Transforming Mental Health Care for Children and
Their Families
Larke Huang
Beth Stroul
Robert Friedman
Patricia Mrazek
Barbara Friesen
Sheila Pires
Steve Mayberg
In April 2002, the President’s New Freedom Commission
on Mental Health was created by executive order to study
the mental health care delivery system in our nation and to
make recommendations for improvements so that individ-
uals with serious mental disorders can live, work, learn,
and fully participate in their homes and communities. In its
report, “Achieving the Promise: Transforming Mental
Health Care in America,” the commission provided strate-
gies to address critical infrastructure, practice, and re-
search issues. This article focuses on the work of the
commission’s Subcommittee on Children and Families, de-
scribing its vision for mental health service delivery for
children and providing suggestions for strengthening com-
munity-based care for youths with or at risk of behavioral
health disorders. Training, research, practice, and policy
implications for psychologists are discussed.
Keywords: children’s mental health, systems of care, trans-
formation
M ental health problems in children and adoles-
cents have created a “health crisis” (Satcher,
2000, p. 1) in this country. These problems
affect a growing number of youths, they impact these
children and their families in all spheres of their lives, and
their consequences are costly and often tragic. Recent
studies indicate an alarmingly high prevalence rate, with
approximately 1 in 5 children having a diagnosable mental
disorder and 1 in 10 youths having a serious emotional or
behavioral disorder that is severe enough to cause substan-
tial impairment in functioning at home, at school, or in the
community (Friedman, Katz-Leavy, Manderscheid, &
Sondheimer, 1996). The National Institute of Mental
Health’s National Advisory Mental Health Council, Work-
group on Child and Adolescent Mental Health (2001) con-
cluded that “no other illnesses damage so many children so
seriously” (p. 1).
In conjunction with this prevalence rate, there is an
extremely high level of unmet need. It is estimated that
about 75% of children with emotional and behavioral dis-
orders do not receive specialty mental health services (Rin-
gel & Sturm, 2001). Former Surgeon General David
September 2005 ● American Psychologist
Copyright 2005 by the American Psychological Association 0003-066X/05/$12.00
Vol. 60, No. 6, 615– 627 DOI: 10.1037/0003-066X.60.6.615
American Institutes for Research
Management and Training Innovations, Inc.
University of South Florida
Rochester, Minnesota
Portland State University
Human Service Collaborative
California Department of Mental Health
Satcher, at his National Conference on Children’s Mental
Health, stated that “growing numbers of children are suf-
fering needlessly because their emotional, behavioral, and
developmental needs are not being met by those very
institutions which were explicitly created to take care of
them” (Satcher, 2000, p. 1). Yet despite these levels of
prevalence and unmet need and the serious impact of
mental health problems on the functioning of our children,
our nation has failed to develop a comprehensive, system-
atic approach to this crisis in children’s mental health. This
article highlights the strategies put forth by the Subcom-
mittee on Children and Families of the President’s New
Freedom Commission on Mental Health to transform men-
tal health care for children and families.1
Although the mandate of the commission focused on
intervention for children with serious emotional disorders,
the subcommittee expanded this mandate to include inter-
vention for children at risk for mental disorders as well as
prevention of mental health problems and promotion of
Larke Huang, American Institutes for Research, Washington, DC; Beth
Stroul, Management and Training Innovations, Inc., Fairfax, Virginia;
Robert Friedman, Department of Child and Family Studies, Louis de la
Parte Florida Mental Health Institute, University of South Florida; Patricia
Mrazek, Rochester, Minnesota; Barbara Friesen, Research and Training
Center on Family Support and Children’s Mental Health, Portland State
University; Sheila Pires, Human Service Collaborative, Washington, DC;
Steve Mayberg, California Department of Mental Health, Sacramento,
California.
Larke Huang and Steve Mayberg served as co-chairs of the Subcom-
mittee on Children and Families that was established as part of the
President’s New Freedom Commission on Mental Health; the remaining
authors served as consultants to the commission in the area of children’s
mental health. This article is based on the findings and recommendations
of the Subcommittee on Children and Families.
Correspondence concerning this article should be addressed to Larke
Huang, American Institutes for Research, 1000 Thomas Jefferson St.,
NW, Washington, DC 20007. E-mail: lhuang@air.org
1
This article is not the official report of the Subcommittee on
Children and Families of the President’s New Freedom Commission on
Mental Health. The content of this article reflects the discussions of the
subcommittee and its expert consultants. It does not reflect the position of
the President’s New Freedom Commission on Mental Health or any
agency of the United States Government.
615
positive mental health for all children. The focus of this
article is on the overall system for preventing mental health
problems in children and on restoring those children with
such challenges to as high a level of functioning as possi-
ble. The focus on the system incorporates an examination
of both the services that are provided to children and their
families and the overall structure and policies that are
designed to facilitate the delivery of effective services and
supports. This overall structure includes such features as
the manner in which the system is organized and financed;
the values, principles, and data on which it is based; the
nature of collaborations across service sectors, between
families and professionals, and across levels of govern-
ment; and planning, governance, quality improvement, and
workforce development procedures.
Reform Efforts in Children’s Mental
Health Policy
The inadequacy of the children’s mental health system
has been repeatedly documented. The Joint Commission on
the Mental Health of Children (1969) concluded that only
a fraction of children in need were actually receiving men-
tal health services and that the services that were provided
were largely ineffective. Subsequent policy studies docu-
mented similar conclusions, indicating (a) that children
were not getting needed mental health services; (b) that
those served were often in excessively restrictive settings;
(c) that services were limited to outpatient, inpatient, and
residential treatment, with few intermediate-care, commu-
nity-based options available; and (d) that the coordination
among child-serving systems responsible for mental health
needs was weak (Knitzer, 1982; President’s Commission
on Mental Health, 1978; U.S. Congress, Office of Tech-
nology Assessment, 1986). These various reports served as
a catalyst for federal attention to children’s mental health.
