Mental Health Services
Effectiveness of Insurance Coverage and Federal Programs for Children Who Have Experienced Trauma Largely Unknown Gao ID: GAO-02-813 August 22, 2002Eighty-eight percent of children nationwide have private or public health insurance that, to varying degrees, covers mental health services, including those that may be needed to help children recover from traumatic events, such as natural disasters, school shootings, or family violence. Despite the widespread prevalence of health insurance coverage for children, depending on their type of insurance coverage and where they live, children may face certain limitations in coverage or other barriers that could affect their access to needed services. The 16 percent of children who are enrolled in Medicaid and the State Children's Health Insurance Program public insurance programs generally have coverage for a wide range of mental health benefits, and those enrolled in Medicaid are not subject to day or visit restrictions. Beyond providing insurance that can give children access to mental health services, a range of federal programs can help children who have experienced trauma obtain needed services. GAO identified over 50 programs that can be used by grantees to provide mental health and other needed services to children who have never experienced trauma, although many of these programs have a broader focus and were not designed specifically for this purpose.
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Director: Team: Phone:GAO-02-813, Mental Health Services: Effectiveness of Insurance Coverage and Federal Programs for Children Who Have Experienced Trauma Largely Unknown
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Report to Congressional Requesters:
August 2002:
Mental Health Services:
Effectiveness of Insurance Coverage and Federal Programs for Children
Who Have Experienced Trauma Largely Unknown:
GAO-02-813:
Contents:
Letter:
Results in Brief:
Background:
Most Children Have Health Insurance Coverage, But Mental Health
Coverage May Have Limits and Not Guarantee Access:
Federal Programs Can Help Children Who Have Experienced Trauma to
Obtain Mental Health Services, But Extent of Assistance Is Largely
Unknown and Little Evaluation Has Occurred:
Conclusions:
Recommendation for Executive Action:
Agency Comments and Our Evaluation:
Appendixes:
Appendix I: Scope and Methodology:
Appendix II: victimization Data:
Child Abuse and Neglect Data Collected by HHS‘s Administration for
Children and Families:
Child Access and Visitation Data Collected by HHS‘s Administration for
Children and Families:
Victimization Data Collected by the Department of Justice:
Appendix III: Information on SCHIP Program in the 50 States and the
District of Columbia:
Appendix IV: Selected Individual Insurers‘ Coverage for Specified
Mental Health Coverage in Six States as of 2002:
Appendix V: Summary of Selected Laws Regarding Mental Health Coverage
in Six States:
Appendix VI: Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services:
Appendix VII: State Crime Victim Compensation Benefits, May 2002:
Appendix VIII: Comments from the Department of Health and Human
Services:
Appendix IX: Comments from the Department of Health and Human Services:
Appendix X: Comments from the Department of Education:
Appendix XI: GAO Contact and Staff Acknowledgements:
Related GAO Products:
Tables:
Table 1: Type of Insurance Coverage for Children under Age 19 in 2000:
Table 2: Percentage of Health Plans Offered by Employers with More Than
500 Employees That Limited Inpatient and Outpatient Mental Health
Services in 2001:
Table 3: Number of Victims in Selected Categories Served by State
Victim
Assistance Programs in Four States, Fiscal Year 2001:
Table 4: Number of Referrals to Child Protective Services and
Substantiated Cases of Child Maltreatment, by State, 1999:
Table 5: Information on Child Victims of Maltreatment, by State, 1999:
Table 6: Services Provided to Child Victims of Maltreatment, by State,
1999:
Table 7: Number of Reports of Child Maltreatment, by Source of Report
and State, 1999:
Table 8: Child Access and Visitation Grant Data, by State:
Table 9: Estimated Number of Persons Raped or Physically Assaulted by
an
Intimate Partner during Lifetime and Previous 12 Months, by Sex of
Victim:
Table 10: Estimated Rates of Law Enforcement Actions, as Reported by
Victims of Selected Intimate Partner Crimes:
Table 11: Instances of Forcible Rape of Women Reported to Police, All
Ages, 2000:
Table 12: Sexual Assault Convictions in State Courts, 1998:
Table 13: Program Type, Maximum Income Eligibility Levels, and Fiscal
Year 2001 Enrollment for SCHIP Programs in the 50 States and the
District of Columbia:
Table 14: Summary of Parity Laws That Exceed Federal Standards in Three
States:
Table 15: Summary of Selected Laws Related to Mental Health Coverage in
Illinois:
Table 16: Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services:
Table 17: Crime Victim Compensation Maximum Overall Benefits and
Maximum
Mental Health Benefits:
Figures:
Figure 1: Comparison of State Medicaid and SCHIP Coverage for Selected
Mental Health Treatments in California and Utah:
Figure 2: Public and Private Insurance Coverage Options in California
and Illinois for a Hypothetical 5-Year Old Child Who Has Experienced
Trauma:
Figure 3: Estimated Number of Victims of Intimate Partner Violence, by
Sex, 1993 to 1998:
Figure 4: Selected Individual Insurers‘ Coverage for Specified Mental
Health Services Available to Children in Six States:
Abbreviations:
ACF: Administration for Children and Families:
CMS: Centers for Medicare & Medicaid Services:
DSM: Diagnostic and Statistical Manual of Mental Disorders:
EPSDT: Early and Periodic Screening, Diagnostic, and Treatment:
ERISA: Employee Retirement Income Security Act of 1974:
FEMA: Federal Emergency Management Agency:
HHS: Department of Health and Human Services:
HMO: health maintenance organization:
HRSA: Health Resources and Services Administration:
MHPA: Mental Health Parity Act of 1996:
OVC: Office for Victims of Crime:
POS: point of service:
PPO: preferred provider organization:
PTSD: posttraumatic stress disorder:
SAMHSA: Substance Abuse and Mental Health Services Administration:
SCHIP: State Children‘s Health Insurance Program:
SED: serious emotional disturbance:
SMI: severe mental illness:
VOCA: Victims of Crime Act:
Letter:
August 22, 2002:
The Honorable Richard J. Durbin
The Honorable Edward M. Kennedy
The Honorable Paul Wellstone
United States Senate:
One-time traumatic events like natural disasters, terrorist incidents,
and school shootings as well as ongoing exposure to trauma such as
family and community violence can have serious psychological,
emotional, and developmental repercussions for children. In the short
term, children‘s lives can be radically disrupted, and longer-term
effects can include difficulties in school, work, and personal
relationships. If children who have experienced trauma do not receive
the care they need, these problems can continue into adulthood.
Large numbers of children are at risk for trauma-related mental health
problems. The Department of Justice reported in 1997 that almost 9
million children aged 12 to 17 had witnessed serious violence during
their lifetimes; Justice has also reported that during the period of
1993 through 1998, children under the age of 12 resided in 43 percent
of households where intimate partner violence was known to have
occurred. Further, the Department of Health and Human Services (HHS)
reported that about 826,000 children and adolescents were found to be
victims of abuse and neglect in 1999.
In response to your request for information on the ability of children
who have experienced trauma to obtain mental health services, this
report addresses (1) the extent to which private health insurance and
the primary public programs that insure children--Medicaid and the
State Children‘s Health Insurance Program (SCHIP)--cover mental health
services needed by children exposed to traumatic events and (2) other
federal programs that help children who have experienced trauma receive
needed mental health services.[Footnote 1] As requested, we are also
providing national data that are available through federal agency
sources on the incidence of child abuse and neglect, sexual assault,
rape, intimate partner violence, and children‘s witnessing such
violence. (See app. II.):
To determine the extent of private and public insurance coverage of
mental health services for children, we reviewed available employer
survey data; reviewed the benefit design of health plans provided by 13
insurers in the individual market as well as state Medicaid programs
and SCHIP programs; and interviewed representatives of private insurers
and public officials in California, Georgia, Illinois, Massachusetts,
Minnesota, and Utah. We selected these states on the basis of variation
in the number of beneficiaries covered, in geographic location, in the
extent to which the insurance market is regulated, and in the design of
the SCHIP program. To describe other federal programs that can help pay
for mental health services for children who have experienced trauma or
that try to ensure that these children receive needed services, we
reviewed grant program documents obtained from officials of federal
agencies, such as HHS, Justice, the Department of Education, and the
Federal Emergency Management Agency (FEMA), and interviewed agency
officials and representatives of national health care and child
advocacy organizations. To gather information on services provided to
children and on problems in obtaining needed services, we reviewed the
relevant literature and contacted state and local mental health
agencies, state crime victim compensation and assistance agencies,
child welfare and protective service agencies, and other organizations
receiving federal grants in California and Massachusetts, as well as
additional service providers with federal grants in Colorado, Illinois,
Minnesota, and Oregon. The programs and efforts we discuss in this
report do not represent an exhaustive list of all federally funded
programs that can address the mental health needs of children exposed
to traumatic events; they highlight a range of programs that target
varied populations, services, and systems that come into contact with
this population. In addition, we obtained data on child abuse and
neglect, intimate partner violence, and sexual assault that were
collected and analyzed by HHS‘s Administration for Children and
Families (ACF) and Justice‘s Bureau of Justice Statistics, National
Institute of Justice, and Federal Bureau of Investigation. We did not
verify the accuracy of these data. (For additional information on our
methodology, see app. I.):
We conducted our work from September 2001 through August 2002 in
accordance with generally accepted government auditing standards.
Results in Brief:
Eighty-eight percent of children nationwide, or over 67 million, have
private or public health insurance that, to varying degrees, covers
mental health services, including those that may be needed to help
children recover from traumatic events. Despite the widespread
prevalence of health insurance coverage for children, depending on
their type of insurance coverage and where they live, children may face
certain limitations in coverage or other barriers that could affect
their access to needed services. Employer-sponsored health plans cover
nearly two-thirds of children nationwide, or over 50 million, and
federal law requires plans that cover more than 50 employees and
include mental health benefits to cover mental health services to the
same extent as other services in terms of annual or lifetime dollar
limits. However, the federal law does not preclude these employer-
sponsored plans from including other features, such as day or visit
limits, that are more restrictive for mental health services. In
addition, the 4 percent of children, or over 3 million, covered by
private-sector individual health insurance may face even greater
coverage restrictions. For example, insurers in the individual market
may offer only limited mental health coverage, such as a lifetime limit
of $10,000 on mental health benefits; exclude specific disorders from
coverage, such as posttraumatic stress disorder (PTSD); or offer no
mental health coverage at all.
The 16 percent of children, or over 12 million, who are enrolled in
Medicaid and SCHIP public insurance programs generally have coverage
for a wide range of mental health benefits, and those enrolled in
Medicaid are not subject to day or visit restrictions. In addition to
any mental health services that states explicitly cover in their
Medicaid programs, federal law requires states to provide all children
enrolled in Medicaid with any service necessary to treat physical and
mental conditions detected through Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) screenings. Because EPSDT is not a
mandatory component of SCHIP, however, states have more discretion in
how they design their SCHIP programs, including the extent to which
they cover mental health services. In states that model their SCHIP
programs on private insurance plans rather than Medicaid, children may
face day or visit limits, as in California and Utah. In addition,
certain other factors, such as the availability of providers willing to
participate in the Medicaid program or cost-sharing requirements of
SCHIP, could also constrain the ability of some children to obtain
needed services. The extent to which children enrolled in Medicaid and
SCHIP receive covered mental health services is not fully known, but
available evidence suggests that enrolled children in some states may
not be obtaining services they need.
Beyond providing insurance that can give children access to mental
health services, a range of federal programs can help children who have
experienced trauma obtain needed services. We identified over 50
programs--primarily in HHS, Justice, FEMA, and Education--that can be
used by grantees to provide mental health and other needed services to
children who have experienced trauma, although many of these programs
have a broader focus and were not designed specifically for this
purpose. Some federal programs pay for crisis counseling, such as the
Crisis Counseling Assistance and Training Program to assist victims of
disasters, which is administered by FEMA in collaboration with HHS‘s
Substance Abuse and Mental Health Services Administration (SAMHSA).
Justice‘s Victims of Crime Act (VOCA) Crime Victim Compensation grants
to states are an important federal source of funding for mental health
services for victims of crimes. However, children‘s access to benefits
may be constrained by states‘ eligibility requirements or program
limitations, such as caps on mental health services. In addition, other
factors may also hamper some child victims‘ ability to obtain financial
assistance for needed mental health services. These include families‘
lack of knowledge about state victim compensation programs and state
program requirements such as filing a police report within 72 hours of
a crime. Several federal grant programs encourage coordination among
mental health and other service systems--such as child welfare, health
care, and justice--so that children who have experienced trauma and
their families can more easily gain access to the full range of
services they need. Furthermore, some federal grants, such as Justice‘s
VOCA Crime Victim Assistance grants to states, can improve service
providers‘ ability to meet the needs of children who have experienced
trauma by providing access to services, such as case management, that
may not be covered by insurance.
While federal grant programs expand the number of children whose mental
health services may be reimbursed or help increase the available
services in a community, some children who need services may not
benefit from such programs. For example, some grants are awarded to a
relatively small number of communities and expire after a defined
period. Moreover, little is known about the effectiveness of federal
programs that can help children who have experienced trauma to obtain
mental health services or about gaps in access to needed services.
SAMHSA‘s National Child Traumatic Stress Initiative, which is
specifically designed to take a coordinated approach to improving
mental health care for children who have experienced various kinds of
trauma, plans to evaluate both its overall program and individual
components. If carefully implemented, the SAMHSA evaluations have the
potential to provide information on ways to effectively provide mental
health services to children who have experienced trauma. Some key
programs have not conducted evaluations to assess their effectiveness
in helping traumatized children obtain needed mental health services,
and others have lagged in establishing their evaluation frameworks. For
example, FEMA and SAMHSA have not evaluated the effectiveness of the
disaster crisis counseling program. Without evaluations of the
effectiveness of federal programs that have a clear goal of helping
children who experienced trauma obtain mental health services, federal
managers and policymakers lack information that would help them assess
which federal efforts are successful; determine which programs could be
improved, expanded, or replicated; and effectively allocate resources
to identify and meet additional service needs.
We are recommending that the Director of FEMA work with the
Administrator of SAMHSA to evaluate the effectiveness of the disaster
crisis counseling program. We provided a draft of this report to four
departments and agencies for their review. FEMA and HHS concurred with
our discussion of the Crisis Counseling Assistance and Training
Program, agreed that evaluation of this program is needed to ensure
program effectiveness, and stated that they have initiated additional
evaluation activities. However, the activities they described do not
constitute the programwide effectiveness evaluation we are recommending
and FEMA did not indicate whether it intends to implement our
recommendation to coordinate with SAMHSA to conduct such an evaluation.
Both HHS and Education suggested that the report more fully address
their concerns that the mental health workforce does not include enough
appropriately trained providers to meet the service needs of children
who have experienced trauma. We included additional information on this
subject, but a detailed discussion of this issue is outside the scope
of this report. HHS also suggested that the report treat in greater
depth several other topics, including the role of stigma associated
with mental health problems. We modified the report to acknowledge the
role of stigma, but although we agree that this and other subjects are
important, detailed discussion of them is outside the scope of this
report. Justice provided technical comments.
