Child Welfare and Juvenile Justice
Several Factors Influence the Placement of Children Solely to Obtain Mental Health Services Gao ID: GAO-03-865T July 17, 2003Recent news articles in over 30 states and prominent mental health advocacy organizations have described the difficulty many parents have in accessing mental health services for their children. As these reports documented, some parents choose to place their children in the child welfare or juvenile justice systems in order to obtain the mental health services that their children need. Senators Susan Collins and Joseph Lieberman of the Senate Committee on Governmental Affairs asked GAO to testify on: (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. This testimony is based on our April 2003 report on the results of a study addressing these same objectives. For that report, 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 because of the decentralized nature of the juvenile justice system. We also researched laws and regulations and conducted site visits to 6 states.
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 some mental health services, difficulties accessing 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 fund mental health services, bringing services into a single location to improve access, and expanding the array of available services. Few of these practices have been rigorously evaluated. In a related report, we recommended that (1) the Secretary of Health and Human Services (HHS) and the Attorney General investigate the feasibility of tracking these children to identify the extent and outcomes of these placements, (2) the Secretaries of HHS and Education and the Attorney General develop an interagency working group to identify the causes of the misunderstandings and create an action plan to address those causes, and (3) the agencies continue to encourage states to evaluate the child mental health programs that states fund or initiate and that they 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 that report, Education, HHS, and the Department of Justice generally agreed with our findings but did not fully concur with the recommendations, particularly related to tracking the children. All three agencies said they would participate in any interagency working group that might be established based on our recommendation.
GAO-03-865T, Child Welfare and Juvenile Justice: Several Factors Influence the Placement of Children Solely to Obtain Mental Health Services
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Testimony:
Before the Committee on Governmental Affairs, U.S. Senate:
United States General Accounting Office:
GAO:
For Release on Delivery Expected at 9:30 a.m. EDT:
Thursday, July 17, 2003:
Child Welfare and Juvenile Justice:
Several Factors Influence the Placement of Children Solely to Obtain
Mental Health Services:
Statement of Cornelia M. Ashby, Director Education, Workforce, and
Income Security Issues:
GAO-03-865T:
GAO Highlights:
Highlights of GAO-03-865T, a testimony for the Committee on
Governmental Affairs, United States Senate
Why GAO Did This Study:
Recent news articles in over 30 states and prominent mental health
advocacy organizations have described the difficulty many parents have
in accessing mental health services for their children. As these
reports documented, some parents choose to place their children in the
child welfare or juvenile justice systems in order to obtain the
mental health services that their children need. Senators Susan
Collins and Joseph Lieberman of the Senate Committee on Governmental
Affairs asked GAO to testify on: (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. This testimony is based on our April 2003 report on the
results of a study addressing these same objectives. For that report,
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 because of
the decentralized nature of the juvenile justice system. We also
researched laws and regulations and conducted site visits to 6
states.
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 some mental health services, difficulties
accessing 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
fund mental health services, bringing services into a single location
to improve access, and expanding the array of available services. Few
of these practices have been rigorously evaluated.
In a related report, we recommended that (1) the Secretary of Health
and Human Services (HHS) and the Attorney General investigate the
feasibility of tracking these children to identify the extent and
outcomes of these placements, (2) the Secretaries of HHS and Education
and the Attorney General develop an interagency working group to
identify the causes of the misunderstandings and create an action plan
to address those causes, and (3) the agencies continue to encourage
states to evaluate the child mental health programs that states fund
or initiate and that they 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 that report,
Education, HHS, and the Department of Justice generally agreed with
our findings but did not fully concur with the recommendations,
particularly related to tracking the children. All three agencies said
they would participate in any interagency working group that might be
established based on our recommendation.
www.gao.gov/cgi-bin/getrpt?GAO-03-865T.
To view the full product, 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]
Madam Chairman and Members of the Committee:
Thank you for inviting me here today to discuss how federal agencies
could do more to help states reduce the number of children placed in
child welfare and juvenile justice systems solely to obtain mental
health services. As recent news articles in over 30 states and
prominent mental health advocacy organizations have reported, many
parents have difficulty accessing mental health services for their
children with severe mental illnesses.[Footnote 1] In some cases,
parents must choose to remove their children from their homes 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] Various federal laws require
that state and local agencies provide services to mentally ill children
in the most integrated 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.