The Child and Adolescent Service System Program
(CASSP), was launched by the National Institute of Mental
Health in 1984 with the objective of helping states and
communities build their capacity to develop systems of
care particularly targeted to children with serious and com-
plex needs who were involved with multiple service sec-
tors, for example, mental health, special education, child
welfare, and juvenile justice (called children with “serious
emotional disturbances”). The CASSP explicitly promoted
the policy direction of identifying children with serious
emotional disturbances as the priority population, and be-
fore long, most states designated this group as their priority
population (Friedman, Kutash, & Duchnowski, 1996). The
intent of this focus was not to neglect or diminish the
importance of preventive efforts but to redirect public
mental health systems away from serving children with
mild problems that did not significantly interfere with their
functioning and toward serving those who had severe prob-
lems that interfered with their functioning and who were a
particular challenge and expense to service systems.
An early accomplishment of the CASSP was the re-
fining of the concept of a system of care to serve as a
framework for reform (Stroul & Friedman, 1986, 1996). A
616
system of care was defined as “a comprehensive spectrum
of mental health and other services and supports organized
into a coordinated network to meet the complex and chang-
ing needs of children and their families” (Stroul & Fried-
man, 1986, p. 3). It included a set of core values and
principles to guide service delivery to children and fami-
lies. The core values specified that services should be
community based, child centered and family focused, and
culturally appropriate. Key principles specified that ser-
vices should (a) be comprehensive, with a broad array of
services and supports; (b) be individualized to each child
and family; (c) be provided in the least restrictive, appro-
priate setting; (d) be coordinated at both the system and
service delivery levels; (e) include early intervention ef-
forts; and (f) engage families and youths as full partners.
These principles were based on a recognition of the diverse
nature and multiple needs of children with serious emo-
tional disturbances and their families.
This system of care approach helped to seed other
federal and foundation initiatives geared to developing
more comprehensive, integrated systems of community-
based services and supports for children. The largest of
these programs, the federal Comprehensive Community
Mental Health Services for Children and Their Families
Program, authorized by Congress in 1992, has a current
budget of approximately $100 million and to date has
provided 92 grants to states, communities, territories, and
Indian tribes and tribal organizations to improve systems of
care to meet the needs of youths with emotional problems
and their families (U.S. Department of Health and Human
Services, 2002). All but two states have received a grant to
either the state or a local community within the state. A
national evaluation of this program shows a reduction in
mental health problems and costly out-of-state residential
placements and an increase in behavioral and emotional
strengths. Residential stability, school attendance, and
school performance improved, and contacts with law en-
forcement and substance use decreased (Center for Mental
Health Services, 2001).
Despite progress in improving systems of care for
children with emotional disorders and their families, recent
examinations have highlighted areas that need improve-
ment and that represent significant challenges. The land-
mark Mental Health: A Report of the Surgeon General
(U.S. Department of Health and Human Services, 1999)
underscored the need for a developmental perspective in
understanding and treating mental disorders in children and
synthesized the evidence base for services. The goal of
providing care for children with mental health needs in
their homes and communities was further supported in
1999 by the U.S. Supreme Court’s groundbreaking deci-
sion in Olmstead v. L. C., which specified that the institu-
tionalization of persons with disabilities who, given appro-
priate supports, could live in the community is a form of
discrimination. The intent of the Olmstead decision for
children with serious emotional disorders is consistent with
the system of care philosophy—avoiding out-of-home
placements to the extent possible and returning children to
September 2005 ● American Psychologist
their home communities in a timely way with appropriate
services and supports in place (Lezak & Macbeth, 2002).
In 2000, the U.S. Surgeon General convened a con-
ference on children’s mental health that resulted in a na-
tional action agenda, which set forth children’s mental
health as a national priority and delineated action steps to
organize and coordinate services in the child’s cultural and
community context (U.S. Public Health Service, 2000).
This movement toward comprehensive, community-based
care culminated most recently in President Bush’s New
Freedom Initiative, announced in 2001, which included
proposals to eliminate barriers for people with disabilities.
As part of this initiative, the President issued an executive
order to create a presidential commission on mental health
with a specific mandate to study the existing mental health
service delivery system and make recommendations for
improvements that would enable adults with serious mental
illness and children with serious emotional disorders to
live, work, learn, and fully function in their homes, schools,
and communities. In July 2003, the President’s New Free-
dom Commission on Mental Health issued its report,
Achieving the Promise: Transforming Mental Health Care
in America. The report presented recommendations that, in
the aggregate, would begin to change how mental health
care is organized, financed, and delivered in order to
achieve the goal of recovery and resilience and a thriving
life in the community for those with serious mental health
problems.
A Vision for Children’s Mental Health
Given the complex needs of children with mental health
problems, the President’s New Freedom Commission on
Mental Health created a Subcommittee on Children and
Families. This subcommittee proceeded with the task of
gathering information and reviewing testimony about the
deficits and strengths of the existing service system for
youths and their families. Testimony, reports, and research
studies were reviewed from over 250 stakeholder groups,
including youths and families, national and regional orga-
nizations, provider associations and practitioners, clinical
and services researchers, and state and community-based
program directors. Site visits by the subcommittee were
made to innovative prevention and treatment programs that
had demonstrated positive outcomes. These included early
childhood programs, school-based programs, community-
based wraparound services, innovative juvenile court-
based services, and comprehensive community mental
health programs serving ethnic and racially diverse youths.
The subcommittee requested a content analysis of the over
1,200 comments submitted to the commission through its
Web site pertaining to children in order to further identify
issues and innovative strategies. The subcommittee worked
with experts in the field of children’s mental health to
address the issues being identified. The subcommittee
worked for almost the entire year of the commission’s
duration, analyzing and synthesizing this information, and
then crafted policy recommendations to begin the transfor-
mation of care for children and families. Many of the
recommendations of the subcommittee are reflected
September 2005 ● American Psychologist
throughout the goals and recommendations of the final
report of the President’s New Freedom Commission on
Mental Health (2003). A more extensive discussion of the
subcommittee’s work is presented in a background paper
that details 9 policy areas, 26 policy recommendations, and
120 implementation options to advance children’s mental
health. This report is to be released by the Substance Abuse
and Mental Health Services Administration, the agency
charged with implementing the President’s New Freedom
Commission recommendations.
