PROMOTING PRESERVING AND RESTORING CHILDREN’S MENTAL HEALTH
February 5, 2003
Introduction
A Public Health Crisis
The scope of this public health crisis can be characterized by the following:
§ The problem of emotional disorders in children is large-20% of all children are affected-and seems to be growing.
§ Emotional problems in children often are both serious and long lasting, and can lead to tragic consequences: poor academic achievement, failure to complete high school, substance abuse, involvement with the correctional system, lack of vocational success, inability to live independently, health problems, and suicide.
§ Youngsters with emotional problems not only have diagnosable disorders but also show significant impairments in important life domains, such as family, education, peers, work, and community.
§ The human and financial costs of emotional problems in children are both broad and deep; they affect the children and their families, schools, communities, employers and the nation as a whole. Expenditures for mental health services in the specialty mental health and general health sectors alone were $11.75 billion in 1998.
§ A disproportionate number of low-income children experience emotional problems and a disproportionate number of low-income and racial and ethnic minority children do not access services for their emotional problems.
§ Youth with emotional problems are invariably involved with more than one specialized service system, including mental health, special education, child welfare, juvenile justice, substance abuse, and health; but no agency or system is clearly responsible or accountable for them.
The Vision
In response to this identified need, the Subcommittee seeks to advance a new vision for children’s mental health that will make a real difference in the lives of children and their families. The vision calls for a commitment to promote the emotional wellbeing of children and ensure that children with emotional disorders live, learn, work, and thrive in their communities. The vision for children’s mental health is one in which our communities, states, and nation provide access to comprehensive, home and community-based, family-centered services and supports for children with mental health disorders and their families, while at the same time creating conditions that promote positive mental health and emotional well-being and prevent the onset of emotional problems in all children.
Our vision embraces:
§ A comprehensive array of home and community-based services and supports to provide treatment and to support the functioning of children with emotional disorders and their families at home, school, work, and in the community;
§ The full participation and partnership of families and other caregivers at all levels;
§ The recognition that this is a nation of diverse races, ethnicities, and cultures and that services must be culturally competent and equitable for all children and families; and
§ Efforts to promote mental health and prevent emotional disorders among children, as well as to identify disorders and intervene early in order to maximize positive outcomes and minimize disability.
The values underpinning our vision reflect certain “standards of care” for children’s mental health:
§ Home and Community-Based Care – Children belong in their homes and in their communities and every effort should be made to keep them there and to return them from institutional to home and community settings.
§ Family Partnerships – The family is the most important and life long resource in a child’s life, as well as being legally and morally responsible for a child.
§ Comprehensive Services and Supports – A broad array of services and supports should be available to children and their families, responding to issues that are biological, neurological, psychological, and social.
§ Cultural Competence – Services and systems should be responsive to the cultural perspectives and racial, ethnic, cultural and linguistic characteristics of the diverse populations served.
§ Individualized Care – Services should be individualized to each child and family, guided by a comprehensive, single plan of care for each child and family, that addresses strengths, as well as problems and needs.
§ Evidence-Based Practices – When state-of-the-art, evidence-based interventions are available, families should be informed of them, and these interventions should be made available to children and families.
§ Coordination – Services and systems should be coordinated at the service delivery level, and the agencies and programs that serve children should be linked with those serving adults.
§ Early Identification and Intervention – Services and supports should emphasize early identification and intervention, as well as prevention of mental health problems, to maximize the likelihood of positive outcomes.
§ Accountability – There should be a clear point of responsibility and accountability for children’s mental health care at all levels.
Expanding on the Commission’s Interim Report, the Subcommittee delineates nine problem areas that hinder the vision for children’s mental health and its underlying values from becoming reality:
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§ Fragmentation in responsibility and funding |
§ Lack of family partnerships and family support |
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§ Unmet need and disparities in access |
§ Gaps in services |
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§ Gap between what we know and what we do |
§ Lack of prepared workforce |
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§ Lack of focus on prevention and early intervention |
§ Lack of accountability and quality improvement |
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§ Lack of understanding of mental health problems in children and stigma |
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Policy Options to Achieve the Vision
The Subcommittee highlights ten policy options as essential strategies to begin building a better system to address the mental health needs of the nation's children. These ten, followed by implementation options, are the first steps toward achieving the Subcommittee’s vision. In its final report, the Subcommittee offers a more extensive blueprint for building the system.
1. Implement a Comprehensive Approach to Children’s Mental Health at Federal and State Levels
The federal government and each state government should plan and implement a comprehensive, cross-agency, public health approach for promoting, preserving, and restoring children’s mental health. The approach should focus on both strengthening services and supports for children with serious emotional disorders and their families, and on prevention and early intervention strategies for all children.
