Hurricane Katrina
Barriers to Mental Health Services for Children Persist in Greater New Orleans, Although Federal Grants Are Helping to Address Them Gao ID: GAO-09-935T August 4, 2009This testimony discusses the protection of children during disaster recovery and to provide highlights of our July 2009 report entitled Hurricane Katrina: Barriers to Mental Health Services for Children Persist in Greater New Orleans, Although Federal Grants Are Helping to Address Them. The greater New Orleans area has yet to fully recover from the effects of Hurricane Katrina, which made landfall on August 29, 2005. One issue of concern in the recovery is the availability of mental health services for children. In our report, we estimated that in 2008 about 187,000 children were living in the greater New Orleans area--which we defined as Jefferson, Orleans, Plaquemines, and St. Bernard parishes. Many children in the greater New Orleans area experienced psychological trauma as a result of Hurricane Katrina and its aftermath, and studies have shown that such trauma can have long-lasting behavioral, psychological, and emotional effects on children. Poor children in this area may also be at additional risk, because studies have also shown that children who grow up in poverty are at risk for the development of mental health disorders. In 2007 the poverty rate for each of the four parishes in the greater New Orleans area was higher than the national average, and in Orleans and St. Bernard parishes, the rate was at least twice the national average. Experts have found increases in the incidence of depression, post-traumatic stress disorder symptoms, risk-taking behavior, and somatic and psychosomatic conditions in children who experienced the effects of Hurricane Katrina. In addition, children in greater New Orleans may continue to experience psychological trauma because of the slow recovery of stable housing and other factors, such as the recurring threat of hurricanes. Data collected by Louisiana State University (LSU) Health Sciences Center researchers indicate that of the area children they screened in January 2008, 30 percent met the threshold for a possible mental health referral. Although this was a decrease from the 49 percent level during the 2005-06 school year screening, the rate of decline was slower than experts had expected. Experts have previously identified barriers both to providing and to obtaining mental health services for children. Barriers to providing services are those that affect the ability of health care organizations to provide services, such as a lack of providers; and barriers to obtaining services are those that affect the ability of families to gain access to services, such as concerns regarding the stigma often associated with mental health services for children. The devastation to the health care system in greater New Orleans caused by Hurricane Katrina may have exacerbated such barriers.
Stakeholder organizations most frequently identified a lack of mental health providers and sustainability of funding as barriers to providing mental health services to children in the greater New Orleans area, and they most frequently identified a lack of transportation, competing family priorities, and concern regarding stigma as barriers to families' obtaining mental health services for children. A range of federal programs are helping to address these barriers, but much of the funding they provide is temporary. Among the 18 stakeholder organizations that participated in our structured interviews, the most frequently identified barrier to providing mental health services was a lack of providers. With regard to families' ability to obtain services for their children, 12 of the 18 organizations identified lack of transportation as a barrier. A range of federal programs address barriers to mental health services for children in the greater New Orleans area by supporting various state and local efforts--including hiring providers, assisting families, and utilizing schools as delivery sites--but much of the funding is temporary. Funding from several HHS programs has been used to transport children to mental health services. Federal programs also provide funding that is used to alleviate conditions that create competing family priorities--including dealing with housing problems, unemployment, and financial concerns--to help families more easily obtain children's mental health services. Louisiana has used federal funds to help support school-based health centers (SBHC), which have emerged as a key approach in the greater New Orleans area to address barriers to obtaining mental health services for children.