The executive order creating the President’s New
Freedom Commission on Mental Health called for recom-
mendations that would advance a community-based service
delivery system built on efficiency and demonstrably ef-
fective practices. The objectives and guiding principles
outlined in the executive order aligned remarkably well
with the values and operating principles of the systems of
care approach being implemented in local communities and
states around the country as part of the federally legislated
Comprehensive Community Mental Health Services Pro-
gram for Children and Their Families. Given this congru-
ence, the subcommittee drew on the strategies and innova-
tions from this program and, in conjunction with input from
key stakeholders (including youths and families, policy-
makers, researchers, and providers in specialty mental
health, school-based services, and other child-serving sys-
tems), crafted a vision for children’s mental health. The
vision is based on a system of care approach and calls for
a broad array of services and supports to be provided in the
child’s home, school, and community, in partnership with
the family and consistent with the culture, values, and
preferences of the child, the youth, and the family. The
vision goes beyond the focus on children with serious
emotional disturbances and presents a public health ap-
proach to preventing mental health problems and creating
conditions that promote positive socioemotional health for
all children. Implementing this vision begins with a set of
values that reflect standards of care for children’s mental
health, as summarized in Table 1.
Achieving the Vision: Strengthening
Children’s Mental Health Services
This vision is consistent with the recommendations of the
overall report of the President’s New Freedom Commission
on Mental Health (2003). Achieving this vision will require
a significant transformation of the current service delivery
system: its organization, financing, and clinical services
and supports. The Subcommittee on Children and Families
identified 10 specific challenges that need to be addressed
and possible strategies for addressing them. These 10 chal-
lenges are discussed below as separate issues; however, the
subcommittee viewed all of them as being interrelated and
part of a systemic approach to prevention and treatment.
1. Developing Comprehensive Home- and
Community-Based Services and Supports
In the past 20 years, there has been a substantial growth in
services other than traditional office-based outpatient ther-
617
Table 1
Vision for Children’s Mental Health Services
Value
1. Comprehensive home- and
community-based services and
supports
2. Family partnerships and support
3. Culturally competent care
4. Individualized care
5. Evidence-based practices
6. Coordination of services,
responsibility, and funding
7. Prevention, early identification,
and early intervention
8. Early childhood intervention
9. Mental health services in schools
10. Accountability
apy and residential or inpatient care. These include services
such as intensive home-based care, day treatment, mentor-
ing, respite care, wraparound care, and therapeutic foster
care. Comprehensive, individualized, and culturally com-
618
Standard of 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. A broad array of services and supports should be available
and responsive to the biological, neurological, psychological, and social aspects
of children’s mental health and supportive of the multiple areas of functioning in
a child’s life. These services should be home- and community-based, should be
provided in the least restrictive, clinically appropriate setting, and should
emphasize the natural settings in which children are found, such as families,
schools, primary health care settings, day care, and other child-serving systems.
The family is the most important and lifelong resource in a child’s life and is
responsible for the child from both a legal and a moral perspective. Policies
should be designed to support families, substitute families, and other primary
caregivers and to ensure that they are respected partners in all aspects of the
system, from treatment planning and service delivery to policymaking, system
development, evaluation, and management. Families should be provided with
reasonable and meaningful choices of services and supports for their children.
Our nation is one of increasingly diverse races, ethnicities, and cultures. Services
and supports should be equitable and responsive to the cultural and linguistic
characteristics of the populations served.
Services should be individualized and guided by a comprehensive, single plan of
care for each child and family. Each plan should incorporate a focus on
strengths as well as on problems and needs, which together should dictate the
types and mix of services provided.
Children and families should be informed of and given access to evidence-based
practices. When the scientific basis is incomplete, services should be guided by
experience, clinical judgment, and family preference.
This coordination should occur at the service delivery level with care coordination
mechanisms, at the system level with linkage among child-serving agencies, and,
for youths in transition to adulthood, with linkage between child- and adult-
serving systems.
Services and supports should emphasize prevention, early identification, and
intervention in order to maximize positive outcomes.
Early childhood programs must be prioritized to prevent the negative
developmental trajectories documented in the research.
Schools are where children spend each weekday. Schools should be supported to
meet the social-emotional needs of children to ensure that they are healthy and
ready to learn.
There should be a clear focal point for responsibility and accountability for
children’s mental health care. Services and systems should be guided by
standards for access to and quality of care and performance measures of
service delivery and outcomes in order to reduce inappropriate and ineffective
care and to produce data for continuous improvement of services and supports.
petent treatment plans for children with serious and com-
plex needs and their families are frequently developed now
by multidisciplinary teams including families, are based on
partnerships between parents and professionals, and exam-
September 2005 ● American Psychologist
ine strengths as well as needs in many life domains (Stroul
& Friedman, 1996; VanDenBerg & Grealish, 1996). In
many communities, overreliance on out-of-home and out-
of-community treatment options and overemphasis on tra-
ditional psychotherapeutic interventions still exist. At the
same time, the range of individualized and culturally com-
petent home- and community-based services and supports,
including preventive and school-based services, remains
underdeveloped (see Burns & Hoagwood, 2002, and Stroul
& Friedman, 1986, for a description of home- and com-
munity-based services). There has been a documented shift
to outpatient care over the past 15 years, based on an
analysis of mental health service use and expenditures
(Sturm et al., 2001), but significant service gaps in the
continuum of care for children and their families remain.
Some of the increase in outpatient care is accounted for by
significant increases in the use of medications for children,
often without accompanying therapies and supports; the
number of children taking psychiatric drugs more than
doubled from 1987 to 1996 (Zito et al., 2003). Despite
widespread interest in home-, school-, and community-
based services and supports, the capacity to provide many
of these services is lacking, and investments in service
capacity development have been insufficient to ensure ac-
cess to a broad array of services and supports in commu-
nities (Stroul, Pires, & Armstrong, 2001). Service gaps also
are perpetuated by the outdated mental health benefits
provided by many insurance carriers, which offer little
coverage for the home- and community-based services that
could replace costly out-of-home treatment.
The vision for a comprehensive service array in-
cludes a full range of both nonresidential and residential
services and supports, going well beyond the traditional
office-based outpatient, inpatient, and residential treat-
ment that have typically been available in communities
and covered by public and private insurers. Federal and
state governments should provide incentives, and work
in partnership with families and the private sector, to
encourage the investment of resources in building a full
range of home- and community-based services and sup-
ports. State plans for comprehensive coordinated care
for children should be developed. Financial and other
resources should be provided to support the start-up or
retooling costs for such services. In addition, a model
benefit design that includes a comprehensive array of
treatments, services, and supports and, when available,
promotes the use of evidence-based interventions should
be developed and widely disseminated.