Background:
Many children across the country have been victims of, or witnesses to,
violence in their homes, schools, or communities. In 1999, according to
the most recent edition of a joint Justice and Education report,
students aged 12 through 18 were victims of about 186,000 violent
crimes at school and about 476,000 violent crimes away from
school.[Footnote 2] In addition, thousands of children have been
exposed to natural disasters or terrorist acts such as those that
occurred on September 11, 2001, placing them at risk for mental health
problems. While many children respond to these situations with
resilience, others suffer acute and chronic effects. Children‘s
reactions to trauma may appear immediately after the traumatic event or
may appear days, weeks, months, or even years later. Researchers report
that children who experience traumatic events show a wide range of
reactions, and their nature and intensity vary on the basis of factors
such as the type and frequency of trauma, whether a child knew the
offender or victim, the strength of the family support system, and a
child‘s sex and age. For example, children age 5 and younger typically
react to traumatic events with crying, screaming, and fear of being
separated from a parent, while adolescents tend to have reactions
similar to adults, such as flashbacks, nightmares, and suicidal
thoughts.[Footnote 3] A child‘s reactions to traumatic events,
including disasters, may also vary based on how well their parents cope
with the situation and on whether a child or parent has a preexisting
mental disorder. Some children have a special vulnerability to the
impact of traumatic events. Studies indicate that the impact is likely
to be greatest for a child who had previously been victimized or
already had a mental health problem.[Footnote 4]
Certain psychiatric diagnoses are associated with exposure to traumatic
events, including acute stress disorder, PTSD, depression, and conduct
disorder. Children with acute stress disorder can display multiple
symptoms, including reexperiencing of the event, avoidance of
situations that remind them of the traumatic event, sleep disturbances,
poor concentration, and regressive behavior. The disorder is of short
duration, with symptoms beginning within 4 weeks of a traumatic
experience and lasting from 2 days to 4 weeks. If symptoms continue,
the diagnosis may be reevaluated and changed to PTSD. PTSD is similar
to acute stress disorder and shares many of the same symptoms, but
lasts longer. It is diagnosed when symptoms persist more than a month,
although the disorder may develop either immediately after a traumatic
event or several months later. Exposure to traumatic events may also
result in depression, which is generally characterized by changes in
appetite, sleep disturbances, constant sadness, and irritability.
Conduct disorder may also develop after experiencing a traumatic event.
The disorder is identified by a persistent pattern of behavior that
violates major age-appropriate societal norms, such as aggression
toward people and animals or destruction of property.
The prevalence of different diagnoses varies based on factors such as
age and sex. For example, a preliminary report on how the September 11,
2001, attack affected New York City public school students found that
children in grades 4 and 5 were more likely than children in grades 6
to 12 to experience PTSD and other disorders involving intense fear and
avoidance of usual activities, while the older children were more
likely to have conduct disorder or depression. Similarly, girls had
higher rates of PTSD, depression, and generalized anxiety than boys,
who had higher rates of conduct disorder.[Footnote 5]
Depending on the nature and severity of a traumatized child‘s
condition, a variety of mental health treatment options and service
settings may be recommended. These include outpatient individual,
family, or group therapy; inpatient hospital care; and residential
care. A range of service providers, including psychiatrists,
psychologists, psychiatric nurses, counselors, and clinical social
workers, may treat children who have experienced trauma. Optimal care
of these children often requires participation by a variety of service
systems, such as mental health and social services.
The Surgeon General has reported that there are not enough mental
health professionals trained to work with children.[Footnote 6]
Moreover, trauma experts report that even professionals who are trained
to work with children may not have specialized training or experience
in working with children who have experienced trauma. Children whose
families do not speak English can have a particularly difficult time
finding providers who can assist them.
Because the types of trauma that children experience vary considerably,
numerous pathways can lead to the identification, referral, assessment,
and treatment of traumatized children needing mental health services.
These pathways include families; schools; day care; primary health
care; and the law enforcement, juvenile justice, and child protective
services systems. However, the professionals working in these systems
may not be trained to identify children with trauma-related mental
health problems. For example, a recent report by the Surgeon General
noted that primary care providers often have little training on mental
health services and vary in their capacity to recognize and diagnose
disorders and to coordinate with mental health providers.[Footnote 7]
In addition, the Institute of Medicine recently concluded that health
professionals are not sufficiently educated about family
violence.[Footnote 8] Further, not all teachers are aware of the
connection between academic or behavioral problems and the possibility
that they are related to a child‘s exposure to violence. Justice has
also reported that law enforcement personnel are generally not
sufficiently aware of the psychological effects that witnessing
violence can have on children.[Footnote 9]
At the national level, few data are available on the number of children
who need mental health services as a result of exposure to trauma and
the number who receive services. For example, there are no nationwide
data on the number of children in foster care and the juvenile justice
system--populations likely to have been exposed to trauma--who need
mental health care, or on the number who have received
treatment.[Footnote 10]
Private and Public Health Insurance Coverage for Children:
Access to health care services, including mental health services, is
highly correlated to having health insurance coverage. According to
March 2001 Current Population Survey data, over 67 million children
nationwide have health insurance coverage. More than two-thirds of
children under age 19--almost 54 million--obtain health insurance
privately, either as a dependent under a parent‘s or guardian‘s
employer-sponsored health plan or through the individual insurance
market. In addition, almost 14 million children are enrolled in public
programs such as Medicaid, SCHIP, or other federal insurance programs.
Although most children have insurance coverage, over 9 million remain
uninsured. (See table 1.):
Table 1: Type of Insurance Coverage for Children under Age 19 in 2000:
Type of insurance: Private; Employer-sponsored; Percentage of
children under 19[A]: 65.9.
Type of insurance : Private/Individual; Percentage of
children under 19[A]: Type of insurance : 4.1.
Type of insurance: Public; Medicaid (including SCHIP); Percentage of
children under 19[A]: 16.3.
Type of insurance : Medicare[B]; Percentage of
children under 19[A]: Type of insurance : 0.5.
Type of insurance : TRICARE[C]; Percentage of
children under 19[A]: Type of insurance : 1.2.
Type of insurance: Uninsured; [Empty]; Percentage of
children under 19[A]: 12.0.
[A] Some people may receive coverage from several sources. To avoid
double counting, we assigned an individual reporting coverage from two
or more sources to one source, based on a hierarchy in the following
order: employer-sponsored, Medicare, Medicaid, TRICARE, private/
individual, and uninsured. Therefore, percentages for specific sources
of coverage, such as Medicaid, may be underestimated.
[B] Children with a disability or End-Stage Renal Disease may be
eligible for Medicare.
[C] TRICARE is a program administered by the Department of Defense for
families of active duty, retired, and deceased service members.
Source: GAO analyses of March 2001 Current Population Survey.
[End of table]
Despite widespread health insurance coverage of children, private
health insurance plans historically included greater restrictions on
mental health benefits than on benefits for other health services.
Consequently, federal and state laws have attempted to partially
equalize benefit levels. The federal Mental Health Parity Act of 1996
(MHPA) prohibits certain group health plans sponsored by employers with
more than 50 employees from imposing annual or lifetime dollar limits
on mental health benefits that are more restrictive than those imposed
on other benefits.[Footnote 11] As of March 2000, more than half of the
states had also passed laws that exceeded the federal law by requiring
that certain health insurers not only have parity in dollar limits, but
also in service limits and cost-sharing provisions. However, these
state mental health parity provisions do not affect employers who pay
their employees‘ health expenses directly rather than by purchasing
insurance. Federal law permits states to regulate insurance, but
employers‘ self-funded health plans, which covered almost half of all
employees enrolled in employer-sponsored plans in 1999, are not
affected by such state insurance regulations.[Footnote 12]
Medicaid operates as a joint federal-state program to finance health
care coverage for certain categories of low-income individuals. Within
guidelines established by federal law, states have considerable
flexibility in how they structure their programs, including determining
eligibility levels and what benefits to cover. For example, federal law
requires states to offer Medicaid coverage to children age 5 and under
if their family incomes are at or below 133 percent of the federal
poverty level and to children ages 6 to 18 if their family incomes are
at or below the federal poverty level.[Footnote 13] To offer coverage
to additional children, many states have set family income eligibility
thresholds beyond these minimum federal levels.
Benefits covered by state Medicaid programs are either mandatory or
optional. For example, states are required to cover EPSDT services,
which include comprehensive, periodic health and developmental
evaluations or screenings. A state must cover any services necessary to
treat physical and mental conditions detected through these screenings,
regardless of whether the services are covered by the state‘s Medicaid
program.[Footnote 14] We have previously reported that the extent to
which children actually receive EPSDT services is not fully known,
largely because no reliable, national utilization data exist for these
services.[Footnote 15] States also have the option to provide
beneficiaries with a number of other services, such as inpatient
psychiatric and psychological services. HHS‘s Centers for Medicare &
Medicaid Services (CMS), the federal agency that oversees Medicaid and
SCHIP programs, does not have current data that comprehensively
summarize the extent to which states cover mental health services;
however, other available sources suggest that the majority of states
provide some level of mental health coverage as an optional
benefit.[Footnote 16]
In 1997, the Congress enacted SCHIP to provide health care coverage to
low-income children living in families whose incomes exceed the
eligibility limits for Medicaid.[Footnote 17] Although SCHIP is
generally targeted to families with incomes at or below 200 percent of
the federal poverty level, each state may set its own income
eligibility limits within certain guidelines. As a result, SCHIP
maximum income eligibility levels vary considerably among states,
ranging from 100 to 350 percent of the federal poverty level. States
have three options in designing SCHIP: expand their Medicaid programs,
develop separate child health programs that function independently of
the Medicaid programs, or do a combination of both. States that
implement SCHIP by expanding Medicaid must use Medicaid‘s enrollment
structures and benefit packages (including EPSDT services); in
contrast, separate SCHIP programs may depart from Medicaid requirements
for benefits and for the plans, providers, and delivery systems
available. (See app. III for a state summary of SCHIP programs.):
Federal Agencies with Responsibility for Assisting Children Who Have
Experienced Trauma:
Several federal departments and agencies have responsibility for
addressing the mental health needs of children who have experienced
trauma. For example, HHS agencies have responsibility for improving the
accessibility and delivery of mental health services, conducting
research on children‘s mental health issues, disseminating information
on promising approaches for improving children‘s mental health, and
promoting the well-being of children. In addition to CMS, these
agencies include ACF, the Health Resources and Services Administration
(HRSA), the Indian Health Service, and SAMHSA. In addition, the
National Institutes of Health, the Centers for Disease Control and
Prevention, and the Agency for Health Care Research and Quality fund
research on a range of topics related to child victims and trauma,
including the effects of trauma on children and interventions to assist
children who have experienced trauma. HHS‘s Office of Public Health and
Sciences coordinates programs across agencies and supports crosscutting
initiatives involving children‘s mental health.
FEMA is charged with providing financial and technical assistance to
states and federally recognized Indian tribes for crisis counseling and
other services to children and adults affected by presidentially
declared disasters, which can include earthquakes, fires, floods,
hurricanes, and terrorism. Justice seeks to mitigate the effects of
violence on children, including by paying for mental health services
for children who are victims of, or witnesses to, violent crimes.
Offices within Justice that focus on this population include the Office
of Juvenile Justice and Delinquency Prevention, the Violence Against
Women Office, and the Office for Victims of Crime (OVC), all within the
Office of Justice Programs. In addition, Education, through its Office
of Elementary and Secondary Education, oversees programs that can help
students obtain services to ensure that mental health problems do not
interfere with their ability to learn.
Most Children Have Health Insurance Coverage, But Mental Health
Coverage May Have Limits and Not Guarantee Access:
Private health insurance plans, such as employer-sponsored or
individually purchased plans, and public programs, such as Medicaid or
SCHIP, provide health insurance coverage to 88 percent of children.
Although most children have health insurance, the level of mental
health coverage available to children varies and depends largely on the
type of insurance they have. While children enrolled in private
insurance plans often face limitations in their mental health coverage,
such as the exclusion of certain diagnoses from coverage or limits on
the number of covered visits for outpatient therapy, children in
Medicaid and SCHIP programs generally have coverage for a wide range of
mental health services. The typically broader coverage of Medicaid
programs and SCHIP programs that are Medicaid expansions is largely due
to these programs being required to cover all necessary health care for
problems detected through an EPSDT screening. Despite the availability
of public insurance coverage, other factors, such as low Medicaid
reimbursement rates that discourage provider participation or SCHIP
cost-sharing requirements that may make services unaffordable for some
families, could affect children‘s access to services. Although little
is known nationwide about the extent to which children in public
insurance programs receive mental health services, available evidence
suggests that children in some states may not be receiving services
they need.
Coverage Limitations in Private Health Insurance Plans Could Affect
Children‘s Ability to Obtain Mental Health Services:
The extent to which private health insurance plans cover mental health
services varies. Most employer-sponsored health plans cover inpatient
and outpatient mental health services, as do individual insurers,
although to a lesser extent. However, private insurance plans often
contain coverage or other restrictions, which may limit the
availability of mental health services to enrollees, including children
who have been exposed to trauma. For example, private plans may impose
day or visit limits on mental health treatment, exclude certain
diagnoses or benefits from coverage, or not offer mental health
coverage at all.
Employer-Sponsored Group Health Plans:
Employer-sponsored group health plans, which cover over 50 million
children, or 66 percent, typically include mental health benefits that
children who have experienced trauma may need. However, many of these
plans impose more restrictive limits, such as day or visit limits, on
mental health benefits than on other benefits. For example, in a prior
survey of nearly 900 employers, we found that 87 percent of employer
plans complied with the dollar parity requirements of the MHPA but set
other limits that were not prohibited by MHPA, such as the number of
allowable outpatient visits or inpatient days for mental health
treatment.[Footnote 18] In contrast, few plans imposed limits on
hospital days or office visits for health conditions not related to
mental health. In addition, a survey conducted by Mercer/Foster Higgins
of 2,813 employers that sponsor health plans found that at least 73
percent of preferred provider organization (PPO), point of service
(POS), and health maintenance organization (HMO) health plans offered
by employers with more than 500 employees imposed annual limits on
mental health services.[Footnote 19] These plans most commonly imposed
day and visit limits on mental health services, with median limits of
30 inpatient days and 30 outpatient visits per year.[Footnote 20] (See
table 2.) Although for some children these service levels are
sufficient, these limits may not provide adequate coverage for some
traumatized children who require long-term mental health treatment.
Table 2: Percentage of Health Plans Offered by Employers with More Than
500 Employees That Limited Inpatient and Outpatient Mental Health
Services in 2001:
Plans with annual inpatient day limits; Percentage of health plans:
PPO: 78; Percentage of health plans: HMO: 77; Percentage of health
plans: POS: 78.
Plans with annual outpatient visit limits; Percentage of health plans:
PPO: 78; Percentage of health plans: HMO: 77; Percentage of health
plans: POS: 73.
Note: Data for indemnity (fee-for-service) health plans were not
reported in 2001 because sufficient data for these plans were not
available. According to Mercer/Foster Higgins, only 6 percent of
employees of large employers were enrolled in indemnity plans in 2001.
