hand, the lack of tra-
sumed with the challenges of life to everyone in life had begun to iden- ditional formal training also presents
benefit from therapeutic approaches tify her as a “cutter.” Support staff challenges. For example, it is impor-
that require cognitive processing of helped her plan, prepare for and tant that direct support workers un-
their behavior. And because direct carry out a “perfect day” of her derstand basic theories of behavior,
support services provide practice in choice. They role modeled and possess strong listening and commu-
the immediate environment in which participated in bike riding, paddle nication skills, see the value of proper
the child lives, positive outcomes are boating, and helping Linda make documentation, and recognize ethical
likely to be sustained. For all of these dinner for her family. Support obligations. However, many parapro-
reasons, direct support is an excellent fessionals and behavioral health tech-
service option in
children’s mental
health systems as Some of our own agency’s best direct support workers
a means of aug-
menting custom- had little or no prior experience in the field of behavioral
ary clinical treat-
ment services.
health, yet they have helped some of our community’s
The follow-
ing examples il-
most complex youth live successfully in their community
lustrate some of and overcome significant challenges and risk factors.
the ways direct
support services
may be used in children’s mental workers helped Linda identify nicians have little training and expe-
health to address the needs of fami- her own positive qualities based rience in these areas. What is more,
lies. (Names and identifying informa- on the day’s activities. These were direct support work usually occurs in
tion have been removed or changed.) important steps in helping Linda homes and in the community rather
• The family and their support team build a new life of purpose and than in an office, leaving the worker
identified a need for family mem- meaning. without immediate assistance or over-
bers to celebrate their spirituality sight. It thus is essential that agencies
together. Their goal was to attend Integration of Bachelor’s offer high-quality training and super-
church as a family. In the past, Level and Paraprofessional vision to direct support workers, in
Brandon’s anxiety in social situa- Workforce order to ensure that they are properly
tions had led to his being kicked prepared to meet the challenges that
out of church repeatedly. Direct Unlike clinical service roles, most are inherent in their jobs.
support workers helped him plan direct support service roles do not re-
and practice how to dress, talk quire a graduate degree in a behavior- Licensed Mental Health
and act while at the service. They al health field. Instead, the workforce Professionals and Direct
showed him new skills such as ty- predominately consists of bachelor’s- Support
ing a necktie and shaking hands level employees (behavioral health
with others so that he would feel technicians) and individuals with less Licensed mental health profes-
comfortable at church. They ac- formal education but with a talent for sionals play several critical roles in
companied him to church along connecting with children (paraprofes- community-based direct support.
with his family to help ensure his sionals). Such a workforce has both First, although somewhat of an anom-
success. advantages and challenges. One of aly, a masters-level, licensed clinician
the advantages is the opportunity to can be one of the most effective direct
• Two siblings needed to have posi- support workers in a system of care,
tive relationships with peers. They create an agency culture based on the
direct service philosophy described especially when paired with a commu-
frequently got into fights with oth- nity-based, support-driven approach
ers during any activity that they above. This is more difficult in an
agency where most workers have had to helping others. Such employees
perceived to be competitive. Di- are often the products of established
rect support workers helped initi- formal training and experience in
professional cultures dominated by systems of care, where community-
ate neighborhood flag football based work is an expected practice,
games to help the two young sib- deficit-based approaches and medical
models. Some of our own agency’s or they emerge from schools of social
lings make friends in their neigh- work or community health, where
borhood and learn how to play in best direct support workers had little
or no prior experience in the field a belief in working in homes and
competitive situations. During the communities comes more naturally.
football games, the support work- of behavioral health, yet they have
helped some of our community’s Unfortunately, many fee-for-service
ers modeled sportsmanship and
6 focal point

3. Winter 2008, Vol. 22, No. 1
reimbursement schedules are based cies offering home-based services and coercion, criticism, and making op-
on the type of service (counseling as behavior coaching use deficit-based portunities to participate in the com-
opposed to skills training, for exam- approaches as the default operating munity contingent on good behavior.