The subcommittee recognized that achieving its vision
of children’s mental health would require going beyond the
mental health system. Despite growing awareness and at-
tention to mental health issues, children remain an under-
served population, with most children in need receiving no
services in the specialty mental health sector (Ringel &
Sturm, 2001). Recent data suggest that when children do
receive mental health services, they frequently receive
them in non-mental-health systems, such as the education,
primary care, juvenile justice, and child welfare systems. In
these other child-serving systems, however, high levels of
September 2005 ● American Psychologist
unmet need occur. For example, in a study of children in
detention in the Chicago juvenile justice system, Teplin,
Abram, McClelland, Dulcan, and Mericle (2002) found a
prevalence rate for mental health disorders of 66.3%, and
Cocozza and Skowyra (2000) found a prevalence rate for
serious mental disorders, often co-occurring with substance
abuse disorders, in the juvenile justice system of at least
20%. The further youths penetrate into the juvenile justice
system, the higher the rates of mental disorder (Friedman &
Simmons, in press; Lyons, Baerger, Quigley, & Griffin,
2001); however, only a fraction of youths in need receive
mental health treatment. Similarly, children in the child
welfare system have higher rates of prevalence for emo-
tional disorders than do the general population, but they
often do not receive needed care (Claussen, Landsverk,
Ganger, Chadwick & Litrownik, 1998; Garland et al.,
2001). These children confront ongoing challenges arising
from multiple risk factors such as poverty, violence, home-
lessness, maltreatment, exposure to alcohol or drugs, and
the emotional trauma of separation from families and living
in an unpredictable and unstable environment (McCarthy &
Woolverton, 2001).
To promote a vision of home- and community-based
care, mental health providers need to go where the children
are and where children are at risk of being removed from
their homes and communities. For example, given the high
prevalence rate of mental health problems and the high rate
of unmet need in the juvenile justice and child welfare
systems, mental health screening of children should be
implemented upon their entry into these systems. When
mental health problems are identified, appropriate services
and supports should be provided to enable these children to
remain in their home communities while making use of
empirically supported interventions such as treatment fos-
ter care or developmentally targeted diversion programs.
Screening should also occur in pediatric care and in pop-
ulations with known high risk, such as the Medicaid pop-
ulation. Such screening should utilize instruments and ap-
proaches that are well developed; that are sensitive to
racial, ethnic, linguistic, and cultural differences; and that
respect the privacy of the child and the family.
2. Developing Family Partnerships and
Family Support
Although a strong family movement is evolving, true
partnerships between families and professionals have yet
to be achieved. Partnerships with families are needed
both at the service delivery level with respect to their
own children and at the system level in terms of poli-
cymaking, planning, and refining of service systems.
When emotional disorders become apparent in their chil-
dren, parents are often beset by confusion, anxiety, and
fear; they do not have the information they need to
recognize and understand mental health problems or to
locate appropriate, effective services (Friesen & Huff,
1996). As they begin to seek services for the often-
complex needs of their children, assuming new roles as
advocates and case managers, family caregivers encoun-
ter many barriers to locating, accessing, and paying for
619
appropriate services. Ironically, our policy and program-
matic commitment to important values—that children
should live at home and in their communities— has
contributed to the pressures and demands placed on
families. In order to keep their children at home, these
families bear responsibilities previously assumed by
psychiatric treatment centers or other specialized out-of-
home treatment settings, including 24/7 continuous care
and supervision and dealing with extremely difficult
behaviors while arranging for and coordinating appro-
priate treatment, educational, and recreational opportu-
nities for their children. Some parents must rearrange
their work lives to accommodate their children’s needs,
cutting back on work hours, seeking more flexible work-
places, or quitting work altogether (Rosenzweig, Bren-
nan, & Ogilvie, 2002).
New roles are emerging for families that involve them
as partners in intervention, treatment, research, and evalu-
ation; in planning and policy; in co-teaching in universities;
and in quality improvement (McCammon, Spencer, &
Friesen, 2001; Sabin & Daniels, 1999). When the natural
family is not involved, efforts are needed to reach out to
engage and support the surrogate or substitute family or
other caregivers (Stroul & Friedman, 1996). A recent study
of sustainability of innovative systems of care for children
pointed to family involvement and strong family support
organizations as critical components in sustaining this ser-
vice approach beyond the period of grant funding (Stroul,
2004).
Given the challenges faced by families of children
with emotional disorders and the research documenting the
positive impact of their involvement, policies are needed to
strengthen families. This can be done by (a) fostering their
participation as partners in services both for their own
children and at the system level in the design, implemen-
tation, and evaluation of services and supports; (b) provid-
ing information and a constellation of formal and informal
“family support services” (such as education and training,
peer support, home aides, and respite care); (c) eliminating
the need to relinquish custody in order to receive necessary
care; and (d) enhancing the capacity of family organiza-
tions to provide information, support, and advocacy. These
policies should be supported by expanding funding to fam-
ily organizations and providing coverage for family support
services in public and private insurance. These recommen-
dations are consistent with those of the President’s New
Freedom Commission on Mental Health (2003), which
says that mental health care should be consumer and family
driven and that
in a consumer- and family driven system, consumers choose their
own programs and the providers that will help them most . . . care
is consumer-centered, with providers working in full partnership
with the consumers they serve to develop individualized plans of
care. Individualized plans of care help overcome the problems
that result from fragmented or uncoordinated services and sys-
tems . . . increasing choice protects individuals and encourages
quality. (p. 28)
620
3. Providing Culturally Competent Care and
Reducing Unmet Need and Disparities in
Access to Services
The problem of unmet need is particularly severe for chil-
dren from racially and ethnically diverse backgrounds. As
former Surgeon General Satcher noted, “It is essential that
our Nation continues on the road toward eliminating racial
and ethnic disparities in the accessibility, availability, and
quality of mental health services” (U.S. Department of
Health and Human Services, 2001, p. 9). Within the chil-
dren’s mental health field, there has been a major effort to
promote the development of culturally competent services
and systems (Cross, Bazron, Dennis, & Isaacs, 1989; Her-
nandez & Isaacs, 1998); however, although progress has
been made, as pointed out by the Surgeon General’s report
on Mental Health: Culture, Race and Ethnicity, there is still
a long way to go to achieve equity in access, quality, and
outcomes for people of color (U.S. Department of Health
and Human Services, 2001). For example, children of color
tend to receive more mental health services in restrictive
and coercive settings, such as juvenile justice and child
welfare systems, than in schools or mental health settings
(Alegrı́a, 2000). African American youths receive less
treatment in schools and more treatment in restrictive res-
idential treatment centers (Firestone, 1990). African Amer-
ican and Latino children have the highest rates of unmet
need (Ringel & Sturm, 2001), and although Black and
Latino youths are identified and referred from primary care
at the same rates as youths in the general population, they
are less likely to receive specialty mental health services or
medications (Kelleher, 2000). Latino and Asian adolescent
girls have among the highest rates of depression and more
barriers to care (Commonwealth Fund, 1998). Many fam-
ilies, particularly Latino families, speak limited English,
which creates an extra barrier to effective care and a need
as well for linguistic competence in mental health and
related systems.