GAO-09-935T, Hurricane Katrina: Barriers to Mental Health Services for Children Persist in Greater New Orleans, Although Federal Grants Are Helping to Address Them
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Testimony:
Before the Ad Hoc Subcommittee on Disaster Recovery, Committee on
Homeland Security and Governmental Affairs, U.S. Senate:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 10:00 a.m. EDT:
Tuesday, August 4, 2009:
Hurricane Katrina:
Barriers to Mental Health Services for Children Persist in Greater New
Orleans, Although Federal Grants Are Helping to Address Them:
Statement of Cynthia A. Bascetta:
Director, Health Care:
GAO-09-935T:
Madam Chairman and Members of the Subcommittee:
I am pleased to be here today to discuss the protection of children
during disaster recovery and to provide highlights of our July 2009
report entitled Hurricane Katrina: Barriers to Mental Health Services
for Children Persist in Greater New Orleans, Although Federal Grants
Are Helping to Address Them.[Footnote 1] The greater New Orleans area
has yet to fully recover from the effects of Hurricane Katrina, which
made landfall on August 29, 2005. One issue of concern in the recovery
is the availability of mental health services for children.[Footnote 2]
In our report, we estimated that in 2008 about 187,000 children were
living in the greater New Orleans area--which we defined as Jefferson,
Orleans, Plaquemines, and St. Bernard parishes.[Footnote 3]
Many children in the greater New Orleans area experienced psychological
trauma as a result of Hurricane Katrina and its aftermath, and studies
have shown that such trauma can have long-lasting behavioral,
psychological, and emotional effects on children. Poor children in this
area may also be at additional risk, because studies have also shown
that children who grow up in poverty are at risk for the development of
mental health disorders.[Footnote 4] In 2007 the poverty rate for each
of the four parishes in the greater New Orleans area was higher than
the national average, and in Orleans and St. Bernard parishes, the rate
was at least twice the national average. Experts have found increases
in the incidence of depression, post-traumatic stress disorder
symptoms, risk-taking behavior, and somatic and psychosomatic
conditions in children who experienced the effects of Hurricane
Katrina. In addition, children in greater New Orleans may continue to
experience psychological trauma because of the slow recovery of stable
housing and other factors, such as the recurring threat of hurricanes.
Data collected by Louisiana State University (LSU) Health Sciences
Center researchers indicate that of the area children they screened in
January 2008, 30 percent met the threshold for a possible mental health
referral. Although this was a decrease from the 49 percent level during
the 2005-06 school year screening, the rate of decline was slower than
experts had expected.
Experts have previously identified barriers both to providing and to
obtaining mental health services for children.[Footnote 5] Barriers to
providing services are those that affect the ability of health care
organizations to provide services, such as a lack of providers; and
barriers to obtaining services are those that affect the ability of
families to gain access to services, such as concerns regarding the
stigma often associated with mental health services for children. The
devastation to the health care system in greater New Orleans caused by
Hurricane Katrina may have exacerbated such barriers.
Multiple federal agencies support the provision of mental health and
related services for children in the greater New Orleans area through
various programs. These agencies include the Department of Health and
Human Services' (HHS) Administration for Children and Families (ACF),
Centers for Medicare & Medicaid Services (CMS), Health Resources and
Services Administration, and Substance Abuse and Mental Health Services
Administration (SAMHSA) and the Departments of Education and Justice.
For example, since Hurricane Katrina, the federal government has
directed over $400 million toward restoring health services, including
mental health services for children, in Louisiana and the greater New
Orleans area. Other federal funding not targeted to Hurricane Katrina
recovery, available through several grant programs, also supports the
delivery of children's mental health services in the area. These
programs provide funding through annual formula grants--noncompetitive
awards based on a predetermined formula--to Louisiana and through
various discretionary grants to state and local agencies and
nongovernmental organizations.[Footnote 6]
My statement today is based on our July 2009 report, in which we (1)
identified barriers to providing and barriers to obtaining mental
health services for children in the greater New Orleans area, and (2)
described how federal programs, including grant programs, address
barriers to providing and to obtaining mental health services for
children.
To do this work, we developed and used a structured interview and a
written data collection instrument to gather views on barriers from 18
state and local stakeholder organizations selected on the basis of
experts' referrals and the organizations' roles in children's mental
health. The representatives of the 18 organizations we interviewed were
asked, as a group, to identify the three greatest barriers to providing
and to obtaining mental health services for children in the greater New
Orleans area. Because the 18 organizations were not selected by random
sample, their views cannot be generalized to all organizations or
individuals working in the field of children's mental health services
in the greater New Orleans area. To learn how federal programs address
these barriers, we reviewed documents from and interviewed federal,
state, and local officials involved in providing mental health services
to children. Our work included a site visit to greater New Orleans. We
conducted our work from April 2008 through June 2009 in accordance with
all sections of GAO's Quality Assurance Framework that are relevant to
our objectives. The framework requires that we plan and perform the
engagement to obtain sufficient and appropriate evidence to meet our
stated objectives and to discuss any limitations in our work. We
believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions
in this product. A detailed explanation of our methodology is included
in our July 2009 report.
