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CWLA 2008 Children's Legislative Agenda
Mental Health Care Services
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Action
- Support the recommendations of the President's New
Freedom Commission on Mental Health, including consumer-
and family-driven mental health care and early
mental health screening, referral, and assessment.
- Increase funding for the Children's Mental Health
Services Program, the Community Mental Health
Services Performance Partnership Block Grant, Mental
Health Programs of Regional and National Significance,
and key programs that target the social and emotional
development of infants and toddlers at heightened risk
for mental health problems.
- Ensure availability and accessibility to comprehensive
preventive health care services, including physical and
mental health screenings and interventions, for children
in foster care who are guaranteed the services under federal
law through the Early Periodic Screening, Diagnosis,
and Treatment (EPSDT) program for children younger
than 21 receiving Medicaid.
- Protect and strengthen Medicaid and corresponding
mental health services, including the Medicaid options
of targeted case management (TCM) and Rehabilitative
Services.
- Pass strong mental health parity legislation requiring
health insurance plans provide mental health benefits-
if these benefits are already included in the plan-on
the same terms as other medical conditions (H.R.
1424/S. 558).
- Pass the Child Health Care Crisis Relief Act (H.R.
2073/S. 1572)-legislation addressing acute shortages
of child and adolescent mental health professionals.
- Pass the Keeping Families Together Act (H.R. 687/S.
382)-legislation preventing parents from relinquishing
their custody rights to the state to obtain mental health
care for their seriously ill children.
- Fully fund the Lifespan Respite Care Act (P.L. 109-
442)-legislation assisting foster parents and other caregivers
access affordable, high quality respite care.
Background
- 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 that come into contact with the child welfare
system grow up in home environments characterized
by poverty, instability, or parents and caregivers with limited
psychological well-being themselves. Many are also
victims of abuse and neglect and then, if separated from
their families, must attempt to make sense of their situations
and deal with the ensuing traumatic emotional roller
coaster. In short, due to these stressors, children in foster
care represent an extremely high-risk population. An estimated
50% to 80% suffer from moderate to severe mental
health problems. 1
Findings from the federal Child and Family Service
Reviews (CFSRs), however, reveal that the mental health
needs of these vulnerable children are often not met. The
Children's Bureau, within the U.S. Department of Health and
Human Services, reported after the first round of CFSRs
that only four states received a "strength" rating for properly
addressing the mental and behavioral health needs of
children in care. 2 Common concerns and frustrations cited by
states in attempting to meet foster children's mental health
needs 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. 3
Most states have committed to better addressing the
mental health needs of children and families in their child
welfare systems by including appropriate action steps in
their Program Improvement Plans (PIPs). An optimal array
of mental health services supporting children who come into
contact with the child welfare system include a comprehensive
mental health assessment, prevention and early intervention
services, home- and community-based services, and
out-of-home services. Mental health services for children in
out-of-home care 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. 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,
when appropriate and possible, 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. As a congressionally
requested report recently stated, "For children,
mental health is not seen as residing solely within the child,
but within the web interactions among the individual child;
the family; the school, health, and other child service systems;
and the neighborhoods and communities in which the
child lives." 4
A complex nexus of state Medicaid, child welfare, and
behavioral health care systems currently work with extremely
limited resources to provide the mental health services so
many children in foster care need. These vulnerable children
deserve to lead healthy, productive lives and, therefore,
more federal resources must be dedicated to research and
services. Congress must protect and increase the currently
strained funding streams for critical mental health services
to children in foster care. As Medicaid steps in to provide
many children in foster care with mental health care that
gets them on the road to recovery, the program as a whole,
as well as Medicaid EPSDT and the Medicaid options of
TCM and Rehabilitative Services, must be protected and
strengthened (see "Medicaid" section). Finally, broader
scale mental health legislation is necessary to address
other shortcomings and inequities.