Many of the barriers that deter communities of color
from accessing services pertain to all populations: fragmen-
tation of services, lack of availability, cost, and stigma.
However, there are additional barriers affecting families of
color, such as mistrust and fear of treatment, different
cultural conceptualizations of mental health and illness,
different approaches to help seeking, language and com-
munication differences, and racism and discrimination at
both the personal and institutional levels (Huang, 2002).
Given the number of different racial and ethnic groups in
this country, and the heterogeneity within each group, there
is no simple solution to this problem. It is essential, how-
ever, that strategic plans addressing these disparities be
developed and implemented and that they be based on the
voices, views, and recommendations of representatives and
families from diverse racial and ethnic groups. Thus, fed-
eral, state, and local agencies should work with national
and local ethnic and racial minority leaders, organizations,
families, and consumers to identify and remove structural,
linguistic, cultural, and financial barriers and to improve
access to quality care. These efforts should target infra-
September 2005 ● American Psychologist
structure, management, and capacity and address some of
the following key needs: consistent racial/ethnic data col-
lection; effective evaluation of disparities and reductions in
programs; minimum standards for culturally and linguisti-
cally competent behavioral health services; locally deter-
mined benchmarks and indicators for culturally competent
care; reimbursement policies for culturally based interven-
tions and alternative care; and greater diversity within the
workforce that reflects the populations being served.
4. Individualizing Care
Research on children with emotional disorders has clearly
demonstrated that they are a diverse group in terms of
diagnostic characteristics, strengths and needs, level of
functioning, family strengths and issues, co-occurring con-
ditions, values and beliefs, and involvement with service
systems (Angold, Costello, & Erkanli, 1999; Friedman et
al., 1996; McGonaughy & Skiba, 1993; Silver et al., 1992).
It is in response to this diversity that a strong focus on the
development of individualized, culturally competent ser-
vice plans has developed in the children’s mental health
field (Behar, 1986; Goldman, 1999; VanDenBerg, 1999).
Such an approach, often referred to as the “wraparound
process” (VanDenBerg, 1999), seeks to build a compre-
hensive treatment plan based on the special strengths,
needs, and goals of each child and family and utilizing both
formal services and resources in the child’s and the fami-
ly’s natural support system. Research has documented in-
dividualized care as promising (Burns, Hoagwood, &
Mrazek, 1999), and the application of this model in practice
has grown rapidly around the country. The President’s New
Freedom Commission on Mental Health (2003) specifically
highlighted Wraparound Milwaukee as an example of a
highly individualized care approach to serving youths with
serious emotional disturbances (Kamradt, 2000). This ur-
ban program, which uses a case rate model of funding to
maximize flexibility, includes an extensive range of ser-
vices, a large provider network, and strong family partici-
pation and choice; it has reduced delinquency, improved
school attendance, improved clinical outcomes, reduced
hospitalizations, and reduced costs of care (Kamradt,
2000). Building on the promising findings of this approach,
and consistent with the recommendations of the overall
President’s New Freedom Commission on Mental Health
(2003), states and communities should ensure that each
child with a serious emotional disorder has an individual-
ized, single plan of care that addresses the child and the
family’s needs across life domains and incorporates ser-
vices and supports from all needed agencies and systems.
The family should assume a key partnership role with
providers in the development, implementation, and moni-
toring of the plan.
5. Implementing Evidence-Based Practices
Many states and communities continue to offer traditional
services as opposed to community-based care, have diffi-
culty adopting evidence-based services and supports, and
fail to incorporate knowledge from biopsychosocial re-
search into services and policy. In terms of community-
September 2005 ● American Psychologist
based interventions, there is an accumulating evidence base
in the field of children’s mental health; however, there is a
lag in the dissemination of evidence-based practices and in
their incorporation into clinical practice. Further, despite
the progress that has been made, many interventions have
not as yet been tested on the highly diverse population of
children with multiple needs, problems, and co-occurring
conditions who typically are served within public systems
(Friedman, 2001; Friedman & Hernandez, 2002; Shirk,
2001).
An important step toward improving the effectiveness
of services and supports involves the development, dissem-
ination, and implementation of interventions that are sup-
ported by scientific evidence. The availability of such in-
terventions provides families with the ability to make
informed choices about the services they would like to
receive, provides practitioners with the opportunity to learn
new and improved approaches, and, most important, has
the potential to significantly improve outcomes. The chal-
lenge is promoting not just the dissemination of these
interventions in an effective manner but also their imple-
mentation with fidelity—moving “science to services.” At
the same time, it is important to recognize that children and
their families are highly heterogeneous, with a diverse set
of strengths and needs. Evidence-based interventions are
not available for all problems and needs and, even when
available, do not work uniformly with all families. Jensen
(2001) emphasized that it is essential, therefore, not to lose
sight of the importance of using the best clinical consensus
and experience in working collaboratively with families to
make decisions about services when an evidence base has
yet to be developed. It also is important (a) that there be
support for innovative efforts to develop new interventions
at the same time that evidence-based practices are being
disseminated, (b) to identify promising practices that are
emerging in communities around the country that may be
candidates for evaluation, and (c) to broaden the concept of
evidence-based interventions to include evidence-based
processes that may cut across a number of clinical inter-
ventions, such as relationship building or skill building or
the individualized, wraparound approach to service deliv-
ery (Chorpita, 2003; Friedman, 2003; see Weisz, Sandler,
Durlak, & Anton, 2005).