My testimony today will focus on three key issues: (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) state and local
practices that may reduce the need for some child welfare and juvenile
justice placements. My comments are based on the findings from our
April 2003 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,
April 21, 2003). In conducting that study, we analyzed responses to our
survey of state child welfare directors in all states and the District
of Columbia and our survey of 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 interviewed officials of child-serving
agencies,[Footnote 3] caseworkers, and parents in 6 states (Arkansas,
California, Kansas, Maryland, Minnesota, and New Jersey) and judges in
each state we visited except Minnesota.[Footnote 4] We also observed
programs that state officials identified as model programs in those 6
states; interviewed key federal officials and national experts; and
researched state laws and regulations regarding voluntary placement and
relinquishment of parental rights.
In summary, state child welfare officials in 19 states and county
juvenile justice officials in 30 counties 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. Nationwide,
this number is likely higher because 32 state child welfare 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 did not have an estimate to
provide, such placements occurred in their state. Also, we surveyed
juvenile justice officials in only 33 counties; 30 of which responded
with an estimate. Although no federal or state agency tracks these
children or maintains data on their characteristics, officials said
most are male, adolescent, and often have multiple problems. Many
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.
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; these included limitations in health
insurance coverage, shortages of mental health services in some
localities, difficulties in accessing services through mental health or
education agencies, eligibility requirements for services provided by
different agencies and programs, and misunderstandings among state and
local officials and service providers regarding the responsibilities of
various agencies to meet children's mental health needs. For example,
despite guidance issued by various federal agencies with
responsibilities for serving children, 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.
The state officials that we interviewed identified a range of practices
in their states that they believe may help to prevent some child
welfare and juvenile justice placements. These included finding new
ways to reduce the cost of or to fund mental health services, bringing
mental health services into a single location to improve access, and
expanding the array of available services. However, the effectiveness
of these practices is generally unknown because many were new, few were
rigorously evaluated, and many served a small number of children or
only children in specific locations.
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 recommended in our April 2003 report that
the Secretary of Health and Human Services (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 recommended
that the Secretaries of HHS and Education and the Attorney General
develop an interagency working group to identify the causes of the
misunderstandings and to create an action plan to address those causes.
We further recommended that these agencies continue to encourage states
to evaluate the child mental health programs that 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 the report, the Department of 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 would 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.
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 in coverage barriers depending on their type
of coverage and where they live.[Footnote 5]
At the federal level, several federal agencies--including HHS's SAMHSA,
Centers for Medicare & Medicaid Services (CMS), and the Administration
for Children and Families (ACF); DOJ's Office of Juvenile Justice and
Delinquency Prevention (OJJDP); and Education's Office of Special
Education and Rehabilitative Services (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
Mentally Ill Children:
Department and agency: HHS (CMS); Key activities related to children's
mental health: Administers the Medicaid and SCHIP programs that provide
health insurance coverage to certain low-income individuals and
disabled children, including some children with severe mental illness;
Awards research grants; Provides technical assistance to state
agencies; 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 (ASFA) of
1997 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; Statute: Title
IV, Part B and 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; 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 block grant
funding that enables states to maintain and enhance mental health
services; Sponsors the Systems of Care Initiative to help children and
adolescents with serious 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; 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; 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,
DOJ's Division of Civil Rights, and HHS's and Education's Office for
Civil Rights, also have responsibilities for children with
disabilities, including children with a mental illness.
[End of table]
Federal law does not require parents to relinquish their parental
rights to place their children with child welfare agencies. However,
after children are in care for a specific period of time, the law
requires that the court be involved to determine if termination of the
parents' rights are in the best interest of the child. 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 6]
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
7] Laws in the remaining states are generally silent regarding
voluntary placements for mental health.
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 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. At the state and county level, a similar array of agencies
provides or funds services for mentally ill children, and state and
federal laws and policies often determine their roles and
responsibilities. Importantly, federal agencies play a key 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 adhere to the principle of "least restrictive alternative."
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 U.S. 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 provides 24 hours of care, 7 days a week,
can cost $250,000 a year or more. Nationwide, about 87 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 8]
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 health
parity bills. Most of these laws meet or exceed the federal MHPA
standard. However, the Employee Retirement Income Security Act of 1974
preempts states from directly regulating self-funded, employer-
sponsored health plans; under such circumstances, states requirements
usually do not apply.
