Child Welfare and Juvenile Justice
Federal Agencies Could Play a Stronger Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental Health Services Gao ID: GAO-03-397 April 21, 2003Recent news articles in over 30 states describe the difficulty many parents have in accessing mental health services for their children, and some parents choose to place their children in the child welfare or juvenile justice systems in order to obtain the services they need. GAO was asked to determine: (1) the number and characteristics of children voluntarily placed in the child welfare and juvenile justice systems to receive mental health services, (2) the factors that influence such placements, and (3) promising state and local practices that may reduce the need for child welfare and juvenile justice placements.
Child welfare directors in 19 states and juvenile justice officials in 30 counties estimated that in fiscal year 2001 parents placed over 12,700 children into the child welfare or juvenile justice systems so that these children could receive mental health services. Nationwide, this number is likely higher because many state child welfare directors did not provide data and we had limited coverage of county juvenile justice officials. Although no agency tracks these children or maintains data on their characteristics, officials said most are male, adolescent, often have multiple problems, and many exhibit behaviors that threaten the safety of themselves and others. Neither the child welfare nor the juvenile justice system was designed to serve children who have not been abused or neglected, or who have not committed a delinquent act. According to officials in the 6 states we visited, limitations of both public and private health insurance, inadequate supplies of mental health services, limited availability of services through mental health agencies and schools, and difficulties meeting eligibility rules for services influence such placements. Despite guidance issued by the various federal agencies with responsibilities for serving children with mental illness, misunderstandings among state and local officials regarding the roles of the various agencies that provide such services pose additional challenges to parents seeking such services for their children. Officials in the states we visited identified practices that they believe may reduce the need for some child welfare or juvenile justice placements. These included finding new ways to reduce the cost of or to fund mental health services, improving access to mental health services, and expanding the array of available services. Few of these practices have been rigorously evaluated.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-03-397, Child Welfare and Juvenile Justice: Federal Agencies Could Play a Stronger Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental Health Services
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Play a Stronger Role in Helping States Reduce the Number of Children
Placed Solely to Obtain Mental Health Services' which was released on
April 21, 2003.
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Play a Stronger Role in Helping States Reduce the Number of Children
Placed Solely to Obtain Mental Health Services‘.
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Report to Congressional Requesters:
United States General Accounting Office:
GAO:
April 2003:
CHILD WELFARE AND JUVENILE JUSTICE:
Federal Agencies Could Play a Stronger Role in Helping States Reduce
the Number of Children Placed Solely to Obtain Mental Health Services
Children‘s Services:
GAO-03-397:
GAO Highlights:
Highlights of GAO-03-397, a report to Congressional Requesters
Why GAO Did This Study:
Recent news articles in over 30 states describe the difficulty many
parents have in accessing mental health services for their children,
and some parents choose to place their children in the child welfare or
juvenile justice systems in order to obtain the services they need. GAO
was asked to determine: (1) the number and characteristics of children
voluntarily placed in the child welfare and juvenile justice systems to
receive mental health services, (2) the factors that influence such
placements, and (3) promising state and local practices that may reduce
the need for child welfare and juvenile justice placements.
What GAO Found:
Child welfare directors in 19 states and juvenile justice officials in
30 counties estimated that in fiscal year 2001 parents placed over
12,700 children into the child welfare or juvenile justice systems so
that these children could receive mental health services. Nationwide,
this number is likely higher because many state child welfare directors
did not provide data and we had limited coverage of county juvenile
justice officials. Although no agency tracks these children or
maintains data on their characteristics, officials said most are male,
adolescent, often have multiple problems, and many exhibit behaviors
that threaten the safety of themselves and others.
Neither the child welfare nor the juvenile justice system was designed
to serve children who have not been abused or neglected, or who have
not committed a delinquent act. According to officials in the 6 states
we visited, limitations of both public and private health insurance,
inadequate supplies of mental health services, limited availability of
services through mental health agencies and schools, and difficulties
meeting eligibility rules for services influence such placements.
Despite guidance issued by the various federal agencies with
responsibilities for serving children with mental illness,
misunderstandings among state and local officials regarding the roles
of the various agencies that provide such services pose additional
challenges to parents seeking such services for their children.
Officials in the states we visited identified practices that they
believe may reduce the need for some child welfare or juvenile justice
placements. These included finding new ways to reduce the cost of or to
fund mental health services, improving access to mental health
services, and expanding the array of available services. Few of these
practices have been rigorously evaluated.
What GAO Recommends:
The Departments of Health and Human Services (HHS) and Justice (DOJ)
should consider the feasibility of tracking children placed by their
parents in the child welfare and juvenile justice systems to obtain
mental health services. HHS, DOJ, and the Department of Education
(Education) should develop an interagency working group to identify the
causes of the misunderstandings at the state and local levels and
create an action plan to address those causes. These agencies should
also continue to encourage states to evaluate the programs that the
states fund or initiate and determine the most effective means of
disseminating the results of these and other available studies.
www.gao.gov/cgi-bin/getrpt?GAO-03-397.
To view the full report, including the scope and methodology, click on
the link above. For more information, contact Cornelia Ashby at (202)
512-8403 or ashbyc@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
While No Formal Tracking Occurs, Available Estimates Indicate That Many
Children Were Placed with the State--Primarily Adolescent Males--to
Access Mental Health Services:
Multiple Factors Influence Decisions to Place Children:
States Have Developed a Range of Practices That May Reduce the Need for
Some Mental Health-Related Child Welfare and Juvenile Justice
Placements:
Conclusions:
Recommendations:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: State Statutes Containing Language Allowing
Voluntary Placement to Obtain Mental Health
Services:
Appendix III: Comments from the Department of Education:
Appendix IV: Comments from the Department of Health and Human Services:
Appendix V: Comments from the Department of Justice:
Appendix VI: GAO Contacts and Acknowledgments:
GAO Contacts:
Acknowledgments:
Related GAO Products:
Tables:
Table 1: Characteristics of Key Agencies with Responsibilities for
Children with a Mental Illness:
Table 2: States‘ Estimated Number of Children Placed in the Child
Welfare System to Obtain Mental Health Services in Fiscal Year 2001:
Table 3: Estimated Number of Children Placed in the Juvenile Justice
System in 33 Counties to Obtain Mental Health Services in Fiscal Year
2001:
Table 4: Key Features of Health Insurance Parity Laws in 6 States:
Table 5: Key Medicaid and SCHIP Programs for Children with Mental
Illness in 6 States:
Table 6: Survey Numbers and Response Rates:
Table 7: Statutes in 11 States Allowing Parents to Place Children in
Child Welfare Systems in Order to Obtain Mental Health Services While
Retaining Custody of the Child:
Abbreviations:
ACF: Administration for Children and Families:
AFCARS: Adoption and Foster Care Analysis and Reporting System:
CMS: Centers for Medicare & Medicaid Services:
DOJ: Department of Justice:
EPSDT: Early Periodic Screening, Diagnostic and Treatment:
ERISA: Employee Retirement Income Security Act:
HCBS: Home and Community-Based Services:
HHS: Health and Human Services:
IDEA: Individuals with Disabilities Education Act:
IEP: Individualized Education Program:
JADE: Juvenile Alternative Defense Effort:
MHPA: Mental Health Parity Act:
OSERS: Office of Special Education and Rehabilitative Services:
OJJDP: Office of Juvenile Justice and Delinquency Prevention:
SAMHSA: Substance Abuse and Mental Health Services Administration:
SCHIP: State Children‘s Health Insurance Program:
SED: serious emotional disturbances:
SSI: Supplemental Security Income:
TANF: Temporary Assistance for Needy Families:
TBS: Therapeutic Behavioral Services:
TEFRA: Tax Equity and Fiscal Responsibility Act:
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United States General Accounting Office:
Washington, DC 20548:
April 21, 2003:
The Honorable Susan M. Collins
United States Senate:
The Honorable Pete Stark
The Honorable Patrick Kennedy
House of Representatives:
Recent news articles in over 30 states and prominent mental health
advocacy organizations have reported on the difficulty many parents
have accessing mental health services for their children with severe
mental illness.[Footnote 1] In some cases, parents must choose to keep
their children at home without receiving the mental health and
supportive services that they need or to remove them from their home
and seek alternative living arrangements by inappropriately placing
them in the child welfare or juvenile justice system to obtain mental
health services--two systems not designed to care for children solely
because of their mental health needs[Footnote 2] Although the people
and conditions described in the reports varied, all documented that
many children with severe mental illness needed services such as
psychiatric and family support services that are not readily accessible
in their communities. Various federal laws require that state and local
agencies provide services to disabled children, including children with
a mental illness, in the least restrictive setting appropriate to their
needs; that is, children have a right to receive services in their
communities unless their needs can only be met by the state in
residential or institutional placements.
Several federal agencies have various responsibilities for children
with mental health needs. For example, HHS‘sSAMHSA provides funds and
guidance to help states and localities address the needs of children
with mental illness. HHS‘s Centers for Medicare & Medicaid Services
(CMS) administers both the Medicaid Program and the State Children‘s
Health Insurance Program (SCHIP). These programs provide funds to
states for public health insurance programs, which can cover mental
health services, for the approximately 26.5 million enrolled children
who are members of low-income families and certain children with
disabilities. Similarly, the Department of Education‘s (Education)
Office of Special Education and Rehabilitative Services (OSERS)
provides funding and technical assistance to help states provide needed
services, including mental health services, to disabled children with
special education needs. Title IV-E of the Social Security Act provides
reimbursement for foster care maintenance payments to states, which is
available when child welfare agencies place eligible children in
approved out-of-home settings, including some residential treatment
facilities.[Footnote 3],[Footnote 4] In many cases, these costs are
high; residential treatment facilities can cost over $250,000 a year
for one child. Federal law does not require parents to relinquish their
parental rights to place their children with child welfare agencies.
However, after children have been in care for a specific period of
time, the law requires the court to review the child‘s status and
determine the best interest of the child--which, in some cases, may
include termination of parental rights.
State laws addressing the ability of parents to place their children in
child welfare systems vary across states. Nationwide, laws in 11 states
allow parents to place children in child welfare systems on a voluntary
basis in order to access mental health services for as long as
necessary without relinquishing custody of the child to the
state.[Footnote 5] Child welfare directors in
8 other states and the District of Columbia advised us that their
states do not allow parents to place children voluntarily in child
welfare agencies to access such services.[Footnote 6] Laws in the
remaining states are generally silent regarding voluntary placements
for mental health. (See app. II for a description of state placement
statutes.):
You asked us to determine: (1) the numbers and characteristics of
children voluntarily placed in the child welfare and juvenile justice
systems in order to receive mental health services, (2) the factors
that influence such placements, and (3) promising state and local
practices that may reduce the need for some child welfare and juvenile
justice placements.
To address your questions, we surveyed state child welfare directors in
all states and the District of Columbia and juvenile justice officials
in
33 counties in the 17 states with the largest populations of children
under age 18. We surveyed juvenile justice officials at the county
level, rather than at the state level, because of the decentralized
nature of the juvenile justice system. In addition, we researched state
laws and regulations regarding voluntary placement and relinquishment
of parental rights, and interviewed officials of child-serving
agencies,[Footnote 7] caseworkers, and parents in 6 states (Arkansas,
California, Kansas, Maryland, Minnesota, and New Jersey) and judges in
5 states. We chose these states because they represented diversity in
geographical location, legal requirements concerning children‘s
placement, use of Medicaid waivers and optional services,[Footnote 8]
and the role of state and county agencies in administering child
welfare and juvenile justice programs. Also, we observed programs that
state officials identified as model programs in those 6 states and
interviewed key federal officials and national experts. A more detailed
discussion of our scope and methodology appears in appendix I. We
conducted our work between March 2002 and February 2003 in accordance
with generally accepted government auditing standards.
Results in Brief:
State child welfare officials in 19 states and county juvenile justice
officials in 30 counties who responded to our surveys estimated that in
fiscal year 2001 parents in their jurisdictions placed over 12,700
children--mostly adolescent males--into the child welfare or juvenile
justice systems so that these children could receive mental health
services. However, this estimate understates the prevalence of these
children for two reasons. First, 32 state officials, including
officials of 5 states with the largest populations of children, did not
provide us with data. However, officials in 11 of those states
indicated that although they could not provide an estimate, such
placements occurred in their state. Also, we surveyed juvenile justice
officials in only 33 counties, 30 of which responded with an estimate.
Moreover, no formal or comprehensive federal or state tracking of such
placements occurs. According to the officials we interviewed, many of
these children exhibited behavior that threatened their safety and the
safety of others. In addition, these officials said children who were
placed came from families of all financial levels and that the
seriousness of the child‘s illness strained the family‘s ability to
function. For example, some parents found they were not able to meet
the needs of other children in the family or fulfill job-related
responsibilities.
A variety of factors influenced whether parents placed their children
in the child welfare and juvenile justice systems to receive mental
health services for them. Some parents we spoke to in all 6 states
reported these factors often created delays or prevented them from
obtaining the mental health services that their children needed.
According to child welfare, child mental health, and juvenile justice
officials, a number of parents placed children in the child welfare and
juvenile justice systems because their health insurance had
limitations, such as restrictions on mental health services. These same
officials said some mental health services, such as child psychiatric
and residential services, were in short supply. In all the states we
visited, some parents who could not afford or access needed mental
health services said they sought help from mental health agencies and
schools but reported these agencies had limited resources. Parents
seeking placements for children in residential treatment facilities
faced further challenges. Mental health and education officials in the
6 states we visited did not support residential placement for children
except in extraordinary situations because federal law requires that
mental health officials provide services for children in the least
restrictive setting as possible and requires education officials to
educate children with disabilities with children who are not disabled
to the maximum extent possible. These officials believed providing
services in a community-based program is a better option for children
and families than providing services in residential treatment
facilities. In addition, some parents in all 6 states said gaps in
services occurred because child-serving agencies have different
eligibility requirements for programs and this made it difficult for
them to access the child mental health and family support services they
needed from various agencies. For example, children who were eligible
for psychological services under Medicaid could lose these services if
their families‘ income increases beyond eligibility thresholds.
Finally, state and local officials‘ views of the roles of their own
agency and other agencies, such as mental health, child welfare,
education, and juvenile justice, showed that they misunderstood those
roles and, therefore, could not effectively give parents complete and
accurate information about available services their agency and other
agencies could provide. Federal officials, experts, and service
providers agreed that agencies must work together to meet the needs of
children. Although federal officials work together on various advisory
and information-sharing committees, co-sponsor programs designed to
help children with a mental illness, and disseminate much guidance
regarding their policies and programs, some state and local officials
with responsibilities for children with a mental illness did not
understand the program requirements and capacities of their agencies
and other child-serving agencies.
Officials in all 6 states that we visited identified a range of
practices in their states that they believe may help reduce the need
for some child welfare and juvenile justice placements. Overall, these
practices are consistent with those suggested by federal agencies and
child mental health experts, and most parents we spoke with who had
children in these programs found these practices helpful. However, the
effectiveness of the practices is generally unknown because many were
new and few were rigorously evaluated. In addition, many of these
practices served a small number of children or only served children in
specific locations. To fund mental health services, some state and
county officials developed practices that increased the use of less
expensive services and providers and distributed mental health costs
among several agencies so no single agency paid the entire cost of a
child‘s care. For example, a program in Minnesota used experienced,
masters-level staff to supervise less experienced, bachelor-level staff
instead of using the more costly master‘s level workers as the primary
service provider. States and counties identified several practices that
may improve access to mental health services, such as providing a
variety of services for children in a convenient public facility and
creating a single entity with responsibility for meeting children‘s
mental health needs. For example, a service provider in Kansas operated
a facility that housed a variety of county child welfare, juvenile
justice, and education service providers as well as county child mental
health providers. States and counties also identified several practices
that may improve the treatment of children with a mental illness, such
as expanding the array of available mental health services for children
and addressing the needs of the family to help the family maintain
children with a mental illness at home. For example, in one city in
Kansas, caseworkers from one mental health center worked with families
of children with severe mental illness to identify community supports
and services, such as mentors and after-school programs, which support
the entire family.
