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Testimony:

Before the Committee on Governmental Affairs, U.S. Senate:

United States General Accounting Office:

GAO:

For Release on Delivery Expected at 9:30 a.m. EDT:

Thursday, July 17, 2003:

Child Welfare and Juvenile Justice:

Several Factors Influence the Placement of Children Solely to Obtain 
Mental Health Services:

Statement of Cornelia M. Ashby, Director Education, Workforce, and 
Income Security Issues:

GAO-03-865T:

GAO Highlights:

Highlights of GAO-03-865T, a testimony for the Committee on 
Governmental Affairs, United States Senate 

Why GAO Did This Study:

Recent news articles in over 30 states and prominent mental health 
advocacy organizations have described the difficulty many parents have 
in accessing mental health services for their children. As these 
reports documented, some parents choose to place their children in the 
child welfare or juvenile justice systems in order to obtain the 
mental health services that their children need. Senators Susan 
Collins and Joseph Lieberman of the Senate Committee on Governmental 
Affairs asked GAO to testify on: (1) the number and characteristics of 
children voluntarily placed in the child welfare and juvenile justice 
systems to receive mental health services, (2) the factors that 
influence such placements, and (3) promising state and local practices 
that may reduce the need for child welfare and juvenile justice 
placements. This testimony is based on our April 2003 report on the 
results of a study addressing these same objectives. For that report, 
we surveyed state child welfare directors in all states and the 
District of Columbia and juvenile justice officials in 33 counties in 
the 17 states with the largest populations of children under age 18. 
We surveyed juvenile justice officials at the county level because of 
the decentralized nature of the juvenile justice system. We also 
researched laws and regulations and conducted site visits to 6 
states. 

What GAO Found:

Child welfare directors in 19 states and juvenile justice officials in 
30 counties estimated that in fiscal year 2001 parents placed over 12,
700 children into the child welfare or juvenile justice systems so 
that these children could receive mental health services. Nationwide, 
this number is likely higher because many state child welfare 
directors did not provide data and we had limited coverage of county 
juvenile justice officials. Although no agency tracks these children 
or maintains data on their characteristics, officials said most are 
male, adolescent, often have multiple problems, and many exhibit 
behaviors that threaten the safety of themselves and others.

Neither the child welfare nor the juvenile justice system was designed 
to serve children who have not been abused or neglected, or who have 
not committed a delinquent act. According to officials in the 6 states 
we visited, limitations of both public and private health insurance, 
inadequate supplies of some mental health services, difficulties 
accessing services through mental health agencies and schools, and 
difficulties meeting eligibility rules for services influence such 
placements. Despite guidance issued by the various federal agencies 
with responsibilities for serving children with mental illness, 
misunderstandings among state and local officials regarding the roles 
of the various agencies that provide such services pose additional 
challenges to parents seeking such services for their children.

Officials in the states we visited identified practices that they 
believe may reduce the need for some child welfare or juvenile justice 
placements. These included finding new ways to reduce the cost of or 
fund mental health services, bringing services into a single location 
to improve access, and expanding the array of available services. Few 
of these practices have been rigorously evaluated. 

In a related report, we recommended that (1) the Secretary of Health 
and Human Services (HHS) and the Attorney General investigate the 
feasibility of tracking these children to identify the extent and 
outcomes of these placements, (2) the Secretaries of HHS and Education 
and the Attorney General develop an interagency working group to 
identify the causes of the misunderstandings and create an action plan 
to address those causes, and (3) the agencies continue to encourage 
states to evaluate the child mental health programs that states fund 
or initiate and that they determine the most effective means of 
disseminating the results of these and other available studies to 
state and local entities. In commenting on a draft of that report, 
Education, HHS, and the Department of Justice generally agreed with 
our findings but did not fully concur with the recommendations, 
particularly related to tracking the children. All three agencies said 
they would participate in any interagency working group that might be 
established based on our recommendation. 

www.gao.gov/cgi-bin/getrpt?GAO-03-865T.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact Cornelia Ashby at 
(202) 512-8403 or ashbyc@gao.gov.

[End of section]

Madam Chairman and Members of the Committee:

Thank you for inviting me here today to discuss how federal agencies 
could do more to help states reduce the number of children placed in 
child welfare and juvenile justice systems solely to obtain mental 
health services. As recent news articles in over 30 states and 
prominent mental health advocacy organizations have reported, many 
parents have difficulty accessing mental health services for their 
children with severe mental illnesses.[Footnote 1] In some cases, 
parents must choose to remove their children from their homes and seek 
alternative living arrangements by inappropriately placing them in the 
child welfare or juvenile justice system to obtain mental health 
services--two systems not designed to care for children solely because 
of their mental health needs.[Footnote 2] Various federal laws require 
that state and local agencies provide services to mentally ill children 
in the most integrated setting appropriate to their needs; that is, 
children have a right to receive services in their communities unless 
their needs can only be met by the state in residential or 
institutional placements.

