Tier 2 services in the NH Children’s System of Care include proven outpatient treatments and approaches to address specific mental health conditions such as depression, anxiety, or aggressive behavior. Tier 2 services also include outpatient treatments and programs to treat a youth’s alcohol or drug use.
These services are provided by agencies or schools with staff who have been specifically trained to provide each type of treatment. Tier 2 supports may also include case management and mental health evaluations. The need for these services may come up in school, perhaps when the child or youth is struggling when compared to other students because of a mental health or behavior concern.
Who are Tier 2 Services for?
Tier 2 services are for a young child, school-age child, teenager, or young adult who is having problems with everyday life that last more than a few weeks due to a mental health concern or substance use. You should seek an evaluation and ask about treatment if your child (or if you are a youth who) is experiencing:
- Feeling sad all the time, having unusually low or no energy, or upset or anxious.
- Having trouble with relationships, such as inability to form healthy and lasting friendships with other children or inability to make or keep friends.
- Problems concentrating or focusing on important tasks such as homework.
- Getting suspended from school repeatedly or sent home from childcare or pre-school because of behavior problems such as fighting or extreme verbal aggression.
- Talking about hurting oneself or others, self-harming, or attempting suicide.
- Acting out at home or school, yelling at others for no reason, throwing objects, getting into fights, and running away.
- Substance misuse, such as vaping in school, using cannabis, drinking alcohol, taking someone else’s prescription drugs, using opioids, or using any other drug not prescribed to them for a specific purpose.
- Eating issues include refusing to eat or making oneself sick after eating, losing weight but still refusing to eat.
- Extreme and concerning changes in behavior, such as refusing to go to school, refusing to come home at a reasonable time, or hanging out with people who seem to be doing drugs or drinking, lying, or hiding things.
- Spending too much time on the computer or phone, to the point where they are not socializing with anyone else.
- Unexplained aches and pains, such as frequent stomachaches or headaches, and you have ruled out medical or physical causes.
- Talking about or seeing things that don’t seem reasonable or real, saying that other people are out to get them or targeting them when the evidence suggests otherwise.
If what you are seeing or experiencing is severe or dangerous (such as threatening suicide or threatening to harm others), call or text the Rapid Response Access Point immediately: 1-833-710-6477.
Some children and youth have Intellectual and Developmental Disabilities (IDD) and mental health or behavioral concerns. These children and youth need specialized treatment because their mental health concerns may be related to their specific needs around their development. You may hear terms such as “neuro-diverse” or “developmental disability” from providers.
These situations include:
- Autistic children or youth – Autism spectrum disorder (ASD) is a developmental disability caused by differences in the brain. It can impact how the child or youth behaves, communicates, interacts, and learns in ways that are different from most other people. It’s important to get specialized help as typical behavioral health treatments may not work and could be harmful.
- Other developmental disabilities include brain injury, cerebral palsy, fetal alcohol syndrome, Down Syndrome, and intellectual disability. Not all people with developmental disabilities have behavioral or mental health concerns, but if they do, they should receive treatment from a provider with training and experience in working with people with disabilities.
If your child has one of these developmental conditions, NH’s Area Agency system or organization, NH Family Voices, may be able to help you.
What can I expect if my child receives a Tier 2 Treatment or program?
You may have to wait to get treatment. Once you get into treatment, the process typically is:
- You will likely have what is called an "intake." An intake ensures the provider understands your child's and family's situation and has basic information, including your contact information and insurance coverage. At this point, you will be asked to sign consent forms that authorize treatment and outline what you agree to and that your information will be kept private.
- The next step typically is a comprehensive evaluation. The provider will gather information from you and your child to understand the concerns of mental health or substance use and pinpoint specific issues. This part of the process can take a few weeks and often results in a diagnosis. It's crucial to receive a picture of what is happening that is as accurate as possible so that the right treatment can be recommended. Your cooperation and honesty will help with this process.
- The provider will meet with you (and your child, when appropriate) to discuss the assessment results and treatment options. This conversation typically results in a treatment plan. You should ask questions and be a full partner in the plan's development because successful treatment depends on your child and your family agreeing with the plan! The plan should include the goals (what you can expect at the end of the treatment), how and why the treatment works, who does what, how the treatment is delivered, and how long the treatment may last. Your child and family may be responsible for doing certain things during treatment and homework between sessions. Feel free to ask questions and do your own research about the recommended treatment or program.
- Engaging in Tier 2 treatments or programs is typically time limited. There are often data points or benchmarks during the process that the provider will share with you and your child. You are looking for gradual progress and there can be setbacks, which is common. Ask for a meeting with the provider if you are unhappy with or worried about how the treatment is going. The treatment plan can be revised along the way, or the provider may recommend a more intensive or different approach if you are still waiting to see progress. You can ask for a different provider as well.
- You should have a discharge meeting when you and your child have achieved the treatment goals or if there has been no progress and the provider is not a good fit for your child or family. The provider should give you a list of strategies to use to maintain your child's progress, or they may refer you to a different provider.
Your child and your family may receive Tier 2 outpatient services in multiple settings. For example, your child may receive mental health or behavioral services at school and see a therapist in a mental health center after school. You will want to ensure that everyone helping your family and child are on the same page. You can ask that these helpers work with you and communicate with each other.