To determine the extent to which children may be placed inappropriately
in the child welfare and juvenile justice systems in order to obtain
mental health services, we are recommending that the Secretary of HHS
and the Attorney General investigate the feasibility of tracking these
children to identify the extent and outcomes of these placements. To
help reduce misunderstandings at the state and local level, we also
recommend that the Secretaries of HHS and Education and the Attorney
General develop an interagency working group to identify the causes of
these misunderstandings and create an action plan to address those
causes. We further recommend that these agencies continue to encourage
states to evaluate the child mental health programs that the states
fund or initiate and that the Secretaries of HHS and Education and the
Attorney General determine the most effective means of disseminating
the results of these and other available studies to state and local
entities. In commenting on a draft of this report, Education, HHS, and
DOJ generally agreed with our findings but did not fully concur with
the recommendations. Education said that it did not understand how
tracking the children discussed in this report will increase the
likelihood of progressive practices to provide children‘s mental health
services and noted that no recommendations were made for increased
grant spending to duplicate or disseminate the positive features of
such practices. HHS said that asking the agencies to track this
population of children in foster care does not address the larger point
of the lack of mental health resources for families and communities and
does not address the problems of the children or their parents. DOJ
agreed that tracking should occur, but only in the short term, and said
that HHS should take the lead in this activity. All three agencies said
they would participate in any interagency working group that might be
established based on our recommendation and DOJ suggested an existing
group as the forum. HHS, however, said that such a group would do
little to address the lack of resources. Education also said we should
be more specific on the role of the interagency working group and added
that such a group would not have the power to address congressional
lawmaking.
Background:
As defined by the President‘s New Freedom Commission on Mental Health,
the mental health system in the United States collectively refers to
the full array of private and public programs for individuals with
mental illness that deliver or pay for treatment and services. The
federal government plays a major role in funding mental health services
through public insurance--Medicaid and SCHIP--and grants to states and
local agencies, and state and local governments play a major role in
delivering services. Most families depend on private and public
insurance to pay for mental health services because such services are
expensive; although, as we discussed in a previous report, children may
face certain limitations depending on their type of coverage and where
they lived.[Footnote 9]
At the federal level, several federal agencies--including HHS‘s SAMHSA,
CMS, and the Administration for Children and Families (ACF); DOJ‘s
Office of Juvenile Justice and Delinquency Prevention (OJJDP); and
Education‘s OSERS--have a role in addressing the mental health needs of
children. However, all have individual mandates, target different but
often overlapping populations, and share responsibilities to varying
degrees with state and county agencies. (See table 1.):
Table 1: Characteristics of Key Agencies with Responsibilities for
Children with a Mental Illness:
Department and agency: HHS (CMS); Key activities related to
children‘s mental health: Administers the Medicaid and SCHIP programs
that provide health insurance coverage, including some coverage for
severe mental illness; Awards research grants; Provides technical
assistance to state agencies; [Empty]; Authorizing Statute: Title XIX
of the Social Security Act; Population targeted and definition of
mental illness: Certain low-income individuals and certain disabled
individuals; Uses a clinical classification of diseases to identify
children with a mental illness.
Department and agency: HHS (ACF); Key activities related to
children‘s mental health: Oversees the Adoption and Safe Families Act
of 1997 (ASFA) that improves the safety of children and promotes
adoption and permanent homes for children who need them and supports
families; Administers Title IV-B of the Social Security Act that
provides funds to states for services that protect the welfare of
children. For example, these services address problems that may result
in the abuse and neglect of children. The funds may also be used to
provide services to families of children with a mental illness;
Administers the Title IV-E Foster Care Funds Program that provides
funds to states to partially cover the costs of room and board for
eligible children from low-income families who are placed in approved
out-of-home living arrangements; Maintains the Adoption and Foster
Care Analysis and Reporting System (AFCARS), to which states report
demographic data on children in foster care, including diagnoses of
mental illness; Awards development, training, research, and
demonstration grants; Disseminates research; Provides technical
assistance; [Empty]; Authorizing Statute: Title IV, Part E of the
Social Security Act; ASFA; Population targeted and definition of
mental illness: Children and families; Uses a clinical
classification to identify children with a mental illness and accepts
classifications used by individual states in identifying children with
mental health needs.
Department and agency: Education (OSERS); Key activities related to
children‘s mental health: Monitors the implementation of the
Individuals with Disabilities Education Act (IDEA). IDEA established
the right of disabled children--including children with mental illness-
-to receive special education and related services, such as mental
health services, designed to meet their unique needs and prepare them
for employment and independent living when such services are needed for
children to make adequate progress in school. IDEA requires schools to
evaluate children who are referred for special education services and,
if services are required, develop an individualized education program
(IEP) that documents the type and intensity of services that will be
provided; Funds formula and discretionary grants; Provides technical
assistance; Disseminates research; [Empty]; Authorizing Statute:
IDEA; Population targeted and definition of mental illness: Promotes
improvement in educational results for infants, toddlers, and children
with disabilities; Under IDEA, the term ’child with a disability“
means a child, who by reason of a physical or mental disability, needs
special education and related services.
Department and agency: HHS (SAMHSA); Key activities related to
children‘s mental health: Provides funds to states and local entities
to help them administer, support, or establish programs that
specifically target the mental health needs of children and provides
block grant funding that enables the states to maintain and enhance
mental health services; Sponsors the Systems of Care Initiative to
help children and adolescents with severe mental illnesses and their
families receive a variety of services from schools, community mental
health centers, and social services organizations and facilitate
coordination among these service providers; Awards formula and
discretionary development and demonstration grants; Disseminates
research; Provides technical assistance; [Empty]; Authorizing
Statute: Public Health Service Act; Population targeted and definition
of mental illness: Individuals with substance abuse problems, mental
illness or at risk of substance abuse and mental illness; Children
served meet the following criteria:; * age 0 to 18 and; * have a
diagnosed mental, behavioral, or emotional disorder of sufficient
duration to meet diagnostic criteria that results in impairment that
substantially interferes with or limits the child‘s functioning in
family, school, or community activities.
Department and agency: DOJ (OJJDP); Key activities related to
children‘s mental health: Helps oversee juvenile justice programs
across the nation and supports states and local communities in their
efforts to develop and implement effective and coordinated prevention
and intervention programs. Helps improve the juvenile justice system‘s
ability to protect public safety, hold offenders accountable, and
provide mental health treatment and rehabilitative services; Funds
formula and discretionary grants; Provides technical assistance;
Disseminates research; [Empty]; Authorizing Statute: Juvenile Justice
and Delinquency Prevention Act; Population targeted and definition of
mental illness: Children who commit crimes or are delinquent and
children at risk for delinquency; Accepts mental illness
classifications used by states to identify children with mental health
needs.
Source: GAO.
Note: Other agencies, such as HHS‘s Social Security Administration,
Department of DOJ‘s Division of Civil Rights, and HHS‘s and Education‘s
Office of Civil Rights, also have responsibilities for children with
disabilities, including children with a mental illness.
[End of table]:
Federal agencies with responsibilities for children with mental illness
support interagency collaboration at the federal and local level. For
example, officials at SAMHSA are collaborating with Safe and Drug Free
Schools officials at Education and OJJDP to improve mental health
services for children with emotional and behavioral disorders who are
at risk of violent behavior by developing and implementing a large
grant program that targets these children. This program awarded
grants--about $53.2 million in fiscal year 2001--to some local school
districts that formed partnerships with local mental health and law
enforcement agencies to provide comprehensive planning and services for
children with emotional and behavioral disorders. In addition, ACF,
Education, SAMHSA, and a private foundation are jointly administering a
program that assesses the collaborative processes being used to provide
multiagency services to very young children affected by mental illness
and substance abuse. At the state and county level, a similar array of
agencies provides or funds services for children with a mental illness,
and state and federal laws and policies often determine their roles and
responsibilities. In addition, federal agencies play an important role
in funding research and evaluation studies and disseminating the
findings of these efforts. For example, SAMSHA, OJJDP, and OSERS fund
research and evaluation studies that target children with mental
illness and disseminate the findings of these efforts, descriptions of
promising practices, and other information through their
clearinghouses, journals, and Web sites.
Despite their differences, programs run by agencies at all levels of
government generally adhere to the principle of the ’least restrictive
environment.“[Footnote 10] This principle assumes that children, like
adults, have liberty interests that include the right to live in a
family situation. Under this principal, the state has the burden of
demonstrating that state-funded out-of-home placements are necessary
for the protection of the child or society. In 1999, the Supreme Court
established this principle as a right for disabled children. In
Olmstead v. L.C., the Court held that, under Title II of the Americans
with Disabilities Act, states may be required to serve people with
disabilities in community settings when such placements can be
reasonably accommodated.
Mental health treatment can be very expensive and most families rely
upon insurance to help cover the cost of these services. For example,
one outpatient therapy session can cost more than $100, and residential
treatment facilities, which provide 24 hours of care, 7 days a week,
can cost $250,000 a year or more. Nationwide, 88 percent of American
children are covered by private or public health insurance plans.
Private plans, such as employer-sponsored or individually purchased
plans, provide health insurance coverage to about 68 percent of
American children, and public programs, such as Medicaid and SCHIP,
provide health insurance coverage to about 19 percent.[Footnote 11]
Most private health insurance plans offer different coverage for mental
health services than for physical health services. To ensure more
comparable coverage, the federal government passed the federal Mental
Health Parity Act (MHPA) of 1996. MHPA prohibited certain employer-
sponsored group plans from imposing annual or lifetime restrictions on
mental health benefits that are lower than those imposed on other
benefits. However, the act did not eliminate other restrictions and
limitations on mental health coverage, such as limiting the number of
treatments per year that are reimbursable. In addition, the law does
not apply to plans sponsored by employers with 50 or fewer employees,
group plans that experience an increase in plan claims costs of at
least 1 percent because of compliance, and coverage sold in the
individual market. According to the National Council of State
Legislatures, as of November 2001, 46 states have passed mental heath
parity bills. Most of these laws meet or exceed the federal MHPA
standard. However, the Employee Retirement Income Security Act (ERISA)
of 1974 preempts states from directly regulating self-funded, employer-
sponsored health plans; under such circumstances, state requirements
usually do not apply.
For more than 30 years, Medicaid has provided comprehensive health
coverage for children from low-income families. Although individual
states determine many coverage, eligibility, and administrative
details, the federal government has established certain requirements
for state Medicaid programs. These requirements include providing
preventive screening and necessary treatment of any detected health
condition for children. Under Medicaid, a state may apply for waivers
from the federal government, which exempt the state from certain
provisions of the Medicaid statute in order to operate a specific
program, change the benefits offered under Medicaid, or make
comprehensive changes to their Medicaid or SCHIP programs. For example,
states can use the Home and Community-Based Services (HCBS) (section
1915(c) of the Social Security Act) waiver to provide home and
community-based long-term care services to targeted groups of
individuals who would otherwise require care in a hospital, skilled
nursing facility, or intermediate care facility. To receive the HCBS
waiver, states must demonstrate that the cost of the services to be
provided under the waiver is no more than the cost of institutionalized
care plus any other Medicaid services provided to institutionalized
individuals. Additional flexibility is available to states under the
’Katie Beckett“ option, which enables states to use federal Medicaid
funds more flexibly to cover the costs of health care services in the
home and community rather than just in institutional settings,
regardless of the income and assets of the family.[Footnote 12] States
choosing this option provide Medicaid coverage for children under age
19 who meet certain standards for disability, would be eligible for
Medicaid if they were in an institution, and are receiving medical care
at home that would be provided in an institution. Although family
income and resources are not considered in determining eligibility for
services under the Katie Beckett option, states can require families to
contribute to the cost of the program. The Rehabilitation option allows
states to provide optional Medicaid services such as psychiatric
rehabilitation and other diagnostic, screening, and preventive
services. Under this option, children can obtain services in nonmedical
settings, including school-based or other day treatment and home-based
services.
States can expand public health insurance for uninsured children from
low-income families by implementing SCHIP programs. States have three
options in designing SCHIP programs. They may (1) expand Medicaid
programs to include children from low-income families with earnings too
high to qualify for Medicaid, (2) develop a separate child health
insurance program with benefits that differ from those offered under
Medicaid, or
(3) provide a combination of both. Twenty-four states are implementing
SCHIP by expanding Medicaid. Fourteen states are enrolling children
into separate non-Medicaid plans. Other states use a combination of
Medicaid and non-Medicaid plans to serve children in families at
different income levels. If a state elects to implement SCHIP by
expanding Medicaid, it must offer the same benefit package to SCHIP
beneficiaries as it does to Medicaid beneficiaries.
In addition, states operating SCHIP Medicaid-expansion or Medicaid-
combination programs must also screen children for various conditions
so that health problems can be found early and treated before they
worsen. This Medicaid requirement for Early and Periodic Screening,
Diagnostic and Treatment services (EPSDT) requires states to provide
children and adolescents under age 21 with access to comprehensive,
periodic evaluations of health, developmental and nutritional status,
as well as vision, hearing, and dental needs. States must provide all
services needed for conditions discovered through routine pediatric
screenings regardless of whether the service is covered for other
beneficiaries by the state Medicaid plan. In 2000, more than 1 million
children were enrolled in SCHIP Medicaid expansion programs and were,
therefore, eligible for EPSDT screens.
Certain disabled children, including children with a mental illness,
may qualify for monthly Supplemental Security Income (SSI) if they and
their families have little or no income and resources and they meet
SSI‘s definition of disability. To meet SSI‘s definition, a child must
have a physical or mental condition or conditions that can be medically
proven, and which result in marked and severe functional limitations;
the condition or conditions must last or be expected to last at least
12 months or be expected to result in death; and the child may not work
at a job that is considered substantial work. The monthly SSI depends
generally on where the child lives and his or her parents‘ assets.
However, the monthly SSI payment for children living in certain
institutions throughout a month, where private health insurance paid
for their care or when Medicaid paid more than half of the cost of
their care, is currently capped at $30.[Footnote 13]
While No Formal Tracking Occurs, Available Estimates Indicate That Many
Children Were Placed with the State--Primarily Adolescent Males--to
Access Mental Health Services:
State child welfare and county juvenile justice officials estimated
that parents in their jurisdictions placed over 12,700 children in
fiscal year 2001, generally adolescent males, to child welfare and
juvenile justice agencies so that the children could receive mental
health services. Nationwide, the number is likely higher because
officials in 32 states, including the 5 states with the largest
populations of children, did not provide us with estimates.
Additionally, officials in 11 states that could not provide estimates
indicated that such placements occurred in their state. Moreover, we
surveyed juvenile justice officials in only 33 counties, with 30
providing estimates. Only estimates were available because no federal
or state agency tracked children placed to obtain mental health
services in a formal or comprehensive manner. Officials in the 6 states
we visited reported that placed children came from families of all
financial levels and said that the seriousness of the children‘s
illnesses strained families‘ abilities to function. For example, some
parents are not able to meet the needs of children in the home and some
found that they were less able to meet work demands.
Some Officials Estimate That Parents Placed Over 12,700 Children to
Access Mental Health Services:
The state child welfare officials and county juvenile justice officials
who responded to our surveys estimated that over 12,700 children
entered the child welfare or juvenile justice systems in order to
receive mental health services in fiscal year 2001. Of these children,
about 3,700 entered the child welfare system. State child welfare
officials reported estimates that ranged from 0 to 1,071 children, with
a median of 71. Table 2 provides detailed information about the number
of children placed in the child welfare system.[Footnote 14]
Approximately 9,000 children entered the juvenile justice system.
County juvenile justice officials reported estimates that ranged from 0
to 1,750, with a median of 140. Table 3 provides details on the
estimated number of children placed in the juvenile justice system.