Source: Mercer/Foster Higgins National Survey of Employer-Sponsored
Health Plans, 2001.
[End of table]
Individual Health Insurance Market:
Limitations in mental health coverage are more pronounced for the over
3 million children covered by individual insurance plans. Unless
precluded by state law, mental health benefits in the individual market
can be more restrictive than other benefits in such areas as annual or
lifetime dollar limits on what the plan will pay and service limits,
such as fewer covered hospital days or outpatient office visits. The
individual market may also have higher cost-sharing, such as
deductibles, copayments, or coinsurance. We found such limitations
among individual health plans we reviewed. For example, one insurer
imposed a lifetime limit of $10,000 on mental health benefits, while
another insurer that sells individual health plans in nearly 40 states
includes mental health coverage only if required by state law. Another
insurer limited annual mental health coverage to $1,500 for each
member. (See app. IV for a summary of differences in individual market
health plan coverage for certain mental health treatments available to
children in six states.) In addition, few states require insurers in
the individual market to guarantee access to health insurance coverage
for people with mental disorders, leaving some children unable to
obtain any health insurance. We recently reported that in several
states, applicants for individual health insurance who had certain
conditions, such as PTSD, would likely be denied coverage by five of
the seven insurers reviewed.[Footnote 21]
State Responses to Limitations in Private Health Insurance Plans:
To address these and other limitations in mental health coverage, many
states have passed laws that exceed the requirements of MHPA.[Footnote
22] Among the six states we reviewed, three--California, Massachusetts,
and Minnesota--mandated that health plans offer mental health benefits
at the same level as other benefits. The other three states--Georgia,
Illinois, and Utah--took varied approaches to requirements on mental
health coverage. Laws in these states apply only to certain types of
health plans or do not require health plans to include mental health
coverage. However, self-funded employer group plans, which covered
close to half of all private sector employees in group health plans in
1999, are beyond the purview of state regulation and thus exempt from
these reforms. (See app. V for a summary of selected laws related to
mental health insurance coverage in these states.):
State Medicaid and SCHIP Programs Typically Cover a Wide Array of
Mental Health Benefits, but Children May Encounter Difficulties
Obtaining Covered Services:
The 16 percent of children enrolled in Medicaid and SCHIP typically
have coverage for a wide range of mental health benefits. However,
coverage limitations and other factors, such as Medicaid reimbursement
rates to providers and SCHIP cost-sharing requirements, could affect
children‘s access to services and available data suggest that some
enrolled children are not receiving mental health services they need.
Medicaid Program:
With few exceptions, the Medicaid programs in the six states we
reviewed provided children with coverage for a wide range of mental
health services. For example, all six states provided children with
coverage for diagnostic assessments, outpatient therapy, medication
management, and mental health treatment in residential care facilities,
and did not impose day or visit limits or cost-sharing
requirements.[Footnote 23] In addition to specified mental health
services, Medicaid requires states to cover all necessary health
treatment services when a health problem that could affect a child‘s
development is detected during an EPSDT screening, regardless of
whether the condition or treatment is explicitly covered by the state‘s
Medicaid program. A required element of an EPSDT screening is a
comprehensive history, which is supposed to include an assessment of a
child‘s mental health needs. Although many states have developed
recommended screening protocols for health care providers to complete
on specified schedules, CMS defines screenings very broadly and
considers any encounter with a health care provider to be a screening
sufficient to identify and require the provision of needed services.
One mental health service that can be important to families of children
who have experienced trauma is respite care. Although respite care is
not a mandatory Medicaid service, states may use flexibility available
under the Medicaid statute to cover respite services, such as child
care and weekend group home services, in order to provide some relief
for an eligible child‘s parent, guardian, or primary
caregiver.[Footnote 24] By providing a temporary period of time apart
for parents and their children, respite care services can decrease
stress in the family and increase the likelihood that a child with a
mental illness can continue to live at home and avoid placement in an
institution. However, only one of the six state Medicaid programs we
reviewed--Minnesota--explicitly covered respite services for some
children with mental illness.[Footnote 25]
Despite having mental health coverage, children enrolled in Medicaid
may face constraints when they attempt to obtain covered services. For
example, children may have difficulty finding providers to treat their
mental health needs. Officials in the six states we reviewed said that
their states had shortages of mental health providers, especially child
psychiatrists, and that these shortages were particularly acute in
rural areas. In addition, some providers said that low Medicaid
reimbursement rates, coupled with delayed payments from states,
discourage providers from participating in Medicaid. Although not
specifically focused on mental health services, studies have compared
Medicaid fee-for-service reimbursement rates to Medicare and have shown
that Medicaid rates are significantly lower.[Footnote 26] For example,
in the six states we reviewed, Medicaid reimbursed physicians for a
psychiatric diagnostic interview at rates that ranged from 28 to 78
percent of the average national rate Medicare pays for the same
service.[Footnote 27]
SCHIP:
The SCHIP programs in the six states we reviewed varied in their extent
of mental health service coverage and the extent to which they have
instituted cost-sharing requirements for covered beneficiaries. Four of
the six SCHIP programs we reviewed covered generally the same extensive
mental health benefits as Medicaid programs in their states. For
example, SCHIP beneficiaries in Minnesota have coverage for the same
unlimited mental health benefits as Medicaid beneficiaries and are not
responsible for any out-of-pocket costs. Similarly, the SCHIP benefits
of Illinois, Georgia, and Massachusetts generally mirror the benefits
available under their state Medicaid programs, albeit with limited
cost-sharing that Medicaid does not require. For example, Georgia
families must pay a premium of $7.50 per month for each child over age
six, with a monthly limit of $15 per family. Similarly, families in
Illinois with incomes over 150 percent of the federal poverty level
must pay $5 for each outpatient or inpatient mental health visit and a
monthly premium of $15 for one child, $25 for two children, and $30 for
three children.[Footnote 28]
In contrast to these four states, SCHIP beneficiaries in California and
Utah generally have coverage for fewer benefits than Medicaid
beneficiaries and may face limits on treatment days and visits. Unlike
their state Medicaid programs, the SCHIP programs in each of these
states are modeled after the private insurance plan available to public
employees in the state.[Footnote 29] These SCHIP plans are not required
to cover residential care or targeted case management services and are
not required to provide all enrolled children with EPSDT screenings or
coverage for services these screenings identify as necessary.[Footnote
30],, (See fig. 1.) Also, children in Utah‘s SCHIP program are allotted
a maximum of 30 outpatient visits and 30 days of inpatient care per
year and are not covered for family therapy visits.[Footnote 31]
Similarly, California SCHIP allows participating health plans to limit
children to 20 outpatient visits and 30 days of inpatient care per
year. Some health plans have chosen not to impose these limits; health
plans that do impose limits told us that children rarely reach them. In
addition, these limits do not apply to children in California who are
diagnosed with a serious emotional disturbance (SED) or one of nine
severe mental illnesses (SMI).[Footnote 32] These children are eligible
to receive unlimited mental health services. Whether limits in
California and Utah SCHIP plans prevent children from obtaining needed
services is unknown; however, these limits may not provide sufficient
coverage to some traumatized children who require long-term mental
health treatment.
Figure 1: Comparison of State Medicaid and SCHIP Coverage for Selected
Mental Health Treatments in California and Utah:
[See PDF for image]
[A] SCHIP children in California who are diagnosed with SED have
coverage for all of these services without limitations through the
county mental health departments. In addition, day and visit limits do
not apply to SCHIP children diagnosed with SMI.
[B] Health plans may limit outpatient care for non-SED/non-SMI children
to 20 visits per year.
[C] Health plans limit enrollees to a maximum of 30 visits per year.
[D] Health plans may limit inpatient care for non-SED/non-SMI children
to 30 days per year.
[E] Health plans limit enrollees to a maximum of 30 days per year and
60 days in a 3-year period.
[F] The Medicaid programs in both states cover mental health services
provided to enrollees in residential care facilities but not the cost
of room and board.
Source: State Medicaid and SCHIP health plans.
[End of figure]
In addition to inpatient day and outpatient visit limits, children in
California and Utah are also subject to cost-sharing requirements
through SCHIP that may make mental health services unaffordable for
some families. For example, depending upon the level of their income,
families in California must pay $5 for each outpatient visit and must
also pay a monthly premium of $4 to $9 for each child enrolled in the
program, with a monthly limit of $27 per family.[Footnote 33] Although
Utah‘s SCHIP program does not charge monthly premiums, it requires
families with incomes from 100 to 150 percent of the federal poverty
level to pay a $5 copayment for each outpatient visit, and families
with incomes from 151 to 200 percent of the federal poverty level to
pay for half of the total cost of the outpatient service.[Footnote 34]
Utilization of Mental Health Services:
Little is known about the extent to which traumatized children with
public insurance utilize mental health services, largely because no
reliable, national utilization data exist for mental health services
covered by Medicaid or SCHIP. While states are required by law to
submit annual reports on the utilization of EPSDT services, CMS‘s
efforts to assemble reliable information about EPSDT participation in
each state have been unsuccessful, despite 1999 revisions to the annual
report that sought to clarify and simplify reporting requirements.
State-reported data are often untimely or inaccurate, particularly in
states where children receive services through managed care plans that
are prospectively paid on a capitated basis, meaning the plans receive
a flat payment per member, regardless of the cost of treating the
patient.[Footnote 35] Moreover, states are not required to report
mental health services provided under the EPSDT program. Limitations in
other CMS data reporting requirements also make it difficult for the
agency to determine the extent to which children are receiving mental
health services. For example, periodic reports on health care
utilization and expenditures that CMS requires states to submit do not
collect consistent data on mental health services covered by Medicaid
and SCHIP.
Although national data regarding publicly insured children‘s use of
mental health services are not available, numerous lawsuits alleging
shortcomings in the provision of EPSDT services, coupled with
individual state utilization data that were available from most of the
states we reviewed, indicate that children enrolled in Medicaid or
SCHIP may not be obtaining needed services. According to the National
Health Law Program, a national public interest law firm, as of
September 1, 2001, 49 court opinions had been rendered on challenges
alleging a state‘s failure to properly implement EPSDT or to provide
access to necessary services. In several of these cases, courts have
found that a state violated EPSDT requirements by not providing all
necessary mental health services to children.[Footnote 36] For example,
in response to a class action lawsuit alleging that children were not
being provided with access to mental health services, the court
approved a consent decree by the parties under which West Virginia
agreed to ensure that all EPSDT screens and subsequent treatments
include behavioral and mental health services.[Footnote 37]
In addition, statewide utilization data collected by four of the six
states we reviewed--California, Illinois, Minnesota, and Utah--
indicated that a small percentage of children enrolled in the state‘s
Medicaid and SCHIP programs, ranging from 0.7 percent of children in
Illinois to 6 percent of children in Minnesota, used mental health
services.[Footnote 38] Utilization data collected by Massachusetts,
however, indicated that close to 16 percent of the children enrolled in
its Medicaid and SCHIP managed care program were using available mental
health services.[Footnote 39] Based on their experience and their
reviews of research, officials in California and Utah told us they
would expect the proportion of children needing mental health services
to be higher. State officials and providers told us that various
factors, such as the difficulty associated with identifying children
with mental illness, lack of parental awareness of mental illness, and
the stigma associated with mental illnesses, could contribute to lower
than expected utilization of services.
Type of Insurance Coverage and State of Residence Affect Mental Health
Service Coverage and Costs:
A child‘s type of health insurance and state of residence generally
determine the extent of mental health coverage available. To
demonstrate the variation between public and private insurance programs
in the availability and cost of mental health services for children, as
well as variation among states, the following example outlines the
covered benefits and annual benefit limitations of various types of
insurance available to a hypothetical 5 year-old child who has
experienced trauma and resides in either California or Illinois.
Depending on the recommended treatment, which may include individual,
group, or family therapy; inpatient hospitalization; or care in a
residential facility, the services available and their cost to the
child‘s family could vary considerably. (See fig. 2.):
For example, if enrolled in Medicaid, the child in California would
have coverage for all these services at no cost; if enrolled in SCHIP,
the child may not have coverage for residential care or transportation
and could face limits on the number of inpatient days and outpatient
visits allowed.[Footnote 40] In addition, the family of the SCHIP-
enrolled child would be responsible for a $5 copayment for each
outpatient visit. This child would experience similar differences among
types of coverage in Illinois. Under Illinois‘ Medicaid and SCHIP
programs, the child would have coverage for all these services without
limitations. However, the family of the child enrolled in SCHIP would
also have to pay a copayment for each outpatient visit, and depending
on the family‘s income, could be responsible for a monthly premium as
well. In comparison, a child in Illinois who relied on coverage from
the individual insurer specified would not have coverage for
residential care and would be limited to 10 inpatient days and 20
outpatient visits each year.
Figure 2: Public and Private Insurance Coverage Options in California
and Illinois for a Hypothetical 5-Year Old Child Who Has Experienced
Trauma:
[See PDF for image]
[A] The Medicaid programs in both states cover mental health services
provided to enrollees in residential care facilities but not the cost
of room and board.
[B] Some health plans in California do not choose to impose these
limits on services. In addition, children in California who are
diagnosed with SED have coverage for all the services included in
figure 2, without limitations, through county mental health
departments. Also, day and visit limits do not apply to SCHIP children
diagnosed with SMI.
[C] Maximum of $27 premium per family per month.
[D] Maximum family copayment of $250 per year.. However, copayments are
not required for services provided to SED children in county mental
health centers.
[E] These data represent conditions and in-network costs for a sample
of PPO plans of employers with 500 or more employees; these plans had a
median family deductible of $600. The data represent the most common
day and visit limitations and other costs, and the average employee
premium portion for family coverage.
[F] Data are from a PPO that is one of the most popular health plans
sold in the individual insurance market in California and has a $1,000
deductible per person (maximum of $2,000 per family). Children who are
diagnosed with a SED or one of nine SMI are eligible for unlimited
benefits and pay 25 percent of service fees.
[G] This applies only to a child in a family whose income exceeds 150
percent of the federal poverty level. For two children, the premium is
$25; for three, the premium is $30.
[H] Maximum copayment per year per family is $100.
[I] This example represents conditions for a sample of HMO plans of
employers with 500 or more employees. The data represent the most
common day and visit limitations, and the average employee premium
portion for family coverage and outpatient copayment costs.
[J] Data are from an HMO that is one of the most popular plans sold in
the individual health insurance market in Illinois.
[K] A health plan official told us that this service is available to
members who meet the plan‘s medical necessity criteria.
Sources: State Medicaid and SCHIP health plans, Mercer/Foster Higgins
National Survey of Employer-Sponsored Health Plans 2001, and individual
insurers in California and Illinois.
[End of figure]
Federal Programs Can Help Children Who Have Experienced Trauma to
Obtain Mental Health Services, But Extent of Assistance Is Largely
Unknown and Little Evaluation Has Occurred:
Beyond insurance, a range of federal programs--including over 50 grant
programs we identified--can help children who have experienced trauma
obtain needed mental health services. (See app. VI for descriptions of
selected federal grant programs.) Some federal programs pay for crisis
counseling, such as the crisis counseling program for victims of
disasters, which is administered by FEMA in collaboration with SAMHSA.