Critical Mental Health Funding
Children's Mental Health Services Program
The Children's Mental Health Services Program funds comprehensive,
community-based systems of care for children
with serious emotional disturbance (SED) in the nation's
child welfare, juvenile justice, and special education programs.
Extensive evaluation reveals this program has significant
positive impact on individuals and communities.
Children experience reduced emotional and behavioral problems
and improved school attendance and achievement.
Congress funded this program at $104 million in FY 2007
and at $102 million in FY 2008.
Community Mental Health Services
Block Grant and Programs of Regional
and National Significance
The Community Mental Health Services Performance
Partnership Block Grant is the principal federal program
supporting community-based mental health services for
children and adults. For SED children, these funds support
services such as case management, emergency interventions,
residential care, and 24-hour hotlines to stabilize
people in crisis, as well as coordinate care for individuals
with schizophrenia or manic depression needing extensive
supports. Congress appropriated $428 million in FY 2007
and $421 million for this program FY 2008.
By granting state and local mental health authorities
access to information about the most promising methods for
improving programs, Mental Health Programs of Regional
and National Significance promotes the implementation
of effective, evidence-based practices for adults and SED
children. Recent areas of importance include services for
children and adolescents with post-traumatic stress, coordination
of cross-system mental health activities and services,
and prevention of youth violence and suicide. Congress
appropriated $263 million for this program in FY 2007, and
$299 million in FY 2008.
Early Intervention Programs
According to 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. These extremely young, vulnerable
infants and toddlers remain in foster care twice as long as
older children, on average, and are at heightened risk for
mental health and behavioral problems. To avoid missing
the chance to get these infants and toddlers on a healthy
trajectory, giving them appropriate and timely mental health
evaluation, knowledgeable and responsible caregiving, and
specialized intervention is essential. CWLA asks Congress
to provide increased, sufficient funding for key programs
targeting the social and emotional development of infants
and toddlers at heightened risk for poor outcomes, including
Head Start (see "Head Start" section) and the federal
IDEA "Part C" program, which gives states financial assistance
to offer services for infants and toddlers with developmental
disabilities or delays.
Medicaid
When children are removed from their homes and placed in
state custody, Medicaid steps in and provides key mental
health services that start them on the road to recovery. As
discussed in greater detail in the Medicaid section, EPSDT
and the Medicaid options of TCM and Rehabilitative
Services are especially vital to this equation. The Medicaid
program and its components as a whole must remain
strong, viable streams of care and aggressive efforts must
be made to thwart any contrary, restrictive actions. Only
then will Medicaid fulfill its purpose of bettering the health
of some of our nation's most vulnerable children.
Legislation
Mental Health Parity
Insurers have long been permitted to impose more restrictive
treatment limitations and cost sharing requirements on
mental health coverage than medical coverage. Full mental
health parity is necessary to erase these discriminatory
barriers to mental health treatment. CWLA urges passage of
strong federal mental health parity legislation, such as the
Paul Wellstone Mental Health and Addiction Equity Act,
introduced by Congressmen Patrick Kennedy (D-RI) and Jim
Ramstad (R-MN) (H.R. 1424), as well as the Mental Health
Parity Act, introduced by Senators Ted Kennedy (D-MA),
Pete Domenici (R-NM), and Michael Enzi (R-WY) (S. 558).
Such policy will greatly help all Americans with mental
health problems, particularly vulnerable, lower-income families
and those involved with the child welfare system who
experience a disproportionate rate of mental struggles.
CWLA also strongly urges mental health parity be required
in the State Children's Health Insurance Program (CHIP or
SCHIP), such as in S. 1337 or H.R. 3963.
Children's Mental Health Workforce
Congress should pass the Child Health Care Crisis Relief
Act (S. 1572/H.R. 2073) to increase the number of qualified
mental health care providers serving children and
adolescents. This legislation 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.