Table 2: States‘ Estimated Number of Children Placed in the Child
Welfare System to Obtain Mental Health Services in Fiscal Year 2001:
State: Alaska; Number of children placed: [A].
State: Alabama; Number of children placed: 130.
State: Arkansas; Number of children placed: [D].
State: Arizona; Number of children placed: [D].
State: California; Number of children placed: [B].
State: Colorado; Number of children placed: [B].
State: Connecticut; Number of children placed: 738.
State: District of Columbia; Number of children placed: [C].
State: Delaware; Number of children placed: 0.
State: Florida; Number of children placed: [C].
State: Georgia; Number of children placed: [C].
State: Hawaii; Number of children placed: [C].
State: Iowa; Number of children placed: [D].
State: Idaho; Number of children placed: 123.
State: Illinois; Number of children placed: [A].
State: Indiana; Number of children placed: 0.
State: Kansas; Number of children placed: [C].
State: Kentucky; Number of children placed: 14.
State: Louisiana; Number of children placed: [A].
State: Massachusetts; Number of children placed: [B].
State: Maryland; Number of children placed: 54.
State: Maine; Number of children placed: [D].
State: Michigan; Number of children placed: [B].
State: Minnesota; Number of children placed: 1,071.
State: Missouri; Number of children placed: [C].
State: Mississippi; Number of children placed: 13.
State: Montana; Number of children placed: [C ,D].
State: North Carolina; Number of children placed: 440.
State: North Dakota; Number of children placed: [D].
State: Nebraska; Number of children placed: [B].
State: New Hampshire; Number of children placed: [C].
State: New Jersey; Number of children placed: [B].
State: New Mexico; Number of children placed: [B].
State: Nevada; Number of children placed: 20.
State: New York; Number of children placed: [B].
State: Ohio; Number of children placed: [D].
State: Oklahoma; Number of children placed: 3.
State: Oregon; Number of children placed: 101.
State: Pennsylvania; Number of children placed: 71.
State: Rhode Island; Number of children placed: 279.
State: South Carolina; Number of children placed: [A].
State: South Dakota; Number of children placed: [D].
State: Tennessee; Number of children placed: [D].
State: Texas; Number of children placed: [C].
State: Utah; Number of children placed: [D].
State: Virginia; Number of children placed: [D].
State: Vermont; Number of children placed: 60.
State: Washington; Number of children placed: 423.
State: Wisconsin; Number of children placed: [B].
State: West Virginia; Number of children placed: 135.
State: Wyoming; Number of children placed: 5.
State: Total; Number of children placed: 3,680.
Source: GAO survey.
[A] State did not respond to our survey.
[B] State could not provide the data requested.
[C] State officials said the practice of voluntary placement is not
legal in the state.
[D] State could not provide the data requested, but indicated that
voluntary placement happens.
[End of table]
Table 3: Estimated Number of Children Placed in the Juvenile Justice
System in
33 Counties to Obtain Mental Health Services in Fiscal Year 2001:
State: Arizona; County: Maricopa; Number of
children placed: 60.
State: Arizona; County: Pima; Number of
children placed: 1,750.
State: California; County: Los Angeles; Number of
children placed: [A].
State: California; County: San Diego; Number of
children placed: 200.
State: Colorado; County: El Paso; Number of
children placed: 40.
State: Colorado; County: Jefferson; Number of
children placed: 100.
State: Florida; County: Broward; Number of
children placed: 0.
State: Florida; County: Miami-Dade; Number of
children placed: 999.
State: Georgia; County: Fulton; Number of
children placed: 172.
State: Georgia; County: Gwinnett; Number of
children placed: 100.
State: Illinois; County: Cook; Number of
children placed: 0.
State: Illinois; County: DuPage; Number of
children placed: 35.
State: Indiana; County: Lake; Number of
children placed: 600.
State: Indiana; County: Marion; Number of
children placed: 100.
State: Louisiana; County: Jefferson Parish; Number of
children placed: 50.
State: Michigan; County: Oakland; Number of
children placed: 160.
State: Michigan; County: Wayne; Number of
children placed: 400.
State: New Jersey; County: Bergen; Number of
children placed: [A].
State: New Jersey; County: Middlesex; Number of
children placed: 999.
State: New York; County: Brooklyn; Number of
children placed: 74.
State: New York; County: Queens; Number of
children placed: 49.
State: Ohio; County: Cuyahoga; Number of
children placed: [A].
State: Ohio; County: Franklin; Number of
children placed: 363.
State: Pennsylvania; County: Montgomery; Number of
children placed: 20.
State: Pennsylvania; County: Philadelphia; Number of
children placed: 500.
State: Texas; County: Dallas; Number of
children placed: 200.
State: Texas; County: Harris; Number of
children placed: 200.
State: Virginia; County: Fairfax; Number of
children placed: 350.
State: Virginia; County: Prince William; Number of
children placed: 840.
State: Washington; County: King; Number of
children placed: 575.
State: Washington; County: Pierce; Number of
children placed: 0.
State: Wisconsin; County: Dane; Number of
children placed: 120.
State: Wisconsin; County: Milwaukee; Number of
children placed: 0.
State: Total; County: [Empty]; Number of
children placed: 9,056.
Source: GAO survey.
[A] County was unable to estimate the number of children.
[End of table]:
Nationwide, the number of children placed is likely to be higher.
Eleven states reported that they could not provide us with an estimate
even though they were aware that such placements occurred. Moreover,
officials in 9 additional states that responded to our survey did not
provide an estimate and did not mention whether or not parents turned
to the child welfare system to access mental health services. However,
child welfare workers we interviewed in 2 of these 9 states--California
and New Jersey--confirmed that these placements did in fact occur.
Although some of the state child welfare officials that we visited in
California said children do not enter that system to obtain mental
health services, county child welfare workers said that they knew of
such placements and explained how the cases were coded in their system.
Four states did not respond to the survey.[Footnote 15] Information on
the prevalence of children present in the juvenile justice system is
also limited in this report since we surveyed only 33 counties. In 3 of
those counties, juvenile justice officials reported that while they
were not able to provide estimates, they knew that children were
entering the system to obtain mental health services because they were
not able to access such services in other ways.
Federal and state systems that track children in the juvenile justice
and child welfare systems do not track in a formal or comprehensive way
children placed to receive mental health services. For example, ACF‘s
AFCARS, which contains data reported by states about children in foster
care or adopted out of foster care, does not have a data element that
identifies this population. Similarly, every 2 years OJJDP conducts the
Census of Juveniles in Residential Placement, which gathers information
on children in juvenile residential facilities and their
characteristics but no database variable exists to isolate children
whose parents sought the help of the juvenile justice system to meet
children‘s mental health needs from other children in the juvenile
justice system who may also have mental health problems. OSERS
maintains extensive data about children who receive special education
services, but data are aggregated at the state level and do not include
information about who has custody of the child.
Officials Said Placed Children Were Mostly Adolescent Males with Severe
Mental Health Problems:
According to our survey of state child welfare directors, placed
children are more likely to be boys than girls and are more likely to
be adolescent. Child welfare directors in 19 states reported that, in
fiscal year 2001,
65 percent of placed children were male and 67 percent were between the
ages of 13 and 18. While juvenile justice officials could not provide
information about the gender and ages of children placed in their
system, most children in the juvenile justice population are male and
range in age from 13 to 18.[Footnote 16]
The officials from state and county child-serving agencies and parents
we interviewed in the 6 states that we visited said that children who
were placed had severe mental illnesses, sometimes in combination with
other disorders, and their parents believed they required intense
treatment that could not be provided in their homes. Many of these
children were violent and had tried to hurt themselves, their parents,
or their siblings and often prevented their parents from meeting the
needs of the other children in the family. For example, in Kansas, one
parent reported that her three other children refused to remain in the
home with her son who has bipolar disorder,[Footnote 17] is very
aggressive, and has molested other children in the past. In Maryland,
officials from both state and county child-serving agencies told us
about a teenage boy who was mentally ill, developmentally disabled,
autistic, and hospitalized. Because the boy was both violent and
sexually aggressive, the county told his mother that if she brought him
home from a stay in the hospital, they would remove her other children
from the house. Caring for children who are seriously mentally ill can
also prevent parents from obtaining full-time work or cause disruptions
in their work lives. For example, an Arkansas parent now raising her
grandchild does not work because of the time necessary to care for her
mentally ill granddaughter. State and county officials from child-
serving agencies in
5 of the 6 states that we visited told us that finding placements for
children who were mentally ill and who also had other developmental
disabilities was particularly difficult. One such child in Maryland was
rejected by facilities that serve the developmentally disabled because
he was mentally ill and rejected by facilities that serve the mentally
ill because he was developmentally disabled. Moreover, parents and
officials in 4 of the
6 states that we visited also told us of youth who were not only
mentally ill, but who also abused illegal drugs and alcohol as a way to
self-medicate their mental illnesses.
Children who are placed or are at risk of placement come from families
that span a variety of economic levels. Officials from state and county
child-serving agencies in all 6 states that we visited reported that
families of all economic levels have placed children or are at risk of
doing so. Officials in child-serving agencies in all of the 6 states
that we visited said children from middle class families are more
likely to be placed because they are not eligible for Medicaid and
their families do not have the funds to pay for treatments not covered
by insurance.
Multiple Factors Influence Decisions to Place Children:
Multiple factors influence parents‘ decisions to place their children
in the child welfare and juvenile justice systems so that they can
obtain mental health services for them. Private health insurance plans
often have gaps and limitations in the mental health coverage they
provide--for example, some may not cover certain mental illnesses and
others may limit the amount and type of services that are covered--and
not all children covered by Medicaid received needed services. Even
when parents could afford mental health services, some could not access
services--such as child psychiatric services--at times when they needed
those services because of an inadequate supply of such services. In
other instances, some mental health agencies and schools have limited
resources to provide mental health services and are required to serve
children in the least restrictive environment possible or to educate
eligible disabled children with children who are not disabled to the
maximum extent possible, respectively--which can limit the alternatives
available to parents whose children need residential placements. In
other instances, parents sometimes have difficulty obtaining all needed
services for their children in their communities because eligibility
requirements for services provided by various agencies differ.
Furthermore, some officials and service providers have misunderstood
the role of their own and other agencies and, therefore, gave parents
inaccurate or incomplete information about available services for
families. These misunderstandings created gaps in services for some
children.
Limitations in Private and Public Insurance Often Restrict Access to
Mental Health Care, and Some Services are Limited:
Almost all state child welfare directors and county juvenile justice
officials who responded to our surveys reported that private health
insurance limitations were increasing the number of child welfare and
juvenile justice placements to obtain mental health services, and well
over half reported Medicaid rules also increased such placements. For
example, according to parents and state and local officials in all 6
states that we visited, many private insurance plans and separate SCHIP
plans offered limited coverage for traditional or clinical treatments,
such as psychotherapy or psychiatric consultations,[Footnote 18] and
did not cover residential treatment placements. In addition, state
officials in 3 of the 6 states we visited said that Medicaid rules in
some states that require the preauthorization of services could result
in delays and denials of community-based services.
The legislatures in the 6 states that we visited passed health
insurance parity laws to increase the coverage that was available for
mental health services by requiring insurance companies to provide
mental health coverage that was comparable to what they offered for
physical health care. Although these laws met or exceeded the standard
established by the federal MHPA, they did not require private plans to
cover intensive, long term, and nontraditional services such as respite
care and wrap-around services,[Footnote 19] although mental health
officials and service providers in the states that we visited said
these services were often necessary to help families maintain their
severely children with a mental illness in their homes. Furthermore,
federal law[Footnote 20] preempts states from directly regulating self-
funded, employer-sponsored health insurance plans and in doing so
exempted many families from the enhanced benefits and protections found
in state parity laws. Table 4 shows the key features of these laws.
Table 4: Key Features of Health Insurance Parity Laws in 6 States:
State: Arkansas; Major provisions: * Does not apply to state employees
and companies with less than 50 workers; * Exempts any group health
plan whose costs increase 1 percent or more due to the act‘s
application; * Does not apply to health insurance plans if the act‘s
application to these plans will result in an increase in the cost of
the health plan of at least 1.5 percent; Meets FMPHA: [Empty];
Exceeds: FMHPA: 3.
State: California; Major provisions: * Applies generally to all
employers, regardless of size; * Applies to all health plans that
provide benefits; * Coverage is limited to 20 outpatient visits and 30
days of inpatient care for mental illnesses that do not meet the
state‘s SED criteria; * Covers severely emotionally disturbed children
with certain categories of mental illness; Meets FMPHA: [Empty];
Exceeds: FMHPA: 3.
State: Kansas; Major provisions: * Applies to health insurance plans
that provide mental health benefits; * Plans must provide coverage for
psychotherapeutic drugs used for the treatment of mental health under
conditions no less favorable than for other drugs; * Coverage is
limited to 45 outpatient visits and 45 days of inpatient care; Meets
FMPHA: [Empty]; Exceeds: FMHPA: 3.
State: Maryland; Major provisions: * Applies to all health insurance
policies that provide coverage on an expense-incurred basis; *
Includes drug and alcohol disorders; * Co-payments and deductibles
must be equal to those for other conditions; * Outpatient coverage
schedule provides for 80 percent coverage for the first five visits in
a 12-month period, 65 percent for the 6-30th visits, and 50 percent for
the 31st and subsequent visits; Meets FMPHA: [Empty]; Exceeds: FMHPA:
3.
State: Minnesota; Major provisions: * Applies to all health plans that
provide mental health benefits; * Applies to all health plans that
provide benefits except self-insured health insurance plans; * Plans
with 100 subscribers or more can limit mental health coverage to 80
percent of the customary charge for the first 10 hours of treatment
over a 12-month period and
75 percent for additional treatment over the same 12-month period;
Meets FMPHA: [Empty]; Exceeds: FMHPA: 3.
State: New Jersey; Major provisions: * Every individual health
insurance policy must provide coverage for biologically based mental
illness; * Covers biologically based mental illness under the same
terms as other sicknesses; Meets FMPHA: [Empty]; Exceeds: FMHPA: 3.
Source: GAO analysis.
[End of table]
In the 6 states that we visited, state and local mental health
officials agreed that Medicaid had far fewer restrictions and
limitations than private health insurance plans. In addition, mental
health officials in Arkansas, California, and Maryland told us that
differences between private insurance and Medicaid programs had created
two distinct systems of child mental health services. Under these
systems, children covered by Medicaid had greater coverage for mental
health services than children covered by private insurance.
All 6 of the states that we visited covered optional Medicaid and SCHIP
services by expanding their programs for children with mental illness
who were ineligible for Medicaid on the basis of their families‘
income. These included the HCBS waivers, Katie Beckett option,
Rehabilitation option, and SCHIP programs. See table 5 for Medicaid and
SCHIP programs used in the states that we visited.
Table 5: Key Medicaid and SCHIP Programs for Children with Mental
Illness in 6 States:
State: Arkansas; Waivers: Home and Community-Based Services[A]:
[Empty]; [Empty]; Types of optional services: Katie Beckett: Yes; Types
of optional services: Rehabilitation: Yes; [Empty]; Types of SCHIP
programs: Medicaid expansion: Yes; Types of SCHIP programs: Separate
(non-Medicaid) program: [Empty]; Types of SCHIP programs: Combination
(Medicaid
expansion and separate) program: [Empty].
State: California; Waivers: Home and Community-Based Services[A]: Yes;
[Empty]; Types of optional services: Katie Beckett: [Empty]; Types of
optional services: Rehabilitation: Yes; [Empty]; Types of SCHIP
programs:
Medicaid expansion: [Empty]; Types of SCHIP programs: Separate
(non-Medicaid) program: [Empty]; Types of SCHIP programs: Combination
(Medicaid
expansion and separate) program: Yes.