ple) rather than on the qualifications modality. As a community moves to-
of the person providing the service. ward becoming a true system of care, Conclusion
This provides a disincentive to agen- a significant amount of workforce
cies to use masters-level profession- and supervisor retraining may thus be While an abundance of research
als for many direct support roles. In necessary. is available regarding the effective-
systems where direct support thrives, Positive Behavior Support works ness of Positive Behavior Support for
agencies are paid nearly the same rate well with individuals for whom more youth with complex needs, additional
for services by a licensed masters-lev- traditional behavioral interventions research is needed to explore how to
el worker, regardless of whether the have not been successful. Youth and optimize PBS-based direct support
unit of service involves therapy, within systems of care. Impor-
respite or any other service. tant research questions include
Configuring rates in this pro- the following: What is the best
gressive manner allows willing way to balance and/or combine
clinicians to provide services in PBS-based direct support with
any manner most likely to help traditional clinical services? Is
a family, including direct sup- there a particular benefit to us-
port when needed. ing family members of children
Separate from direct service with behavioral health needs as
provision, licensed clinicians providers of direct support ser-
may be a valuable part of direct vices? Does family-led recruit-
support programs by contrib- ing and hiring for direct support
uting clinical supervision and workers help improve the qual-
guidance for the workforce. As ity of the workforce?
mentioned previously, direct Direct support services are
support services are often pro- a growing trend in the field of
vided by individuals with little for- even adults with complex behavioral children’s mental health, particularly
mal training and experience. These needs often reach a point where ap- in connection with the move toward
workers benefit tremendously from proaches such as timeout, removing Systems of Care. Direct support
consistent and frequent supervision. privileges, and punishment are not workers have an exciting opportunity
In providing clinical supervision, it successful. In some instances, not to become involved in the growing
is imperative that the clinician under- only are these approaches ineffective, trend of strength-focused, commu-
stand and emulate the principles and they may make matters worse. This nity-based work. This opportunity is
values of community-based care and often results in a temptation to give available to individuals with little or
direct support services. Perhaps no up on the individual or to label the no prior behavioral health experience
other position has more influence on person as being unresponsive to help. and to licensed mental health profes-
the work performed by frontline staff. PBS uses a different approach to sionals. Agencies that ground their
A clinician who is not aligned with challenging behavior. It removes the direct support approach in the princi-
the values of community-based work coercive and punitive interventions ples of Positive Behavior Support are
may contradict and render ineffective and focuses on positive opportuni- more likely to experience successful
even the finest training program. It is ties and choices. It is not possible to outcomes for children and families
thus essential to carefully select, train, control the actions of others, and for with complex needs.
and supervise licensed clinicians who individuals with complex behavioral
take on supervisory or administrative needs, attempts to do so sometimes Reference
roles in a direct support program. backfire. The success of Positive Be-
havior Support for youth with very 1. Carr, E. G., Dunlap, G., Horner,
Positive Behavior Support complex needs is well documented as R. H., Koegel, R. L., Turnbull,
an alternative approach to traditional A., Sailor, W., et al. (2002). Posi-
Positive Behavior Support (PBS) interventions.1 tive Behavior Support: Evolution
is a strengths-based, non-coercive PBS focuses on preserving the of an applied science. Journal of
approach to behavioral intervention respect and dignity of the individual Positive Behavior Interventions, 4, 4-
that is the foundation of effective di- and family, giving people real choices, 16.
rect support work in children’s mental improving quality of life, and creating
health.1 This positive approach is con- opportunities to help people practice Author
sistent with system of care values, but (rather than just talk about) being
is very different from the deficit-based contributing members of society. PBS Tim Penrod is Chief Executive Of-
approaches that predominate in tradi- discourages and avoids punishment, ficer of Child & Family Support Ser-
tional mental healthcare. Many agen- behavior level systems, ultimatums, vices, Inc. in Tempe, Arizona.
focal point