§ Strengthen Children’s Mental Health Focus in State Governments
§ Establish a Federal Interagency Entity for Children’s Mental Health
§ Re-Institute White House Conferences on Children
2. Finance a Broad Array of Services and Support
Federal and state agencies and commercial insurers should realign funding policies related to children’s mental health to support a comprehensive array of services and supports, including home and community based services and supports that are individualized, family focused, coordinated, and culturally competent.
§ Develop a Plan for Medicaid to Support Home and Community-Based Services and Supports and Individualized Care
§ Allow Families to Buy Into Medicaid in Order to Access Intensive Rehabilitative Community Services and Supports only Available Through Publicly-funded Systems
3. Strengthen Family and Youth Partnerships and Family Support
Federal, state, and local governments should ensure that families, substitute families, and other caregivers, as well as youth, are full partners and have substantial involvement in all aspects of service planning and decision making for their children at federal, state, and local levels.
Implementation Options
§ Implement Strategies to Prevent the Unnecessary Transfer of Custody in Order to Provide Care
§ Review and Strengthen Federal and State Requirements for Family Participation
§ Expand Support for Family Organizations to Provide Information and Training
§ Provide Coverage for Family Support Services in Public and Private Insurance
4. Individualize Care: A Single Plan of Care for a Child and Family
States should ensure that each child with a serious emotional disorder has an individualized, single plan of care (Individualized Service and Support Plan – ISSP) that addresses the child and family’s needs across life domains and incorporates services and supports from all needed agencies and systems.
§ Develop and Implement an Individualized Service and Support Plan (ISSP) for Each Child with a Serious Emotional Disorder
5. Broaden the Range of Services and Supports and Build Capacity
Federal and state governments should promote a broader concept of “mental health” services for children and adolescents with emotional disorders and their families. This concept should include the comprehensive array of treatment services and supports needed to enable these youngsters to reach and maintain their optimal level of functioning within their homes, schools, and communities.
§ Develop a Model Benefit Design for Children’s Mental Health Services for public and private insurers
§ Provide Incentives to State Governments to Invest in Building Service Capacity
§ Increase Development of Services for Youth with Co-Occurring Substance Abuse and Mental Health Disorders
6. Strengthen Mental Health Services to Children Within Schools
Recognizing that children receive more services through schools than any other public system, federal, state, and local agencies should more fully recognize and address the mental health needs of youth in the education system. Likewise, these agencies should work collaboratively with families and develop, evaluate, and disseminate effective approaches for providing mental health services and supports to youth in schools.
§ Ensure State Special Education and Related Services for Children with Emotional Disorders Under IDEA
7. Screen High-Risk Populations (Juvenile Justice and Child Welfare Populations) and Link Them with Services
Systematic screening procedures to identify mental health and substance abuse problems and treatment needs should be implemented in specific settings in which youngsters are at high risk for emotional disorders or where there is known to be a high prevalence of these or co-occurring mental health and substance abuse disorders. Screening should be implemented upon entry into, and periodically thereafter in, the juvenile justice and child welfare systems, as well as in other settings and populations with known high risk, such as the Medicaid population. When mental health problems are identified, youth should be linked with appropriate services and supports.
§ Analyze Existing Tools for Screening and Identifying Mental Health Problems and Support Research to Develop New Tools Where Needed
§ Incorporate Developmentally and Culturally Appropriate Behavioral Health Screening into EPSDT Screens
8. Strengthen Early Childhood Mental Health Interventions
A national effort focusing on the mental health needs of young children and their families should be implemented. Grounded in emerging neuroscience research highlighting the ability of environmental factors to shape brain development and subsequent behavior, this effort should include educating parents, the public, and professionals about the importance of the first years of a child’s life for developing a foundation for healthy social and emotional development.
Implementation Options
§ Develop a Collaborative State Plan for Early Childhood Mental Health
§ Provide Technical Assistance to States to Implement a Comprehensive Approach to Early Childhood Mental Health Services
§ Explore Feasibility of Coverage for Early Childhood Mental Health Services in Public and Private Insurance and Eliminate Barriers to Coverage
§ Train Mental Health Practitioners to Diagnose and Treat Mental Health Problems in Young Children and Families
9. Prevent Mental Health Disorders
The federal government should develop and implement a comprehensive approach for enhancing the well being of children and adolescents, based on a bio-psychosocial model, through preventive interventions prior to the onset of mental and behavioral disorders.
§ Screen All Children Ages 0 to 5 for Social and Emotional Development as Part of Primary Health Care Visits
§ Provide Mental Health Screening in Community Health Centers
§ Address Barriers to Coverage of Preventive Intervention Services in Health Insurance
10. Build an Adequate Workforce
The federal government should work in partnership with state governments, national accrediting organizations, professional disciplines and organizations, licensure entities, family organizations, and universities to ensure an adequate workforce for the delivery of children’s mental health services.
§ Develop and Implement a Strategic Plan to Develop the Children’s Mental Health Workforce
§ Develop and Implement a Strategic Plan to Address the Workforce Crisis in Mental Health Services and Research for Racial and Ethnic Minority Youth and their Families