State: Kansas; Waivers: Home and Community-Based Services[A]: Yes;
[Empty]; Types of optional services: Katie Beckett: [Empty]; Types of
optional services: Rehabilitation: Yes; [Empty]; Types of SCHIP
programs:
Medicaid expansion: [Empty]; Types of SCHIP programs: Separate
(non-Medicaid) program: Yes; Types of SCHIP programs: Combination
(Medicaid
expansion and separate) program: [Empty].
State: Maryland; Waivers: Home and Community-Based Services[A]: Yes;
[Empty]; Types of optional services: Katie Beckett: Yes; Types of
optional services: Rehabilitation: Yes; [Empty]; Types of SCHIP
programs:
Medicaid expansion: [Empty]; Types of SCHIP programs: Separate
(non-Medicaid) program: [Empty]; Types of SCHIP programs: Combination
(Medicaid
expansion and separate) program: Yes.
State: Minnesota; Waivers: Home and Community-Based Services[A]: Yes;
[Empty]; Types of optional services: Katie Beckett: Yes; Types of
optional services: Rehabilitation: Yes; [Empty]; Types of SCHIP
programs:
Medicaid expansion: Yes; Types of SCHIP programs: Separate
(non-Medicaid) program: [Empty]; Types of SCHIP programs: Combination
(Medicaid
expansion and separate) program: [Empty].
State: New Jersey; Waivers: Home and Community-Based Services[A]:
[Empty]; [Empty]; Types of optional services: Katie Beckett: [Empty];
Types of optional services: Rehabilitation: Yes; [Empty]; Types of
SCHIP
programs: Medicaid expansion: [Empty]; Types of SCHIP programs:
Separate
(non-Medicaid) program: [Empty]; Types of SCHIP programs: Combination
(Medicaid
expansion and separate) program: Yes.
Source: GAO analysis.
[A] Of the 4 of the 6 states that we visited that had a HCBS waiver,
only Kansas had a waiver specifically for children with serious
emotional disturbances.
[End of table]
States used different approaches to expand Medicaid coverage. For
example, Medicaid officials in Kansas received permission from CMS to
implement a HCBS waiver to expand coverage for community-based mental
health services for a limited number of children who are chronically
mentally ill. Although Medicaid officials in New Jersey financed its
new child mental health system through a Medicaid Rehabilitation
option, the option extends Medicaid coverage to only a limited number
of children who have exhausted benefits under other insurance and who
have chronic and severe mental illness. This option provides 60 days of
community-based services and limited hospitalization.[Footnote 21]
Arkansas, Maryland, and Minnesota used Medicaid‘s Katie Beckett option
to expand Medicaid coverage to physically or mentally disabled children
who meet CMS‘s requirements for institutional care. Arkansas‘s program
did not require parents to share program costs to receive services, but
Minnesota‘s program required parents to pay according to their ability
as defined by a sliding scale.
While states chose to use different waivers and options to expand
access to mental health services, all 6 states used SCHIP programs to
extend health insurance coverage to low-income families whose incomes
exceeded allowable limits under Medicaid. Kansas offered a separate
child health (non-Medicaid) expansion program. Arkansas and Minnesota
offered expanded Medicaid coverage and California, Maryland, and New
Jersey offered both and Medicaid-expansion and separate child health
programs to low-income families of different income levels. However,
mental health officials in 3 states said that their separate SCHIP
programs generally resemble many private insurance plans in terms of
limits and restrictions. For example, New Jersey‘s separate SCHIP plan
limits some mental health services. California‘s plan, however,
entitles children who meet the state‘s definition of severely
emotionally disturbed to receive the same services from county mental
health services as children covered by Medicaid.
Although Medicaid‘s EPSDT provision requires Medicaid coverage for all
medically necessary health services that are identified during routine
periodic screening as long as the treatment is reimbursable under
federal Medicaid guidelines, some state officials said many eligible
children are unable to access necessary services through Medicaid
because practitioners in the states implement EPSDT unevenly. For
example, a Medicaid official in Maryland told us that the
implementation of EPSDT varied from county to county. Medicaid
officials in California said implementation varied from practitioner to
practitioner although access to EPSDT services was increasing as a
result of litigation. These officials explained that some practitioners
are reluctant to recommend services if such services are not available,
some do not have the time to question parents about their child‘s
mental health, and others are not well informed about children‘s mental
health issues. In a previous report, we recommended that the
Administrator of CMS work with states to develop criteria and time
frames for consistently assessing and improving EPSDT reporting and
provision of services.[Footnote 22] As we stated in that report,
comprehensive national data on the implementation of EPSDT are needed
to judge states‘ success in implementing EPSDT requirements.
Low Medicaid reimbursement rates may restrict mental health providers‘
participation in the program and thus further restrict services. In all
6 states, officials from a variety of agencies said Medicaid rates for
some services are lower than the usual and customary rates in their
areas and, in some areas, psychiatrists and psychotherapists will not
accept Medicaid patients or expand the number that they are presently
seeing because of low Medicaid reimbursements. For example, a
psychologist in Minnesota told us that Medicaid reimbursement for a
psychotherapy session is about half the customary rate, and a mental
health official in New Jersey said that Medicaid reimburses only $5 per
visit for monitoring the use and effects of psychotherapeutic
medication.
Even when insurance covered the costs of mental health services, some
mental health officials and parents indicated parents often could not
access services or placements in their community because the supplies
of these services were limited. Fifteen of the 28 child welfare
officials and
9 of the 23 juvenile justice officials who responded to our survey
question on the relationship between community mental health services
and voluntary placements indicated that the lack of such services
increased voluntary placements. In every site we visited, officials of
state and local child-serving agencies and parents reported inadequate
supplies of mental health service providers and specialized mental
health placements. Many of these officials said that shortages of child
psychiatrists, child psychologists, respite care workers, and behavior
therapists existed on statewide levels and were worse in rural areas.
For example, state and local mental health officials in Arkansas,
California, Kansas, Maryland, and Minnesota told us that some rural
counties had very limited or no child mental health services. Also,
specialized, out-of-home mental health placements, such as psychiatric
in-patient services and residential treatment facilities, were often
not available or had long waiting lists. For example, Arkansas
officials said the state has no state-run psychiatric hospital
placements for children under age 12, and, in California, some children
have to wait about 8 months for a residential placement. Child welfare,
mental health, and juvenile justice officials in California, Maryland,
and New Jersey noted that relatively fewer residential placements are
available for girls than are available for boys and that few placements
would accept children with histories of arson and sexual aggression.
Moreover, these officials noted children placed in the child welfare or
juvenile justice systems received preference for services, particularly
when the services were court-ordered.
Difficulties Accessing Services through Certain Agencies, Difficulties
in Meeting Service Eligibility Requirements, and Misunderstandings
among Officials and Service Providers Can Influence Placements:
In the 6 states that we visited, limited resources in mental health
agencies and public schools to fund mental health services and agency
officials‘ attempts to minimize the use of residential services posed
additional challenges for parents seeking services and placements for
their children. In addition, some children who needed multiple supports
experienced gaps in services because of differences in the eligibility
requirements for obtaining such services. Moreover, some officials and
service providers often misunderstood the responsibilities and
resources of their own and other agencies and communicated the
misunderstandings to parents, compounding service gaps and delays.
Difficulties Accessing Services through Mental Health or Education
Agencies:
According to some mental health and education officials, budgetary
shortfalls in the 6 states that we visited contributed to agencies‘
attempts to cut or control costs, including the cost of mental health
services. Mental health agencies used a variety of strategies to
control costs, such as reducing spending, requiring that services
covered by Medicaid be approved before they are provided, and limiting
the number of children served. In each state we visited, some parents
believed the strategies affected the quality of the services their
children received and created unnecessary delays in getting services.
In Arkansas, private, nonprofit mental health providers that contract
with the state to provide community mental health said that state
officials cut their funding and, as a result, they had to reduce the
length of counseling and therapy sessions and increase the length of
waiting lists. In 3 of the states that we visited--Arkansas, Maryland,
and New Jersey--state officials said that they contracted with private,
nonprofit agencies to authorize the medical necessity of mental health
services covered by Medicaid. Arkansas required preauthorization of all
Medicaid-financed mental health services, including those that were
legally required, such as the screening of foster children for mental
health services. A variety of officials in this state and a parent
reported that the preauthorization agency often denied services for
children because they had not benefited from similar services in the
past. For example, this parent said the preauthorization agency refused
her son‘s therapist‘s request to hospitalize him to treat his suicidal
behavior because past hospitalizations for suicide attempts had not
reduced the behavior. In New Jersey, state mental health officials
reduced the number of counties that had been targeted to implement the
state‘s new child mental health system and limited the number of
children served by the system. For example, officials from a variety of
county agencies reported that the new system of care limited the number
of children receiving the highest level of care in their county to 180
a year, although juvenile justice officials said that at least 500
children in their system alone needed such services. Officials from
child welfare, mental health, and juvenile justice agencies said
eligible children who did not receive the highest level of care were
placed on waiting lists and provided less intensive services.
Other ways of controlling costs in the states that we visited included
limiting placements of children in residential treatment facilities.
Mental health officials said community-based services supported the
right of children with a mental illness to receive services in the
least restrictive setting, were more effective than residential
services in helping children and their families, and cost less, thus
allowing more children to receive services. To implement the limits and
to ensure placements are necessary, states required interagency review
boards to approve such placements or reduced the time spent in
residential placements. For example, local mental health agency
officials in Maryland explained that they could not place children in
private residential facilities even if they presented a danger to
themselves and others because the state did not allow them to pay for
such placements. These officials further explained that private
residential placements had to be approved by a county interagency
coordinating committee and subsequently reviewed by a state
coordinating committee that could return requests for further
consideration. A parent in this county said the approval process took
6 months. In New Jersey, child welfare officials said a goal of the new
child mental health system is to reduce the average stay at residential
treatment facilities from 18 to 6 months, and some parents in Maryland
told us that funding limits, rather than the success of the treatment,
determine the date children will be discharged from residential
treatment.
Officials from a variety of county agencies and some parents also
reported that public schools in their county--in order to control
costs--were often reluctant to provide individualized mental health
services for special education children beyond services that are
routinely available. For example, child welfare officials in three
locations we visited said schools fit children with a mental illness
into preexisting programs, and school officials in two of these
locations agreed, stating that children‘s IEPs could only contain
services that were available in the schools. Almost all the parents
that we interviewed said that school officials were reluctant to
evaluate their children to determine eligibility for special education
services or provide specialized services for them. For example, a
parent of a child with a mental illness in Kansas said officials in her
daughter‘s school refused to evaluate the child for a year and a half.
After this evaluation, the school recommended that the child work with
a learning disability specialist for 30 minutes a week, even though the
parent said this service was insufficient and did not address her
daughter‘s destructive, violent, and aggressive behavior.
As a result of the difficulties encountered at both mental health
agencies and schools, some parents could not access the community-based
services they needed to care for their child at home nor place their
child in a residential treatment facility. In 4 of the 6 states that we
visited, some teachers and mental health service providers encouraged
parents to refuse to bring their child home from a hospital or other
supervised placement, such as a detention center, when they were
informed their child was being discharged in order to obtain mental
services from child welfare agencies. Although these parents realized
they were abandoning their child and, as a result, could be arrested
and lose custody, they believed that this was the only alternative that
remained to obtain services. Some parents that we interviewed told
child welfare workers they would physically abuse their child in their
presence to force them to place the child in their system if they could
not get help for their child any other way, and juvenile justice
officials told us other parents asked the police to arrest their
children. However, state officials in 2 of the states that we visited
said children often remain hospitalized or in a shelter for months
without appropriate services because child welfare agencies did not
have the resources to provide the needed level of services or
specialized placement, could not obtain resources from other agencies,
or could not access appropriate services or placements that had the
capacity to treat another child. In addition, although federal law does
not require custody relinquishment to obtain mental health services,
state child welfare officials in 2 states that we visited said that
their state required parents to relinquish custody of their child to
the state after the voluntary placement period ends. In
1 state, these officials misconstrued federal requirements and believed
that they required relinquishment and in the other state, officials
said relinquishment enabled them to have more control over the child‘s
care.
Difficulties Meeting Eligibility Requirements for Mental Health
Services:
Eligibility requirements for obtaining mental health services pose
several challenges for parents. For example, state and local Medicaid
officials in
3 states told us that some children lose their eligibility for
Medicaid-funded services because their families‘ income increased
beyond Medicaid‘s threshold or move in and out of eligibility as their
families‘ income fluctuates. Also, some child welfare officials said
some children receive Medicaid because they are in foster care and lose
their eligibility when they return home if the family is not eligible.
Alternatively, juvenile justice officials in 6 states said that
children in juvenile justice correctional or detention facilities lose
Medicaid eligibility and have to reapply to resume coverage when they
are released from the facility.
In addition, in all 6 of the school districts we visited, schools used
different eligibility criteria for mental health services than mental
health or other child-serving agencies in their area. For example,
school officials in four districts told us that some children with a
mental illness are not eligible for mental health services through
their special education programs because they were making adequate
educational progress or because behavior problems--rather than mental
illness--prevented them from making adequate progress. However, mental
health officials who work with children attending some of these schools
reported that schools often have a narrow definition of educational
progress and do not recognize that inappropriate behavior might be a
symptom of mental illness. For example, a parent of a child with
attention deficit[Footnote 23] and bipolar disorders said her son‘s
school refused to provide special education services for him because
his lack of educational progress was due to his failure to pay
attention and to get his work done, rather than his mental illness, and
a parent of a bipolar, schizophrenic son[Footnote 24] said school
officials told her that she was responsible for her son‘s behavior and
poor school performance.
Although a variety of officials said schools had more restrictive
eligibility requirements for mental health than other child-serving
agencies, school officials in a county in California said that their
county mental health agency used a more restrictive definition than the
schools. In California, state law required that county mental health
agencies treat children covered by Medicaid and SCHIP who were
diagnosed as SED or who were eligible for special education
services.[Footnote 25] California also requires that children be
evaluated by county mental health agencies and fit a statutory
definition of SED. School officials said that these children get
priority and their services consumed all available county child mental
health resources. According to these officials, other children,
including children with dual diagnoses of mental illness and substance
abuse, mental retardation, or autism-related disorders and children
without the required diagnoses have to wait for county mental health
services or might not receive services at all, although some may
receive services through their school guidance counselors or social
workers.
Some parents bypass eligibility restrictions for special education
services and procedures for receiving child welfare, mental health, and
juvenile justice services by petitioning the court to provide mental
health and specific education services for their child. These petitions
have varying names. For example, Maryland refers to them as CINS
(children in need of supervision) petitions and Arkansas refers to them
as FINS (family in need of services) petitions. Three of the states
that we visited--Arkansas, Maryland, and Minnesota--allowed parents to
directly petition the court to order mental health services for the
child. In Arkansas, a child in a court-ordered residential placement
was automatically eligible for Medicaid regardless of his or her
family‘s income. In that state, a variety of officials told us that
court-ordered placement was the most common way for parents to obtain
residential mental health and education services for their child.
Juvenile court officials told us that parents often come to court
requesting residential treatment and lobbying judges for placement in a
specific facility. Some state officials were concerned that this
practice could result in inappropriate placements for some children
because judges can make placement decisions with no clinical input.
Mental health and juvenile justice officials told us staff from private
residential facilities often evaluate children on a pro bono basis and,
based on these evaluations, recommend that judges place the children in
their facility. These officials said that they were concerned about the
objectivity of such evaluations.