Barriers to Mental Health Services for Children Persist, Although
Federal Grants Are Helping to Address Them:
Stakeholder organizations most frequently identified a lack of mental
health providers and sustainability of funding as barriers to providing
mental health services to children in the greater New Orleans area, and
they most frequently identified a lack of transportation, competing
family priorities, and concern regarding stigma as barriers to
families' obtaining mental health services for children. A range of
federal programs are helping to address these barriers, but much of the
funding they provide is temporary.
Lack of Providers Was Most Frequently Identified Barrier to Providing
Children's Mental Health Services, and Lack of Transportation Was Most
Frequently Identified Barrier to Obtaining Services:
Among the 18 stakeholder organizations that participated in our
structured interviews, the most frequently identified barrier to
providing mental health services was a lack of providers. (See table
1.) Fifteen of the 18 organizations identified a lack of mental health
providers--including challenges recruiting and retaining child
psychiatrists, psychologists, and nurses--as a barrier to providing
services. In addition, 13 of the 18 organizations identified
sustainability of funding, including difficulty securing reliable
funding sources and limitations on reimbursement for services, as a
barrier to providing services.
Table 1: Most Frequently Identified Barriers to Providing Mental Health
Services for Children in the Greater New Orleans Area:
Barrier: Lack of mental health providers;
Number of organizations identifying barrier: 15.
Barrier: Sustainability of funding;
Number of organizations identifying barrier: 13.
Barrier: Availability of referral services;
Number of organizations identifying barrier: 5.
Barrier: Lack of coordination between mental health providers or other
providers serving children;
Number of organizations identifying barrier: 3.
Barrier: Availability of physical space for programs;
Number of organizations identifying barrier: 2.
Source: GAO.
Note: Data are from analysis of structured interview data collected
from September through November 2008. Each of 18 stakeholder
organizations was interviewed and asked to identify the three greatest
barriers to providing mental health services for children. In some
cases, organizations offered fewer than three barriers. Barriers named
by only 1 organization were omitted from this table.
[End of table]
With regard to families' ability to obtain services for their children,
12 of the 18 organizations identified lack of transportation as a
barrier.[Footnote 7] (See table 2.) In addition, 11 of the 18
organizations identified competing family priorities--such as housing
problems, unemployment, and financial concerns--as a barrier to
obtaining services. An equal number identified concern regarding the
stigma associated with receiving mental health services as a barrier.
Table 2: Most Frequently Identified Barriers to Obtaining Mental Health
Services for Children in the Greater New Orleans Area:
Barrier: Lack of transportation;
Number of organizations identifying barrier: 12.
Barrier: Competing family priorities;
Number of organizations identifying barrier: 11.
Barrier: Concern regarding stigma;
Number of organizations identifying barrier: 11.
Barrier: Lack of available services;
Number of organizations identifying barrier: 8.
Barrier: Not knowing where to go to obtain services;
Number of organizations identifying barrier: 3.
Barrier: Lack of health insurance;
Number of organizations identifying barrier: 2.
Source: GAO.
Note: Data are from analysis of structured interview data collected
from September through November 2008. Each of 18 stakeholder
organizations was interviewed and asked to identify the three greatest
barriers to obtaining mental health services for children. Barriers
named by only 1 organization were omitted from this table.
