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Home > Advocacy > CWLA 2007 Children's Legislative Agenda > Mental Health Care Services


CWLA 2007 Children's Legislative Agenda

Mental Health Care Services

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  • Support the recommendations of the President's New Freedom Commission on Mental Health, including early co-occurring mental health and substance abuse screening, assessment, and referral to services to properly address and enhance the mental health of young and adolescent children.

  • Ensure the availability of and accessibility to comprehensive preventive health care services, including the physical and mental health screenings and interventions for children in foster care that are guaranteed in federal law through the Early Periodic Screening Diagnosis and Treatment (EPSDT) program for children younger than 21 receiving Medicaid.

  • Ensure that Medicaid Targeted Case Management (TCM) and Rehabilitative Services remain available to children in the child welfare system.

  • Pass comprehensive mental health parity legislation (H.R. 1402 in the 109th Congress) which would require health insurance plans to provide equal coverage for mental and physical health care.

  • Pass the Child Health Care Crisis Relief Act (H.R. 1106), legislation to address acute shortages of child and adolescent mental health professionals by increasing the number of mental health care providers qualified to serve youth with serious emotional disorders.

  • Pass the Keeping Families Together Act (S. 380/H.R. 823), legislation designed to prevent parents from having to relinquish their custody rights to the state to obtain mental health care for their seriously ill children.

  • Increase funding for the Children's Mental Health Services Program, which provides six-year grants to help states and local communities develop intensive, comprehensive, community-based mental health services for children with serious emotional disturbances.

  • Increase funding for the Community Mental Health Performance Partnership Block Grant, the principal federal discretionary program for residential and community-based mental health services for adults and children, and the Mental Health Programs of Regional and National Significance.

  • Increase funding for key programs that target the social and emotional development of infants and toddlers who are at heightened risk, including those in the child welfare system, such as Head Start, IDEA "Part C," and Foundations For Learning Act grants.

  • Fully fund the Lifespan Respite Care Act (S. 1283/H.R. 3248), legislation providing relief for foster parents and other caregivers caring for children with severe disabilities who have difficulty finding trained respite care providers or paying for respite services.


The President's New Freedom Commission on Mental Health found that our nation's failure to prioritize mental health is a national tragedy. Nowhere is this more evident than among children in foster care who have extensive mental health needs as a result of their often trying lives. Many children in the child welfare system grow up in home environments characterized by poverty, instability, or parents and caregivers with limited psychological well-being themselves. Many also are victims of abuse and neglect and then, if separated from their families, must attempt to make sense of their situations and deal with the traumatic emotional roller coaster that ensues. In short, due to these stressors, children in foster care represent an extremely high-risk population for mental health problems. 1
Findings from the recent federal Child and Family Service Reviews (CFSRs), which evaluate state child welfare systems, show that most states are not able to meet the mental health needs of these most vulnerable children. Through the CFSRs, the U.S. Department of Health and Human Services has documented concerns about states' abilities to adequately meet the mental health needs of children and families. Findings include the following:
  • a lack of appropriate mental health services for children in the child welfare system, including specialized services such as treatment for children who have been sexually abused, treatment foster care, substance abuse treatment, and treatment addressing domestic violence;

  • concerns about the quality of available mental health services;

  • inconsistency in conducting mental health assessments for children when an assessment is warranted;

  • inconsistency in providing appropriate services to meet the identified needs of children and parents;

  • fathers, mothers, and children not being routinely involved in case planning; and

  • scarcity of appropriate placement services for children with developmental disabilities or behavioral problems.
Among the 2000 and 2001 CFSR reviews, only one state demonstrated strength under the well-being indicator for meeting the mental health needs of children in foster care. In 2002, common concerns in the other states included a scarcity of mental health services, the questionable quality of mental health services, and the lack of mental health assessments of children, even when there was adequate reason to conduct such an assessment. 2 Most states have included actions in their Program Improvement Plans responding to the CFSR reviews that aim to better address the mental health needs of children and families in the child welfare system. An optimal array of mental health services supporting children and families who enter the child welfare system would include prevention and early intervention services, home-based services, and out-of-home services. Out-of-home mental health services for children in the foster care system must include accessible options such as outpatient mental health services, day treatment, therapeutic/treatment foster care, or, if ultimately necessary, inpatient child and adolescent mental health and/or substance abuse treatment. 3 Children and adolescents in foster care who need mental health treatment should receive services in the least restrictive environment possible.

