APPENDIX A: THE HISTORICAL
PERSPECTIVE OF CHILDREN'S
MENTAL HEALTH POLICY
Luanne Southern (personal communication, October 4, 2000) provided the following
information regarding the Historical Perspective of Children's Mental Health
Policy:
In 1969, Congress ordered a report be conducted on the status of children's
mental health in the United States. This report came as a result of a larger
study conducted on adults with mental illness. The Joint Commission on the
Mental Health of Children submitted the report entitled, "Crisis in Children's
Mental Health", to Congress. The report indicated that the fragmentation of
a national response for children with mental health needs resulted in a "non-system."
In 1974, as part of the Federal Community Mental Health Center's Act, $20
million was allocated to states as part of a seven-year effort at funding children's
mental health programs. These programs could either be provided by non-profit
agencies or community mental health centers. However, this federal funding
was cut in 1976 with no explanation. In 1975, the Texas Department of Mental
Health and Mental Retardation estimated that on a state-wide basis, 47.1 percent
of the children needing inpatient care were served, compared to 2.1 percent
needing emergency care, 4.4 percent needing outpatient care and 6.8 percent
needing day treatment or evening programs. This data reflects the reliance
on institutional care due to the lack of available community-based alternatives.
In the 1980s several important events took place to help change the entire
focus of public policy in relation to children with mental health needs and
their families. The first occurred between 1979-80 when a class action lawsuit
was filed in the state of North Carolina. The suit was filed due to North Carolina's
failure to serve a group of violent, acting out youth who were shuffled between
the juvenile justice and mental health systems. The Willie M case, as it was
called, set a precedent for states to create a network of case managers to
coordinate care through a "system of care" and adopted a "no reject/no eject" policy.
The second event occurred in 1982, when the Children's Defense Fund was commissioned
to conduct a study and report on issues relating directly to children's mental
health. The report, written by Dr. Jane Knitzer, entitled, Unclaimed
Children: The Failure of Public Responsibility to Children and Adolescents
in Need of Mental Health Services, portrayed a nation that had neglected
children with mental health needs. The Knitzer report continues to serve as
a catalyst for all children's mental health reform in the United States. The
issues outlined in the 1982 Knitzer report included:
- 3,000,000 children in the United States had mental health needs;
- Two-thirds of those children were not getting their mental health needs
met;
- For families, there was a poor match between services and needs;
- Treatment focused on inpatient or residential care;
- Only seven states were looking at changing the system to put more money
into the community and out of institutions;
- Only 17 states provided children the right to access legal counsel during
a voluntary admission to a facility;
- Federal funds were used to purchase medically-oriented inpatient care;
- Child-serving governmental systems did not work together collaboratively;
- Families were maltreated by the mental health system which often blamed
them for their child's problems;
- Only 17 percent of all community mental health center funds purchased
services for children; and
- 40 to 60 percent of all children in psychiatric hospitals did not need
to be there.
The data presented in the Knitzer report captured the attention of federal
leaders in health and human services and resulted in a nation-wide effort at
reforming the way children with mental health needs received assistance. For
example, in 1983, Ventura County, California developed the first cross-system
management structure for the provision of intensive case management services
that integrated state and local money in order to reduce out-of-home placements
of children with mental health needs.
A third significant event occurred in 1984, when the National Institute of
Mental Health allocated $1.5 million to develop the Child and Adolescent Service
System Program (CASSP), a federal reform effort designed to integrate services
and create systems of care across the United States for children with mental
health needs and their families. The CASSP initiative in Texas began in 1986
with several children's mental health staff being hired at the Texas Department
of Mental Health and Mental Retardation. This was the first time the state
mental health agency designated employees to work specifically on issues relating
to children's mental health.
Another key occurrence was the 1986 publication of a report written by Beth
Stroul and Robert Friedman, entitled, A System of Care for Children and
Youth with Severe Emotional Disturbances. This report outlined what
a system of care for every community in the United States should look like.
It outlined how a community should respond to children with mental health needs
and their families in a way that embraces values, philosophical models and
approaches that promote cultural competence, family involvement and designing
systems where services meet needs.
For the first time in 1989, the Texas Department of Mental Health and Mental
Retardation created a separate line item in their budget specifically designated
for children's mental health. The Department set aside $2.2 million that was
allocated through a competitive bidding process to community mental health
centers in order to create services that promoted the system of care and were
designed to prevent the out-of-home placement of children with mental health
needs. Through this competitive process, in 1990, the Austin Travis County
Mental Health Mental Retardation Center was awarded $500,000 for the creation
of the Family Preservation Program, one of the first home-based mental health
services programs of its kind in the state of Texas. In 1992, the state legislature
passed the Texas Children's Mental Health Plan, and allocated additional state
general funds for the expansion of specialized services for children with mental
health needs and their families across Texas. This initiative required the
creation of multi-agency management teams at the state and local level to coordinate
services, manage mental health revenue and design innovative service models
for children with mental health needs and their families.
The Stoul/Friedman report sparked great interest by the federal government
and in 1992, the Child, Adolescent and Family Branch of the Center for Mental
Health Services grant community project was born. The monies allocated through
this initiative are designated to communities to "develop a broad array of
community-based, family focused services for children with serious emotional,
behavioral or mental disorders to enable communities to develop coordinated
local systems of care involving mental health, child welfare, education, juvenile
justice and other agencies as appropriate" (CMHS, 1994). This grant program
started with $4 million and has grown to a current allocation of $87 million.
To date, 45 communities across the United States have received grant funds
through this program and are working to implement systems of care for children
with mental health needs and their families based on the values, philosophical
model and approach outlined in the Stroul/Friedman report. The Children's Partnership
is one of these 45 sites and the only site in Texas awarded with CMHS funding
for the purpose of creating a system of care in Austin, Travis County, for
children with mental health needs and their families.
Many of the needs outlined in the Knitzer report still remain today. However,
with the research and support provided by federal and state governments, private
foundations and local communities, major reforms in children's mental health
are occurring. The healthcare debate has sparked an additional phenomenon among
mental health, as the issues around parity of coverage must be dealt with sooner
rather than later. Families who traditionally relied on private care are now
coming to government-funded programs to receive services that their managed
care plans do not cover. These public-funded providers often turn parents with
healthcare coverage away or ask them to pay 100 percent of the cost to provide
care. Often, parents do not have the resources to pay for the services, so
the child does not receive the treatment required to meet his/her needs. The
cost to provide inpatient and residential care have not declined; however,
managed care has resulted in the decreased length of stay for many children
with serious needs. The amount of resources available in communities does not
match the need for alternative care and choices of services for children who
are returning from or at risk for out-of-home placements. In addition, the
services families need are often not what they are offered by the current provider
community.
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