6. Coordinating Services, Responsibility, and
Funding to Reduce Fragmentation
The current mental health system is a maze that defies easy
description. Responsibility is spread over a complex patch-
work of programs operated by federal, state, and local
governments and the private sector that provide and pay for
treatment, services, and supports, each with different man-
dates, missions, service settings, financing streams, eligi-
bility rules, and requirements. This fragmentation is com-
pounded exponentially for children because of the range of
additional child-serving systems responsible for children
with emotional and behavioral disorders. Child welfare,
public health, mental health, substance abuse, developmen-
tal disabilities, juvenile justice systems, and particularly the
schools are involved in the delivery and funding of mental
621
health services and other services to children; however,
these delivery systems are often sharply divided by differ-
ing policies, procedures, and philosophies (Knitzer & Yel-
ton, 1990; Wishmann, Kates, & Kaufmann, 2001). School,
child welfare, and juvenile justice systems provide and pay
for significant amounts of mental health services, often
more than the specialty mental health system, although
they are not specifically designed to be mental health
delivery systems (U.S. Public Health Service, 2000). The
confusion that results from the involvement of so many
agencies creates often insurmountable systemic barriers to
effective and comprehensive service delivery.
The focus on a multisector, multilevel approach to
system transformation has been identified as essential if
significant change is to take place in complex health and
mental health systems (Ferlie & Shortell, 2001; Ringeisen,
Henderson, & Hoagwood, 2003). In bridging the science,
policy, and practice fields, Masten (2003) pointed out that
“dynamic multisystem models of human learning, devel-
opment, and psychopathology are transforming sciences,
practices, and policies concerned with the health, success,
and well-being of children and the adult citizens of society
they will become” (p. 172).
Further complication at the policy, system, and prac-
tice levels exists because some children and families are
covered through employer-based commercial insurance
programs that, in the absence of parity with physical health
coverage, typically cover brief, short-term services and a
narrow, fairly traditional range of outpatient and inpatient
care. Families with private insurance who exhaust their
coverage or who need services not available through their
private carriers must turn to the public systems for services.
In some states, families must go through the painful pro-
cess of relinquishing custody of their children to become
eligible for intensive mental health services in public sys-
tems (Giliberti & Schulzinger, 2000).
Coordinating the delivery and financing of services to
support a vision of a comprehensive community-based
system of care is a formidable task. As a first step, each
state government should plan and implement a comprehen-
sive, cross-agency plan for prevention, early intervention
and treatment for children’s mental health, clarifying re-
sponsibility among the child-serving systems. Collabora-
tive efforts to deliver community-based services and sup-
ports, revision of rules that impede service delivery, and
alignment of financing to support prevention and treatment
should be integral aspects of this effort.
A critical component of such planning should be re-
vising funding policies related to children’s mental health
to support a full array of home- and community-based
services and supports. Effective efforts have been deployed
by various states and local communities to draw on multi-
ple funding streams and create innovative financing sys-
tems (Bruns, Burchard, & Yoe, 1995; Kamradt, 2000;
VanDenBerg & Grealish, 1996). For example, Hayes
(2002) described financing strategies through which states
and communities can make better use of resources and
improve child and family outcomes by (a) shifting funds
from higher cost (e.g., out-of-state residential care) to
622
lower cost programs and services (e.g., intensive in-home
services) and reinvesting “saved” funds in new or alterna-
tive supports and services that are equally, if not more,
effective; (b) maximizing federal and state revenues by
using programs that provide funding contingent on state,
local, or private matches (e.g., Medicaid’s Early and Peri-
odic Screening, Diagnosis, and Treatment program); (c)
creating more flexibility by pooling funds from several
agencies into a single unified funding stream; or (d) creat-
ing new dedicated revenue streams (e.g., creating a chil-
dren’s trust fund from a state’s share of a national tobacco
settlement). In the current climate of limited resources and
major shortfalls in state budgets, maximizing the benefits
from available funds requires flexibility at the federal and
state levels, combining resources in innovative ways, and
reshaping the way dollars already in the system are spent
(Koyanagi, Boudreaux, & Lind, 2003).
7. Increasing Prevention, Early Identification,
and Early Intervention
The Surgeon General’s report on mental health has set the
stage for the incorporation of prevention, early identifica-
tion, and early intervention services into a spectrum of
mental health interventions (U.S. Department of Health and
Human Services,1999). It points out, for example, “that the
field of prevention has now developed to the point that
reduction of risk, prevention of onset, and early interven-
tion are realistic possibilities” (pp. 132–133). Other articles
in this issue make the same point (see Tolan & Dodge,
2005; Weisz et al., 2005).
Yet there are significant barriers that have hampered
efforts to translate what is known about prevention and
early intervention into action. In a paper prepared for the
Subcommittee on Children and Families, Mrazek (2002)
identified five significant barriers: (a) There is no clear
infrastructure for delivery of preventive and early interven-
tion services that by their very nature cut across agencies,
disciplines, service delivery systems, and outcome do-
mains; (b) there are few training opportunities for families,
teachers, health practitioners, and mental health clinicians
to learn how to reliably screen and assess children, how to
connect them and their families with services, and how to
deliver effective services; (c) resources for effective pre-
vention and/or early intervention services, like other parts
of the child mental health system, are limited, fragmented,
and categorical and are a low priority in overstretched
systems; (d) public advocacy by families for prevention
and early intervention services has been lacking; and (e) the
relevance of specific interventions for different cultural and
socioeconomic groups has not been adequately tested.
In a landmark publication on prevention in mental
health, the Institute of Medicine (1994), presented a model
that distinguishes between universal prevention interven-
tions, which are targeted at an entire population group,
selective preventive interventions, which are targeted to
individuals or a subgroup whose risk of developing mental
or behavioral disorders is significantly higher than average,
and indicated preventive interventions, which are directed
September 2005 ● American Psychologist
at individuals who are already showing signs or symptoms
that foreshadow a mental or behavioral disorder.