Particularly within the realm of the child welfare system, it is important that comprehensive mental health assessments, services, and supports be both child-focused and family-centered, including a thorough look at the child in all life domains, as well as the strengths and needs of the child and family. Medicaid funding should be used to ensure children in foster care receive the comprehensive screenings when entering the child welfare system, and the periodic interventions thereafter, that are guaranteed to them by federal law through EPSDT (see "Medicaid" section). When specific mental health and developmental needs are identified, these children should also be linked with appropriate services, including formal and informal treatment and supports.

More federal resources must be dedicated to research and services for children in out-of-home care so that they can receive the mental health services they need and deserve to live healthy, productive lives. A complex nexus of state Medicaid, child welfare, and behavioral health care systems currently works with extremely limited resources to provide the mental health services needed by so many children in foster care. Congress must ensure the already limited funding streams for critical mental health services to children in foster care, including the Medicaid options of Targeted Case Management and Rehabilitative Services (see "Medicaid" section) are protected and aggressive efforts are made to improve the national mental health system for children and adults. It is crucial federal policymakers recognize the vital role comprehensive mental health care plays in enhancing a child's chance for health development, reducing stress for caregivers, stabilizing foster care placements, and providing the services families need to care for their children. 4

Mental Health Parity

Mental health parity is necessary to ensure mental disorders receive the same insurance coverage as other illnesses. CWLA supports the passage of federal mental health parity legislation, such as the Mental Health Equitable Treatment Act (H.R. 1402) in the 109th Congress, which would require insurers who provide mental health coverage and medical/surgical coverage to offer those benefits at the same level. The success rate and efficacy for treating mental illnesses is as good, if not better, than treatment for illnesses such as heart disease. Lack of access to mental health treatment has tragic implications for individuals and families, as well as huge hidden costs to society from lost productivity and earnings, and increased burdens on public health systems.
Mental illness is the country's leading cause of disability and plays a significant role in child welfare cases. Despite a number of effective new medicines and treatments, a fragmented and inadequately funded mental health system prevents most people from accessing them. 5 All families, and particularly vulnerable families with low incomes, would greatly benefit from national health policies that address prevalent mental health problems in a cost-effective manner.

Children's Mental Health Workforce

Congress should pass The Child Health Care Crisis Relief Act (H.R. 1106) in the 109th Congress to increase the number of mental health care providers serving children and adolescents. This legislation, introduced in the last four sessions of Congress, would help remove one of the main barriers to treatment for youth with emotional and behavioral disorders-acute shortages of mental health service professionals. 6 If passed, the Act would create educational incentives and federal support for children's mental health training programs, including the authorization of scholarships, loan repayment programs, training grants, and specialty training program support for children's mental health professionals. Here, "mental health professionals" include child and adolescent psychiatrists and psychologists.

Keeping Families Together Act

Endorsed by CWLA, the Keeping Families Together Act (S. 380/H.R. 823) in the 109th Congress is expected to be reintroduced early in 2007. Designed to address the obstacles that prevent families with children who have mental or emotional disorders from accessing critical mental health services, this legislation would allow states to build new infrastructures to more efficiently serve children who need mental health services, while keeping them at home with their families. A 2003 study by the United States General Accounting Office (GAO) found that in 2001, parents placed more than 12,700 children into the nation's child welfare or juvenile justice systems solely to obtain mental health services for them. 7 The Act provides $55 million in grants to states over six years to help ensure the children and youth who are in state custody or at risk of entering the state's custody receive critical mental health services. Fewer families, therefore, would have to hand over custody of their children to the state in order for them to obtain adequate care.