Justice‘s VOCA Crime Victim Compensation grants and Crime Victim
Assistance grants to states help pay for mental health treatment needed
by crime victims. However, factors such as state eligibility
requirements and mental health service caps, as well as families‘ lack
of knowledge about the programs, may limit some child victims‘ ability
to benefit from these programs. Several federal grant programs
encourage coordination among mental health and other service systems--
such as social services, health care, and justice--so that children who
have experienced trauma and their families can more easily gain access
to the full range of services they need. One such program is SAMHSA‘s
National Child Traumatic Stress Initiative, a recent effort
specifically designed to take a coordinated approach to improving
mental health care for children who have experienced various kinds of
trauma. Some federal programs have a broader focus, such as general
mental health, or are targeted to specific populations, such as
children in foster care, but grantees can elect to use program funds to
provide mental health and other needed services to children who have
experienced trauma and their families. Little is known about the extent
to which these broader programs assist these children. Moreover, little
is known about the effectiveness of federal programs that help children
who have experienced trauma to obtain mental health services. For
example, FEMA and SAMHSA have not evaluated the effectiveness of the
disaster crisis counseling program.
Federal Disaster Grants Provide Some Mental Health Services to
Children:
Federal agencies provide financial and technical assistance to states
and localities to meet crisis-related mental health needs of children
and adults who are victims of natural disasters and mass violence. FEMA
collaborates with SAMHSA‘s Center for Mental Health Services to provide
financial and technical assistance to states and federally recognized
Indian tribes that request aid for crisis counseling[Footnote 41] and
other services for children and adults affected by presidentially
declared disasters.[Footnote 42] FEMA funds the program, and SAMHSA,
through an interagency agreement, provides technical assistance,
program guidance, and oversight. The Crisis Counseling Assistance and
Training grant funds are generally available for up to
12 months after a disaster declaration. FEMA reported that in fiscal
year 2001, it had obligated about $16.2 million in crisis counseling
funds.
In addition to crisis counseling, program funds are used for such
activities as training paraprofessionals to provide crisis counseling,
distributing information to increase public awareness about the effect
disasters can have on children, and helping identify and refer children
who may need longer term mental health treatment.[Footnote 43] For
example, New York and Virginia were declared disaster areas after the
September 11, 2001, terrorist attacks and, as of May 2002, FEMA had
approved about $160.6 million in crisis counseling grants.[Footnote 44]
As of March 2002, New York had reported using the FEMA funds to provide
free crisis counseling to approximately 10,000 children under age 18
affected by the attacks. In addition, HHS has allocated over $28
million for crisis counseling and other mental health and substance
abuse services to help areas affected by the terrorist attacks,
including $6.8 million that was awarded to eight states and the
District of Columbia to help support crisis mental health services and
to assist mental health and substance abuse systems in these locations.
HHS also awarded $10 million to 33 New York City and New Jersey
community health centers to support response-related services,
including the provision of grief counseling and other mental health
services. The Congress also appropriated $68.1 million to Justice to
further meet the crisis counseling needs of victims, their families,
and crisis responders. According to Justice, as of July 2002, the
department had awarded more than $40 million of this amount to
California, New Jersey, New York, Massachusetts, Pennsylvania, and
Virginia.[Footnote 45]
According to federal officials, communities have generally found the
12-month time frame sufficient for responding to all but the most
serious types of disasters, and extensions of limited duration have
occasionally been approved.[Footnote 46] However, SAMHSA officials and
trauma experts told us that there are concerns about whether the crisis
counseling grant‘s time frame is sufficient for identifying all
children who may require trauma-related mental health assistance as a
result of a large-scale natural disaster or act of terrorism that
results in mass casualties. These experts told us, for example, that in
the case of the 1995 bombing of the Alfred P. Murrah Federal Building
in Oklahoma City, the time frame was not sufficient to find, assess the
mental health needs of, and provide assistance to the large number of
children and adults who needed help. Although FEMA extended total grant
funding to about 33 months, crisis counseling services were still
needed after the funds had finally expired. As a result, Justice
provided an additional $264,000 to Oklahoma‘s Project Heartland to fund
crisis counseling services needed by individuals with problems stemming
from the bombing. Because there was a resurgence of mental health
problems during the federal bombing trials, Justice also provided about
$235,000 to help provide victims and other family members with needed
crisis counseling services. According to a SAMHSA official, the
September 11, 2001, attacks have led program officials to discuss
whether changes are needed in the nature and duration of federal
assistance available to address the special, longer-term mental health
service needs that can arise from mass casualty disasters, especially
those caused by terrorism.
SAMHSA is collaborating with the National Association of State Mental
Health Program Directors on the association‘s review of states‘
emergency response plans to identify ways that states can better plan
for the mental health care needs of disaster victims. According to
trauma experts and SAMHSA officials, most states have dedicated few
resources to planning for mental health needs that result from such
events and most have insufficient capacity to coordinate and mobilize
the mental health services needed for large-scale disasters. This could
result in the loss of valuable time, duplicative efforts, and missed
opportunities to identify children who could benefit from mental health
assistance.
Another federal resource for crisis situations is Education‘s School
Emergency Response to Violence program, commonly known as Project SERV.
Local school districts can apply for crisis response grants for
generally up to 18 months to help deal with the aftermath of violent or
traumatic events, such as school shootings and acts of
terrorism.[Footnote 47] Education officials said school districts have
used grants for children‘s crisis counseling, school security,
transportation to safe locations, and translation services.[Footnote
48] In addition, under the program, Education can send trauma and
violence experts to a school district to help school personnel handle
disaster situations. In fiscal year 2001, Project SERV obligated nearly
$9.8 million to school districts responding to violence and disasters,
with nearly 90 percent of the funds awarded to schools in communities
affected by the September 11, 2001, terrorist attacks.
Federal Crime Victims Fund Pays for Some Children‘s Mental Health
Services:
The federal Crime Victims Fund is an important federal funding source
for meeting the mental health needs of children who are victims of
violent crimes, including mass violence and terrorism. The fund is
administered by Justice‘s OVC, and most of the funds available[Footnote
49] are used to support victim compensation grants and victim
assistance grants to all states, the District of Columbia, Puerto Rico,
and U.S. territories.[Footnote 50] Federal VOCA victim compensation
grants supplement state funds to provide direct financial assistance
and reimbursements to, or on behalf of, eligible crime victims or their
survivors[Footnote 51] for a wide range of crime-related expenses,
including those for mental health services.[Footnote 52] Federal victim
assistance grants are provided to the states, which in turn award these
funds to eligible public and private nonprofit organizations that work
directly with crime victims to determine their needs and provide them
with a range of free services, including mental health services. In
fiscal year 2002, OVC allocated about $477 million to these two grant
programs.[Footnote 53]
Victim Compensation:
States use federal victim compensation grants to supplement their
efforts to compensate eligible crime victims or their survivors who
file claims with state victim compensation programs for their crime-
related expenses.[Footnote 54] In some instances, children who witness
crimes may be eligible for compensation.[Footnote 55] State victim
compensation programs provide financial assistance and reimbursement to
crime victims only to the extent that other financial resources, such
as health insurance, do not cover a victim‘s loss. Crisis counseling,
individual and group therapy, psychiatric hospital care, and
prescription drugs are among the mental health services covered by
states. According to OVC, state victim compensation programs reimbursed
approximately $50 million in mental health expenditures to children and
adults in fiscal year 2000.[Footnote 56] The percentage of annual
compensation expenditures that provides reimbursement for mental health
services varies widely by state. For example, in fiscal year 2001, 91
percent of California‘s victim compensation funds that paid for
services to children were for mental health services, while 14 percent
of Illinois‘s compensation funds that paid for children‘s services were
for mental health services.
State officials told us that the availability of victim compensation
funds can be particularly helpful for uninsured children or children
whose insurance does not cover all needed mental health services. For
example, of the claims for children‘s services reimbursed by
California‘s compensation program in fiscal year 2001, about 58 percent
were for children who were uninsured, 21 percent for children with
private insurance, 10 percent for children enrolled in Medicaid, and
about 11 percent for children with other financial resources.
Similarly, Illinois officials told us that the state‘s compensation
program serves many children who have no insurance.
Although crime victim compensation program guidelines require states to
reimburse victims for mental health expenses, states are given
discretion in setting program eligibility requirements and benefits. As
a result, states have different rules for who can qualify to receive
compensation benefits. In addition, states‘ mental health benefits vary
with respect to overall dollar limits, whether there are caps on mental
health coverage within those limits and the amounts of those caps, the
number of treatment sessions allowed, and the length of time that crime
victims can receive mental health benefits through the victim
compensation program. Furthermore, in most states when there are
multiple victims of a crime, they typically must share the available
overall maximum benefits. However, each family member or secondary
victim is typically eligible for mental health counseling benefits up
to specified caps, which generally apply to individuals and do not have
to be shared. For example, the total maximum compensation in California
for all victims of a crime is $70,000, with a $10,000 cap on mental
health services for all direct victims, and Minnesota‘s total maximum
award limit is $50,000, with a $7,500 cap on mental health
services.[Footnote 57] In Massachusetts and Illinois, the overall
compensation ceilings are $25,000 and $27,000, respectively, with no
mental health caps. New York has the most generous compensation
benefit, with no overall maximum and no cap on reimbursement for
victims‘ mental health expenses. (See app. VII for a summary of state
benefit information.):
Whether state eligibility requirements and caps on mental health
services are preventing some children from obtaining needed services is
largely unknown. Federal and state victim compensation program
officials told us that most child claimants obtain reimbursement for
needed mental health services and that many do not reach their benefit
limits. The state victim compensation officials, however, also told us
that eligibility requirements and benefit limits may exclude some
children who need assistance to pay for mental health services. OVC has
not undertaken a nationwide analysis of the effect of state
requirements and benefit limits on meeting the mental health needs of
child crime victims. Furthermore, OVC officials told us that there are
no detailed data at the national level on state compensation programs‘
payment for mental health services provided to children who have
experienced trauma. While OVC requires states to submit annual reports
on certain activities, including overall expenditures for mental health
services, it does not require information on expenditures for
children‘s mental health services and the types of mental health
services provided to these children. Therefore, the number of children
who have benefited from the mental health coverage available through
state victim compensation programs is uncertain.
Victim Assistance:
OVC‘s victim assistance grants to the states are another vehicle that
can help children and their families obtain needed mental health
services. In fiscal year 2000, these grants were combined with state
victim assistance funds to award grants to about 4,300 public and
private nonprofit organizations that in turn provided crime victims
with free medical, mental health, social service, and criminal justice
advocacy services.[Footnote 58] In contrast to state victim
compensation programs, which require crime victims to submit detailed
applications and supporting documentation, local organizations that
receive grants from state victim assistance programs typically do not
require as much documentation from crime victims before providing them
with needed assistance. State and local officials told us that some
crime victims many obtain faster help through victim assistance
programs than through filing compensation claims and waiting for
reimbursement for their crime-related expenses--a process that took, on
average, about 23 weeks in fiscal year 2000.
State victim assistance agencies reported allocating about $542.6
million in fiscal year 2000 to provide a range of services to about 3
million crime victims. For example, nearly 1.5 million of these victims
received crisis counseling and about 230,000 received individual
therapy.[Footnote 59] In the four states we reviewed, children
benefiting from these grants included those who had been sexually or
physically abused. (See table 3.):
Table 3: Number of Victims in Selected Categories Served by State
Victim Assistance Programs in Four States, Fiscal Year 2001:
Type of victimization: Child physical abuse; California: 4,758;
Illinois: 646; Massachusetts: 1,291; Minnesota: 4,769.
Type of victimization: Child sexual abuse; California: 21,817;
Illinois: 5,742; Massachusetts: 3,380; Minnesota: 7,569.
Type of victimization: Adults molested as children; California: 5,327;
Illinois: 945; Massachusetts: 1,351; Minnesota: 1,324.
Source: Statewide Victim Assistance Performance reports.
[End of table]
State victim assistance programs have reported to OVC that their
programs helped children who have experienced trauma and their families
in varied ways. For example, California, Illinois, and Massachusetts
officials reported paying for individual and group therapy in cases
where children either did not have insurance or their insurance
provided reimbursement for fewer sessions than were needed. In
addition, California and Massachusetts officials reported that victim
assistance funds had helped provide comprehensive services to children
and other family members, including case management, counseling
services in their native languages, translation assistance, and help in
filing claims for victim compensation.
Several Factors May Limit Some Children‘s Use of Victim Compensation
and Victim Assistance Benefits:
Although many children who are crime victims obtain mental health and
other services through state victim compensation programs, federal,
state, and local officials told us that many victims do not file
compensation claims and that program limitations can constrain access
to services. It is difficult to determine the exact number of
victimized children who need trauma-related mental health services and
who also need the financial assistance available through state victim
compensation programs to obtain such services. Many crime victims may
not need to file a claim for state victim compensation because they
have not incurred any crime-related expenses or they have other
resources, such as insurance, to help them pay for needed services.
Nonetheless, California and Illinois victim compensation officials said
that based on their analyses of claimant rolls and crime victim
statistics in their states, they believe that many potentially eligible
victims who could benefit from the assistance their programs offer had
not applied for compensation. For example, an Illinois Crime Victim
Compensation office analysis comparing 2000 county-level crime
statistics with compensation claims received in 2001 showed that while
there were 30,630 violent crimes reported in Chicago, the state victim
compensation office received only 2,796 claims from victims in that
city.[Footnote 60]
A 2001 Justice-funded report on state victim compensation and victim
assistance programs indicated that several program-related factors
might impede victims‘ access to services supported by such programs.
These factors included (1) lack of knowledge about the programs‘
existence, (2) lack of information on how to obtain available benefits,
and (3) state eligibility requirements that might make it difficult for
some victims to qualify for benefits. For example, most states
stipulate
that to qualify for compensation, a victim must file a report with law
enforcement authorities shortly after a crime occurs, generally within
72 hours, and must cooperate with these authorities. However, victims
of some crimes, such as sexual assault or domestic violence, may not
report the crimes immediately and may be apprehensive about cooperating
with authorities due to fear of retaliation by the offender. Other
program barriers identified by state program managers surveyed for the
report included (1) limited outreach and education, especially to
racially and ethnically diverse populations and to rural communities,
(2) lengthy and complex compensation award determination and payment
processes, and (3) insufficient coordination between state victim
compensation and victim assistance programs and with other agencies
that work with these victims to eliminate gaps in assistance or
duplicative services.[Footnote 61]
Efforts to address some of these problems are under way in the states
we contacted. For example, the Los Angeles County District Attorney‘s
office placed victim advocates in county courts to inform victims of
their right to benefit from the victim compensation and assistance
programs and to help children and their families obtain needed
services, including mental health care. In addition, California,
Illinois, and Minnesota officials told us that they are now more
flexible with their time frames for filing crime reports with police
and will accept other official reports, such as those from child
protective agencies and forensic sexual assault examinations. OVC
published a report in 1998 that included a recommendation that state
crime victim compensation programs reexamine their mental health
benefits to ensure that they are adequate.[Footnote 62]
Federal Agencies Encourage Coordination to Meet the Needs of Children
Who Experienced Trauma:
Coordination among mental health, child welfare, education, law
enforcement, and juvenile justice systems can help ensure that children
who have experienced trauma and their families obtain comprehensive,
timely, and appropriate services. Several federal agencies have funded
grant programs to promote collaborations within and across these
systems--some of which have not traditionally worked together, such as
police and mental health professionals. For example, although research
has documented the frequent co-occurrence of domestic violence and
child abuse,[Footnote 63] government officials and family violence
experts report that the child welfare and domestic violence advocacy
systems often fail to work together to devise safe, coordinated, and
effective responses to family violence, due in part to differing
missions, priorities, and perspectives. In some instances, child
welfare officials want to remove a child from a home where domestic
violence has allegedly occurred, while advocates for the nonoffending
parent argue that taking the child out of the home would penalize that
parent.