Misunderstandings of Agencies‘ Responsibilities and Resources:
Program officials‘ and service providers‘ misunderstandings of
agencies‘ responsibilities and resources also affect service
provision.[Footnote 26] For example, misunderstandings about Medicaid
coverage created gaps and delays in services. In 3 states, some state
and county officials did not know the Katie Beckett option could expand
Medicaid coverage for children with a mental illness regardless of
family status. In 1 of these states, a parent told us that county
Medicaid officials incorrectly told her that her son was ineligible for
coverage under this option because he had a two-parent family. In 2
other states, county mental health officials erroneously told us that
this option applied only to children with very severe medical
conditions. In another state, a Medicaid official did not know that
children enrolled in SCHIP Medicaid expansion programs were entitled to
EPSDT services. Furthermore, state child welfare officials in 2 states
and mental health workers in a third did not know Medicaid‘s EPSDT
provision includes mental health screenings, diagnosis, and treatment
and thought the provision covered only physical health services.
In all 6 states, some parents, a variety of state and local officials,
mental health service providers, caseworkers, and judges misunderstood
the role and responsibilities of schools in implementing IDEA. For
example, some parents we interviewed in 5 of these states said that
their children waited over a year to receive special education services
because they and the mental health professionals they worked with did
not understand the procedures IDEA required schools to follow. For
example, some parents were told that referrals for special education
had to be in writing. Also, some parents and professionals
misunderstood that IDEA gives all eligible children, including children
with a mental illness, the right to a free appropriate education and
parents did not know that they could appeal a school‘s decision about
providing special education services. For example, a parent in Kansas
agreed to home-school her 10 year old, sexually aggressive, child with
a mental illness because the school would not put the child in a
setting that would ensure the safety of his classmates. Despite her
long-term involvement with a community mental health agency, this
parent believed home schooling was her child‘s only option.
States Have Developed a Range of Practices That May Reduce the Need for
Some Mental Health-Related Child Welfare and Juvenile Justice
Placements:
Although few strategies were developed specifically to prevent mental
health-related child welfare and juvenile justice placements, state and
local officials identified a range of practices that they believe may
prevent such placements by addressing key issues that have limited
access to child mental health services in their state. State and local
practices focused on three main areas: finding new ways to reduce costs
or to fund services, consolidating services in a single location, and
expanding community mental health services and supporting families.
Many of these practices were developed to reduce treatment costs and
provide a better way to treat children with a mental illness in their
communities. Although some programs were modeled on practices that had
been evaluated in other settings, the effectiveness of the practices is
unknown because many of them were implemented on a small scale in one
location or with a small target group or were too new to be rigorously
evaluated.
Finding New Ways to Reduce Costs or to Fund Services May Help Agencies
Pay for Mental Health Treatment:
According to officials in the 6 states that we visited, one way to
reduce the cost of services is to better match children‘s needs to the
appropriate level of service. One goal of some of the programs we
reviewed was to ensure that children with lower-level needs were
appropriately served with lower-level and less expensive services,
reserving the more expensive services for children with more severe
mental illnesses. Under New Jersey‘s Systems of Care Initiative, the
state contracted with a private, nonprofit organization for a variety
of services, such as mental health screenings and assessments to
determine the level of care needed, authorization of service, insurance
determination, billing, and care coordination across all agencies
involved with the children. When the Initiative is fully implemented
statewide, the contractor in each county will use standardized tools to
assess children‘s mental health and uniform protocols to determine
appropriate levels of care--children requiring lower levels of care
will be referred to community-based providers, while children requiring
a higher level of care will be approved to receive services from local
Care Management Organizations specifically created to serve them.
Presently, the System of Care Initiative has been implemented in 5 of
the state‘s 21 counties.
As another cost-saving method, some programs substituted expensive
traditional mental health providers with nontraditional and less
expensive providers. Many state and local officials we interviewed in 5
of the states we visited told us that the historic way to treat
children with a mental illness included psychiatrists and residential
placements. However, officials in New Jersey, Kansas, and Minnesota
said their states had switched their focus to using less expensive
providers such as using nurses to distribute medicines instead of
psychiatrists or nontraditional bachelor-level workers for case
management instead of masters-level social workers. For example,
Uniting Networks for Youth--a private, county-based provider in
Minnesota--used two commercially available, highly structured programs
that allowed them to substitute lower-credentialed bachelor-level staff
under the supervision of a masters-level clinician as the primary
service provider instead of using higher-level clinicians. County
officials told us this structured program has many safeguards,
including the collection of extensive data from providers, teachers,
and families that allow masters-level clinicians to review the
appropriateness and effectiveness of provided mental health services.
State officials in 5 states also recommended increasing the use of
volunteer and charitable organizations to reduce the cost of services
because these organizations can provide inexpensive or free supportive
services to children with a mental illness and their families. While
these services were not therapeutic, officials said that they helped
families cope with problems associated with mental illness and kept
some mental health problems from escalating. For example, the Four
County Mental Health Center in Kansas used volunteers from churches,
community agencies, and charities, such as the Salvation Army, to
provide services such as mentoring and tutoring for children with a
mental illness. A county in New Jersey increased its reliance on Big
Brother-Big Sister volunteers and the local YMCA to provide after
school supervision and mentoring for children with severe mental
illness.
In addition to reducing the cost of services, state officials in all 6
states identified the blending of funds from multiple sources as
another way to pay for services, thus working around agencies‘
limitations on the types of mental health services and placement
settings each can fund. For example, in a county in Maryland, a local
Coordinating Council blends funds from multiple agencies to provide
community-based services to children with a mental illness involved
with the judicial, child welfare, and mental health systems and with
district special education programs. The Council, headed by a judge,
leveraged funding by inviting key decision makers--those that could
commit resources--from a variety of child-serving agencies and
organizations, including the local departments of social services and
juvenile justice, the public defenders office, prosecutors, attorneys,
and Catholic Charities, to serve on the Council. The Juvenile
Alternative Defense Effort (JADE), a county juvenile justice diversion
program in California, combines funds from a federal Juvenile
Accountability Incentive Block Grant and the state Temporary Assistance
for Needy Families Program (TANF)[Footnote 27] to provide the range of
mental health services necessary to prevent a juvenile justice
placement for mentally ill youths. In Kansas, the Family Service and
Guidance Center blends funds from federal Medicaid and Department of
Transportation programs, designated funds from the state‘s Master
Tobacco Settlement and Attorney General‘s Office, funds from county
juvenile justice and social services agencies, county general funds,
the United Way, and several local philanthropic clubs to provide a wide
range of mental health and supportive services for children who are
seriously mentally ill in its county.
In addition to blending funds to pay for services, state officials in 4
of the
6 states that we visited identified the use of flexible funds, with few
restrictions, to pay for nontraditional services that are not generally
allowable under state guidelines. For example, Arkansas‘s Together We
Can Program used flexible funds from a federal Social Services Block
Grant, state general revenue, and the Title IV-B program to provide a
wide range of nontraditional supportive services and items to children
with a mental illness and their families. Using these funds, the
program provided services and items such as in-home counseling,
community activities, respite care, mentoring, tutoring, clothing, and
furniture that helped the family care for the child at home and
supported the child in his community.
Bringing Mental Health Services into a Single Location May Improve
Access:
To improve access to mental health services and bring clarity to a
confusing mental health system, 3 of the states that we visited
developed a facility to be a single point of entry into the mental
health system. Typically, several agencies are represented at the
facility and children are assessed with a common instrument and
eligible for the same services regardless of what agency had primary
responsibility. Kansas‘s Shawnee County Child and Family Resource
Center is a one-stop facility and, according to state mental health
officials, a model for the rest of the state. The center houses workers
from 11 social services agencies, including mental health, child
welfare, juvenile justice, and education. All children with mental
health needs, regardless of which agency first encountered the child,
are referred to the center. Case managers at the Center assess the
child‘s psychological, educational, and functional needs, determine
appropriate services and placements, make referrals, provide some
direct counseling services, and determine how to pay for services. The
facility includes four bedrooms for children who need to be removed
from their homes for short periods of time and a secure juvenile
justice intake suite that is staffed 24 hours a day. County officials
from a variety of agencies told us that the center ended service
fragmentation and prevented duplication of services for children with a
mental illness and their families by implementing one intake procedure
for all county social services. For example, case managers work with
police to prevent the placement of children with mental illness in
correctional facilities. If a mental illness is identified during the
intake assessment, the intake workers immediately link the child with a
mental health worker. Working collaboratively with juvenile justice,
school, and other appropriate officials, the case manager develops a
diversion[Footnote 28] plan all can agree to that is aimed at
preventing the need for juvenile justice or child welfare custody, or
residential or other out-of-home placements with the goal of keeping
the child at home with the child‘s own family.
State officials in all 6 of the states that we visited also identified
co-locating services in public facilities such as schools and community
centers as another way to improve access. In California, Los Angeles
county officials told us that integrating mental health services into
the school system has been a very effective way of reaching poor
families without transportation and working families, and helps to
ensure regular participation in mental health services. In Harford
County, Maryland, for example, mental health services are collocated at
an elementary school specifically to improve access to care for
students with mental illness. Using county health and mental health
funds, the school developed an in-house mental health clinic that
provides mental health services through a bachelor-level social worker,
a nurse practitioner, and consultative services from a physician and a
psychiatrist. In addition, the school has a variety of internal support
staff available to children with a mental illness, including a guidance
counselor, a behavior specialist, a home visitor who supports families
and assesses the home situation, and a pupil personnel worker who
visits homes and helps with transportation issues. The school has
several programs available to children with a mental illness, including
the Classroom Support Program, an intensive, in-school program for
children with a mental illness staffed with a full-time school
psychologist for individual counseling; the Teen 2000 program, a
mentoring program for teens that uses paid school staff, high school
students, and volunteer community members to provide a combination of
homework support, play, and social skills development; the School
Outreach Advocacy Program, a program that provides counseling,
tutoring, recreation, social skills groups, home visits, referrals and
some psychiatric rehabilitation services; Project Prepare, a program to
identify mentally ill elementary school children and increase their
access to services; and two collaborative programs with contracted
mental health providers that provide community support and prevention
services and intensive case management services.
Expanding Community Mental Health Services and Supporting Families May
Improve Treatment for Children with a Mental Illness:
Officials from child-serving agencies in all 6 states we visited
identified the expansion of the number and range of community-based
services to provide an entire continuum of care as a way to improve
treatment for children with a mental illness. Some programs we reviewed
developed a complete range of community-based mental health services
for children, including early intervention, diversion, transitional
services, and crisis intervention. In addition, some programs supported
families of children with a mental illness and encouraged parent
involvement in their children‘s care. State and county officials we
spoke with in all 6 states stressed the importance of early
identification of children at risk of mental illness and the provision
of therapeutic services when they were young in hopes of preventing the
need for extensive, and costly, residential services later on. Examples
of these programs follow.
Early Intervention: Working with local hospitals, workers from the
Family Service and Guidance Center in Shawnee County, Kansas, screen
newborns in local hospitals. If babies appear at-risk, social workers
conduct home visits and refer families to health care professionals or
others for support. The Center also developed a therapeutic preschool
practice directed at 3-5 year old children, with or without a mental
illness diagnosis, who were likely to need special education services
when they entered kindergarten. The program serves 32-36 children and
provides a half-day of services.
Diversion: Los Angeles‘ JADE was designed to prevent or reduce the time
of expensive juvenile justice placements for youths with mental
illness, by arranging assessments, providing referrals to mental health
providers and advocating for these youth to ensure they receive the
treatment they need. Upon referral to JADE, a psychiatric social worker
performs an extensive psychosocial evaluation, including a
developmental history, family history, and educational history that
include failures and successes, gang-related behaviors, delinquency
behaviors, and a mental health status exam. Based on the evaluation,
the social worker makes placement and service recommendations to the
juvenile court judge who makes the final decisions. JADE officials said
that the evaluations and recommendations give the judges the
information they need to consider alternatives to incarceration.
Transitional Services: State and county juvenile justice and mental
health officials in the 6 states we visited stressed the importance of
including transitional services in a continuum of care. These services
are typically provided to a child leaving a residential setting and
returning to his or her home or community. For example, Minnesota‘s Red
Wing facility is a secure juvenile justice facility that provides in-
house mental health services and places a strong focus on transitional
services so youth can successfully reenter their own community. Red
Wing officials told us that transition planning and reintegration
efforts are very important in preventing recidivism and they take
several steps to ensure a successful transition. The program is
designed in levels that reward good behavior by allowing youth to move
to lower levels of supervision. For instance, at level 4, youth begin
to transition back to the community by making periodic visits, called
furloughs, to their homes. Officials see furloughs as an opportunity
for youth to try out the new positive behaviors that they have learned.
At level 5, youth move to a transitional living unit at Red Wing that
focuses on applying new skills to activities in their homes and
communities. After youth leave Red Wing, a county juvenile justice
worker monitors them for 90 days.
Out of frustration with the difficulties it had finding appropriate
services for mentally ill youth who were aging out of child mental
health programs, The Sycamores, a residential mental health facility in
Los Angeles County, California, created community-based transitional
homes for older teens who were leaving their facility and were unable
to return to their own homes. Its Emancipated Youth Program provides an
apartment for every two residents, a youth advocate worker to provide
support, and case managers to coordinate services. For this program,
the Sycamores uses reasonably priced private apartments in the
community, instead of a group home that would house several mentally
ill youths in the same building. When the youths become able to live
independently, the Sycamores turns the leases over to them. They also
started a business card company at one community center to provide
vocational training for adolescents aging out of their program.
Crisis Intervention: Programs we reviewed in 4 states had a mobile
crisis unit. These units consist of teams of staff that visit homes to
stabilize crisis situations. Funding, staffing, and authority of these
teams vary. Some of the crisis teams can provide direct mental health
services; others conduct assessments and make emergency petitions to
psychiatric hospitals on behalf of the family. One of the difficulties
noted by program officials is determining how to pay for crisis
services since these services may not be covered by insurance and
families may not have the ability to pay. In Harford County, Maryland,
the mobile crisis team is not a fee-for-service provider but is funded
by a grant. The team--a psychiatrist, a psychologist, and a licensed
social worker--provide direct mental health services and are authorized
to do an emergency petition to get a child with a mental illness
admitted to a hospital psychiatric unit.
A second way some states improve treatment for children with a mental
illness is to provide services to support families and encourage
parental involvement in their child‘s care. State and local officials
in all 6 states pointed out that involving parents was a fundamental
change in philosophy. Previously, services were provided solely to the
children and parents were not included in the decisions about their
child‘s care. Now, the focus is on providing the services parents need
to maintain the child in the home and helping parents make informed
decisions about their child‘s care. For example, The Sycamores works
extensively with parents of children who are seriously mentally ill at
the facility and requires their participation. To help parents
successfully prepare for and keep their child with a mental illness at
home, The Sycamores provides a variety of supportive services--anything
the family needs to make a child‘s return home successful--including
household items like refrigerators, washers, dryers, stoves, and car
seats, and services such as transportation to and from the facility. In
addition, as part of its transitional Home-Based Program, The Sycamores
trains parents to use Therapeutic Behavioral Services (TBS), one-on-
one, in-home services provided whenever needed 24 hours a day, 7 days a
week. TBS workers model good parenting skills so parents will be
prepared for their child‘s return home, such as modeling for the
parents how to get their child with a mental illness who may have
violent outbursts ready for the school bus in the morning without
incident. The Four County Mental Health Center in Kansas‘s provides
free parenting classes designed to teach effective parenting skills for
children with mental illness and a parent support coordinator who can
provide support and information on mental health services for children.
The Center also works with Kansas‘s Keys for Networking, a statewide
parent advocacy organization that educates parents about their child‘s
right to services and advocates on their behalf to obtain needed
services.
Conclusions:
Some parents are placing their children, mostly adolescent boys with
severe mental illness, in the child welfare and juvenile justice
systems to access mental health services. Although these children may
not have been abused or neglected, or may not have committed a criminal
or delinquent act, parents are turning to these agencies because they
see no alternatives for obtaining comprehensive services for them.
Because federal, state, and local agencies do not systematically track
these children, the extent and outcomes of these placements are not
fully known.