Children's Mental Health Services Program

The Children's Mental Health Services Program develops organized systems of care for children with serious emotional disturbances in child welfare, juvenile justice, and special education who often do not receive the mental health services they need. Extensive evaluation reveals this program has had a significant effect on the communities it serves. Outcomes for children and their families have improved, including reduction of symptoms, improvement in school performance, fewer out-of-home placements, and fewer hospitalizations. This program was funded at $105 million in FY 2006, unchanged from the previous year.

Mental Health Services Block Grant and Programs of Regional and National Significance

The Community Mental Health Services Performance Partnership Block Grant is an increasingly critical source of funding for state and local mental health programs. These funds support services such as case management, emergency interventions, residential care, and 24-hour hotlines to stabilize people in crisis, as well as coordination of care for individuals with schizophrenia or manic depression who need extensive supports. Congress appropriated $410.9 million in FY 2006, a $21.8 million decrease from FY 2005.

The Mental Health Programs of Regional and National Significance give local communities the opportunity to improve mental health services by implementing proven, evidence-based practices for adults and children with serious emotional disorders. These programs grant state and local mental health authorities access to information about the most promising methods for improving programs so that they can act accordingly. Current areas of importance include state child welfare systems, the criminal justice system, children who are victims or witnesses of violence, services for persons with co-occurring mental illnesses and additional disorders, and school violence and suicide prevention. In FY 2006, this program was funded at $410.9 million, a $22.2 million reduction from FY 2005.

Early Intervention

According to preliminary estimates by the Adoption and Foster Care Analysis Reporting System (AFCARS), 38% of children entering foster care in FY 2005 were age 4 or younger; 15% were less than 1 year old. Furthermore, infants and toddlers remain in foster care twice as long as older children, on average. 8 These most vulnerable, extremely young children in foster care are at heightened risk for mental health problems, and need appropriate and timely evaluation, knowledgeable and responsible caregiving, and specialized intervention to improve their opportunity for healthy development. CWLA asks Congress to provide more funding for key programs targeting the social and emotional development of infants and toddlers at heightened risk for poor outcomes, including those in the child welfare system. Such programs include Head Start (see "Head Start" section), the federal IDEA "Part C" program, which gives states financial assistance to offer services for infants and toddlers with developmental delays, and Foundations for Learning Act grants, which provide funding for early childhood programs that promote the healthy emotional and social development of young children before they enter school.

Lifespan Respite Care Act

Just before the end of the 109th Congress, legislators approved passage of the Lifespan Respite Care Act, authorizing $289 million over five years for states to train volunteers and provide other services to an estimated 50 million families-including foster families-caring for adults or children with special needs at home. If fully funded, this legislation will give foster families a coordinated system of accessible, community-based respite options.

The need for such funding is substantial and CWLA calls on Congress to appropriate the full amount authorized. The family caregiver role too often results in substantial emotional, physical, and financial hardship. Current available respite care programs cannot sufficiently meet needs, and they struggle to recruit trained respite workers, leaving many family caregivers and foster families without adequate support. Foster families deserve community support, and ignoring or minimizing the pressures of foster parenting puts foster placements, especially of children in foster care with emotional problems, at great risk.