Justice awards grants to help support more than 350 Children‘s Advocacy
Centers, which assist children who come into contact with the court
system as a result of being abused.[Footnote 64] The centers aim to
bring together a multidisciplinary team and promote coordination among
various service systems to ensure that a child‘s multiple needs are
met, including access to mental health services for the child and other
family members. Typically consisting of law enforcement
representatives, child protection workers, prosecutors, victim
advocates, and mental health professionals, the teams work to ensure
that the child does not have to recount the traumatizing event in
multiple interviews, which could result in additional trauma.
To help communities minimize the adverse impact of family and community
violence on young children, Justice initiated the Safe Start
Demonstration Project in 1999. The grant program, which will last about
5 years, is designed to improve access to, and the quality of, services
for young children who are at high risk of exposure to violence or who
have already been exposed to violence. The program‘s goal is to help
communities strengthen partnerships among key service systems such as
Head Start, health care, mental health care, domestic violence shelters
and advocacy organizations, child welfare, and law enforcement. In
fiscal year 2000, the agency awarded grants to nine communities, with
each receiving $250,000 for a first-year planning phase. In addition,
grantees will receive up to $670,000 annually for implementation
activities.
Another way federal agencies are trying to encourage service systems to
work together is the Collaborations to Address Domestic Violence and
Child Maltreatment Project, which is jointly funded and administered by
eight agencies and offices within HHS and Justice.[Footnote 65] The
one-time demonstration grant, commonly called the Greenbook Project,
funds initiatives in six communities that are each receiving $350,000
annually for 3 years, starting in fiscal year 2000.[Footnote 66] The
project‘s goal is to help communities develop partnerships among three
key stakeholders--the child welfare system, domestic violence groups,
and juvenile and family courts--to improve the delivery of services to
victims of domestic violence and their children.[Footnote 67] For
example, a grantee in Colorado has used program funds to hire a
domestic violence advocate to work in the child welfare system to
improve screening for domestic violence and assess the risk to
children. The grantee has also used these funds to enhance an existing
program that houses police and child protective personnel at one
location, allowing them to jointly respond to domestic violence calls
so they can deal with the needs of all family members, including
children who have witnessed the violence.
Education, HHS, and Justice created the Safe Schools/Healthy Students
demonstration project in 1999 to help schools and communities draw on
three traditionally disparate service systems--education, mental
health care, and justice--to promote the healthy development of
children and address the consequences of school violence. The program,
which through fiscal year 2001 had made awards totaling about $439
million, requires local education agencies to establish formal
partnerships with mental health providers and local law enforcement
professionals. One of the project‘s six core elements is the
enhancement of school-and community-based mental health preventive and
treatment services. In fiscal year 2001, the agencies awarded about
$177 million to 97 urban, suburban, rural, and tribal community
grantees.
SAMHSA‘s National Child Traumatic Stress Initiative is a recent
initiative specifically designed to take a coordinated approach to
improving mental health care for children who have experienced various
kinds of trauma. Launched in October 2001, the 3-year effort is
designed primarily to
(1) improve the quality, effectiveness, and availability of therapeutic
services for all children and adolescents who experience traumatic
events, (2) develop a national network of centers, programs, and
stakeholders dedicated to improving the identification, assessment, and
treatment of children, and (3) reduce the frequency and severity of
negative consequences of traumatic events through greater public and
professional understanding of childhood trauma and greater acceptance
for child trauma intervention services. SAMHSA has taken a tiered
approach in structuring the $30 million initiative by establishing
three grantee categories: a National Center for Child Traumatic Stress
to coordinate the overall initiative; 10 Intervention Development and
Evaluation Centers, which plan to develop scientifically-based
improvements in treatment and service delivery; and 25 Community
Treatment and Services Centers, which focus on treating victims of
various types of trauma.[Footnote 68] The initiative emphasizes
partnerships and coordination among grantees at each level and across
levels. It also encourages grantees to collaborate with professionals
in various community service systems--including child protection,
justice, education, and health care--that interact with children who
have experienced trauma and their families. Because this initiative is
in its early stages, information on the effectiveness of its efforts is
not available.
Federal Programs with Broader Focus May Help Fund Services Needed by
Children Who Experienced Trauma:
Other federal grant programs not specifically targeted to assisting
children who have experienced trauma may also help fund mental health
and other services needed by these children and their families. These
federal grants focus on broader issues, such as general mental health
or maternal and child health services or services for specific
populations, such as children in foster care, homeless youth, or
migrant farmworkers. (See app. VI for descriptions of selected federal
grant programs.) Grantees can, if they choose, use these funds to
provide a range of services beneficial to children who have been
traumatized. For example, funds from the Indian Health Service‘s Urban
Indian Health Program, which provides health services to child and
adult American Indians living in urban areas, can be used to screen,
refer, and treat children who need mental health services due to
trauma. ACF‘s Transitional Living for Homeless Youth program, which
operates transitional living projects and promotes self-sufficiency for
homeless youth, requires grantees to offer mental health services,
either directly or by referral. SAMHSA‘s Comprehensive Community Health
Services for Children and Their Families program, commonly known as the
System-of-Care program, provides supportive services to children and
adolescents with SED and their families. Many of the children served
through this program have been exposed to violence in their homes and
many have been referred by social service and law enforcement agencies.
In fiscal year 2001, 45 communities received System-of-Care grants to
fund a range of services, including case management, intensive home-
based treatment services, family counseling, and respite care. State
officials and service providers told us that some of the broader
federal grants improved their ability to meet the needs of traumatized
children and their families because the grants can fund services that
are not always eligible for insurance reimbursement, such as case
management and ancillary services for parents, including child care and
transportation.
Some of these broader federal grants also support screening and
identification of children with trauma-related mental health problems.
For example, ACF‘s Head Start program, which promotes school readiness
for low-income children, requires grantees to ensure that each child
receives mental health screening within 45 days of entering the
program. The grantees are required to consult with mental health or
child development professionals, teachers, and family members in
devising appropriate responses to address identified problems. In 1990,
HRSA and CMS cosponsored the initiation of the Bright Futures project
to help primary care health professionals promote the physical and
mental well-being of children, recognize problems, and intervene early.
Recently, HRSA funded the development of mental health practice
guidelines outlining risk factors and potential interventions related
to domestic and community violence.[Footnote 69] In addition, HRSA and
the National Highway Traffic Safety Administration administer the
Emergency Medical Services for Children program, which provides funds
to ensure that children‘s services are well integrated into the
emergency medical system. Among its initiatives, the program provides
training grants to improve the ability of emergency medical services
workers and emergency department physicians and nurses to identify the
mental health needs of children in emergency situations.
Because they are not specifically designed to assist the mental health
needs of children who have experienced trauma, these grants‘ data
reporting requirements often do not produce information on the extent
to which children have been screened for trauma-related problems and
the number of children who have obtained mental health services as a
result of trauma. In addition, program officials were generally unable
to provide specific information on the portion of program funds used to
serve these children.
Few Federal Programs Have Evaluated Their Effectiveness in Assisting
Children Who Experienced Trauma:
Despite the many federal efforts that contribute to varying degrees to
helping children who have experienced trauma and their families obtain
mental health and other needed services, little is known about their
effectiveness. Few programs have undertaken formal evaluations to
assess program progress and results and to guide decisions to improve
service to targeted beneficiaries. For example, FEMA and SAMHSA have
not conducted an evaluation of the effectiveness of FEMA‘s crisis
counseling program. SAMHSA officials told us that there were no
immediate plans to conduct such an evaluation. In 1995, FEMA‘s Office
of Inspector General recommended that the agency, in consultation with
experts in disaster mental health and mental health outcomes research,
evaluate the effectiveness and efficiency of the crisis counseling
program.[Footnote 70] In its response to the recommendation, FEMA
indicated that FEMA and SAMHSA monitored grantee activities through
grantee reports and joint site visits. However, these activities do not
constitute an evaluation of the crisis counseling program. For example,
the site visits generally involve monitoring the grantee‘s program to
ensure that it is carrying out reported activities and providing
technical assistance. SAMHSA recently developed guidance for grantees
outlining recommended program evaluation strategies. An agency official
told us that grantees are encouraged to conduct evaluations of their
individual programs, but are not required to adhere to the guidance in
managing their programs. According to HHS, the Department of Veterans
Affairs‘ National Center for Post-Traumatic Stress Disorder will
conduct case studies of past and current crisis counseling program
grantees‘ programs and will make recommendations on programwide
evaluation activities. The scope and nature of these efforts have not
been fully determined. Education also has not evaluated Project SERV,
which provides crisis response grants to schools, and ACF has not
evaluated the Transitional Living for Homeless Youth program, which
requires grantees to offer mental health services to homeless youth.
Justice has funded a multiyear evaluation of the Crime Victim
Compensation and Victim Assistance programs. The study was designed to,
among other things, evaluate how the victim compensation and assistance
programs serve crime victims and how variations in program
administration and operations affect the effectiveness and efficiency
of services to victims. The initial report, issued in March 2001,
primarily consisted of a survey of state program managers‘ views on
program operations and needed improvements.[Footnote 71] The final
report, which is scheduled for issuance in fall 2002, will be based on
case studies of six states‘ compensation and assistance programs,
including a survey of compensation claimants and a survey of assistance
clients in those states. The results of the survey of compensation
claimants will partly reflect the experience of child victims and of
victims who used mental health services. Because the survey of
assistance clients had less participation by adults who could comment
on a child‘s experience, the study may provide less information about
child victims‘ experience with the assistance program.[Footnote 72] The
case studies also involved discussions with state administrators and
service providers that received victim assistance funds on the
programs‘ ability to help child victims obtain mental health services.
Some federal grants include formal evaluation components, but have yet
to establish their evaluation framework, including detailed outcome
measures. For example, the Greenbook and Safe Start grants, which
support coordination efforts, included a year-long planning process to
develop their evaluation frameworks. However, as of May 2002, when
these grants had been under way for almost 2 years, neither had
finalized its evaluation process, including development of core
performance measures. SAMHSA‘s National Child Traumatic Stress
Initiative also plans to undertake an evaluation of the overall
initiative and individual grantee projects. As of May 2002, SAMHSA and
the grantees had begun to discuss the evaluation framework but had not
finalized it. In addition, other grants have established their
evaluation frameworks and performance measures, but their evaluations
have yet to yield results. For example, the Safe Schools/Healthy
Students program is collecting data, with an interim report planned for
fiscal year 2002 and a final report in fiscal year 2004.
Conclusions:
Many children who have experienced trauma are resilient and may suffer
few ill effects. Others, however, require mental health services to
help them cope and minimize long-term psychological, emotional, or
developmental difficulties. While most children have health insurance
that covers mental health services to varying degrees, coverage
limitations are common and may constrain children‘s ability to obtain
care. Numerous federal grant programs could expand the number of
children whose mental health services may be reimbursed or help
increase the available services in a community, but some children who
need services may not benefit from such programs. For example, some
grants are awarded to a relatively small number of communities and
expire after a defined period, and evidence suggests that families of
some children who are eligible to benefit from Justice‘s victim
compensation and assistance programs may not be aware of the programs.
The effectiveness of federal programs that could help children who have
experienced trauma remains largely unknown. Some programs with planned
evaluations, such as the Greenbook Project, have lagged in establishing
their evaluation frameworks. SAMHSA‘s recent National Child Traumatic
Stress Initiative, which focuses specifically on the mental health
needs of these children, intends to evaluate the results of grantee
projects and the overall program. This effort could develop information
on ways to effectively provide mental health services to traumatized
children, but because the initiative is new, it is too early to gauge
its success. Justice‘s current evaluation of its Crime Victim
Compensation and Crime Victim Assistance programs should provide some
information on the experience of child victims in using the victim
compensation program to obtain needed mental health services, but may
provide less information on children‘s ability to obtain mental health
services through the victim assistance program. FEMA and SAMHSA have
not evaluated the effectiveness of the long-standing disaster crisis
counseling program and have no immediate plans to conduct a programwide
evaluation. Without evaluations of the effectiveness of federal
programs that have a clear goal of helping children who experienced
trauma to obtain mental health services, federal managers and
policymakers lack information that would help them assess which federal
efforts are successful; determine which programs could be improved,
expanded, or replicated; and effectively allocate resources to identify
and meet additional service needs.
Recommendation for Executive Action:
We recommend that, to provide federal policymakers and program managers
with additional information on federal grant programs serving children
who have experienced disaster-related trauma, the Director of FEMA work
with the Administrator of SAMHSA to evaluate the effectiveness of the
Crisis Counseling Assistance and Training Program, including its
assistance to children who need mental health services as the result of
a disaster.
Agency Comments and Our Evaluation:
We provided a draft of this report to four federal departments and
agencies for their review. FEMA, HHS, and Education submitted written
comments that are provided in appendixes VIII through X, respectively.
HHS and Education also provided technical comments, as did Justice. We
have modified the report, as appropriate, in response to written
general and technical comments.
In general, HHS stated that the report will be a useful tool for
policymakers and brings important attention to the needs of children
exposed to traumatic events. HHS and FEMA both agreed with our
description of the Crisis Counseling Assistance and Training Program
and with our conclusions on the importance of evaluating the program‘s
effectiveness. HHS stated that it strongly agreed that evaluation
activities are critical for this program and other child trauma
programs to ensure program effectiveness and the appropriate use of
resources. Both agencies said they have begun, or plan to take steps,
to engage in additional evaluation activities, and HHS commented that
it plans to continue ongoing evaluation efforts to assure that services
are appropriate, efficient, and responsive to the needs of disaster
victims. At their request, we modified the report to reflect additional
information the agencies provided on current evaluation activities.
However, neither the FEMA and HHS activities that we described nor
those that they cited in their comments constitute the programwide
evaluation of the program‘s effectiveness that we are recommending.
Furthermore, FEMA did not indicate in its response whether it intends
to implement our recommendation to coordinate with SAMHSA to conduct
such an evaluation, which is needed to help federal policymakers and
program managers assess whether the Crisis Counseling Assistance and
Training Program is effectively assisting children who have experienced
disaster-related trauma.