My testimony today will focus on three key issues: (1) the numbers and 
characteristics of children voluntarily placed in the child welfare and 
juvenile justice systems in order to receive mental health services, 
(2) the factors that influence such placements, and (3) state and local 
practices that may reduce the need for some child welfare and juvenile 
justice placements. My comments are based on the findings from our 
April 2003 report, Child Welfare and Juvenile Justice: Federal Agencies 
Could Play a Stronger Role in Helping States Reduce the Number of 
Children Placed Solely to Obtain Mental Health Services (GAO-03-397, 
April 21, 2003). In conducting that study, we analyzed responses to our 
survey of state child welfare directors in all states and the District 
of Columbia and our survey of juvenile justice officials in 33 counties 
in the 17 states with the largest populations of children under age 18. 
We surveyed juvenile justice officials at the county level, rather than 
at the state level, because of the decentralized nature of the juvenile 
justice system. In addition, we interviewed officials of child-serving 
agencies,[Footnote 3] caseworkers, and parents in 6 states (Arkansas, 
California, Kansas, Maryland, Minnesota, and New Jersey) and judges in 
each state we visited except Minnesota.[Footnote 4] We also observed 
programs that state officials identified as model programs in those 6 
states; interviewed key federal officials and national experts; and 
researched state laws and regulations regarding voluntary placement and 
relinquishment of parental rights.

In summary, state child welfare officials in 19 states and county 
juvenile justice officials in 30 counties estimated that in fiscal year 
2001 parents in their jurisdictions placed over 12,700 children--mostly 
adolescent males--into the child welfare or juvenile justice systems so 
that these children could receive mental health services. Nationwide, 
this number is likely higher because 32 state child welfare officials, 
including officials of 5 states with the largest populations of 
children, did not provide us with data. However, officials in 11 of 
those states indicated that although they did not have an estimate to 
provide, such placements occurred in their state. Also, we surveyed 
juvenile justice officials in only 33 counties; 30 of which responded 
with an estimate. Although no federal or state agency tracks these 
children or maintains data on their characteristics, officials said 
most are male, adolescent, and often have multiple problems. Many 
exhibited behavior that threatened their safety and the safety of 
others. In addition, these officials said children who were placed came 
from families of all financial levels and that the seriousness of the 
child's illness strained the family's ability to function.

A variety of factors influenced whether parents placed their children 
in the child welfare and juvenile justice systems to receive mental 
health services for them; these included limitations in health 
insurance coverage, shortages of mental health services in some 
localities, difficulties in accessing services through mental health or 
education agencies, eligibility requirements for services provided by 
different agencies and programs, and misunderstandings among state and 
local officials and service providers regarding the responsibilities of 
various agencies to meet children's mental health needs. For example, 
despite guidance issued by various federal agencies with 
responsibilities for serving children, state and local officials' views 
of the roles of their own agency and other agencies, such as mental 
health, child welfare, education, and juvenile justice, showed that 
they misunderstood those roles and, therefore, could not effectively 
give parents complete and accurate information about available services 
their agency and other agencies could provide.

The state officials that we interviewed identified a range of practices 
in their states that they believe may help to prevent some child 
welfare and juvenile justice placements. These included finding new 
ways to reduce the cost of or to fund mental health services, bringing 
mental health services into a single location to improve access, and 
expanding the array of available services. However, the effectiveness 
of these practices is generally unknown because many were new, few were 
rigorously evaluated, and many served a small number of children or 
only children in specific locations.

To determine the extent to which children may be placed inappropriately 
in the child welfare and juvenile justice systems in order to obtain 
mental health services, we recommended in our April 2003 report that 
the Secretary of Health and Human Services (HHS) and the Attorney 
General investigate the feasibility of tracking these children to 
identify the extent and outcomes of these placements. To help reduce 
misunderstandings at the state and local level, we also recommended 
that the Secretaries of HHS and Education and the Attorney General 
develop an interagency working group to identify the causes of the 
misunderstandings and to create an action plan to address those causes. 
We further recommended that these agencies continue to encourage states 
to evaluate the child mental health programs that states fund or 
initiate and that the Secretaries of HHS and Education and the Attorney 
General determine the most effective means of disseminating the results 
of these and other available studies to state and local entities. In 
commenting on a draft of the report, the Department of Education, HHS, 
and DOJ generally agreed with our findings but did not fully concur 
with the recommendations. Education said that it did not understand how 
tracking the children would increase the likelihood of progressive 
practices to provide children's mental health services and noted that 
no recommendations were made for increased grant spending to duplicate 
or disseminate the positive features of such practices. HHS said that 
asking the agencies to track this population of children in foster care 
does not address the larger point of the lack of mental health 
resources for families and communities and does not address the 
problems of the children or their parents. DOJ agreed that tracking 
should occur, but only in the short term, and said that HHS should take 
the lead in this activity. All three agencies said they would 
participate in any interagency working group that might be established 
based on our recommendation.