For more than 30 years, Medicaid has provided comprehensive health
insurance for children from low-income families. Although individual
states determine many coverage, eligibility, and administrative
details, the federal government sets certain requirements for state
Medicaid programs. These requirements include coverage of screening and
necessary treatment for children. Under Medicaid, states may apply for
and receive approval from the federal government to waive 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 9] 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
in nonmedical settings.
States are pursuing a variety of approaches for expanding public health
insurance for uninsured children from low-income families by
implementing SCHIP programs. States have three options in designing
SCHIP programs. For example, 24 states implement SCHIP by expanding
Medicaid programs to include children from low-income families with
earnings too high to qualify for Medicaid. Fourteen have developed a
separate or independent child health insurance program with benefits
that differ from those offered under Medicaid. Others use a combination
of Medicaid and non-Medicaid plans to serve children in families at
different income levels.
States operating Medicaid programs--including SCHIP Medicaid-
expansions--must offer the same benefit package to SCHIP beneficiaries
as they do to Medicaid beneficiaries.[Footnote 10] These benefits
include the Early and Periodic Screening, Diagnostic and Treatment
(EPSDT) provision that requires states to provide children and
adolescents under age 21 with access to comprehensive, periodic
evaluations of physical and mental health and developmental and
nutritional status, as well as vision, hearing, and dental needs.
States must provide all services needed for conditions discovered
through these routine pediatric screenings regardless of whether the
service is covered by the state Medicaid plan for other beneficiaries.
In 2000, more than 1 million children were enrolled in SCHIP Medicaid
expansion programs and were, therefore, eligible for EPSDT screens.
While No Formal Tracking Occurs, Available Estimates Indicate That Many
Children--Primarily Adolescent Males--Were Placed with the State 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, in child welfare and
juvenile justice agencies so that the children could receive mental
health services. Nationwide, this 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. Moreover,
we surveyed juvenile justice officials in only 33 counties and three
did not provide 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.
Some Officials Estimate That Parents Placed Over 12,700 Children to
Access Mental Health Services:
State child welfare officials and county juvenile justice officials
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 estimated number of children placed in
the child welfare system. County juvenile justice officials reported
estimates that totaled to approximately 9,000 children and 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: b.
State: Arizona; Number of children placed: b.
State: California; Number of children placed: c.
State: Colorado; Number of children placed: c.
State: Connecticut; Number of children placed: 738.
State: District of Columbia; Number of children placed: d.
State: Delaware; Number of children placed: 0.
State: Florida; Number of children placed: d.
State: Georgia; Number of children placed: d.
State: Hawaii; Number of children placed: d.
State: Iowa; Number of children placed: b.
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: d.
State: Kentucky; Number of children placed: 14.
State: Louisiana; Number of children placed: a.
State: Massachusetts; Number of children placed: c.
State: Maryland; Number of children placed: 54.
State: Maine; Number of children placed: b.
State: Michigan; Number of children placed: c.
State: Minnesota; Number of children placed: 1,071.
State: Missouri; Number of children placed: d.
State: Mississippi; Number of children placed: 13.
State: Montana; Number of children placed: d, b.
State: North Carolina; Number of children placed: 440.
State: North Dakota; Number of children placed: b.
State: Nebraska; Number of children placed: c.
State: New Hampshire; Number of children placed: d.
State: New Jersey; Number of children placed: c.
State: New Mexico; Number of children placed: c.
State: Nevada; Number of children placed: 20.
State: New York; Number of children placed: c.
State: Ohio; Number of children placed: b.
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: b.
State: Tennessee; Number of children placed: b.
State: Texas; Number of children placed: d.
State: Utah; Number of children placed: b.
State: Virginia; Number of children placed: b.
State: Vermont; Number of children placed: 60.
State: Washington; Number of children placed: 423.
State: Wisconsin; Number of children placed: c.
State: West Virginia; Number of children placed: 135.
State: Wyoming; Number of children placed: 5.
Total; Number of children placed: 3,680.
Source: GAO survey.
[A] State did not respond to our survey.
[B] State did not provide the data requested, but indicated that
voluntary placement happens.
[C] State did not provide the data requested.
[D] State officials said the practice of voluntary placement is not
legal in the state.