HHS said that the draft report emphasized the lack of data on the
prevalence of children exposed to trauma and their mental health needs
but did not discuss National Institutes of Health and National
Institute of Mental Health research data, including data from
nationally representative surveys. The types of research studies HHS
referred to in its comments generally focus on specific communities or
certain defined populations, and existing nationwide surveys have
limitations such as not covering certain age ranges or addressing the
full range of traumatic situations that children may experience.
Appendix II of our draft report included ACF‘s nationwide data on
children who have been abused and neglected and the number of those who
received mental health services. However, for other kinds of trauma,
there are few nationwide data estimating the number of children who
need mental health services due to these traumas and the number who
receive services.
HHS suggested that the report should more fully discuss the
availability of providers trained to help children who have experienced
trauma. The department said the country does not have a child mental
health workforce with the capacity to meet the needs of children and
that responding to PTSD in children requires even more specific
training. The draft report did refer to workforce issues that could
affect children‘s access to needed mental health services, and we have
included additional information in response to HHS‘s comments. A
detailed discussion of workforce issues, however, was not within the
scope of this report. HHS also expressed concern that the report did
not discuss the need for more research on specific mental disorders and
effective treatments, the stigma often associated with mental health
problems and its effect on the delivery of mental health services to
children who have experienced trauma, or problems in the public mental
health system. We agree that these are important issues and modified
the report to acknowledge the potential role of stigma. However, a
detailed discussion of these issues was also outside the scope of this
report.
HHS further commented that the report should contain a more thorough
discussion of HRSA‘s grants to help meet the mental health needs of
children. Appendix VI of the draft report described several HRSA
grants, including the Maternal and Child Health Block Grant. Based on
the department‘s comments, we modified the appendix to describe
additional HRSA grants.
HHS acknowledged that the report provides information on the limits
insurance plans often place on mental health coverage, but said that
the draft report did not address the ramifications of mental health
parity. We added clarification that the federal mental health parity
law does not require group health plans to offer mental health
benefits, but otherwise believe the report provides ample information
on the limits of federal and state mental health parity laws.
Education concurred with the information discussed in the report. Like
HHS, the department raised concerns about the availability of mental
health providers to serve children who have experienced trauma.
As arranged with your offices, unless you publicly announce its
contents earlier, we plan no further distribution of this report until
30 days after its issue date. We are sending copies of this report to
the Secretary of Health and Human Services, the Attorney General, the
Secretary of Education, the Director of the Federal Emergency
Management Agency, appropriate congressional committees, and others who
are interested. We will also make copies available to others who are
interested upon request. In addition, the report will be available at
no charge on the GAO Web site at http://www.gao.gov.
If you or your staffs have any questions, please contact me or Kathryn
G. Allen, Director, Health Care--Medicaid and Private Insurance Issues,
at (202) 512-7119. An additional contact and the names of other staff
members who made contributions to this report are listed in appendix
XI.
Janet Heinrich
Director, Health Care--Public Health Issues:
Signed by Janet Heinrich:
[End of section]
Appendix I: Scope and Methodology:
To do our work, we obtained program documents, pertinent studies, and
data from the Department of Health and Human Services‘ (HHS)
Administration for Children and Families (ACF), Centers for Disease
Control and Prevention, Centers for Medicare & Medicaid Services (CMS),
Health Resources and Services Administration, Indian Health Service,
National Institutes of Health, Office of the Secretary, Office of the
Assistant Secretary for Planning and Evaluation, and Substance Abuse
and Mental Health Services Administration (SAMHSA); the Department of
Justice‘s Bureau of Justice Statistics, National Institute of Justice,
Office of Juvenile Justice and Delinquency Prevention, Office for
Victims of Crime, and Violence Against Women Office; the Federal
Emergency Management Agency; the Department of Education; and the
Department of Agriculture. We also interviewed officials from these
agencies. We also reviewed the relevant literature and interviewed
officials or obtained information from national organizations including
the American Academy of Child and Adolescent Psychiatry, American
Academy of Pediatrics, American Psychiatric Association, American
Psychological Association, American Public Human Services Association,
Child Welfare League of America, Family Violence Prevention Fund,
National Association of Crime Victim Compensation Boards, National
Association of Social Workers, National Association of State Mental
Health Program Directors, National Coalition Against Domestic Violence,
National Council of Juvenile and Family Court Judges, and Prevent Child
Abuse America.
To determine the extent to which private and public insurance programs
cover mental health services for children, we reviewed national
employer benefit surveys; reviewed the benefit design of health plans
provided by 13 insurers in the individual market, state Medicaid
programs, and State Children‘s Health Insurance Programs (SCHIP); and
interviewed representatives of private insurers and public officials in
California, Georgia, Illinois, Massachusetts, Minnesota, and Utah.
These states were selected on the basis of variation in the number of
beneficiaries covered, in geographic location, in the extent to which
the insurance market is regulated, and in the design of the SCHIP
program. For information on the extent to which employers offer mental
health benefits to employees, as well as the conditions under which
coverage is made available, we relied on private employer benefit
surveys conducted in 2001, specifically those of (1) William M. Mercer,
Incorporated (formerly produced by Foster Higgins) and (2) the Health
Research and Educational Trust, sponsored by the Kaiser Family
Foundation. These surveys are distinguished from a number of other
private ones largely because of their random samples, which allow their
results to be generalized to a larger population of employers.
For the mental health services covered by private individual market
insurers, we interviewed state insurance regulators in each of the six
states to learn about state laws related to the provision of mental
health benefits and to identify the insurers in the individual market
in the state. We then reviewed the benefit designs of popular health
plans sold in the individual market. To obtain information about the
mental health coverage of the public insurance programs in these
states, we reviewed state Medicaid and SCHIP plans, which specified
program characteristics, including covered benefits and limitations,
and we interviewed program officials to obtain information on income
eligibility and service delivery models. In several of the states, we
also interviewed Mental Health Department officials, providers, and
consumer advocates.
To identify federal programs that help children who have experienced
trauma receive mental health services, we reviewed the Catalog of
Federal Domestic Assistance. After identifying programs, we interviewed
and collected information from federal program officials to confirm
whether these programs can support activities, such as mental health
treatment, screening and referral services, educational outreach,
training for medical and other professionals on the needs of children
exposed to trauma, and research and evaluation of mental health
services. The federal program officials also identified other programs
and efforts that can address the mental health needs of children
exposed to trauma and provided perspectives on barriers to these
children receiving mental health services. We obtained additional
information on grants that appeared to be most relevant to the
population discussed in this report. The programs and efforts we
discuss in this report do not represent an exhaustive list of all
federally funded programs that can address the mental health needs of
children exposed to trauma; they highlight a range of programs that
target varied populations, services, and systems that come into contact
with this population. We report that these programs can provide mental
health services to this population because funds may be used for this
purpose. We were not generally able to obtain information on the nature
of the services provided or the level of service used by children
exposed to trauma because some programs we identified do not collect
information specifically on mental health services provided to children
exposed to trauma.
We obtained additional information on selected federally supported
programs and problems children face in obtaining needed mental health
services through site visits in California and Massachusetts. In these
states, we interviewed officials or obtained data from state and local
mental health agencies, state crime victim compensation and assistance
programs, child welfare and protective service agencies, and other
organizations receiving federal grants. We also contacted service
providers with federal grants located in Colorado, Illinois, Minnesota,
and Oregon. We selected these locations to visit or contact because
they have organizations receiving federal grants focused on children
and trauma, such as SAMHSA‘s Child Traumatic Stress Initiative or HHS/
Justice‘s Greenbook Project, or recognized experts in the field of
child trauma.
We also obtained data on child abuse and neglect, domestic violence,
and sexual assault that were collected and analyzed by HHS‘s ACF and
Justice‘s Bureau of Justice Statistics, National Institute of Justice,
and Federal Bureau of Investigation. We did not verify the accuracy of
these data.
We conducted our work from September 2001 through August 2002 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix II: Victimization Data:
This appendix presents information on child maltreatment,[Footnote 73]
intimate partner violence,[Footnote 74] and sexual assault. ACF data
provide information on children‘s entry into the child protective
service system and the services that they and their families received
(see tables 4 to 7); additional information was provided by ACF on a
program to increase contact between children and their noncustodial
parents. (See table 8.) Justice data provide information on individuals
who were victims of intimate partner violence and sexual assault. (See
tables 9 to 12 and fig. 3.) We did not confirm the accuracy of these
data.
Child Abuse and Neglect Data Collected by HHS‘s Administration for
Children and Families:
In 1996, the Child Abuse Prevention and Treatment Act was amended to
require states receiving a Child Abuse and Neglect State Grant to
report to the National Child Abuse and Neglect Data System, to the
extent practicable, 12 specific data items on child maltreatment, such
as the number of victims of abuse and neglect and the number of
children who received services. States can voluntarily report data in
other categories, such as the number of children receiving mental
health services. All states submitted data for 1999, the most recent
year for which data are available. All states did not respond to all
required items. For example, 10 states did not report information on
the number of victims who received services. (See table 6.) ACF
reported in Child Maltreatment 1999 that the required child
maltreatment data had been validated for consistency and clarity, but
ACF officials told us that state definitions vary, making comparisons
between states difficult.
Table 4: Number of Referrals to Child Protective Services and
Substantiated Cases of Child Maltreatment, by State, 1999:
State: Alabama; Child population (under 18)[A]: 1,066,177; Referrals
screened out[B]: [E]; Referrals screened in[B]: 24,586; Number of
investigations[C]: 24,586; Number of investigations substantiating
maltreatment[D]: 8,610; Percentage of investigations substantiating
maltreatment[D]: 35.0.
State: Alaska; Child population (under 18)[A]: 196,825; Referrals
screened out[B]: 1,767; Referrals screened in[B]: 7,806; Number of
investigations[C]: 13,270; Number of investigations substantiating
maltreatment[D]: 3,766; Percentage of investigations substantiating
maltreatment[D]: 28.4.
State: Arizona; Child population (under 18)[A]: 1,334,564; Referrals
screened out[B]: [E]; Referrals screened in[B]: 32,635; Number of
investigations[C]: 32,635; Number of investigations substantiating
maltreatment[D]: 5,650; Percentage of investigations substantiating
maltreatment[D]: 17.3.
State: Arkansas; Child population (under 18)[A]: 660,224; Referrals
screened out[B]: 11,883; Referrals screened in[B]: 17,036; Number of
investigations[C]: 17,036; Number of investigations substantiating
maltreatment[D]: 5,482; Percentage of investigations substantiating
maltreatment[D]: 32.2.
State: California; Child population (under 18)[A]: 8,923,423; Referrals
screened out[B]: [E]; Referrals screened in[B]: 227,561; Number of
investigations[C]: 227,561; Number of investigations substantiating
maltreatment[D]: 73,188; Percentage of investigations substantiating
maltreatment[D]: 32.2.
State: Colorado; Child population (under 18)[A]: 1,065,510; Referrals
screened out[B]: 17,325; Referrals screened in[B]: 28,774; Number of
investigations[C]: [E]; Number of investigations substantiating
maltreatment[D]: [E]; Percentage of investigations substantiating
maltreatment[D]: [E].
State: Connecticut; Child population (under 18)[A]: 828,260; Referrals
screened out[B]: 12,701; Referrals screened in[B]: 30,452; Number of
investigations[C]: 30,452; Number of investigations substantiating
maltreatment[D]: 11,281; Percentage of investigations substantiating
maltreatment[D]: 37.1.
State: Delaware; Child population (under 18)[A]: 182,450; Referrals
screened out[B]: 2,049; Referrals screened in[B]: 6,316; Number of
investigations[C]: 5,965; Number of investigations substantiating
maltreatment[D]: 1,346; Percentage of investigations substantiating
maltreatment[D]: 22.6.
State: District of Columbia; Child population (under 18)[A]: 95,290;
Referrals screened out[B]: 340; Referrals screened in[B]: 4,048; Number
of investigations[C]: [E]; Number of investigations substantiating
maltreatment[D]: [E]; Percentage of investigations substantiating
maltreatment[D]: [E].
State: Florida; Child population (under 18)[A]: 3,569,878; Referrals
screened out[B]: [E]; Referrals screened in[B]: 152,989; Number of
investigations[C]: 95,790; Number of investigations substantiating
maltreatment[D]: 13,338; Percentage of investigations substantiating
maltreatment[D]: 13.9.
State: Georgia; Child population (under 18)[A]: 2,056,885; Referrals
screened out[B]: 22,917; Referrals screened in[B]: 47,032; Number of
investigations[C]: 47,032; Number of investigations substantiating
maltreatment[D]: 16,024; Percentage of investigations substantiating
maltreatment[D]: 34.1.
State: Hawaii; Child population (under 18)[A]: 289,340; Referrals
screened out[B]: 4,861; Referrals screened in[B]: 2,733; Number of
investigations[C]: 4,646; Number of investigations substantiating
maltreatment[D]: 2,669; Percentage of investigations substantiating
maltreatment[D]: 57.5.
State: Idaho; Child population (under 18)[A]: 350,464; Referrals
screened out[B]: 7,672; Referrals screened in[B]: 9,363; Number of
investigations[C]: 9,363; Number of investigations substantiating
maltreatment[D]: 835; Percentage of investigations substantiating
maltreatment[D]: 8.9.
State: Illinois; Child population (under 18)[A]: 3,181,338; Referrals
screened out[B]: [E]; Referrals screened in[B]: 61,773; Number of
investigations[C]: 61,773; Number of investigations substantiating
maltreatment[D]: 18,779; Percentage of investigations substantiating
maltreatment[D]: 30.4.
State: Indiana; Child population (under 18)[A]: 1,528,991; Referrals
screened out[B]: 6,548; Referrals screened in[B]: 53,897; Number of
investigations[C]: 91,625; Number of investigations substantiating
maltreatment[D]: 21,608; Percentage of investigations substantiating
maltreatment[D]: 23.6.
State: Iowa; Child population (under 18)[A]: 719,685; Referrals
screened out[B]: 11,464; Referrals screened in[B]: 18,666; Number of
investigations[C]: 18,666; Number of investigations substantiating
maltreatment[D]: 6,716; Percentage of investigations substantiating
maltreatment[D]: 36.0.
State: Kansas; Child population (under 18)[A]: 698,637; Referrals
screened out[B]: 12,072; Referrals screened in[B]: 18,897; Number of
investigations[C]: 18,974; Number of investigations substantiating
maltreatment[D]: 5,894; Percentage of investigations substantiating
maltreatment[D]: 31.1.
State: Kentucky; Child population (under 18)[A]: 965,528; Referrals
screened out[B]: [E]; Referrals screened in[B]: 37,285; Number of
investigations[C]: 63,384; Number of investigations substantiating
maltreatment[D]: 18,585; Percentage of investigations substantiating
maltreatment[D]: 29.3.
State: Louisiana; Child population (under 18)[A]: 1,190,001; Referrals
screened out[B]: [E]; Referrals screened in[B]: 28,123; Number of
investigations[C]: 26,868; Number of investigations substantiating
maltreatment[D]: 7,244; Percentage of investigations substantiating
maltreatment[D]: 27.0.