[End of table]
Federal Programs Address Barriers by Supporting State and Local Efforts
to Hire Providers; Assist Families; and Deliver Care through School-
Based Health Centers:
A range of federal programs address barriers to mental health services
for children in the greater New Orleans area by supporting various
state and local efforts--including hiring providers, assisting
families, and utilizing schools as delivery sites--but much of the
funding is temporary. Several federal programs support state and local
efforts to hire or train mental health providers. For example, as of
May 2008, CMS's Professional Workforce Supply Grant, created with the
intent to recruit and retain health professionals in the greater New
Orleans area, was used to provide financial incentives to 82 mental
health providers who agreed to either take a new position or continue
in a position in the area and to serve for at least 3 years. This
funding will be available through September 2009. In addition, a few
federal programs support training of children's mental health
providers. For example, SAMHSA's National Child Traumatic Stress
Initiative awarded two grants in October 2008 to providers in the
greater New Orleans area to provide training on, implement, and
evaluate trauma-focused treatment for children.
Funding from several HHS programs has been used to transport children
to mental health services. For example, Louisiana designated $150,000
in its fiscal year 2009 state plan for SAMHSA's Community Mental Health
Services Block Grant for transportation for children in the greater New
Orleans area, and funding from ACF's 2006 Supplemental Social Services
Block Grant (SSBG) has also been used to supply transportation to
mental health appointments for children.[Footnote 8]
Federal programs also provide funding that is used to alleviate
conditions that create competing family priorities--including dealing
with housing problems, unemployment, and financial concerns--to help
families more easily obtain children's mental health services. Federal
programs address competing priorities, in part, by providing case
management, information, and referral services,[Footnote 9] which can
help families identify and obtain services such as health care, housing
assistance, and employment assistance. For example, officials from a
local organization that received funding from ACF's Head Start told us
that the program had provided families with information and referrals
for mental health services. Some federal programs also address
competing family priorities by providing direct financial assistance,
which may help alleviate family stress and make it easier for families
to devote resources and effort to obtaining mental health services for
their children.
Although most of the federal programs we identified were not
established as a direct result of Hurricane Katrina, the programs that
are hurricane-related have been an important source of support for
mental health services for children in greater New Orleans. However,
much of this funding is temporary and does not fully address the
sustainability barrier. For example, funds from three hurricane-related
grant programs--CMS's Primary Care Access and Stabilization Grant
(PCASG), its Professional Workforce Supply Grant, and ACF's 2006 SSBG
supplemental funding--will no longer be available to grantees after
2010.[Footnote 10]
Louisiana has used federal funds to help support school-based health
centers (SBHC), which have emerged as a key approach in the greater New
Orleans area to address barriers to obtaining mental health services
for children. In general, SBHCs are located in schools or on school
grounds and provide a comprehensive range of primary care services to
children. Louisiana's SBHCs also provide mental health services and are
required to have mental health staff on-site. Furthermore, some SBHCs
in the greater New Orleans area have a psychiatrist on staff on a part-
time basis. Although there is no federal program whose specific purpose
is to support SBHCs, state programs have used various federal funding
sources to support them. For example, a Louisiana official told us
funds from HHS's Maternal and Child Health Services Block Grant and
Community Mental Health Services Block Grant provide some of the
support for SBHCs in greater New Orleans. During the 2007-08 school
year, there were nine SBHCs in greater New Orleans, and state officials
told us in February 2009 that at least four more were in the planning
stages for this area. SBHCs can help address the top three barriers to
obtaining services identified in our structured interviews--a lack of
transportation, competing family priorities, and concern regarding
stigma. For example, because SBHCs are generally located in schools or
on school grounds, students have less need for transportation to obtain
care and parents have less need to take time from work to accompany a
child to appointments. In addition, SBHC services may be provided at
low or no cost to the patient, which lessens the financial burden on
the family. Also, colocation of mental health and other primary care
services may reduce concern regarding stigma because the type of
service the child is receiving at the SBHC is generally not apparent to
an observer.
Agency Comments and Our Evaluation:
We provided a draft of our July 2009 report to HHS and Education for
their review. In its comments, HHS provided additional information on
mental health services provided in schools other than through SBHCs and
emphasized the effect of a lack of stable housing on children's mental
health. In addition, both HHS and Education provided technical
comments. We incorporated HHS's and Education's comments in the report
as appropriate.