[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 did not provide an estimate of 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
of child welfare placements solely to obtain mental health services
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--told us 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 11] Information on
the prevalence of children present in the juvenile justice system is
also limited in this statement since we surveyed only 33 counties. In 3
of those counties, juvenile justice officials reported that while they
did not have an estimate to provide, 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 formally or comprehensively track
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 data base 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 did not provide information about the gender and ages of
children placed in their system, children in the juvenile justice
population are mostly male and range in age from 13 to 18.[Footnote 12]
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 or others, and
often prevented their parents from meeting the needs of the other
children in the family. For example, in Maryland, officials told us
about a teenage boy who was mentally ill, developmentally disabled,
autistic,[Footnote 13] 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 with severe mental
illness 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.
Children who are placed or are at risk of placement come from families
that span a variety of economic levels. However, officials from state
and county child-serving agencies in all 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. Private health insurance plans often
have gaps and limitations in the mental health coverage they provide,
and not all children covered by Medicaid received needed services. Even
when parents could afford mental health services, some could not access
services at times when they needed those services because supplies of
such services were inadequate. In other instances, some mental health
agencies and schools have limited resources to provide mental health
services and are required to serve children with a mental illness in
the least restrictive environment possible--which can limit the
alternatives available to parents who believe their 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 14] 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 15] Mental health officials and
service providers in the states that we visited said these services
were often necessary to help families maintain children with a severe
mental illness in their homes. Furthermore, federal law preempts states
from directly regulating self-funded, employer-sponsored health
insurance plans and in doing so exempted many families from protection
under state laws.
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.
For example, states used different approaches to expand Medicaid
coverage. 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 generally provides
60 days of community-based services and limited
hospitalization.[Footnote 16] 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' program did not require parents to
pay into the program to receive services, but Minnesota's program
required parents to pay according to their ability as defined by a
sliding scale.
Although Medicaid's EPSDT provision requires Medicaid coverage for all
necessary physical and mental 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 July 2001 report, we recommended that the
Administrator of CMS work with states to develop criteria and timelines
for consistently assessing and improving EPSDT reporting and provision
of services.[Footnote 17] 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 the participation of some
practitioners 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 all parents 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. 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 that 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. Officials in 3 states 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 treatment sessions and increase the length of waiting lists.
In 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.
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 3
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 the 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, officials in 2 of the states that we visited said
children often remain hospitalized 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 two 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 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.
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 4 districts told us that some mentally ill children
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 18] and bipolar[Footnote 19] 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[Footnote 20] son 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 21] 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.
Misunderstandings of Agencies' Responsibilities and Resources:
Program officials' and service providers' misunderstandings of
agencies' responsibilities and resources also affect service provision.
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 one 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 eligible for 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.
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 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 bachelors-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.
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 who 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.
In addition to blending funds to pay for services, state officials in 4
of the 6 the 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 array of nontraditional supportive services,
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 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.
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 Harford County, Maryland,
for example, mental health services are collocated at an elementary
school specifically to improve access to care for students with a
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 bachelors-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 an intensive,
in-school program staffed with a full-time school psychologist; a
mentoring program that is run by paid school staff, high school
students, and volunteer community members; a program that provides
counseling, tutoring, recreation, social skills groups, home visits,
referrals, and some psychiatric rehabilitation services; a program to
identify elementary school children with a mental illness 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,[Footnote 22]
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. 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' Juvenile Alternative Defense Effort (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 includes failures and successes, 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. 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 all 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. The
transition program is designed with various levels that allow youth who
exhibit good behavior to move to lower levels of supervision. For
instance, at level 4, youth begin to transition back to the community
by making periodic visits to their homes. 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.
Crisis Intervention: Programs we reviewed in 4 states had a mobile
crisis unit consisting 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 make emergency petitions 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, a
residential mental health facility in Los Angeles County, California,
works extensively with parents of children with severe mental illness
at its facility and requires their participation. The Sycamores also
provides a variety of supportive services, including household items
and services such as transportation to and from the facility. In
addition, as part of its transitional program, The Sycamores uses
Therapeutic Behavioral Services (TBS), one-on-one services provided
whenever needed 24 hours a day, 7 days a week to assist youth in
maintaining their current living situation and in developing the coping
and problem-solving skills needed.
Concluding Observations:
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. 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 recommended in our April
2003 report that the Secretary of HHS and the Attorney General
investigate the feasibility of tracking these children to determine the
extent and outcomes of these placements. In commenting on a draft of
that report, DOJ agreed that tracking should take place, but only in
the short term, and that HHS should take the lead in such an effort.