Experts, agency officials, and service providers agree that agencies
must work together to meet the needs of children who are severely
mentally ill because these children have complex problems and are
likely to need services from multiple community agencies, such as
mental health and education, if they are to remain in their communities
or if they are to successfully transition from a residential facility
back to their community. However, in some cases, state and local
officials‘ misunderstandings of each agency‘s service requirements,
responsibilities, and resources prevent the provision of interagency
services that have the potential to address the needs of these children
and their families. Opportunities exist for HHS, DOJ, and Education to
determine the causes for these misunderstandings at the state and local
level and to identify ways to reduce them.
Although states and counties are implementing practices that may reduce
the need for parents to place their children with child welfare or
juvenile justice agencies, many of the programs are new, small, and
only serve children in specific localities. Furthermore, their
effectiveness in achieving their multiple goals--such as reducing the
cost of mental health services, supporting families, and helping
children overcome their mental illnesses--has not yet been fully
evaluated. Given that states and localities are developing new
approaches to meeting the needs of children with mental illness, it is
important that the federal government continue its role in supporting
evaluations of these programs and disseminating the results.
Recommendations:
To determine the extent to which children may be placed inappropriately
in the child welfare and juvenile justice systems in order to obtain
mental health services, we recommend that the Secretary of HHS and the
Attorney General investigate the feasibility of tracking these children
to identify the extent and outcomes of these placements. To help reduce
misunderstandings at the state and local level, we also recommend that
the Secretaries of HHS and Education and the Attorney General develop
an interagency working group (including representatives from CMS,
SAMHSA, and ACF) to identify the causes of these misunderstandings and
create an action plan to address those causes. We further recommend
that these agencies continue to encourage states to evaluate the child
mental health programs that they fund or initiate and that the
Secretaries of HHS and Education and the Attorney General determine the
most effective means of disseminating the results of these and other
available studies to state and local entities.
Agency Comments:
We provided a draft of this report to Education, HHS, and DOJ to obtain
their comments. Each agency provided comments, which are reproduced in
appendixes III, IV, and V. These agencies also provided technical
clarifications, which we incorporated when appropriate.
Education generally agreed with the findings of our report, but asked
that we change some terminology to be consistent with terminology used
in IDEA. We changed this terminology to reflect IDEA when needed. HHS
also generally agreed with the findings and said that the report is
comprehensive, interesting, and provides an informative overview of the
concerns with which child welfare agencies and juvenile justice systems
are confronted when children and youth do not receive adequate mental
health services within the community. However, HHS also said that the
report is relatively critical of state and local agencies for
’inappropriately“ using child welfare and juvenile justice placements
to get services to children who need them and cannot access them
through other channels. HHS further stated that a broader look at the
status of children‘s mental health services in general would be useful
because the problems leading parents to place their children in child
welfare and juvenile justice systems to obtain mental health services
are part of the bigger problem of children‘s mental health services in
general, such as limited or non-existent services, a lack of access,
and a lack of quality providers. Although a broad assessment of the
availability and effectiveness of children‘s mental health services was
beyond the scope of this report, we have conducted studies relevant to
these problems and reference to them can be found in the related
products list at the end of this report. The purpose of this report was
to shed light on the number of children placed in the two systems
solely to receive mental health services and the factors that lead to
those placements. In doing so, this report does not criticize state and
local child welfare and juvenile justice agencies that place these
children, but instead identifies the circumstances under which these
agencies play a role in meeting mental health needs, as well as the
roles that other agencies should play. DOJ also generally agreed with
our findings but was concerned that the estimates of children placed
provided by child welfare and juvenile justice officials would be taken
as solid and conclusive and be used for policy changes without further
study being undertaken. We explicitly acknowledged the limitations of
these estimates in the report and we recommended that the Secretary of
HHS and the Attorney General investigate the feasibility of obtaining
more precise numbers by tracking these children. Doing so will allow
the agencies to determine the extent of the problem.
In commenting on the recommendations, Education said that it was not
clear to them how collecting more data and tracking outcomes will
increase the likelihood of progressive practices to provide children‘s
mental health services. HHS said that asking the agencies to track this
population of children in foster care does not address the larger point
of the lack of mental health resources for families and communities and
does not address the problems of the children or their parents. HHS
also said we failed to identify to what end these data would be used
and that a request for appropriate funding for states and federal
agencies involved in tracking should accompany the recommendation for
tracking. DOJ agreed that tracking should take place, but only in the
short term, and that HHS should take the lead in such an effort. As we
stated in our recommendation, we believe HHS and DOJ should determine
the feasibility of tracking children to identify the extent and
outcomes of the mental health placements discussed in the report.
Knowledge of the extent of this practice is a necessary first step to
determine what corrective actions might be taken and might be useful in
identifying which progressive practices will most benefit these
children. In addition, without this basic information, the agencies may
unknowingly limit the action steps that they develop to alleviate state
and local officials misunderstandings and thus fail to maximize access
to and the use of existing resources. While the report recognizes that
some mental health resources may be limited, it also describes the
misunderstandings that exist among state and local officials regarding
each agency‘s service requirements, responsibilities, and resources. If
such misunderstandings could be corrected, more children could possibly
be served by the agencies better designed to meet their mental health
needs. Since HHS and DOJ already track various characteristics of all
children placed in the child welfare and juvenile justice systems,
these agencies should determine the feasibility of adding data elements
regarding placement solely to receive mental health services and
determine appropriate time frames for collecting these data.
HHS also said that our estimate of the number of children placed was
presented without context, and asked how the number compares with
various groups--such as the total number of children placed in the two
systems and the number of children who remain outside the system but
are in need of the same kinds of services. We could not, however, make
these comparisons because no agency was tracking these children and we
necessarily relied on the estimates provided, which we believe to be an
underestimate for the reasons stated in this report.
All three agencies said they would participate in any interagency
working group that might be established based on our recommendation and
DOJ recommended using the existing Coordinating Council on Juvenile
Justice and Delinquency Prevention. We believe several organizational
entities may be appropriate and that the member agencies forming this
group should determine the entity that is best suited. HHS, however,
said that an interagency working group would do little to address the
lack of resources. We believe that identifying the causes of the
misunderstandings that are occurring is a first step toward addressing
the lack of resources. Such a group, by promoting a more consistent
understanding of the roles and resources of state and local agencies,
may improve access to services and result in more effective utilization
of existing resources. Education commented that we should be more
specific on the role of the working group in addressing major
differences in terminology and definitions across various legislation,
enormous differences in local interpretation of federal definitions,
and in local practices for establishing eligibility. Education added
that such a group would not have the power to address congressional
lawmaking and noted that no recommendations were made for increased
grant spending to duplicate or disseminate the positive features of
such practices. We believe that our recommendation is broad enough to
encompass the list of issues Education mentions. We also believe that
our recommendation does not preclude the group from recommending
legislative changes as part of its action plan. Regarding Education‘s
comment on information dissemination, we added a recommendation to that
effect.
DOJ also said that while evaluating child mental health programs is a
worthwhile goal, states should consider evaluating their entire systems
of care for children to determine (1) how many children with serious
mental illness are in need of care but unable to obtain it, (2) how
state and local child-serving agencies attempt to address the needs of
these children, and (3) how effective these systemic efforts are in
actually meeting these needs and those of their families. While we
concur that such evaluations are worthwhile, including this suggestion
is beyond the scope of our report.
We also provided a copy of our draft to state officials in the 6 states
we visited (Arkansas, California, Kansas, Maryland, Minnesota, and New
Jersey). Kansas provided technical clarifications, which we
incorporated when appropriate. Minnesota made a general comment that
required no changes in the report, and California said that it had no
suggested corrections or edits.
We are sending copies of this report to the Secretaries of HHS and
Education and the Attorney General, appropriate congressional
committees, state child welfare directors, selected juvenile justice
officials, and others who are interested. We will also make copies
available to others upon request. In addition, the report will be
available at no charge on GAO‘s Web site at http://www.gao.gov.
If you or your staff have any questions, or wish to discuss this
material further, please call me at (202) 512-8403 or Diana Pietrowiak
at (202)
512-6239. Key contributors to this report are listed in appendix VI.
Cornelia M. Ashby
Director, Education, Workforce, and Income Security Issues:
Signed by Cornelia M. Ashby
[End of section]
Appendix I: Scope and Methodology:
To obtain estimates of the number and characteristics of children
voluntarily placed in the child welfare and juvenile justice systems to
receive mental health services, we conducted two surveys. We sent the
first survey to state child welfare directors in the 50 states and the
District of Columbia. We conducted the second survey by telephoning
directors of county juvenile justice agencies in large counties in the
17 states with the largest populations of children under age 18.
Overall, 71 percent of the children in juvenile justice facilities
resided in these states. In most cases, we interviewed juvenile justice
agencies in the two largest counties in each state. We chose to survey
a sample of juvenile justice officials at the county level because,
unlike child welfare, all states do not have a juvenile justice agency.
Also, children who enter the juvenile justice system for mental health
services are more difficult to identify than children who enter through
child welfare systems because parents cannot directly place children in
juvenile justice systems and children cannot enter juvenile justice
solely to access mental health services. Telephone contacts with local
juvenile justice officials allowed us to obtain information from
individuals who were more likely than state officials to have direct
knowledge of how children enter the juvenile justice system.
We asked both groups to estimate[Footnote 29] the number of children
voluntarily placed in their system by actions of their parents in order
to obtain mental health services, the characteristics of the children,
and factors influencing the rate of placements. Table 6 provides survey
numbers and response rates for the surveys.
Table 6: Survey Numbers and Response Rates:
Survey of: Child welfare directors; Number of
surveys conducted: 51; Number of survey responses received: 47.
Survey of: Juvenile justice officials; Number of
surveys conducted: 33; Number of survey responses received: 33.
Source: GAO.
Not all respondents to the surveys answered every survey question. For
example, 19 respondents to the child welfare survey and 30 respondents
to the juvenile justice survey provided estimates of number of children
placed. Some respondents indicated that they were unable to access
information to generate estimates.
[End of table]
Site Visits:
To determine the factors that influence child welfare and juvenile
justice placements for mental health services, we included questions on
these issues in our surveys and interviewed federal, state, and local
officials and national child mental health experts. We interviewed
officials at the Department of Health and Human Services (HHS), the
Department of Justice (DOJ), and Education. We spoke with state and
local officials in
6 states--Arkansas, California, Kansas, Maryland, Minnesota, and New
Jersey--and in one county in each of these states. The officials
represented state and county agencies that were responsible for child
welfare, child mental health, Medicaid, juvenile justice and education
services. We also interviewed judges in 5 states and caseworkers and
parents in all 6 states. Staff of community mental health centers and
other programs serving families with children with a mental illness,
such as a Family Support Organization and a residential treatment
facility, selected parents of children with, or who had, severe mental
illness and invited them to attend our interviews. We selected states
that varied in geographical location, legal requirements concerning
placement, the use of Medicaid options and waivers, and the authority
of state and county agencies in administering child welfare and
juvenile justice programs; and counties that varied in demographic
characteristics.
To identify promising practices that may reduce the need for some child
welfare and juvenile justice placements by meeting the needs of
children with a mental illness and their families, we asked national
experts and state and local officials to identify such practices in the
states that we visited. We visited 16 programs that embodied these
practices.
We conducted our work between March 2002 and February 2003 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix II: State Statutes Containing Language Allowing Voluntary
Placement to Obtain Mental Health Services:
Table 7: Statutes in 11 States Allowing Parents to Place Children in
Child Welfare Systems in Order to Obtain Mental Health Services While
Retaining Custody of the Child:
State: Alaska; Statute citation: M.S.A. Section 260C.201 (3); Statute:
Where a parent enters into a voluntary placement agreement, the
agreement may not preclude the parent from regaining care of the child
at any time.
State: Colorado; Statute citation: C.R.S.A. Section 19-3-701(1);
Statute: Where a parent voluntarily places a child out of the home for
the purpose of obtaining treatment for an emotional disability solely
because the parent is unable to provide care, relinquishment of legal
custody is not required.
State: Connecticut; Statute citation: C.G.S. A. Section 17a-129;
Statute: Their shall be no requirement for the Department to seek
custody or protective supervision of a child or youth who needs or is
receiving voluntary services unless the child or youth is otherwise
alleged to be neglected or abused.
State: Iowa; Statute citation: I.C.A. Section 232.1784 and 232.182 (5)
(d); Statute: Petitions for voluntary placements shall describe the
child‘s emotional disability which requires care and treatment; the
reasonable efforts to maintain the child in the child‘s home; a
determination of whether services or support provided to the family
will enable the family to continue to care for the child in the child‘s
home; and the reason the child‘s parent has requested a foster care
placement. A court may only order foster care placement if it makes a
determination that services or support provided to the family will not
enable the family to continue to care for the child in the child‘s
home. If the court finds that reasonable efforts have not been made and
that services or support are available to prevent placement, the court
may order the services or support to be provided to the child.
State: Maine; Statute citation: 22 M.R.S.A. Section 4004-A(1) and (2);
Statute: If certain conditions are met, a parent may enter into a
voluntary placement agreement in which the parent retains legal custody
of the child.
State: Minnesota; Statute citation: M.S.A. Section 260C.201(3);
Statute: If a court determines a child is in need of special services
to treat a mental disability, the court may order the child‘s parent or
health plan company to provide such services. If the parent or the
health plan is unable to provide care, the court may order that
treatment be provided. If the child‘s disability is not the result of
abuse or neglect by the parent, the court shall not transfer legal
custody of the child in order to obtain treatment solely because the
parent is unable to provide care.
State: North Dakota; Statute citation: N.D.C.C. 50-06-06.13; Statute:
The Department of Human Services may not require a parent to relinquish
legal custody in order to have the child voluntarily placed.
State: Oregon; Statute citation: O.R.S. Section 418.312(1)and (2);
Statute: To have a child placed in a foster home, group home, or
institutional child care setting for the sole purpose of obtaining
services for the child‘s emotional or mental disorder, a parent is not
required to transfer legal custody. Rather, the child is placed
pursuant to a voluntary placement agreement that specifies the rights
and obligations of the parent, the child, and the Department of Human
Services.
State: Rhode Island; Statute citation: R.I.S.T. Section 14-1-11.1;
Statute: Where a parent voluntarily places a child with an emotional
disorder with the Department of Human services for the purpose of
accessing an out-of-home program, relinquishment of legal custody is
not required.
State: Wisconsin; Statute citation: W.S.A. Section 48.13(4) and
938.34(6)(a) and (ar); Statute: Where a parent is financially unable to
provide treatment for a child, the parent may sign a petition giving a
court exclusive jurisdiction. The court may then order an appropriate
agency to provide treatment whether or not legal custody has been taken
from the parent.
State: Vermont; Statute citation: 33 V.S.A. Section 4305(g); Statute: A
child with an emotional disorder may receive services, including an
out-of-home placement, without a parent surrendering legal custody.
Source: GAO analysis.
[End of table]
[End of section]
Appendix III: Comments from the Department of Education:
UNITED STATES DEPARTMENT OF EDUCATION:
OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES:
MAR 19 2003:
THE ASSISTANT SECRETARY:
Ms. Cornelia Ashby:
Director, Education, Workforce, and Income Security Issues:
General Accounting Office 441 G Street, NW Washington, DC 20548:
Dear Ms. Ashby:
Thank you for the opportunity to review Draft Report GAO-03-397, Child
Welfare and Juvenile Justice: Federal Agencies Could Play a Stronger
Role in Helping States Reduce the Number of Children Placed Solely to
Obtain Mental Health Services. I am pleased to respond on behalf of the
Department of Education.
We have shared with your staff a range of comments, suggestions and
editorial observations, some of which we consider significant. It would
be desirable in our view for your final report to use terminology
consistent with the terminology used in the Individuals with
Disabilities Education Act (IDEA) and supporting regulations when
discussing special education and related services, and educational
settings. Many of our comments are directed at increasing technical
accuracy and hopefully reducing confusion in recognition of the fact
that ’children with mental illness“ is not a term used in IDEA.