Key Facts

  • While 1 in 10 children and adolescents has a mental illness severe enough to cause some level of impairment, only 1 in 5 of them receives mental health services in any given year. This means that nearly 80% of children who need mental health services do not receive treatment. 9

  • Suicide is the fourth leading cause of death among youth ages 10 to14, and the third leading cause among young people 15 to 24. 10

  • A 2003 United States General Accounting Office (GAO) study found that in 2001, parents placed more than 12,700 children into the nation's child welfare or juvenile justice systems solely to obtain mental health services for them. 11

  • Of children entering the child welfare or juvenile justice systems, approximately 80% have mental disorders, compared with 20% of the general population. 12

  • Moderate to severe mental health and behavioral problems affect 50% to 80% of children in foster care. Approximately 60% of preschool age children in foster care have developmental delays. Fewer than 5% of children in foster care are without psychological symptoms. 13

  • Although children in foster care represent a very small percentage of Medicaid enrollees, they account for 25-41% of Medicaid mental health expenditures. 14

  • More than 40% of children entering the child welfare system do not receive initial screening for mental health or developmental delays. 15

  • Only about 25% of children in foster care receive mental health services at any given time. 16

  • Children with medical, developmental, or mental health problems are more likely to experience multiple foster care placements and spend more time than the rest of the foster care population in the foster care system. 17

  • According to a recent study, approximately half of adult participants who were placed in foster care as children have one or more mental health problems well into adulthood, and 25% suffer from Post Traumatic Stress Disorder (PTSD). 18


  1. National Child Welfare Resource Center for Family-Centered Practice, a service of the Children's Bureau. (2003, Summer). Mental health issues in the child welfare system: A focus on children and families. Best Practice/Next Practice: Family-Centered Child Welfare. Washington, DC: Author. back
  2. Ibid. back
  3. Ibid. back
  4. Ibid. back
  5. Levine, A. (2005). Parity plus: A third way to fix America's mental health system. Progressive Policy Institute Policy Report. Washington, DC: Progressive Policy Institute. back
  6. Office of the Surgeon General. (1999). Mental health: A report of the Surgeon General. Available online. Washington, DC: U.S. Public Health Service. back
  7. United States General Accounting Office. (2003). Child welfare and juvenile justice: Federal agencies could play a stronger role in helping states reduce the number of children placed solely to obtain mental health services. (GAO-03-397). Washington, DC: Author. back
  8. Dicker, S., Gordon, E., & Knitzer, J. (2001). Improving the odds for health development of young children in foster care. New York: National Center for Children in Poverty. back
  9. Office of the Surgeon General. (2001). Report of the Surgeon General's conference on children's mental health: A national action agenda. Available online. Washington, DC: U.S. Public Health Service. back
  10. National Center for Injury Prevention and Control. (2001). Injury fact book 2001-2002. Available online. Atlanta: U.S. Centers for Disease Control and Prevention. back
  11. United States General Accounting Office, Child welfare and juvenile justiceback
  12. Burns, P., Wagner, B., Kolko, C., & Landsverk, J. (2004). Mental health need and access to mental health services by youths involved with child welfare: A national survey. Journal of American Academy of Child and Adolescent Psychiatry, 43(8), 961. back
  13. Inkelas, M., & Halfon, N. (2002). Medicaid and financing of health care for children in foster care: Findings from a national survey. Available online. Los Angeles: UCLA Center for Healthier Children, Families, and Communities. back
  14. Rubin, D. M., Alessandrini, E. A., Feudtner, C., Mandell, D. S., Localio, A. R., & Hadley, T. (2004). Placement stability and mental health costs for children in foster care. Pediatrics, 113(5): 1336-1341. Available online. back
  15. Leslie, L. K, Hurlburt, M. S, Landsverk, J., Rolls, J. A., Wood, P. A., & Kelleher, K. J. (2003). Comprehensive assessments for children entering foster care: A national perspective. Pediatrics, 112, 134-142. Available online. back
  16. Inkelas & Halfon. back
  17. Rubin, et al. back
  18. Pecora, P., Kessler, R., Williams, J., O'Brien, K., Downs, A. C., English, D., et al. (2005) Improving family foster care: Findings from the Northwest Foster Care Alumni Study. Available online. Seattle, WA: Casey Family Programs. back

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