State: Maine; Child population (under 18)[A]: 290,439; Referrals
screened out[B]: 11,058; Referrals screened in[B]: 4,450; Number of
investigations[C]: 4,450; Number of investigations substantiating
maltreatment[D]: 2,349; Percentage of investigations substantiating
maltreatment[D]: 52.8.
State: Maryland; Child population (under 18)[A]: 1,309,432; Referrals
screened out[B]: [E]; Referrals screened in[B]: 31,220; Number of
investigations[C]: 31,220; Number of investigations substantiating
maltreatment[D]: 8,103; Percentage of investigations substantiating
maltreatment[D]: 26.0.
State: Massachusetts; Child population (under 18)[A]: 1,468,554;
Referrals screened out[B]: 22,654; Referrals screened in[B]: 38,715;
Number of investigations[C]: 34,108; Number of investigations
substantiating maltreatment[D]: 17,851; Percentage of investigations
substantiating maltreatment[D]: 52.3.
State: Michigan; Child population (under 18)[A]: 2,561,139; Referrals
screened out[B]: 58,596; Referrals screened in[B]: 69,133; Number of
investigations[C]: 65,591; Number of investigations substantiating
maltreatment[D]: 13,721; Percentage of investigations substantiating
maltreatment[D]: 20.9.
State: Minnesota; Child population (under 18)[A]: 1,271,850; Referrals
screened out[B]: [E]; Referrals screened in[B]: 16,466; Number of
investigations[C]: 16,466; Number of investigations substantiating
maltreatment[D]: 7,228; Percentage of investigations substantiating
maltreatment[D]: 43.9.
State: Mississippi; Child population (under 18)[A]: 752,866; Referrals
screened out[B]: [E]; Referrals screened in[B]: 18,389; Number of
investigations[C]: 18,389; Number of investigations substantiating
maltreatment[D]: 4,077; Percentage of investigations substantiating
maltreatment[D]: 22.2.
State: Missouri; Child population (under 18)[A]: 1,399,492; Referrals
screened out[B]: 51,362; Referrals screened in[B]: 46,269; Number of
investigations[C]: 46,259; Number of investigations substantiating
maltreatment[D]: 6,117; Percentage of investigations substantiating
maltreatment[D]: 13.2.
State: Montana; Child population (under 18)[A]: 223,819; Referrals
screened out[B]: [E]; Referrals screened in[B]: 10,043; Number of
investigations[C]: 10,043; Number of investigations substantiating
maltreatment[D]: 1,262; Percentage of investigations substantiating
maltreatment[D]: 12.6.
State: Nebraska; Child population (under 18)[A]: 443,800; Referrals
screened out[B]: 2,964; Referrals screened in[B]: 8,456; Number of
investigations[C]: 8,456; Number of investigations substantiating
maltreatment[D]: 2,183; Percentage of investigations substantiating
maltreatment[D]: 25.8.
State: Nevada; Child population (under 18)[A]: 491,476; Referrals
screened out[B]: [E]; Referrals screened in[B]: 13,384; Number of
investigations[C]: 13,384; Number of investigations substantiating
maltreatment[D]: 3,983; Percentage of investigations substantiating
maltreatment[D]: 29.8.
State: New Hampshire; Child population (under 18)[A]: 304,436;
Referrals screened out[B]: 6,150; Referrals screened in[B]: 6,107;
Number of investigations[C]: 6,107; Number of investigations
substantiating maltreatment[D]: 580; Percentage of investigations
substantiating maltreatment[D]: 9.5.
State: New Jersey; Child population (under 18)[A]: 2,003,204; Referrals
screened out[B]: [E]; Referrals screened in[B]: 43,874; Number of
investigations[C]: 74,585; Number of investigations substantiating
maltreatment[D]: 9,222; Percentage of investigations substantiating
maltreatment[D]: 12.4.
State: New Mexico; Child population (under 18)[A]: 495,612; Referrals
screened out[B]: 6,802; Referrals screened in[B]: 6,846; Number of
investigations[C]: 11,638; Number of investigations substantiating
maltreatment[D]: 3,586; Percentage of investigations substantiating
maltreatment[D]: 30.8.
State: New York; Child population (under 18)[A]: 4,440,924; Referrals
screened out[B]: 179,879; Referrals screened in[B]: 139,564; Number of
investigations[C]: 136,489; Number of investigations substantiating
maltreatment[D]: 46,980; Percentage of investigations substantiating
maltreatment[D]: 34.4.
State: North Carolina; Child population (under 18)[A]: 1,940,947;
Referrals screened out[B]: [E]; Referrals screened in[B]: 75,013;
Number of investigations[C]: 127,522; Number of investigations
substantiating maltreatment[D]: 36,976; Percentage of investigations
substantiating maltreatment[D]: 29.0.
State: North Dakota; Child population (under 18)[A]: 160,092; Referrals
screened out[B]: [E]; Referrals screened in[B]: 4,109; Number of
investigations[C]: 4,109; Number of investigations substantiating
maltreatment[D]: [ E]; Percentage of investigations substantiating
maltreatment[D]: [E].
State: Ohio; Child population (under 18)[A]: 2,844,071; Referrals
screened out[B]: [E]; Referrals screened in[B]: 79,400; Number of
investigations[C]: 79,400; Number of investigations substantiating
maltreatment[D]: 8,749; Percentage of investigations substantiating
maltreatment[D]: 11.0.
State: Oklahoma; Child population (under 18)[A]: 882,062; Referrals
screened out[B]: 18,180; Referrals screened in[B]: 35,141; Number of
investigations[C]: 35,141; Number of investigations substantiating
maltreatment[D]: 9,864; Percentage of investigations substantiating
maltreatment[D]: 28.1.
State: Oregon; Child population (under 18)[A]: 827,501; Referrals
screened out[B]: 16,989; Referrals screened in[B]: 17,686; Number of
investigations[C]: 17,686; Number of investigations substantiating
maltreatment[D]: 8,073; Percentage of investigations substantiating
maltreatment[D]: 45.7.
State: Pennsylvania; Child population (under 18)[A]: 2,852,520;
Referrals screened out[B]: 6,135; Referrals screened in[B]: 13,175;
Number of investigations[C]: 22,437; Number of investigations
substantiating maltreatment[D]: 5,076; Percentage of investigations
substantiating maltreatment[D]: 22.6.
State: Rhode Island; Child population (under 18)[A]: 241,180; Referrals
screened out[B]: 4,342; Referrals screened in[B]: 7,882; Number of
investigations[C]: 7,882; Number of investigations substantiating
maltreatment[D]: 2,501; Percentage of investigations substantiating
maltreatment[D]: 31.7.
State: South Carolina; Child population (under 18)[A]: 955,930;
Referrals screened out[B]: 5,663; Referrals screened in[B]: 18,209;
Number of investigations[C]: 18,209; Number of investigations
substantiating maltreatment[D]: 5,518; Percentage of investigations
substantiating maltreatment[D]: 30.3.
State: South Dakota; Child population (under 18)[A]: 198,037; Referrals
screened out[B]: [E]; Referrals screened in[B]: 2,770; Number of
investigations[C]: 6,316; Number of investigations substantiating
maltreatment[D]: 1,163; Percentage of investigations substantiating
maltreatment[D]: 18.4.
State: Tennessee; Child population (under 18)[A]: 1,340,930; Referrals
screened out[B]: [E]; Referrals screened in[B]: 19,782; Number of
investigations[C]: [E]; Number of investigations substantiating
maltreatment[D]: [E ]; Percentage of investigations substantiating
maltreatment[D]: [E].
State: Texas; Child population (under 18)[A]: 5,719,234; Referrals
screened out[B]: 29,379; Referrals screened in[B]: 131,920; Number of
investigations[C]: 110,837; Number of investigations substantiating
maltreatment[D]: 26,978; Percentage of investigations substantiating
maltreatment[D]: 24.3.
State: Utah; Child population (under 18)[A]: 707,366; Referrals
screened out[B]: 7,792; Referrals screened in[B]: 17,514; Number of
investigations[C]: 17,514; Number of investigations substantiating
maltreatment[D]: 5,991; Percentage of investigations substantiating
maltreatment[D]: 34.2.
State: Vermont; Child population (under 18)[A]: 139,346; Referrals
screened out[B]: [E]; Referrals screened in[B]: 2,263; Number of
investigations[C]: 2,263; Number of investigations substantiating
maltreatment[D]: 923; Percentage of investigations substantiating
maltreatment[D]: 40.8.
State: Virginia; Child population (under 18)[A]: 1,664,810; Referrals
screened out[B]: 15,538; Referrals screened in[B]: 32,270; Number of
investigations[C]: 32,270; Number of investigations substantiating
maltreatment[D]: 4,767; Percentage of investigations substantiating
maltreatment[D]: 14.8.
State: Washington; Child population (under 18)[A]: 1,486,340; Referrals
screened out[B]: 39,207; Referrals screened in[B]: 35,940; Number of
investigations[C]: 35,940; Number of investigations substantiating
maltreatment[D]: 5,128; Percentage of investigations substantiating
maltreatment[D]: 14.3.
State: West Virginia; Child population (under 18)[A]: 403,481;
Referrals screened out[B]: 5,791; Referrals screened in[B]: 17,274;
Number of investigations[C]: 17,274; Number of investigations
substantiating maltreatment[D]: 5,587; Percentage of investigations
substantiating maltreatment[D]: 32.3.
State: Wisconsin; Child population (under 18)[A]: 1,348,268; Referrals
screened out[B]: [E]; Referrals screened in[B]: 20,183; Number of
investigations[C]: 34,311; Number of investigations substantiating
maltreatment[D]: 9,791; Percentage of investigations substantiating
maltreatment[D]: 28.5.
State: Wyoming; Child population (under 18)[A]: 126,807; Referrals
screened out[B]: 2,305; Referrals screened in[B]: 2,505; Number of
investigations[C]: 2,505; Number of investigations substantiating
maltreatment[D]: 855; Percentage of investigations substantiating
maltreatment[D]: 34.1.
State: Total for states reporting data; Child population (under 18)[A]:
70,199,435; Referrals screened out[B]: 1,177,874; Referrals screened
in[B]: 1,795,924; Number of investigations[C]: 1,838,427; Number of
investigations substantiating maltreatment[D]: 486,197; Percentage of
investigations substantiating maltreatment[D]: 26.5[F].
[A] Child population data are from the U.S. Bureau of the Census 1999
population estimates, as reported by ACF.
[B] Referrals are screened out if the allegation does not warrant
investigation. For example, the allegation may not meet the statutory
definition of child maltreatment, may not contain sufficient
information upon which to proceed, and/or may not pertain to the
population served by the agency. Referrals alleging maltreatment are
screened in if the child protective services agency decides that they
are appropriate for investigation or assessment.
[C] ACF reports that the number of investigations may differ from the
number of referrals screened in because referrals and investigations
might not occur in the same year and there are variations in the way
that states compile data. In most states, investigations may cover more
than one child.
[D] An allegation is substantiated if the agency‘s investigation
concludes that the allegation of maltreatment or risk of maltreatment
is supported, according to law or policy set by the state.
[E] State did not report data.
[F] Average for all reporting states.
Source: HHS, ACF, Child Maltreatment 1999: Reports from the States to
the National Child Abuse and Neglect Data System (Washington, D.C.:
2001).
[End of table]
Table 5: Information on Child Victims of Maltreatment, by State, 1999:
State: Alabama; Number of victims of maltreatment: 13,773; Percentage
of victims by category of maltreatment[A]: Physically abused: 40.9;
Percentage of victims by category of maltreatment[A]: Neglected: 46.0;
Percentage of victims by category of maltreatment[A]: Sexually abused:
23.1.
State: Alaska; Number of victims of maltreatment: 5,976; Percentage of
victims by category of maltreatment[A]: Physically abused: 29.6;
Percentage of victims by category of maltreatment[A]: Neglected: 60.5;
Percentage of victims by category of maltreatment[A]: Sexually abused:
15.2.
State: Arizona; Number of victims of maltreatment: 9,205; Percentage of
victims by category of maltreatment[A]: Physically abused: 24.8;
Percentage of victims by category of maltreatment[A]: Neglected: 58.4;
Percentage of victims by category of maltreatment[A]: Sexually abused:
5.6.
State: Arkansas; Number of victims of maltreatment: 7,564; Percentage
of victims by category of maltreatment[A]: Physically abused: 27.2;
Percentage of victims by category of maltreatment[A]: Neglected: 68.9;
Percentage of victims by category of maltreatment[A]: Sexually abused:
37.0.
State: California; Number of victims of maltreatment: 130,510;
Percentage of victims by category of maltreatment[A]: Physically
abused: 17.5; Percentage of victims by category of maltreatment[A]:
Neglected: 56.3; Percentage of victims by category of maltreatment[A]:
Sexually abused: 9.1.
State: Colorado; Number of victims of maltreatment: 6,989; Percentage
of victims by category of maltreatment[A]: Physically abused: 27.6;
Percentage of victims by category of maltreatment[A]: Neglected: 70.7;
Percentage of victims by category of maltreatment[A]: Sexually abused:
15.1.
State: Connecticut; Number of victims of maltreatment: 14,514;
Percentage of victims by category of maltreatment[A]: Physically
abused: 16.2; Percentage of victims by category of maltreatment[A]:
Neglected: 90.2; Percentage of victims by category of maltreatment[A]:
Sexually abused: 4.1.
State: Delaware; Number of victims of maltreatment: 2,111; Percentage
of victims by category of maltreatment[A]: Physically abused: 25.3;
Percentage of victims by category of maltreatment[A]: Neglected: 37.5;
Percentage of victims by category of maltreatment[A]: Sexually abused:
11.1.
State: District of Columbia; Number of victims of maltreatment: 2,308;
Percentage of victims by category of maltreatment[A]: Physically
abused: 14.4; Percentage of victims by category of maltreatment[A]:
Neglected: 71.8; Percentage of victims by category of maltreatment[A]:
Sexually abused: 1.7.
State: Florida; Number of victims of maltreatment: 67,530; Percentage
of victims by category of maltreatment[A]: Physically abused: 17.8;
Percentage of victims by category of maltreatment[A]: Neglected: 39.8;
Percentage of victims by category of maltreatment[A]: Sexually abused:
6.5.
State: Georgia; Number of victims of maltreatment: 26,888; Percentage
of victims by category of maltreatment[A]: Physically abused: 13.4;
Percentage of victims by category of maltreatment[A]: Neglected: 63.1;
Percentage of victims by category of maltreatment[A]: Sexually abused:
8.4.
State: Hawaii; Number of victims of maltreatment: 2,669; Percentage of
victims by category of maltreatment[A]: Physically abused: 6.5;
Percentage of victims by category of maltreatment[A]: Neglected: 8.1;
Percentage of victims by category of maltreatment[A]: Sexually abused:
5.3.
State: Idaho; Number of victims of maltreatment: 2,928; Percentage of
victims by category of maltreatment[A]: Physically abused: 29.0;
Percentage of victims by category of maltreatment[A]: Neglected: 49.5;
Percentage of victims by category of maltreatment[A]: Sexually abused:
13.1.