Madam Chairman, this completes my prepared remarks. I would be happy to
respond to any questions you or other members of the subcommittee may
have at this time.
GAO Contacts and Staff Acknowledgments:
For further information about this statement, please contact Cynthia A.
Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. Key contributors to this statement
were Helene F. Toiv, Assistant Director; Roseanne Price; Julie Thomas
Stewart; Laurie F. Thurber; and Malissa G. Winograd.
[End of section]
Footnotes:
[1] GAO, Hurricane Katrina: Barriers to Mental Health Services for
Children Persist in Greater New Orleans, Although Federal Grants Are
Helping to Address Them, [hyperlink,
http://www.gao.gov/products/GAO-09-563] (Washington, D.C.: July 13,
2009).
[2] For the purposes of this statement, such services include inpatient
and outpatient counseling or mental health treatment; related ancillary
services like transportation, translation, and case management; mental
health education and prevention services; and substance abuse
prevention and treatment services.
[3] For details regarding the computation of our estimate, see
[hyperlink, http://www.gao.gov/products/GAO-09-563], appendix I.
[4] See GAO, Catastrophic Disasters: Federal Efforts Help States
Prepare for and Respond to Psychological Consequences, but FEMA's
Crisis Counseling Program Needs Improvements, [hyperlink,
http://www.gao.gov/products/GAO-08-22] (Washington, D.C.: Feb. 29,
2008); V. Murali and F. Oyebode, "Poverty, Social Inequality and Mental
Health," Advances in Psychiatric Treatment, vol. 10 (2004), 216-224;
and K.A.S. Wickrama et al., "Family Antecedents and Consequences of
Trajectories of Depressive Symptoms from Adolescence to Young
Adulthood: A Life Course Investigation," Journal of Health and Social
Behavior, vol. 49, no. 4 (2008), 468-483.
[5] See, for example, the President's New Freedom Commission on Mental
Health, Achieving the Promise: Transforming Mental Health Care in
America (Rockville, Md., 2003).
[6] See [hyperlink, http://www.gao.gov/products/GAO-09-563], appendixes
II and III, for detailed information on selected federal programs that
support mental health and related services for children.
[7] For information on transportation services to hurricane victims,
see GAO, Disaster Assistance: Federal Efforts to Assist Group Site
Residents with Employment, Services for Families with Children, and
Transportation, [hyperlink, http://www.gao.gov/products/GAO-09-81]
(Washington, D.C.: Dec. 11, 2008).
[8] SSBG supplemental funds were appropriated to ACF for allocation to
states for expenses related to the 2005 hurricanes under the Department
of Defense, Emergency Supplemental Appropriations to Address Hurricanes
in the Gulf of Mexico, and Pandemic Influenza Act, 2006, Pub. L. No.
109-148, div. B, title I, ch. 6, 119 Stat. 2680, 2768 (2005).
Additional SSBG supplemental funding was allocated to Louisiana in
January 2009 and is available through September 2009 from an
appropriation made by the Consolidated Security, Disaster Assistance,
and Continuing Appropriations Act, 2009, Pub. L. No. 110-329, div. B,
title I, ch. 7, 122 Stat. 3574, 3594-95 (2008).
[9] For more information on case management services provided after
Hurricane Katrina, see GAO, Disaster Assistance: Greater Coordination
and an Evaluation of Programs' Outcomes Could Improve Disaster Case
Management, GAO-09-561 (Washington, D.C.: July 8, 2009). We reported
that federal agencies provided millions of dollars to support disaster
case management services to assist victims of hurricanes Katrina and
Rita, but a key barrier to providing case management services was a
lack of reliable, continuous funding.
[10] For additional information about the PCASG and the Professional
Workforce Supply Grant, see GAO, Hurricane Katrina: Federal Grants Have
Helped Health Care Organizations Provide Primary Care, but Challenges
Remain, GAO-09-588 (Washington, D.C.: July 13, 2009).
[End of section]
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