An important starting point in changing the present
status in this country and in increasing the focus on pre-
vention, early identification, and early intervention would
be the establishment of an infrastructure at the federal and
state levels, and in every community in America, to plan,
coordinate, and support the development and implementa-
tion of preventive, early identification, and early interven-
tion services. Planning and resources have largely been
devoted to youths with the most serious and complex
disorders, with little attention or funding devoted to the
early identification and screening of mental health prob-
lems in multiple settings and prompt intervention or to the
promotion of positive mental health and the prevention of
mental health disorders. Prevention, early identification,
and intervention (i.e., intervening early in the course of a
mental health problem) offer the best opportunity to max-
imize the likelihood of positive outcomes, yet many chil-
dren and families must wait until their problems have
reached serious or crisis proportions before they can re-
ceive help.
8. Strengthening Early Childhood
Intervention
Despite research that shows a disturbingly high prevalence
of emotional and behavioral disorders among young chil-
dren (Lavigne et al.,1996), this population has been ne-
glected. Emerging neuroscience reveals the impact of en-
vironmental factors on brain development and early
psychosocial behavior and makes the compelling argument
that early detection, assessment, and treatment can prevent
mental health problems from worsening (Shonkoff & Phil-
lips, 2000). There are increasing data on the effectiveness
of mental health services and supports for young children
that focus on the parent (Olds et al., 1998), the child
(Cowen et al., 1996) or the parent– child interaction (Ey-
berg et al., 2001). Group-based (Greenberg, Domitrovich,
& Bumbarger, 2001) and multicomponent interventions
(Ramey & Ramey, 1998) also have empirical support, and
mental health consultation to early childhood programs has
shown promising results (Donahue, 2002).
A national effort focusing on the mental health needs
of young children and their families should be imple-
mented. This effort should include (a) educating parents
and providers about the importance of the first years of a
child’s life in developing a foundation for healthy social
and emotional development; (b) creating greater awareness
about mental health problems in young children; (c) im-
plementing a comprehensive approach to early screening,
assessment, and intervention in natural early childhood
settings; (d) educating and training professionals in effec-
tive intervention and treatment approaches for young chil-
dren and their families; and (e) eliminating disincentives
and barriers, particularly in diagnostic and financing sys-
tems, to serving this population. Such an emphasis on early
childhood intervention—not synonymous with early inter-
vention as discussed in the previous section—is but one
September 2005 ● American Psychologist
part of a broader public health approach to health promo-
tion and problem prevention.
9. Expanding Mental Health Services in
Schools
Every day, over 52 million children attend 114,000 schools
in the United States, and when combined with the 6 million
adults working in these schools, almost one fifth of our
population are to be found in schools on any given week-
day (Jamieson, Curry, & Martinez, 2001). Given the scarce
resources in mental health, it makes sense to link with
schools. Schools are accessible community settings that are
comfortable for most youths and their families. Many of
the barriers in traditional mental health settings, such as
stigma, noncompliance, and inadequate access are not as
great in school-based settings. School-based providers are
able to observe students in a variety of settings, including
the classroom, the lunchroom, and the playground, and
they are able to facilitate partnerships among school per-
sonnel, families, and mental health providers, who can
come together to support the child (Adelsheim, 2003).
Because children receive more services through
schools than through any other public system, strengthen-
ing mental health services in schools offers a strategic
opportunity to provide effective services to many children
in need (Hoagwood & Erwin, 1997) and to prevent the
development of problems. The mission of schools is to
educate all students, and in order to ensure academic
achievement, schools also must attend to the health and
emotional well-being of their students. In a paper prepared
for the President’s New Freedom Commission on Mental
Health, Adelman and Taylor (2002) pointed out that “the
fundamental policy problem related to mental health in
schools is that existing student support services and school
health programs do not have high status in the educational
hierarchy and in current health and education policy initi-
atives . . . since the activity is not seen as essential, the
programs and staff are marginalized” (p. 1).
Nationally, children with emotional and behavioral
disorders in special education have the highest dropout
rates (50.6%), and the next to lowest rate of graduating
with a standard diploma (41.9%), of any group of children
with disabilities in schools (U.S. Department of Education,
2001). The severity and diversity of needs of this popula-
tion have most recently been pointed out in two longitudi-
nal studies funded by the U.S. Department of Education,
the Special Education Elementary Longitudinal Study and
the National Longitudinal Transition Study 2 (Wagner,
2004).
Consistent with recently passed legislation (No Child
Left Behind Act, 2001), the mental health needs of youths
in the education system should be more fully recognized
and addressed, and effective approaches for providing
mental health services and supports to youths in schools
should be developed, evaluated, and disseminated. There is
increasing evidence that school mental health programs
improve educational outcomes by decreasing absences, de-
creasing discipline referrals, and improving test scores
(Jennings, Pearson, & Harris, 2000). The Wingspread
623
Group has recently reviewed the literature on school con-
nectedness, defined as the belief by students that adults in
the school care about their learning and about them as
students, and has found that school connectedness is pos-
itively related to academic, behavioral, and social success
in school (Blum & Libbey, 2004; McNeely, Nonnemaker,
& Blum, 2002). A school-based wraparound approach has
been effective in significantly reducing restrictive out-of-
school and out-of-home placements (Eber, Osuch, & Red-
ditt, 1996). Positive behavior support has become one of
the most frequently used and promising interventions
within schools, focusing part of its work on the entire
school, part on children at risk, and part on children with
significant problems that have already been identified (Hor-
ner & Carr, 1997; Sugai et al., 2000). Thus, a continuum of
mental health services should be provided in schools, in-
cluding prevention, early identification, early intervention,
and treatment. Further, mental health services should be
provided through school health centers, and funding for
school-based mental health services should be included in
federally funded health, mental health, and education pro-
grams at the same time as efforts are made to strengthen
school climate and connectedness. A coordinated effort at
the state level among health, mental health, and education
agencies would support better integration of services. The
Individuals With Disabilities Education Act (Individuals
with Disabilities Education Act Amendments, 1997) has
been an important vehicle for addressing the needs of
children with emotional disorders. Revisions and appropri-
ate technical assistance should be undertaken to assist
states and communities to implement the Individuals With
Disabilities Education Act more effectively to ensure that
all children with emotional and behavioral disorders re-
ceive the assessments, services, and supports that will
enable them to be successful in school.