HHS said that asking agencies to track this population does not address
the lack of mental health resources for families and communities and
does not address the problems of the children and their families.
However, we believe that knowledge of the extent of this practice is a
necessary first step to determine what corrective actions might be
taken and may be useful in identifying which progressive practices will
most benefit these children.
Experts, agency officials, and service providers agree that agencies
must work together to meet the needs of children with severe mental
illness because these children have complex problems and are likely to
need services from multiple agencies if they are to remain in their
communities or if they are to successfully transition from a
residential facility back to their communities. 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. In our April 2003 report, we
recommended 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 to create an action plan to address those causes.
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 for the purposes we stated. We
believe several organizational entities may be appropriate and that the
member agencies forming this group should determine the entity that is
best suited.
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. To further
such efforts, we recommended in the report that the agencies continue
to encourage states to evaluate the child mental health programs that
the states fund or initiate. In commenting on a draft of our April 2003
report, Education said that no recommendations were made for increased
grant spending to duplicate or disseminate the positive features of the
practices we highlighted. As a result, we added a recommendation 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.
Madam Chairman, this concludes my prepared statement. I would be
pleased to respond to any questions that you or other members of the
Committee may have.
GAO Contact and Acknowledgments:
For further contacts regarding this testimony, please call Cornelia M.
Ashby at (202) 512-8403. Individuals making key contributions to this
testimony include Diana Pietrowiak and Kathleen D. White.
[End of section]
Related GAO Products:
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. Washington, D.C.:
April 21, 2003.
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, D.C.: 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.
Children's Health Insurance Program: State Implementation Approaches
are Evolving, GAO/HEHS-99-65. Washington, D.C.: May 14, 1999.
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" to describe such children throughout this statement.
[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 or status offenses--that is, according to
the Department of Justice (DOJ), behaviors that are law violations only
if committed by juveniles--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. However, parents sometimes request that police
arrest their children for behaviors that are related to or stem from
their mental illness when they cannot obtain services through other
means. In this statement, 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] Child-serving agencies include mental health, Medicaid and State
Children's Health Insurance Program (SCHIP), juvenile justice,
education, and child welfare.
[4] We did not interview judges in Minnesota primarily due to
scheduling conflicts.
[5] 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).
[6] The 11 states are: Alaska, Colorado, Connecticut, Iowa, Maine,
Minnesota, North Dakota, Oregon, Rhode Island, Wisconsin, and Vermont.
[7] The 8 states are: Florida, Georgia, Hawaii, Kansas, Missouri,
Montana, New Hampshire, and Texas.
[8] U.S. General Accounting Office, Health Insurance: States'
Protections and Programs Benefit Some Unemployed Individuals,
GAO-03-191 (Washington, D.C.: Oct. 25, 2002).
[9] 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 of 1982.
[10] A state that chooses a stand-alone or combination SCHIP program
may introduce limited cost sharing and base its benefit package on one
of several benchmarks specified in the statute, such as the Federal
Employees Health Benefit program, or state coverage. See 42 U.S.C.
§1397cc(a) and (b) and U.S. General Accounting Office, Children's
Health Insurance Program: State Implementation Approaches are Evolving,
GAO/HEHS-99-65 (Washington, D.C.: May 14, 1999).
[11] These four states were Alaska, Illinois, Louisiana, and South
Carolina.
[12] In commenting on a draft of our April 2003 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.
[13] Autism is a developmental disability typically affecting the
processing, integrating, and organizing of information that
significantly impacts communication, social interaction, functional
skills, and educational performance.
[14] These services are generally provided by licensed or certified
psychiatrists, psychologists, or masters-level social workers.
[15] 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.
[16] In commenting on a draft of our April 2003 report, a Kansas
official said that the state had expanded the services the state
provides under the Rehabilitation option and does not limit the
services to 60 days, but bases services on the individual clinical and
medical needs of the child.
[17] 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).
[18] Attention deficit disorder is a syndrome characterized by serious
and persistent difficulties in attention span, impulse control, and,
sometimes, hyperactivity.
[19] 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.
[20] Schizophrenia is a cluster of disorders characterized by
delusions, hallucinations, disordered thinking, and emotional
unresponsiveness.
[21] The California legislature transferred the responsibility for
providing mental health services to children in special education from
schools to counties in the late 1980s.
[22] Diversion programs attempt to prevent or reduce the time children
spend in inappropriate placements.
