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Class 9_transforming MH Care_systems of Care

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Transforming Mental Health Care for Children andTheir Families
Larke Huang
American Institutes for Research
Beth Stroul
Management and Training Innovations, Inc.
Robert Friedman
University of South Florida
Patricia Mrazek 
Rochester, Minnesota
Barbara Friesen
Portland State University
Sheila Pires
Human Service Collaborative
Steve Mayberg
California Department of Mental Health In April 2002, the President’s New Freedom Commissionon Mental Health was created by executive order to studythe mental health care delivery system in our nation and tomake recommendations for improvements so that individ-uals with serious mental disorders can live, work, learn,and fully participate in their homes and communities. In itsreport,
“Achieving the Promise: Transforming MentalHealth Care in America,”
the commission provided strate-gies to address critical infrastructure, practice, and re-search issues. This article focuses on the work of thecommission’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 behavioralhealth disorders. Training, research, practice, and policyimplications for psychologists are discussed.Keywords:
children’s mental health, systems of care, trans-formation
ental health problems in children and adoles-cents have created a “health crisis” (Satcher,2000, p. 1) in this country. These problemsaffect a growing number of youths, they impact thesechildren and their families in all spheres of their lives, andtheir consequences are costly and often tragic. Recentstudies indicate an alarmingly high prevalence rate, withapproximately 1 in 5 children having a diagnosable mentaldisorder and 1 in 10 youths having a serious emotional orbehavioral disorder that is severe enough to cause substan-tial impairment in functioning at home, at school, or in thecommunity (Friedman, Katz-Leavy, Manderscheid, &Sondheimer, 1996). The National Institute of MentalHealth’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 soseriously” (p. 1).In conjunction with this prevalence rate, there is anextremely high level of unmet need. It is estimated thatabout 75% of children with emotional and behavioral dis-orders do not receive specialty mental health services (Rin-gel & Sturm, 2001). Former Surgeon General DavidSatcher, at his National Conference on Children’s MentalHealth, stated that “growing numbers of children are suf-fering needlessly because their emotional, behavioral, anddevelopmental needs are not being met by those veryinstitutions 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. Thisarticle highlights the strategies put forth by the Subcom-mittee on Children and Families of the President’s NewFreedom Commission on Mental Health to transform men-tal health care for children and families.
Although the mandate of the commission focused onintervention for children with serious emotional disorders,the subcommittee expanded this mandate to include inter-vention for children at risk for mental disorders as well asprevention of mental health problems and promotion of 
Larke Huang, American Institutes for Research, Washington, DC; BethStroul, Management and Training Innovations, Inc., Fairfax, Virginia;Robert Friedman, Department of Child and Family Studies, Louis de laParte Florida Mental Health Institute, University of South Florida; PatriciaMrazek, Rochester, Minnesota; Barbara Friesen, Research and TrainingCenter on Family Support and Children’s Mental Health, Portland StateUniversity; 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 thePresident’s New Freedom Commission on Mental Health; the remainingauthors served as consultants to the commission in the area of children’smental health. This article is based on the findings and recommendationsof the Subcommittee on Children and Families.Correspondence concerning this article should be addressed to LarkeHuang, American Institutes for Research, 1000 Thomas Jefferson St.,NW, Washington, DC 20007. E-mail: lhuang@air.org
This article is not the official report of the Subcommittee onChildren and Families of the President’s New Freedom Commission onMental Health. The content of this article reflects the discussions of thesubcommittee and its expert consultants. It does not reflect the position of the President’s New Freedom Commission on Mental Health or anyagency of the United States Government.