LEARN MORE ABOUT THE VARIOUS TYPES OF TREATMENTS FOR CHILDREN AND YOUTH
Common Treatments or Supports at Tier 2
Trained clinicians in New Hampshire provide many approaches, frameworks, and supports. This is a partial list of Tier 2 treatments and programs that are supported by the NH Children's System of Care and Children's Behavioral Resource Center. It is important to note that some of these treatments or programs are only available through a referral from a state or local agency or your primary care provider.
Cognitive Behavioral Therapy (CBT) is a standard treatment for mental health and substance use. The therapist helps your child or youth understand their thoughts and feelings. The therapist also helps them evaluate if feelings or thoughts may be distorted or illogical and then helps them change their thoughts and the emotional reactions and behaviors that accompany them. Cognitive-behavior therapy often works directly with your child or youth but can also include the caregiver. Trauma-Focused CBT (TF-CBT) is a version of CBT explicitly designed to help children and youth with traumatic stress disorder.
CBT may be delivered individually or in groups. All of New Hampshire’s Community Mental Health Centers provide CBT, and some school counselors, social workers, and private providers. CBT is also provided by substance use treatment providers in New Hampshire, but they may not accept people under the age of 18.
MATCH-ADTC is a proven cognitive-behavioral approach designed for children and youth, ages 3-21, who experience anxiety, depression, traumatic stress, or disruptive behavior problems, including problems associated with Attention Deficit/Hyperactivity Disorder. Treatment is provided in individual sessions with the child or youth, and the caregiver also participates. Some clinicians have been trained in MATCH-ADTC at all of New Hampshire’s 10 Community Mental Health Centers. Your center will assess your child’s needs and refer you for MATCH services if they meet your child’s needs. MATCH is also based on the CBT approach.
Dialectic Behavioral Therapy for Adolescents (DBT-A) is a proven treatment for youth, ages 8-21, who engage in (repeated) suicidal behaviors, self-injury, or other mental health problems that threaten their safety, their relationships, their ability to participate in school, and their emotional well-being. DBT-A has also been successfully adapted to treat people who have substance use disorders. DBT-A treatment requires your child or youth to agree to work or their treatment and teaches them new skills focused on acceptance and change to improve their quality of life.
Child-Parent Psychotherapy (CPP) is a proven treatment designed to address the needs of young children ages 0–5 who have experienced or are at high risk of poor emotional attachment or who are not receiving care that is necessary for healthy growth and development. Trained therapists work with the caregivers to build on their strengths and support attachment. CPP also helps the family heal and grow after stressful experiences, while responding to the family’s individual needs and cultural values.
Resilience, Empowerment, Natural Supports for Education and Work (RENEW) is a structured school-to-career transition planning and individualized wraparound process for youth ages 14 through 26 with emotional and behavioral challenges. Youth work with a trained facilitator to create an individualized plan that builds on their strengths, interests, preferences, long and short-term goals. It outlines specific steps to achieve those goals. The youth and facilitator also form a team of helpers who collaborate to help the youth achieve their goals, RENEW is provided by staff in high schools, community mental health centers, community-based organizations, and residential treatment centers.
There are home visiting programs for parents/caregivers with young children who need to develop their parenting skills. Healthy Families America (HFA) is a proven, voluntary program to support parents of young children and to prevent abuse and neglect in high-risk family situations. The goal is to promote healthy pregnancies and positive birth outcomes, and to create safe and nurturing environments for children and families to thrive.
Learn about Healthy Families America - NH and other services or call 2-1-1 NH.
For additional information about NH’s HFA program and providers, read this fact sheet.
HEALTHY FAMILIES AMERICA (HFA)
There are home visiting programs for parents/caregivers with young children who need to develop their parenting skills. Healthy Families America (HFA) is a proven, voluntary program to support parents of young children and to prevent abuse and neglect in high-risk family situations. The goal is to promote healthy pregnancies and positive birth outcomes, and to create safe and nurturing environments for children and families to thrive.
For additional information about NH’s HFA program and providers, read this fact sheet or call 2-1-1 in NH.
Trust-Based Relational Intervention (TBRI) is a set of strategies that caregivers, teachers, and providers can use to meet the complex needs of children and youth who have experienced adversity, early harm, toxic stress, and/or trauma. The tools and training offer effective strategies for helping the child by building trust and safety, encouraging them to talk about their overwhelming feelings, and teaching them different ways of managing their stress. TBRI training is offered to providers and caregivers such as foster parents, family members, residential treatment providers, and kinship caregivers.
The new service is called Community-Based Voluntary Services (CBVS). When a family is struggling with a high-risk situation, but DCYF does not feel it rises to the level where the child needs to be put into state custody, DCYF can pay for short-term services to help stabilize the situation in the home. These voluntary services can include behavior management support, home visiting, case management, and other services in response to concerns of abuse and/or neglect and to promote safety. Services differ according to the needs of the family. A trained care coordinator will help the family, child or youth develop a short term plan, help connect to the services and supports they need, and monitor progress and next steps. The service is designed to be short-term (no more than 6 months) and can be combined with other services and supports.
Two agencies in New Hampshire provide CBVS:
THE SEVEN CHALLENGES
Youth under age 18 cannot legally use tobacco, non-prescription drugs, or alcohol; however, drug and alcohol use among that population is common, and engaging them in traditional treatments is challenging. The Seven Challenges® is a proven harm reduction treatment for youth and young adults using substances. Harm reduction means the therapist does not insist that the youth stop using substances to receive help. Instead, the therapist guides the youth to work in journals designed to help them understand why they use substances and how it impacts their lives and relationships. It also helps them identify their strengths while looking towards their future.