’Emotional disturbance“ is defined at 34 CFR 300.7(c)(4), however.
’Autism“ and ’other health impairment“ are also defined at 300.7.
Similarly, the term ’mental health services“ is not used in IDEA, but
certain ’related services“ such as counseling services or psychological
services may be provided to students in special education.
In addition to my program responsibilities at the Department I have
been representing Secretary Rod Paige on the President‘s New Freedom
Commission on Mental Health, which is mentioned in the draft report.
The Commission has considered information about the relinquishment
issue and a reference to this may be found on the Commission‘s website
at:
http://www mentalhealtheommission.gov/subcommittee/rights022803.doc:
The Department would, of course, participate in any interagency working
group to be established according to the recommendation on page 38 of
the draft report.
I hope our comments have been helpful.
Signed by Robert H. Pasternack, Ph.D
Child Welfare and Juvenile Justice Draft Report:
Substantive Changes:
1. Page ii in the list of abbreviations, IEP is incorrectly defined.
IEP
stands for ’Individualized Education Program.“ Also make correction on
Table on page 8.
2. Eligibility for special education and related
services (including mental health services) needs to be clarified. It
needs to be clear that a diagnosis of mental illness does not
necessarily qualify a child for special education and related services.
The student must be a ’child with a disability“ as defined by IDEA. The
following pages in the document need clarification in this regard:
a. Page 2, middle of the page. The sentence that reads: ’Similarly, the
Department of Educations‘ (Education) Office of Special Education and
Rehabilitative Services (OSERS) provides funding and technical
assistance to help states provide needed services to disabled children
with special education needs - including those with mental illness.“:
b. Page 28, second paragraph:
c. Page 8 identifies the children IDEA serves as ’children with mental
illness. That terminology is not in the IDEA statute or regulations. A
child with ’emotional disturbance“ (ED) is defined in the regulations
and should be used here. Further, the definition of eligibility used in
this table indicates that ’Only children who fail to make adequate
progress because of their disability are eligible for special education
or related services such as mental health services.“ This is NOT
consistent with the IDEA. Many students with ED are relatively high
functioning and, especially when they receive necessary supports and
services, can be academically successful. Furthermore, many students
’with mental illness“ in terms of other funding agencies are actually
served under different (from ED) categories within IDEA, notably
’autism“ and ’other health impaired.“ See attached page for specific
revisions to this table. Be sure the table is revised consistent with
IDEA.
d. Page 19, section on ’Multiple Factors Influence Decisions to Place
Children.“:
e. Page 30, second paragraph, ’Also, some parents and professionals
misunderstood that IDEA gives all disabled children, including mentally
ill children, the right to a free and appropriate education....“ This
sentence is confusing and unclear. IDEA requires that FAPE be made
available to all children eligible under IDEA. It should be noted that
’free appropriate public education does not contain the word ’and.“:
3. Page 28, first full paragraph: It should be noted that the use of
the
terms ’adequate educational progress,“ ’adequate progress“ and
’educational progress“ is not consistent with the provisions of the
IDEA and the regulations. The
standard used in the regulations is whether the disability ’adversely
affects a child‘s educational performance.“ See 34 CFR 300.7. A student
can be making
progress and advancing from grade to grade but may still require and be
eligible for special education or related services.
4. The ’least restrictive environment“ and the individualized nature of
special education services need to be clarified. The sentence ’... did
not support residential placement for children except in extraordinary
situations because federal law requires that they provide services for
all disabled children including mentally ill children in the least
restrictive setting as possible...“ (page 5, first sentence) does not
accurately reflect the individualized nature of special education. The
requirement under IDEA is not the ’least restrictive environment“ as
possible. Rather, under IDEA, to the maximum extent appropriate,
children with disabilities are to be educated with children who are not
disabled, based on the needs of the child. Although this conception is
attributed to the ’officials,“ it may convey an impression that the
IDEA requires the most ’possibly“ LRE. Similarly, the reference to
’least restrictive alternative“ on page 9 (second paragraph),
oversimplifies the construct of LRE under IDEA which includes a broad
range of appropriate service locations/levels. See also, Page 19,
section on ’Multiple Factors Influence Decisions to Place Children.“:
5. The ’large grant program“ [$52 million] (p. 9, 1st par.) with
collaboration across OJJDP, SAMHSA, and Education is managed, within
the Dept. ED, by Safe and Drug Free Schools (SDFS), without involvement
by OSERS. That should be noted, since OSERS is the only Dept. ED POC/
program identified in the document.
6. ’Wrap-around services....“ described in Footnote 15, p. 20, should
include education, or ’instruction.“ Which is an important component of
wrap-around services for children and their families.
7. Page 17, last sentence regarding OSERS data base. It should be noted
that OSERS does collect data (number and percent) of children with
disabilities age 6 through 21 served in correctional facilities by
state and by race.
8. Page 29, second paragraph, first sentence, refers to ’specialized
education services.“ Is this different than ’special education“?
9. Page 30, second paragraph, should make clear that it is not a
federal
requirement that referrals for special education must be in writing.
10. Throughout the document, numerous references are made to
’misunderstandings“ on the part of state and local personnel in
interpreting Federal law (example, p. 38, middle paragraph, last
sentence). This characterization may be both
prejudicial and, in many instances, incorrect. Most of the various
federal laws concerning this population are purposely vague, open to
interpretation, and (in the case of IDEA) actively supportive of State
determination of actual procedures and how they will be interpreted.
This is particularly apparent for students with emotional disturbance.
Each State defines eligibility for these students, using the federal
definition as guidance. States vary greatly in terms of the labels they
use for this population. More States use variants of ’emotional and
behavioral disorders“ than the terminology of ’emotionally disturbed,“
which is generally considered pejorative. If the term
’misunderstandings“ is retained the following phrase should be added:
’regarding the roles of the various agencies that provide mental health
services...“:
11. The recommendations do not well address the findings of the report.
For example-The conclusion and recommendations sections talk a lot
about tracking data on placements and outcomes (though outcomes are not
defined). However, the bulk of the report speaks to the real issues of
the logistical, policy, and resource limitations that limit the
availability of and access to MH services for kids. Starting on page
31,
several positive examples of more effective practices are also
featured. It is not clear how collecting more data and tracking
unspecified outcomes will increase likelihood of these more progressive
practices. The recommendations do little to build on these strong
practices, and no recommendations are made for increased grant spending
to duplicate or disseminate these positive features.
At a minimum, the report should be more specific about some of the
objectives that the workgroup should address and include key issues
like major differences in terminology and definition across various
legislation, enormous differences in local interpretation of federal
definitions and in local practices for establishing eligibility.
Similarly, attention should be given to the multiplicity,
fractionalization, and incongruity of legislation and funding for these
populations as a major impediment to any cohesive coordination of
services across agencies, at Federal, State, and local levels. A
federal (executive) panel is not the sort of body empowered, or
appropriate, to address Congressional law-making on these services, but
can the GAO recommend an independent organization for that guidance,
and explicitly suggest that they examine inconsistencies and other
problems in the multiple pieces of legislation and programs?
12. The draft report does not mention the Independent Living Services
Program administered by the Rehabilitation Services Administration
(RSA), a component of OSERS. We believe that independent living
programs are a potential resource for supportive services for children
with mental illness and their families.
[End of section]
Appendix IV: Comments from the Department of Health and Human Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES Office of Inspector General:
Washington, D.C. 20201:
APR 3 2003:
Ms. Cornelia M. Ashby Director, Education, Workforce, and Income
Security Issues United States General Accounting Office Washington,
D.C. 20548:
Dear Ms. Ashby:
Enclosed are the department‘s comments on your draft report entitled,
’Child Welfare and Juvenile Justice: Federal Agencies Could Play a
Stronger Role in Helping States Reduce the Number of Children Placed
Solely to Obtain Mental Health Services.“ The comments represent the
tentative position of the department and are subject to reevaluation
when the final version of this report is received.
The department also provided several technical comments directly to
your staff.
The department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Dennis J. Duquette:
Signed by Dennis J. Duquette:
Acting Principal Deputy Inspector General:
Enclosure:
The Office of Inspector General (OIG) is transmitting the department‘s
response to this draft report in our capacity as the department‘s
designated focal point and coordinator for General Accounting Office
reports. The OIG has not conducted an independent assessment of these
comments and therefore expresses no opinion on them.
Comments of the Department of Health and Human Services on the General
Accounting Office‘s Draft Report, ’Child Welfare and Juvenile Justice:
Federal Agencies Could Play a Stronger Role in Helping States Reduce
the Number of Children Placed Solely to Obtain Mental Health Services“
(GAO-03-397):
The Department of Health and Human Services (department) appreciates
the opportunity to comment on this draft report which addresses the
causes for and possible solutions to the high number of children placed
in the child welfare and juvenile justice systems solely to obtain
mental health services.
General Comments:
The department agrees that this report is comprehensive, interesting
and provides an informative overview of the concerns with which child
welfare agencies and juvenile justice systems are confronted when
children and youth do not receive adequate mental health services
within the community. The family scenarios are realistic, presenting
the challenges families face in obtaining mental health services for
severely, emotionally disturbed children.
The GAO‘s use of multiple methods to highlight the deficiencies in how
these clients are currently served increases our federal understanding
of the problems.
The GAO‘s major concern appears to be access to and availability of
mental health services for adolescents outside of state child welfare
systems. The GAO identifies and illustrates the core issue well; mental
health services, particularly community based alternatives, are under-
funded and it is the scarcity of these resources that causes parents to
seek placement to meet the mental health needs of their children. Thus,
the problem is not really with the child welfare or juvenile justice
systems, but caused by a lack of appropriate mental health services at
the state and local levels, and the inadequacy of mental health
insurance coverage in general. The report is relatively critical of
state and local agencies for ’inappropriately“ using child welfare and
juvenile justice placements to get services to children who need them
and who cannot access them through other channels. The department is
concerned that unless or until alternative ways of accessing services
are available, condemning agencies that do what they can to meet
families‘ needs may further impede access for families seeking
treatment for children‘s serious mental health conditions.
The GAO identifies in its report that child welfare agencies often have
the same difficulty accessing services that parents face. Committing a
child to the custody of child welfare does not assure his/her mental
health needs will be met. Such commitments are often made in order to
access the funds that child welfare or juvenile justice has available
to pay for residential treatment services, and may not address other
mental health services.
The Administration for Children and Families (ACF) uses the child and
family services review (CFSR) process to identify states‘ success in
meeting children‘s mental health:
needs. In part, the CFSRs allow ACF and states to evaluate the outcomes
for children involved with the child welfare agency and develop plans
to improve the outcomes when they are inconsistent with federal
standards and requirements. The CFSRs are comprehensive, focusing on
all children receiving child welfare services in their own homes or in
foster care placements. Many of the findings in the GAO report mirror
what the CFSRs have found to date:
* Mental health services are in short supply and often inaccessible to
the children and families who need them.
* Children with mental health problems are often committed to the
custody of the child welfare system which is ill equipped to serve
them.
* State Systems of Care offer effective means of serving children with
high-end needs.
Some of the findings of the CFSRs with regard to mental health services
include:
* All 32 states reviewed to date will need to enter into Program
Improvement Plans (PIP) to strengthen the quality of needs assessment
and service delivery to children and families. This is a critical issue
since caseworkers often fail to identify important needs of children,
including mental health needs, when they develop case plans and provide
services.
* Thirty-one of the 32 states failed to achieve positive ratings on the
indicator in the CFSR that addresses the provision of physical and
mental health services. Most often, it is the mental health area that
is lacking.
* Access to services is one of the weakest areas of performance
identified among the 32 states reviewed. Most often, the more
specialized services, such as children‘s mental health services and
substance abuse treatment, are among the services that are either
lacking or inaccessible due to wait lists, location, etc.
GAO Recommendations for Executive Action:
To determine the extent to which children may be placed inappropriately
in the child welfare and juvenile justice systems in order to obtain
mental health services, we recommend that the Secretary of HHS and the
Attorney General investigate the feasibility of tracking these children
to identify the extent and outcomes of these placements. To help reduce
misunderstanding at the state and local levels, we also recommend that
the Secretaries of HHS and Education, and the Attorney General develop
an interagency working group to identify the causes of these
misunderstandings and create an action plan to address those causes. We
further recommend that these agencies continue to encourage states to
evaluate the child mental health programs they fund or initiate.
Department Response:
The report articulates significant problems already identified, yet
basically recommends further study. The recommendation to track this
population of children in foster care:
does not address the larger point of lack of mental health resources
for families and communities and does not address the problems of the
children or their parents. While the department is not fundamentally
opposed to collecting data on the number of children who enter foster
care solely for mental health reasons, GAO fails to identify to what
end this data would be used. Appropriate funding for states and the
federal agencies involved in tracking should accompany the request for
further tracking.
We are not opposed to meeting with our federal counterparts and have,
in fact, identified it as an activity that ACF needs to undertake to
further the goals of the CFSR. We require interagency coordination at
the state level and ACF intends to model such behavior at the federal
level. We would be glad to participate in a special workgroup or
utilize one of the interagency bodies already established such as the
Public-Private Partnership on Mental Health Services for Children and
Youth to thoroughly examine the issue. If a special workgroup were
chosen as the best way to examine the problem, ACF would agree to co-
chair this activity with appropriate staff from the Substance Abuse and
Mental Health Services Administration (SAMHSA). However, once again, we
fail to see how GAO‘s recommendation will truly address the core issue.
Forming an interagency group to look at state and local
misunderstandings of agency roles and program requirements and
educating state agencies with respect to federal requirements, roles,
and responsibilities will do little to address the lack of resources.
Other comments:
In order to address the specific problem under study, a broader look at
the status of children‘s mental health services in general would be
useful. The report could go further in stating explicitly that the
problems in children‘s mental health that lead to parents committing
their children to the child welfare or juvenile justice system in order
to obtain services are part of the bigger problem of children‘s mental
health services in general, i.e., limited or non-existent services,
lack of access, lack of quality providers, etc.
The data on the Highlights page are presented without context, i.e.,
12,700 children were placed in order to receive mental health services.
What percentage is that of the total number of children placed in these
two systems? And how many children remained ’outside“ the system but in
need of the same kind of deep-end, seriously emotionally disturbed-type
services? Without a comparison group there is no sense of proportion or
scale. Is this a relatively small percentage/low base rate occurrence?
Is this number ’bad“ or a traumatic decision for any parent to make, or
is it an unnecessary drain on the public coffers?
The report would benefit from the inclusion of more detail about the
terms ’voluntary placement“ and ’custody relinquishment.“ What is the
exact meaning of these terms and what are the legal and other
implications for parents and children? In a few pages, e.g., on page
27, the question of ’custody relinquishment“ is mentioned.
The GAO stated that, ’Although Federal law does not require custody
relinquishment to obtain mental health services, state child welfare
officials in two states that they visited:
said that their state required parents to relinquish custody of their
child to the state after the voluntary placement period ended.“ In one
state these officials misconstrued federal requirements and believed
that they required relinquishment and in the other state officials said
relinquishment enabled them to have more control over the child‘s care.
We would like to see a more fundamental and basic discussion on such
questions as whether relinquishment of custody may be permanent or
reversible, how this may differ from state to state, or exactly how
custody relinquishment may affect parents and children. It would be
helpful if these terms and questions were defined and discussed in a
discrete section in the beginning of the report.
Input provided by SAMHSA concerning ’voluntary“ placement was not
accurately reflected in the report. Voluntary placement is a legal term
(in the states that allow this process to be used) which allows custody
to automatically return to the parents at the end of the treatment for
the mental health issues. This term is used in the report as an act on
the part of the parents.
We have some concern about the completeness of the study and the
conclusions it draws based on the sample, to the extent they were
included in the study, that a large group of vested individuals--the
parents of the children who were relinquished--could have provided
additional information regarding their motivations and the outcomes of
their decisions to place children within the child welfare system.