615September 2005
American Psychologist
Copyright 2005 by the American Psychological Association 0003-066X/05/$12.00Vol. 60, No. 6, 615–627 DOI: 10.1037/0003-066X.60.6.615
positive mental health for all children. The focus of thisarticle is on the overall system for preventing mental healthproblems in children and on restoring those children withsuch challenges to as high a level of functioning as possi-ble. The focus on the system incorporates an examinationof both the services that are provided to children and theirfamilies and the overall structure and policies that aredesigned to facilitate the delivery of effective services andsupports. This overall structure includes such features asthe manner in which the system is organized and financed;the values, principles, and data on which it is based; thenature of collaborations across service sectors, betweenfamilies and professionals, and across levels of govern-ment; and planning, governance, quality improvement, andworkforce development procedures.
Reform Efforts in Children’s MentalHealth Policy
The inadequacy of the children’s mental health systemhas been repeatedly documented. The Joint Commission onthe Mental Health of Children (1969) concluded that onlya fraction of children in need were actually receiving men-tal health services and that the services that were providedwere largely ineffective. Subsequent policy studies docu-mented similar conclusions, indicating (a) that childrenwere not getting needed mental health services; (b) thatthose served were often in excessively restrictive settings;(c) that services were limited to outpatient, inpatient, andresidential treatment, with few intermediate-care, commu-nity-based options available; and (d) that the coordinationamong child-serving systems responsible for mental healthneeds was weak (Knitzer, 1982; President’s Commissionon Mental Health, 1978; U.S. Congress, Office of Tech-nology Assessment, 1986). These various reports served asa catalyst for federal attention to children’s mental health.The Child and Adolescent Service System Program(CASSP), was launched by the National Institute of MentalHealth in 1984 with the objective of helping states andcommunities 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, childwelfare, and juvenile justice (called children with “seriousemotional disturbances”). The CASSP explicitly promotedthe policy direction of identifying children with seriousemotional disturbances as the priority population, and be-fore long, most states designated this group as their prioritypopulation (Friedman, Kutash, & Duchnowski, 1996). Theintent of this focus was not to neglect or diminish theimportance of preventive efforts but to redirect publicmental health systems away from serving children withmild problems that did not significantly interfere with theirfunctioning and toward serving those who had severe prob-lems that interfered with their functioning and who were aparticular 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 aframework for reform (Stroul & Friedman, 1986, 1996). A
system of care
was defined as “a comprehensive spectrumof mental health and other services and supports organizedinto 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 andprinciples to guide service delivery to children and fami-lies. The core values specified that services should becommunity based, child centered and family focused, andculturally appropriate. Key principles specified that ser-vices should (a) be comprehensive, with a broad array of services and supports; (b) be individualized to each childand family; (c) be provided in the least restrictive, appro-priate setting; (d) be coordinated at both the system andservice 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 diversenature and multiple needs of children with serious emo-tional disturbances and their families.This system of care approach helped to seed otherfederal and foundation initiatives geared to developingmore comprehensive, integrated systems of community-based services and supports for children. The largest of these programs, the federal Comprehensive CommunityMental Health Services for Children and Their FamiliesProgram, authorized by Congress in 1992, has a currentbudget of approximately $100 million and to date hasprovided 92 grants to states, communities, territories, andIndian tribes and tribal organizations to improve systems of care to meet the needs of youths with emotional problemsand their families (U.S. Department of Health and HumanServices, 2002). All but two states have received a grant toeither the state or a local community within the state. Anational evaluation of this program shows a reduction inmental health problems and costly out-of-state residentialplacements and an increase in behavioral and emotionalstrengths. Residential stability, school attendance, andschool performance improved, and contacts with law en-forcement and substance use decreased (Center for MentalHealth Services, 2001).Despite progress in improving systems of care forchildren with emotional disorders and their families, recentexaminations 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 inunderstanding and treating mental disorders in children andsynthesized the evidence base for services. The goal of providing care for children with mental health needs intheir homes and communities was further supported in1999 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
decision forchildren with serious emotional disorders is consistent withthe system of care philosophy—avoiding out-of-homeplacements to the extent possible and returning children to616 September 2005
American Psychologist
their home communities in a timely way with appropriateservices 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 mentalhealth as a national priority and delineated action steps toorganize and coordinate services in the child’s cultural andcommunity context (U.S. Public Health Service, 2000).This movement toward comprehensive, community-basedcare culminated most recently in President Bush’s NewFreedom Initiative, announced in 2001, which includedproposals to eliminate barriers for people with disabilities.As part of this initiative, the President issued an executiveorder to create a presidential commission on mental healthwith a specific mandate to study the existing mental healthservice delivery system and make recommendations forimprovements that would enable adults with serious mentalillness and children with serious emotional disorders tolive, 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 Carein America.
The report presented recommendations that, inthe aggregate, would begin to change how mental healthcare is organized, financed, and delivered in order toachieve the goal of recovery and resilience and a thrivinglife in the community for those with serious mental healthproblems.
 A Vision for Children’s Mental Health
Given the complex needs of children with mental healthproblems, the President’s New Freedom Commission onMental Health created a Subcommittee on Children andFamilies. This subcommittee proceeded with the task of gathering information and reviewing testimony about thedeficits and strengths of the existing service system foryouths and their families. Testimony, reports, and researchstudies were reviewed from over 250 stakeholder groups,including youths and families, national and regional orga-nizations, provider associations and practitioners, clinicaland services researchers, and state and community-basedprogram directors. Site visits by the subcommittee weremade to innovative prevention and treatment programs thathad demonstrated positive outcomes. These included earlychildhood programs, school-based programs, community-based wraparound services, innovative juvenile court-based services, and comprehensive community mentalhealth programs serving ethnic and racially diverse youths.The subcommittee requested a content analysis of the over1,200 comments submitted to the commission through itsWeb site pertaining to children in order to further identifyissues and innovative strategies. The subcommittee workedwith experts in the field of children’s mental health toaddress the issues being identified. The subcommitteeworked for almost the entire year of the commission’sduration, analyzing and synthesizing this information, andthen crafted policy recommendations to begin the transfor-mation of care for children and families. Many of therecommendations of the subcommittee are reflectedthroughout the goals and recommendations of the finalreport of the President’s New Freedom Commission onMental Health (2003). A more extensive discussion of thesubcommittee’s work is presented in a background paperthat details 9 policy areas, 26 policy recommendations, and120 implementation options to advance children’s mentalhealth. This report is to be released by the Substance Abuseand Mental Health Services Administration, the agencycharged with implementing the President’s New FreedomCommission recommendations.The executive order creating the President’s NewFreedom Commission on Mental Health called for recom-mendations that would advance a community-based servicedelivery system built on efficiency and demonstrably ef-fective practices. The objectives and guiding principlesoutlined in the executive order aligned remarkably wellwith the values and operating principles of the systems of care approach being implemented in local communities andstates around the country as part of the federally legislatedComprehensive 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 fromkey stakeholders (including youths and families, policy-makers, researchers, and providers in specialty mentalhealth, school-based services, and other child-serving sys-tems), crafted a vision for children’s mental health. Thevision is based on a system of care approach and calls fora broad array of services and supports to be provided in thechild’s home, school, and community, in partnership withthe family and consistent with the culture, values, andpreferences of the child, the youth, and the family. Thevision goes beyond the focus on children with seriousemotional disturbances and presents a public health ap-proach to preventing mental health problems and creatingconditions that promote positive socioemotional health forall children. Implementing this vision begins with a set of values that reflect standards of care for children’s mentalhealth, as summarized in Table 1.
 Achieving the Vision: StrengtheningChildren’s Mental Health Services
This vision is consistent with the recommendations of theoverall report of the President’s New Freedom Commissionon Mental Health (2003). Achieving this vision will requirea significant transformation of the current service deliverysystem: its organization, financing, and clinical servicesand supports. The Subcommittee on Children and Familiesidentified 10 specific challenges that need to be addressedand possible strategies for addressing them. These 10 chal-lenges are discussed below as separate issues; however, thesubcommittee viewed all of them as being interrelated andpart 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 inservices other than traditional office-based outpatient ther-617September 2005
American Psychologist

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