10. Strengthening Accountability and Quality
Improvement
The President’s New Freedom Commission on Mental
Health built on the framework presented in the Institute of
Medicine (2001) report Crossing the Quality Chasm: A
New Health System for the 21st Century. The issues put
forth in this report resonated with the concerns of the
Subcommittee on Children and Families. Children’s mental
health services and systems have suffered from a lack of
reliable, practical, policy-relevant data and accountability
mechanisms to guide decision making and quality improve-
ment at both the system and service delivery levels. A
major impediment to accountability in the multiple systems
and agencies that serve children and families, and a starting
point for accountability systems, has been a general failure
to develop theories of change that clearly define the pop-
ulation of concern, goals, intended outcomes, and strategies
for achieving the intended outcomes (Hernandez &
Hodges, 2001b). In addition, data systems at state and local
levels frequently are inadequate to support decision making
and are poorly integrated across child-serving systems.
Ongoing data collection is essential to inform administra-
tors and other stakeholders in the system about how well
624
the system is meeting its goals and to aid in decision
making and resource allocation.
At the service delivery level, consistent with the views
of the President’s New Freedom Commission on Mental
Health (2003), agreement is emerging on emphasizing
functional outcomes for children with mental health prob-
lems—they should be at home, be living productively in
their communities, be in school, be out of trouble, and have
improved (or in some cases, stable) mental health status
(Hernandez & Hodges, 2001a; Osher, 1998; Rugs &
Kutash, 1994). However, communities have not developed
clear theories of change with specific outcomes and indi-
cators to assess progress, and this lack has impeded efforts
to make services and systems more accountable and to use
data-based decision making as a way to continually im-
prove the system. Although child- and family-level out-
come data are an important part of accountability and
continuous quality improvement, it must be recognized that
unless data are also collected on who the system is serving,
and how it is serving them, it will be difficult to interpret
such outcome data. Outcome data that indicate better or
worse outcomes than expected, for example, may reflect
the fact that the population being served is not the popu-
lation that the system intends to serve or that the services
that are being provided are not the services that the system
intends to provide.
The development of strong internal accountability and
continuous quality improvement procedures requires (a)
good information systems (within the guidelines of the
Health Insurance Portability and Accountability Act
[1996]), (b) clearly conceptualized theories of change, (c)
reliable measures, (d) attention to family concerns regard-
ing privacy and confidentiality, (e) feedback systems that
incorporate the data to review progress and determine if
changes are needed, and (f) collaboration from numerous
stakeholders in defining goals and selecting relevant mea-
surement strategies. State and local governments could
benefit greatly from leadership, information, and technical
assistance provided by the federal government on how to
best implement such procedures to improve accountability
and quality improvement in mental health service delivery
to children and their families.
Building the Workforce: Implications
for Psychologists
An important challenge for the field of psychology is
creating an adequate workforce, with both the numbers of
professionals and the values and competencies needed, to
accompany a comprehensive and transformed approach to
children’s mental health. Though curricula are slow to
change, the nature of preservice training must be shifted to
the new philosophy underlying service delivery, which is
based on the inclusion of families as partners in service
delivery, the shift from an almost exclusive focus on office
and clinic-based practice to a greater emphasis on an indi-
vidualized home- and community-based service approach,
and the role of interdisciplinary collaboration in service
planning and intervention. Training must include strengths-
September 2005 ● American Psychologist
based approaches, individualized care, culturally compe-
tent care, and the clinical advances embedded in evidence-
based and promising practices (Friedman, 1993; Morris &
Hanley, 2001). This approach to training is consistent with
several reports prepared by groups of psychologists (Amer-
ican Psychological Association, 1998; Roberts et al., 1998).
For psychologists working with children and families,
a transformed service delivery system would offer ex-
panded roles and approaches to care. In order to fulfill these
roles, psychologists would need training that goes beyond
the clinical treatment of disorders and develops their ability
to harness the strengths of the child, to partner with fami-
lies in treatment planning and decision making, and to
consult and collaborate with providers in other child-serv-
ing systems. Given the stalled movement toward parity and
the shrinking funds in the specialty mental health system,
psychologists must be prepared to work in non-mental-
health settings, such as schools, juvenile justice, primary
care, and child welfare, where there is a high prevalence of
mental health problems. Training in evidence-based prac-
tices is increasingly important, as consumers, families, and
payers are committed to getting “services that work” and
that are based on science or best clinical consensus. With
the growing disparities in access, quality, and outcomes of
services for diverse ethnic and racial populations, psychol-
ogists must become better trained to work with culturally
diverse children and their families. Training must enhance
cultural competence for all psychologists, and the field
must create specific incentives and strategies to recruit and
train culturally and linguistically diverse practitioners. A
great need and great opportunity exist as well for psychol-
ogists who are trained to work effectively with preschool
children and their families.
In a transformed system for children’s mental health,
research roles for psychologists would expand with the
movement toward evidence-based practices and the need to
build the science base for promising field-initiated ap-
proaches. Potential exists for psychologists to advance the
science of dissemination and to shed light on the challenges
of changing organizational and clinical practice to imple-
ment emerging evidence-based interventions. There is a
significant need for ongoing services and systems research
and for new strategies to examine the effectiveness of
combinations of services and supports. As the field increas-
ingly understands the importance of early intervention and
screening in multiple settings, psychologists should use
their expertise in test construction and psychometrics to
participate in the development of screening tools and in-
struments that would be effective in a wide range of
settings.
Finally, the clinical, organizational, and research
training and experience of psychologists prime them well
for the children’s mental health policy arena. Transforming
mental health care for children must be guided by sound,
research-based policy that promotes both empirically sup-
ported clinical interventions and the effective organization
of community-based systems of care and their accompany-
ing service delivery mechanisms. It is this combination that
September 2005 ● American Psychologist
is most likely to yield positive results for children and their
families.
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