Responses to the questions below could provide valuable insight into
this issue:
* Who helped the parents to see this relinquishment as a solution to
the
problem?
* How did the parents approach the child welfare agency or did
the agency approach them?
* Were they satisfied, e.g. did their child receive the services they
needed or the services that the parents wanted for them?
* Did those services help their child and did things get better
(whatever measure the parents used) for their child?
* Did parents try to ’undo“ these relinquishments?
* Did agencies actually deliver on the services?
* Did the kids get what they needed to have better lives?
The report gives a short view of the system‘s placement record with
these children. This missing outcome piece gives an incomplete picture
of the problem.
The GAO mentioned two big caveats, but did not address them as such in
the conclusions. The conclusions should at least include caveats, e.g.,
there are no formal or comprehensive federal or state tracking
placement occurrences and the findings may not have any statistical
significance. Data was not provided from the five states that have the
largest populations of children.
[End of section]
Appendix V: Comments from the Department of Justice:
U.S. Department of Justice Office of Justice Programs:
Office of the Assistant Attorney General
Washington, D. C. 20531:
Cornelia M. Ashby Director:
Education, Workforce, and Income Security Issues General Accounting
Office:
441 G Street, NW, Room 5928 Washington, DC 20548:
APR 07 2003:
Dear Ms. Ashby:
This letter is in response to the General Accounting Office (GAO) draft
report entitled, ’CHILD WELFARE AND JUVENILE JUSTICE: Federal Agencies
Could Play a Stronger Role in Helping States Reduce the Number of
Children Placed Solely to Obtain Mental Health Services ’(GAO-03-397).
It is clear from this report that GAO conducted an in-depth and
comprehensive review under very difficult circumstances. None of the
states surveyed collected data on these children and their families,
and information provided by state officials was most often offered in
anecdotal form. While we consider the draft report to be both thorough
and well-written, we believe that it could be further refined and
strengthened.
In general, we are concerned that the report presents the information
provided by state officials as being solid and conclusive, when, in
fact, it is highly speculative. The danger here is that readers of the
report will conclude that state officials‘ statements are sufficiently
accurate
and reliable to form the basis for recommended changes in policy and
practice. We believe that the tenuous nature of the data precludes its
use as a sound basis for policy change. Instead, we would recommend
that the report emphasize both the lack of empirical support for state
officials‘ statements, as well as the urgent need for state and local
jurisdictions to develop and implement plans for the collection of
reliable, valid, and relevant data.
A number of statements in the report suggest that the evidence base
regarding voluntary custody relinquishment is sufficiently strong to
support recommendations for policy change. The reality, however, is
that data on this issue are minimal, if not non-existent. On the
’Highlights“ page, for example, a sentence in the first paragraph
states, ’Although no agency tracks these children or maintains data on
their characteristics, officials said most are male, adolescent, often
have multiple problems, and many exhibit behaviors that threaten the
safety of themselves and others.“ If no agency maintains relevant data,
then it is unclear how officials could have developed such specific
characterizations of these children. The report should
provide some information regarding how officials have reached these
conclusions in the absence of reliable statistics.
The report contains recommendations that apply specifically to the
Attorney General. While we concur with the general outline of these
recommendations, we believe that certain revisions are appropriate. The
report recommends, ’...that the Secretary of [Health and Human
Services] and the Attorney General investigate the feasibility of
tracking these children to identify the extent and outcomes of these
[inappropriate] placements.“ As noted in the enclosure, we strongly
encourage the collection of relevant data to determine the nature and
extent of these inappropriate placements. Institution of a long-term
tracking program, however, appears premature, as we currently have no
data regarding the true scope of the problem. Our ultimate goal is to
eliminate any need for parents to place their children in the child
welfare or juvenile justice systems to obtain needed mental health
services. Tracking inappropriate placements does little to further this
goal.
Because the primary source of the problem appears to be a lack of
available mental health care services, Health and Human Services (HHS)
should take the lead in this investigation. The Attorney General should
also play a role, especially in data collection from within the
juvenile justice system. Special considerations (e.g.,
confidentiality, coordination with defense and prosecuting attorneys)
may apply to data obtained from youth and families involved with the
juvenile court, and Department of Justice (DOJ) will be glad to assist
HHS in understanding the complexities of data collection in juvenile
justice settings.
The second recommendation involves the creation of an interagency
working group by the Secretaries of HHS and Education and the Attorney
General ’to help reduce misunderstandings at the state and local level
..... [and] to identify the causes of these misunderstandings and
create an action plan to address those causes.“ We agree with the
importance of an interagency effort to elucidate the causes of this
problem, and to identify policy and programmatic changes that would
address those causes. We recommend that the existing, statutorily
mandated Coordinating Council on Juvenile Justice and Delinquency
Prevention‘, which contains representatives from all the identified
Federal agencies, serve as the vehicle for implementing this
recommendation.
GAO concludes the report by recommending that, ’...these agencies
continue to encourage states to evaluate the child mental health
programs that they fund or initiate.“ Although the evaluation of child
mental health programs is a worthwhile goal, it does not appear to
address the specific issues raised by this report. The report does not
identify ineffectiveness of existing mental health programs as a source
of inappropriate placement. Rather, the key issue is a lack of
placement opportunities in existing mental health facilities. States
should consider evaluating their entire systems of care for children,
in order to determine: a) how many children with serious mental illness
are in need of care but unable to obtain it; b) how the state and local
child-serving agencies (e.g. education, child welfare, mental health,
juvenile justice) attempt to
address the needs of these children; and c) how effective these
systemic efforts are in actually meeting the mental health needs of
these youth and their families.
We appreciate the opportunity to provide comments to the draft report.
Additional specific comments are enclosed for GAO‘s consideration. If
you have any questions concerning this response, please contact me on
(202) 307-5933, or LeToya Johnson, Office of Justice Programs Audit
Liaison, on (202) 514-0692.
Sincerely,
Deborah J. Daniels Assistant Attorney General:
Signed by Deborah J. Daniels:
Enclosure:
cc: J. Robert Flores, Administrator:
Office of Juvenile Justice and Delinquency Prevention:
Cynthia J. Schwimer Comptroller, OJP:
LeToya A. Johnson Audit Liaison, OJP:
Vickie L. Sloan Audit Liaison, DOJ:
OAAG Executive Secretariat Control No. 20030602:
[1] 42 U.S.C. § 5616.
[End of section]
Appendix VI: GAO Contacts and Acknowledgments:
GAO Contacts:
Diana Pietrowiak (202) 512-6239
Kathleen D. White (202) 512-8512
:
Acknowledgments:
In addition to those named above, Karen A. Brown, Erin Williams, and
Katherine L. Wulff made key contributions to the report. Rebecca Shea,
Patrick Dibattista, Alice London, Behn Miller, and Carolyn Yocom
provided key technical assistance.
[End of section]
Related GAO Products:
Medicaid and SCHIP: States Use Varying Approaches to Monitor Children‘s
Access to Care. GAO-03-222. Washington, D.C.: January 14, 2003.
Mental Health Services: Effectiveness of Insurance Coverage and Federal
Programs for Children Who Have Experienced Trauma Largely Unknown. GAO-
02-813. Washington, D.C.: August 22, 2002.
Medicaid and SCHIP: Recent HHS Approvals of Demonstration Waiver
Projects Raise Concerns. GAO-02-817. Washington, D.C.: July 12, 2002.
Foster Care: Recent Legislation Helps States Focus on Finding Permanent
Homes for Children, but Longstanding Barriers Remain. GAO-02-585.
Washington, D.C.: June 28, 2002.
Long-term Care: Implications of Supreme Court‘s Olmstead Decision Are
Still Unfolding. GAO-01-1167T. Washington, DC: September 24, 2001.
Medicaid and SCHIP: States‘ Enrollment and Payment Policies Can Affect
Children‘s Access to Care. GAO-01-883. Washington, D.C.: September 10,
2001.
Medicaid: Stronger Efforts Needed to Ensure Children‘s Access to Health
Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001.
Medicaid Managed Care: States‘ Safeguards for Children With Special
Needs Vary Significantly. GAO/HEHS-00-169. Washington, D.C.: September
29, 2000.
Children with Disabilities: Medicaid Can Offer Important Benefits and
Services. GAO/T-HEHS-00-152. Washington, D.C.: July 12, 2000.
Mental Health Parity Act: Employer‘s Mental Health Benefits Remain
Limited Despite New Federal Standards. GAO/T-HEHS-00-113. Washington,
D.C.: May 18, 2000.
Mental Health Parity Act: Despite New Federal Standards, Mental Health
Benefits Remain Limited. GAO/HEHS-00-95. Washington, D.C.: May 10,
2000.
Medicaid Managed Care: Challenges in Implementing Safeguards for
Children with Special Needs. GAO/HEHS-00-37. Washington, D.C.: March 3,
2000.
FOOTNOTES
[1] Federal agencies and states have varying definitions for children
with serious emotional disturbances (SED). For example, the Department
of Health and Human Services‘ (HHS) Substance Abuse and Mental Health
Services Administration (SAMHSA) defines SED as a diagnosable mental
disorder found in persons from birth to 18 years of age that is so
severe and long lasting that it seriously interferes with functioning
in family, school, community, or other major life activities. Because
of these differences, we use the term ’children with severe mental
illness“ throughout this report.
[2] Child welfare systems are designed to protect children who have
been abused or neglected by, for example, placing children in foster
care or providing family preservation services; and juvenile justice
systems are designed to rehabilitate children who have committed
criminal or delinquent acts and to prevent such acts from occurring.
Consequently, the goals of these systems and the background and
training of their staff reflect these purposes. In addition, parents
cannot voluntarily place their children in the juvenile justice system-
-children are detained in this system as a result of their delinquent
acts or status offenses--that is, according to the Department of
Justice (DOJ), behaviors that are law violations only if committed by
juveniles. However, parents sometimes request that police arrest their
children for delinquent behaviors or status offenses that are related
to or stem from their mental illness when they cannot obtain services
through other means. In this report, we use the term ’placed“ to refer
both to children who have been voluntarily placed in the child welfare
system and children who enter the juvenile justice system to receive
mental health services. Because information was not available, we were
not able to report on whether parents relinquished custody of their
children to obtain the services.
[3] In commenting on a draft of this report, HHS said that federal
reimbursement is only available for children placed by a juvenile
justice agency when that agency has an agreement with a child welfare
agency under Title IV-E. HHS also said that many facilities that treat
children with serious mental health issues are not considered within
the scope of foster care and the Title IV-E program. Some states have
developed procedures for using Title IV-E funding for the residential
placement of children with mental health needs by arranging for courts
to make similar findings in these cases as are required for the
placement of children removed for safety reasons in situations of abuse
and neglect.
[4] A residential treatment facility is an inpatient facility, other
than a hospital, that provides psychiatric services to individuals
under age 21.
[5] The 11 states are: Alaska, Colorado, Connecticut, Iowa, Maine,
Minnesota, North Dakota, Oregon, Rhode Island, Wisconsin, and Vermont.
[6] The 8 states are: Florida, Georgia, Hawaii, Kansas, Missouri,
Montana, New Hampshire, and Texas.
[7] Child-serving agencies include mental health, Medicaid and SCHIP,
juvenile justice, education, and child welfare.
[8] Medicaid is a federal-state health financing program for certain
low-income individuals established by Title XIX of the Social Security
Act; under Medicaid, states must meet minimum federal rules of coverage
in order to receive federal matching dollars. People eligible for
Medicaid can generally be divided into three categories: (1) the
mandatory categorically needy, (2) the optional categorically needy,
and (3) the medically needy. States have several methods by which they
can customize their Medicaid program to meet the needs of these
enrollees. States can choose to cover certain optional services, such
as prescription drugs, or certain optional populations; for example,
several states have expanded eligibility for Medicaid to certain groups
of children who would not otherwise qualify for the program because
their families‘ incomes are too high. A limited number of states can
also request that HHS waive certain statutory requirements for a
specified period of time.
[9] U.S. General Accounting Office, Mental Health Services:
Effectiveness of Insurance Coverage and Federal Programs for Children
Who Have Experienced Trauma Largely Unknown, GAO-02-813 (Washington,
D.C.: Aug. 22, 2002).
[10] IDEA requires that, to the maximum extent possible, children with
disabilities are to be educated with children who are not disabled,
based on the needs of the child.
[11] U.S. General Accounting Office, Health Insurance: States‘
Protections and Programs Benefit Some Unemployed Individuals,
GAO-03-191 (Washington, D.C.: Oct. 25, 2002).
[12] This waiver authority for seriously ill children was inspired by
the case of a ventilator dependent child, Katie Beckett. Katie‘s mother
successfully argued that the nursing services her daughter required
could be provided in her home and at a cost less than that of providing
the same care in a hospital. What resulted was the so-called ’Katie
Beckett Waiver,“ enacted as part of the Tax Equity and Fiscal
Responsibility Act (TEFRA) of 1982.
[13] Not all severely limited children with a mental illness who meet
SSI‘s income requirements are eligible for SSI payments because of
SSI‘s strict definition of disability. Federal SSI payments for
disabled children range from $1 to $545 and some states supplement
these payments. Although most children who receive SSI payments are
eligible for Medicaid, some are not.
[14] Twenty-eight states provided estimates. Nine states could not
provide the data requested, 9 states said the practice of voluntary
placement is not legal in their states, 11 states could not provide the
data requested, but indicated that voluntary placement happens. Four
states did not respond to our survey.
[15] These 4 states were Alaska, Illinois, Louisiana, and South
Carolina.
[16] In commenting on a draft of this report, DOJ said that, in the
absence of formal tracking and official data, describing with any
certainty the characteristics of youth placed voluntarily by their
parents in the juvenile justice system is impossible.
[17] Bipolar disorder is characterized by the occurrence of one or more
major depressive episodes accompanied by at least one manic episode
over a brief time interval.
[18] These services are generally provided by licensed or certified
psychiatrists, psychologists, or master‘s level social workers.
[19] Respite care refers to the supervision of mentally ill or other
disabled children by a trained caretaker for brief periods of time in
order to provide parents relief from the strain of caring for a child
with serious mental illness. Wrap-around services encompass a variety
of community supports, including counseling, mentoring, tutoring, and
economic services that are designed to meet the individual needs of
children and their families.
[20] See ERISA, 29 U.S.C. sections 1001-1461.
[21] In commenting on a draft of this report, Kansas said that services
the state provides under the Rehabilitation option are not limited to
60 days, but are based on the individual clinical and medical needs of
a child.
[22] U.S. General Accounting Office, Medicaid: Stronger Efforts Needed
to Ensure Children‘s Access to Health Screening Services, GAO-01-749
(Washington, D.C.: July 13, 2001).
[23] Attention deficit disorder is a syndrome characterized by serious
and persistent difficulties in attention span, impulse control, and,
sometimes, hyperactivity.
[24] Schizophrenia is a cluster of disorders characterized by
delusions, hallucinations, disordered thinking, and emotional
unresponsiveness.
[25] The California legislature transferred the responsibility for
providing mental health services to children in special education from
schools to counties in the late 1980s.
[26] In commenting on a draft of this report, Education said that most
of the federal laws concerning this population are purposely vague,
open to interpretation, and (in the case of IDEA) actively supportive
of state determination of actual procedures and how they will be
interpreted.
[27] TANF, created by the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996, provides assistance and work opportunities
to needy families by granting states federal funds and flexibility to
develop and implement their own welfare programs.
[28] Diversion programs attempt to prevent or reduce the time children
spend in inappropriate placements.
[29] Child welfare directors and juvenile justice officials used a
variety of means to estimate the numbers of children placed. For
example, some child welfare directors spoke to their counterparts at
the local level and asked them to provide estimates. In other
instances, the directors estimated based on the number of children
receiving the highest level of mental health services.
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