State: Illinois; Number of victims of maltreatment: 33,125; Percentage
of victims by category of maltreatment[A]: Physically abused: 11.2;
Percentage of victims by category of maltreatment[A]: Neglected: 40.6;
Percentage of victims by category of maltreatment[A]: Sexually abused:
10.2.
State: Indiana; Number of victims of maltreatment: 21,608; Percentage
of victims by category of maltreatment[A]: Physically abused: 31.1;
Percentage of victims by category of maltreatment[A]: Neglected: 124.9;
Percentage of victims by category of maltreatment[A]: Sexually abused:
25.6.
State: Iowa; Number of victims of maltreatment: 9,763; Percentage of
victims by category of maltreatment[A]: Physically abused: 25.2;
Percentage of victims by category of maltreatment[A]: Neglected: 63.1;
Percentage of victims by category of maltreatment[A]: Sexually abused:
11.1.
State: Kansas; Number of victims of maltreatment: 8,452; Percentage of
victims by category of maltreatment[A]: Physically abused: 30.8;
Percentage of victims by category of maltreatment[A]: Neglected: 49.5;
Percentage of victims by category of maltreatment[A]: Sexually abused:
15.7.
State: Kentucky; Number of victims of maltreatment: 18,650; Percentage
of victims by category of maltreatment[A]: Physically abused: 27.6;
Percentage of victims by category of maltreatment[A]: Neglected: 63.7;
Percentage of victims by category of maltreatment[A]: Sexually abused:
7.7.
State: Louisiana; Number of victims of maltreatment: 12,614; Percentage
of victims by category of maltreatment[A]: Physically abused: 20.9;
Percentage of victims by category of maltreatment[A]: Neglected: 68.1;
Percentage of victims by category of maltreatment[A]: Sexually abused:
6.5.
State: Maine; Number of victims of maltreatment: 4,154; Percentage of
victims by category of maltreatment[A]: Physically abused: 34.4;
Percentage of victims by category of maltreatment[A]: Neglected: 59.2;
Percentage of victims by category of maltreatment[A]: Sexually abused:
21.5.
State: Maryland; Number of victims of maltreatment: 15,451; Percentage
of victims by category of maltreatment[A]: Physically abused: [B];
Percentage of victims by category of maltreatment[A]: Neglected: [B];
Percentage of victims by category of maltreatment[A]: Sexually abused:
[B].
State: Massachusetts; Number of victims of maltreatment: 29,633;
Percentage of victims by category of maltreatment[A]: Physically
abused: [B]; Percentage of victims by category of maltreatment[A]:
Neglected: [B]; Percentage of victims by category of maltreatment[A]:
Sexually abused: [B].
State: Michigan; Number of victims of maltreatment: 24,505; Percentage
of victims by category of maltreatment[A]: Physically abused: 20.9;
Percentage of victims by category of maltreatment[A]: Neglected: 70.8;
Percentage of victims by category of maltreatment[A]: Sexually abused:
6.5.
State: Minnesota; Number of victims of maltreatment: 11,113; Percentage
of victims by category of maltreatment[A]: Physically abused: 24.8;
Percentage of victims by category of maltreatment[A]: Neglected: 77.4;
Percentage of victims by category of maltreatment[A]: Sexually abused:
7.3.
State: Mississippi; Number of victims of maltreatment: 6,523;
Percentage of victims by category of maltreatment[A]: Physically
abused: 26.6; Percentage of victims by category of maltreatment[A]:
Neglected: 47.0; Percentage of victims by category of maltreatment[A]:
Sexually abused: 21.1.
State: Missouri; Number of victims of maltreatment: 9,079; Percentage
of victims by category of maltreatment[A]: Physically abused: 24.1;
Percentage of victims by category of maltreatment[A]: Neglected: 49.6;
Percentage of victims by category of maltreatment[A]: Sexually abused:
26.0.
State: Montana; Number of victims of maltreatment: 3,414; Percentage of
victims by category of maltreatment[A]: Physically abused: 9.2;
Percentage of victims by category of maltreatment[A]: Neglected: 62.0;
Percentage of victims by category of maltreatment[A]: Sexually abused:
9.2.
State: Nebraska; Number of victims of maltreatment: 3,474; Percentage
of victims by category of maltreatment[A]: Physically abused: 21.6;
Percentage of victims by category of maltreatment[A]: Neglected: 64.5;
Percentage of victims by category of maltreatment[A]: Sexually abused:
9.8.
State: Nevada; Number of victims of maltreatment: 8,238; Percentage of
victims by category of maltreatment[A]: Physically abused: 14.6;
Percentage of victims by category of maltreatment[A]: Neglected: 22.1;
Percentage of victims by category of maltreatment[A]: Sexually abused:
2.8.
State: New Hampshire; Number of victims of maltreatment: 926;
Percentage of victims by category of maltreatment[A]: Physically
abused: 27.5; Percentage of victims by category of maltreatment[A]:
Neglected: 65.2; Percentage of victims by category of maltreatment[A]:
Sexually abused: 25.7.
State: New Jersey; Number of victims of maltreatment: 9,222; Percentage
of victims by category of maltreatment[A]: Physically abused: 23.3;
Percentage of victims by category of maltreatment[A]: Neglected: 62.7;
Percentage of victims by category of maltreatment[A]: Sexually abused:
8.0.
State: New Mexico; Number of victims of maltreatment: 3,730; Percentage
of victims by category of maltreatment[A]: Physically abused: 22.3;
Percentage of victims by category of maltreatment[A]: Neglected: 52.4;
Percentage of victims by category of maltreatment[A]: Sexually abused:
6.0.
State: New York; Number of victims of maltreatment: 64,045; Percentage
of victims by category of maltreatment[A]: Physically abused: 24.8;
Percentage of victims by category of maltreatment[A]: Neglected: 23.3;
Percentage of victims by category of maltreatment[A]: Sexually abused:
5.6.
State: North Carolina; Number of victims of maltreatment: 36,976;
Percentage of victims by category of maltreatment[A]: Physically
abused: 3.6; Percentage of victims by category of maltreatment[A]:
Neglected: 87.8; Percentage of victims by category of maltreatment[A]:
Sexually abused: 3.7.
State: North Dakota; Number of victims of maltreatment: 1,284;
Percentage of victims by category of maltreatment[A]: Physically
abused: 12.5; Percentage of victims by category of maltreatment[A]:
Neglected: 64.0; Percentage of victims by category of maltreatment[A]:
Sexually abused: 7.2.
State: Ohio; Number of victims of maltreatment: 55,921; Percentage of
victims by category of maltreatment[A]: Physically abused: 28.0;
Percentage of victims by category of maltreatment[A]: Neglected: 53.3;
Percentage of victims by category of maltreatment[A]: Sexually abused:
14.1.
State: Oklahoma; Number of victims of maltreatment: 16,210; Percentage
of victims by category of maltreatment[A]: Physically abused: 24.9;
Percentage of victims by category of maltreatment[A]: Neglected: 98.0;
Percentage of victims by category of maltreatment[A]: Sexually abused:
8.0.
State: Oregon; Number of victims of maltreatment: 11,241; Percentage of
victims by category of maltreatment[A]: Physically abused: 13.2;
Percentage of victims by category of maltreatment[A]: Neglected: 21.1;
Percentage of victims by category of maltreatment[A]: Sexually abused:
11.8.
State: Pennsylvania; Number of victims of maltreatment: 5,076;
Percentage of victims by category of maltreatment[A]: Physically
abused: 62.1; Percentage of victims by category of maltreatment[A]:
Neglected: 3.8; Percentage of victims by category of maltreatment[A]:
Sexually abused: 80.4.
State: Rhode Island; Number of victims of maltreatment: 3,485;
Percentage of victims by category of maltreatment[A]: Physically
abused: 26.6; Percentage of victims by category of maltreatment[A]:
Neglected: 84.6; Percentage of victims by category of maltreatment[A]:
Sexually abused: 8.9.
State: South Carolina; Number of victims of maltreatment: 9,580;
Percentage of victims by category of maltreatment[A]: Physically
abused: 13.7; Percentage of victims by category of maltreatment[A]:
Neglected: 54.8; Percentage of victims by category of maltreatment[A]:
Sexually abused: 6.3.
State: South Dakota; Number of victims of maltreatment: 2,561;
Percentage of victims by category of maltreatment[A]: Physically
abused: 25.1; Percentage of victims by category of maltreatment[A]:
Neglected: 70.9; Percentage of victims by category of maltreatment[A]:
Sexually abused: 10.0.
State: Tennessee; Number of victims of maltreatment: 10,611; Percentage
of victims by category of maltreatment[A]: Physically abused: 20.0;
Percentage of victims by category of maltreatment[A]: Neglected: 43.5;
Percentage of victims by category of maltreatment[A]: Sexually abused:
21.0.
State: Texas; Number of victims of maltreatment: 39,488; Percentage of
victims by category of maltreatment[A]: Physically abused: 29.3;
Percentage of victims by category of maltreatment[A]: Neglected: 59.6;
Percentage of victims by category of maltreatment[A]: Sexually abused:
14.9.
State: Utah; Number of victims of maltreatment: 8,660; Percentage of
victims by category of maltreatment[A]: Physically abused: 16.6;
Percentage of victims by category of maltreatment[A]: Neglected: 28.8;
Percentage of victims by category of maltreatment[A]: Sexually abused:
21.8.
State: Vermont; Number of victims of maltreatment: 1,080; Percentage of
victims by category of maltreatment[A]: Physically abused: 22.0;
Percentage of victims by category of maltreatment[A]: Neglected: 43.7;
Percentage of victims by category of maltreatment[A]: Sexually abused:
40.4.
State: Virginia; Number of victims of maltreatment: 8,199; Percentage
of victims by category of maltreatment[A]: Physically abused: 31.1;
Percentage of victims by category of maltreatment[A]: Neglected: 64.7;
Percentage of victims by category of maltreatment[A]: Sexually abused:
14.4.
State: Washington; Number of victims of maltreatment: 8,039; Percentage
of victims by category of maltreatment[A]: Physically abused: 27.1;
Percentage of victims by category of maltreatment[A]: Neglected: 70.8;
Percentage of victims by category of maltreatment[A]: Sexually abused:
9.0.
State: West Virginia; Number of victims of maltreatment: 8,609;
Percentage of victims by category of maltreatment[A]: Physically
abused: 25.1; Percentage of victims by category of maltreatment[A]:
Neglected: 43.8; Percentage of victims by category of maltreatment[A]:
Sexually abused: 8.6.
State: Wisconsin; Number of victims of maltreatment: 9,791; Percentage
of victims by category of maltreatment[A]: Physically abused: 21.9;
Percentage of victims by category of maltreatment[A]: Neglected: 42.2;
Percentage of victims by category of maltreatment[A]: Sexually abused:
37.9.
State: Wyoming; Number of victims of maltreatment: 1,221; Percentage of
victims by category of maltreatment[A]: Physically abused: 29.4;
Percentage of victims by category of maltreatment[A]: Neglected: 63.9;
Percentage of victims by category of maltreatment[A]: Sexually abused:
9.0.
State: Total for states reporting data; Number of victims of
maltreatment: 828,716; Percentage of victims by category of
maltreatment[A]: Physically abused: 21.4[C]; Percentage of victims by
category of maltreatment[A]: Neglected: 56.0[C]; Percentage of victims
by category of maltreatment[A]: Sexually abused: 11.3[C].
[A] Percentages do not add up to 100 because some states reported
additional types of maltreatment that are not included here.
[B] State did not report data.
[C] Average for all reporting states.
Source: HHS, ACF.
[End of table]
Table 6: Services Provided to Child Victims of Maltreatment, by State,
1999:
State: Alabama; Number of victims of maltreatment: 13,773; Percentage
of victims who received services, by type of service: Any services:
15.6; Percentage of victims who received services, by type of service:
Family preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: [D].
State: Alaska; Number of victims of maltreatment: 5,976; Percentage of
victims who received services, by type of service: Any services: 30.7;
Percentage of victims who received services, by type of service: Family
preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: [D].
State: Arizona; Number of victims of maltreatment: 9,205; Percentage of
victims who received services, by type of service: Any services: [D];
Percentage of victims who received services, by type of service: Family
preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: 27.3; Percentage of victims
who received services, by type of service: Counseling services[C]:
27.8.
State: Arkansas; Number of victims of maltreatment: 7,564; Percentage
of victims who received services, by type of service: Any services:
100.0; Percentage of victims who received services, by type of service:
Family preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: 1.9; Percentage of victims
who received services, by type of service: Counseling services[C]:
12.9.
State: California; Number of victims of maltreatment: 130,510;
Percentage of victims who received services, by type of service: Any
services: 53.3; Percentage of victims who received services, by type of
service: Family preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: [D].
State: Colorado; Number of victims of maltreatment: 6,989; Percentage
of victims who received services, by type of service: Any services:
34.4; Percentage of victims who received services, by type of service:
Family preservation services in the
past 5 years[A]: 24.0; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: [D].
State: Connecticut; Number of victims of maltreatment: 14,514;
Percentage of victims who received services, by type of service: Any
services: 53.6; Percentage of victims who received services, by type of
service: Family preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: [D].
State: Delaware; Number of victims of maltreatment: 2,111; Percentage
of victims who received services, by type of service: Any services:
62.9; Percentage of victims who received services, by type of service:
Family preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: 1.2; Percentage of victims
who received services, by type of service: Counseling services[C]: 1.7.
State: District of Columbia; Number of victims of maltreatment: 2,308;
Percentage of victims who received services, by type of service: Any
services: 71.4; Percentage of victims who received services, by type of
service: Family preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: [D].
State: Florida; Number of victims of maltreatment: 67,530; Percentage
of victims who received services, by type of service: Any services:
64.5; Percentage of victims who received services, by type of service:
Family preservation services in the
past 5 years[A]: 25.3; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: [D].
State: Georgia; Number of victims of maltreatment: 26,888; Percentage
of victims who received services, by type of service: Any services:
52.7; Percentage of victims who received services, by type of service:
Family preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: [D].
State: Hawaii; Number of victims of maltreatment: 2,669; Percentage of
victims who received services, by type of service: Any services: [D];
Percentage of victims who received services, by type of service: Family
preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: 9.0.
State: Idaho; Number of victims of maltreatment: 2,928; Percentage of
victims who received services, by type of service: Any services: 30.6;
Percentage of victims who received services, by type of service: Family
preservation services in the
past 5 years[A]: 13.8; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: [D].
State: Illinois; Number of victims of maltreatment: 33,125; Percentage
of victims who received services, by type of service: Any services:
15.1; Percentage of victims who received services, by type of service:
Family preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: [D]; Percentage of victims
who received services, by type of service: Counseling services[C]: [D].
State: Indiana; Number of victims of maltreatment: 21,608; Percentage
of victims who received services, by type of service: Any services:
51.8; Percentage of victims who received services, by type of service:
Family preservation services in the
past 5 years[A]: [D]; Percentage of victims who received services, by
type of service: Mental health services[B]: 0.1; Percentage of victims
who received services, by type of service: Counseling services[C]:
