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Larke Huang Beth Stroul Robert Friedman Patricia Mrazek Barbara Friesen Sheila Pires Steve Mayberg 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
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 individuals 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 strategies to address critical infrastructure, practice, and research issues. This article focuses on the work of the commission’s Subcommittee on Children and Families, describing its vision for mental health service delivery for children and providing suggestions for strengthening community-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, transformation
Satcher, at his National Conference on Children’s Mental Health, stated that “growing numbers of children are suffering 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, systematic approach to this crisis in children’s mental health. This article highlights the strategies put forth by the Subcommittee on Children and Families of the President’s New Freedom Commission on Mental Health to transform mental 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 intervention 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 Subcommittee 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: email@example.com
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.
ental health problems in children and adolescents 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 substantial 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, Workgroup on Child and Adolescent Mental Health (2001) concluded 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 disorders do not receive specialty mental health services (Ringel & 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
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 possible. 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 government; 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 mental health services and that the services that were provided were largely ineffective. Subsequent policy studies documented 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, community-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 Technology 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 complex needs who were involved with multiple service sectors, 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 before 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 problems that interfered with their functioning and who were a particular challenge and expense to service systems. An early accomplishment of the CASSP was the reﬁning 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 changing needs of children and their families” (Stroul & Friedman, 1986, p. 3). It included a set of core values and principles to guide service delivery to children and families. The core values speciﬁed that services should be community based, child centered and family focused, and culturally appropriate. Key principles speciﬁed that services 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, appropriate setting; (d) be coordinated at both the system and service delivery levels; (e) include early intervention efforts; 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 emotional 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 communitybased 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 enforcement 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 improvement and that represent signiﬁcant challenges. The landmark 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 decision in Olmstead v. L. C., which speciﬁed that the institutionalization of persons with disabilities who, given appropriate 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 conference on children’s mental health that resulted in a national 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 Freedom 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 organizations, 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, communitybased wraparound services, innovative juvenile courtbased 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 transformation 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 recommendations that would advance a community-based service delivery system built on efﬁciency and demonstrably effective 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 Program for Children and Their Families. Given this congruence, the subcommittee drew on the strategies and innovations from this program and, in conjunction with input from key stakeholders (including youths and families, policymakers, researchers, and providers in specialty mental health, school-based services, and other child-serving systems), 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 approach 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 challenges 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 ther617
Table 1 Vision for Children’s Mental Health Services
Value Standard of Care
1. Comprehensive home- and community-based services and supports
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 adultserving 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.
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
apy and residential or inpatient care. These include services such as intensive home-based care, day treatment, mentoring, respite care, wraparound care, and therapeutic foster care. Comprehensive, individualized, and culturally com618
petent treatment plans for children with serious and complex needs and their families are frequently developed now by multidisciplinary teams including families, are based on partnerships between parents and professionals, and examSeptember 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 outof-community treatment options and overemphasis on traditional psychotherapeutic interventions still exist. At the same time, the range of individualized and culturally competent 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 community-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 communitybased services and supports, the capacity to provide many of these services is lacking, and investments in service capacity development have been insufﬁcient to ensure access to a broad array of services and supports in communities (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 includes a full range of both nonresidential and residential services and supports, going well beyond the traditional ofﬁce-based outpatient, inpatient, and residential treatment 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 supports. 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 attention to mental health issues, children remain an underserved 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 emotional 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, homelessness, 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 foster care or developmentally targeted diversion programs. Screening should also occur in pediatric care and in populations with known high risk, such as the Medicaid population. Such screening should utilize instruments and approaches 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 policymaking, planning, and reﬁning of service systems. When emotional disorders become apparent in their children, 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 oftencomplex needs of their children, assuming new roles as advocates and case managers, family caregivers encounter many barriers to locating, accessing, and paying for 619
appropriate services. Ironically, our policy and programmatic 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-ofhome treatment settings, including 24/7 continuous care and supervision and dealing with extremely difﬁcult behaviors while arranging for and coordinating appropriate treatment, educational, and recreational opportunities for their children. Some parents must rearrange their work lives to accommodate their children’s needs, cutting back on work hours, seeking more ﬂexible workplaces, or quitting work altogether (Rosenzweig, Brennan, & Ogilvie, 2002). New roles are emerging for families that involve them as partners in intervention, treatment, research, and evaluation; 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 service 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, implementation, and evaluation of services and supports; (b) providing 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 organizations to provide information, support, and advocacy. These policies should be supported by expanding funding to family organizations and providing coverage for family support services in public and private insurance. These recommendations 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 systems . . . increasing choice protects individuals and encourages quality. (p. 28)
3. Providing Culturally Competent Care and Reducing Unmet Need and Disparities in Access to Services The problem of unmet need is particularly severe for children 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 children’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; Hernandez & 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 (Alegrıa, 2000). African American youths receive less ´ treatment in schools and more treatment in restrictive residential treatment centers (Firestone, 1990). African American 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 families, 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: fragmentation 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 communication 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, however, 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, federal, 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 infraSeptember 2005 ● American Psychologist
structure, management, and capacity and address some of the following key needs: consistent racial/ethnic data collection; effective evaluation of disparities and reductions in programs; minimum standards for culturally and linguistically competent behavioral health services; locally determined benchmarks and indicators for culturally competent care; reimbursement policies for culturally based interventions 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 conditions, 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 service 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 comprehensive 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 family’s natural support system. Research has documented individualized 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 urban program, which uses a case rate model of funding to maximize ﬂexibility, includes an extensive range of services, a large provider network, and strong family participation 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 individualized, single plan of care that addresses the child and the family’s needs across life domains and incorporates services and supports from all needed agencies and systems. The family should assume a key partnership role with providers in the development, implementation, and monitoring of the plan. 5. Implementing Evidence-Based Practices Many states and communities continue to offer traditional services as opposed to community-based care, have difﬁculty adopting evidence-based services and supports, and fail to incorporate knowledge from biopsychosocial research into services and policy. In terms of communitySeptember 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, dissemination, and implementation of interventions that are supported by scientiﬁc evidence. The availability of such interventions 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 challenge is promoting not just the dissemination of these interventions in an effective manner but also their implementation 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 interventions, such as relationship building or skill building or the individualized, wraparound approach to service delivery (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 patchwork 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 mandates, missions, service settings, ﬁnancing streams, eligibility rules, and requirements. This fragmentation is compounded 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, developmental 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 differing policies, procedures, and philosophies (Knitzer & Yelton, 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, development, 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 practice 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 process of relinquishing custody of their children to become eligible for intensive mental health services in public systems (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 comprehensive, cross-agency plan for prevention, early intervention and treatment for children’s mental health, clarifying responsibility among the child-serving systems. Collaborative efforts to deliver community-based services and supports, 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 revising 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 multiple funding streams and create innovative ﬁnancing systems (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 alternative 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 Periodic Screening, Diagnosis, and Treatment program); (c) creating more ﬂexibility by pooling funds from several agencies into a single uniﬁed funding stream; or (d) creating new dedicated revenue streams (e.g., creating a children’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 identiﬁcation, 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 intervention 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 intervention services that by their very nature cut across agencies, disciplines, service delivery systems, and outcome domains; (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 prevention 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 interventions, 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 prevention, 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 implementation of preventive, early identiﬁcation, and early intervention 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 problems 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 maximize the likelihood of positive outcomes, yet many children and families must wait until their problems have reached serious or crisis proportions before they can receive help. 8. Strengthening Early Childhood Intervention Despite research that shows a disturbingly high prevalence of emotional and behavioral disorders among young children (Lavigne et al.,1996), this population has been neglected. Emerging neuroscience reveals the impact of environmental 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 & Phillips, 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 (Eyberg 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 implemented. 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) implementing a comprehensive approach to early screening, assessment, and intervention in natural early childhood settings; (d) educating and training professionals in effective intervention and treatment approaches for young children and their families; and (e) eliminating disincentives and barriers, particularly in diagnostic and ﬁnancing systems, to serving this population. Such an emphasis on early childhood intervention—not synonymous with early intervention as discussed in the previous section—is but one September 2005 ● American Psychologist
part of a broader public health approach to health promotion 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 weekday (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 personnel, 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, strengthening 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 initiatives . . . 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 population have most recently been pointed out in two longitudinal 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, decreasing discipline referrals, and improving test scores (Jennings, Pearson, & Harris, 2000). The Wingspread 623
Group has recently reviewed the literature on school connectedness, 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 positively 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-ofschool and out-of-home placements (Eber, Osuch, & Redditt, 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 (Horner & Carr, 1997; Sugai et al., 2000). Thus, a continuum of mental health services should be provided in schools, including 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 programs 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 appropriate 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 receive 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 improvement 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 population 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 administrators 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 problems—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 indicators 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 improve the system. Although child- and family-level outcome 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 population 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 ), (b) clearly conceptualized theories of change, (c) reliable measures, (d) attention to family concerns regarding 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 measurement 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 individualized home- and community-based service approach, and the role of interdisciplinary collaboration in service planning and intervention. Training must include strengthsSeptember 2005 ● American Psychologist
based approaches, individualized care, culturally competent care, and the clinical advances embedded in evidencebased and promising practices (Friedman, 1993; Morris & Hanley, 2001). This approach to training is consistent with several reports prepared by groups of psychologists (American Psychological Association, 1998; Roberts et al., 1998). For psychologists working with children and families, a transformed service delivery system would offer expanded 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 families in treatment planning and decision making, and to consult and collaborate with providers in other child-serving 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-mentalhealth 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 practices 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, psychologists 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 psychologists 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 approaches. Potential exists for psychologists to advance the science of dissemination and to shed light on the challenges of changing organizational and clinical practice to implement 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 increasingly 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 instruments 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 supported clinical interventions and the effective organization of community-based systems of care and their accompanying 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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