Keeping Families Together Act
The U.S. General Accounting Office found that in 2001-due
to limits on public and private health insurance, inadequate
supply of services, difficulty meeting eligibility requirements,
and other reasons-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. 6 Endorsed by CWLA, the Keeping Families Together
Act (S. 382/H.R. 687) is designed to alleviate those shortcomings.
Specifically, it would offer competitive matching
grants for states to establish systems of care that provide
mental health treatment and services to all children who are
in their custody or are at-risk of entering their custody for
the purpose of receiving mental health services.
Lifespan Respite Care Act
Just before the 109th Congress concluded, legislators
passed the Lifespan Respite Care Act (P.L. 109-442), 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. CWLA calls on Congress to
appropriate the full amount authorized to ensure family
caregivers, especially those who face substantial emotional,
physical, and financial hardship, receive adequate support
for the familial unit to thrive.
Key Facts
- Moderate to severe mental health and behavioral problems
affect 50% to 80% of children in foster care. One
study found that 33% of youth in foster care have three
or more diagnosed psychiatric problems. 7
- In 2001, parents placed more than 12,700 children into
the nation's child welfare or juvenile justice systems solely
to give them mental health services. 8
- More than 40% of children entering the child welfare
system do not receive initial screening for mental health
or developmental delays. 9
- Despite the disproportionate need, some estimate only
about 25% of children in foster care are receiving mental
health services at any given time. 10
- Children with medical, developmental, or mental health
problems are more likely to experience multiple foster
care placements and spend more time in foster care. 11
- Although children in foster care represent a very small
percentage of overall Medicaid enrollees, they use
Medicaid-reimbursed mental health services at a rate 8
to15 times higher than other Medicaid-eligible youth
because of their intensive mental health needs. 12
- Compared to the general population, youth and adults
formerly in foster care experience a disproportionate
number of mental health disorders. Foster care alumni,
for example, experience higher rates of general mental
health problems (54.4% versus 22.1%), post-traumatic
stress disorder (25.2% versus 4%), and major depression
(20.2% versus 10.2%). 13
Sources
- Halfon, N., Zepeda, A., & Inkelas, M. (2002). Mental health services for children in foster care. Available online. Los Angeles: UCLA Center for Healthier Children, Families, and Communities. back
- Administration for Children and Families. (Last updated June 2007). Child and family services reviews: Fact sheet for mental health professionals. Available online. Washington, DC: Author. back
- McCarthy, J., Marshall, A., Irvine, M., & Jay, B. (2004). An analysis of mental health issues in states' child and family service reviews and program improvement plans. Available online. Washington, DC: Georgetown University Center for Child and Human Development. back
- Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services. (2007). Promotion and prevention in mental health: Strengthening parenting and enhancing child resilience, DHHS Publication No. CMHS-SVP-0175. Available online. Rockville, MD: Author. back
- Dicker, S., Gordon, E., & Knitzer, J. (2002). Improving the odds for the healthy development of young children in foster care. Available online. New York: National Center for Children in Poverty. back
- United States General Accounting Office (GAO). (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). Available online. Washington, DC: Author. back
- Halfon et al., Mental health services for children in foster care; dosReis, S., Magno Zito, J., Safer, D.J., & Soeken, K.L. (2001). Mental health services for youths in foster care and disabled youths. American Journal of Public Health, 91(7), 1094-1099. back
- GAO, 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. back
- 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
- 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
- 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. Available online. Pediatrics, 113(5), 1336-1341. back
- Geen, R., Sommers, A., & Cohen, M. (2005). Medicaid spending on foster children. Available online. Washington, DC: Urban Institute. back
- Pecora, P., Kessler, R., Williams, J., O'Brien, K., Downs, A.C., English, D., White, J., Hiripi, E., White, C.R., Wiggins, T., & Holmes, K. (2005) Improving family foster care: Findings from the Northwest Foster Care Alumni Study. Available online. Seattle, WA: Casey Family Programs. back
CWLA Contact
Laura Weidner
703/412-3168
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