Background:

As defined by the President's New Freedom Commission on Mental Health, 
the mental health system in the United States collectively refers to 
the full array of private and public programs for individuals with 
mental illness that deliver or pay for treatment and services. The 
federal government plays a major role in funding mental health services 
through public insurance--Medicaid and SCHIP--and grants to states and 
local agencies, and state and local governments play a major role in 
delivering services. Most families depend on private and public 
insurance to pay for mental health services because such services are 
expensive, although, as we discussed in a previous report, children may 
face certain limitations in coverage barriers depending on their type 
of coverage and where they live.[Footnote 5]

At the federal level, several federal agencies--including HHS's SAMHSA, 
Centers for Medicare & Medicaid Services (CMS), and the Administration 
for Children and Families (ACF); DOJ's Office of Juvenile Justice and 
Delinquency Prevention (OJJDP); and Education's Office of Special 
Education and Rehabilitative Services (OSERS)--have a role in 
addressing the mental health needs of children. However, all have 
individual mandates, target different but often overlapping 
populations, and share responsibilities to varying degrees with state 
and county agencies. (See table 1.):

Table 1: Characteristics of Key Agencies with Responsibilities for 
Mentally Ill Children:

Department and agency: HHS (CMS); Key activities related to children's 
mental health: Administers the Medicaid and SCHIP programs that provide 
health insurance coverage to certain low-income individuals and 
disabled children, including some children with severe mental illness; 
Awards research grants; Provides technical assistance to state 
agencies; Statute: Title XIX of the Social Security Act; Population 
targeted and definition of mental illness: Certain low-income 
individuals and certain disabled individuals; Uses a clinical 
classification of diseases to identify children with a mental illness.

Department and agency: HHS (ACF); Key activities related to children's 
mental health: Oversees the Adoption and Safe Families Act (ASFA) of 
1997 that improves the safety of children and promotes adoption and 
permanent homes for children who need them and supports families; 
Administers Title IV-B of the Social Security Act that provides funds 
to states for services that protect the welfare of children. For 
example, these services address problems that may result in the abuse 
and neglect of children. The funds may also be used to provide services 
to families of children with a mental illness; Administers the Title 
IV-E Foster Care Funds Program that provides funds to states to 
partially cover the costs of room and board for eligible children from 
low-income families who are placed in approved out-of-home living 
arrangements; Maintains the Adoption and Foster Care Analysis and 
Reporting System (AFCARS), to which states report demographic data on 
children in foster care, including diagnoses of mental illness; Awards 
development, training, research, and demonstration grants; 
Disseminates research; Provides technical assistance; Statute: Title 
IV, Part B and Part E of the Social Security Act; ASFA; Population 
targeted and definition of mental illness: Children and families; 
Uses a clinical classification to identify children with a mental 
illness and accepts classifications used by individual states in 
identifying children with mental health needs.

Department and agency: Education (OSERS); Key activities related to 
children's mental health: Monitors the implementation of the 
Individuals with Disabilities Education Act (IDEA). IDEA established 
the right of disabled children--including children with mental illness-
-to receive special education and related services, such as mental 
health services, designed to meet their unique needs and prepare them 
for employment and independent living when such services are needed for 
children to make adequate progress in school. IDEA requires schools to 
evaluate children who are referred for special education services and, 
if services are required, develop an individualized education program 
(IEP) that documents the type and intensity of services that will be 
provided; Funds formula and discretionary grants; Provides technical 
assistance; Disseminates research; Statute: IDEA; Population 
targeted and definition of mental illness: Promotes improvement in 
educational results for infants, toddlers, and children with 
disabilities; Under IDEA, the term "child with a disability" means a 
child, who by reason of a physical or mental disability, needs special 
education and related services.

Department and agency: HHS (SAMHSA); Key activities related to 
children's mental health: Provides funds to states and local entities 
to help them administer, support, or establish programs that 
specifically target the mental health needs of children and block grant 
funding that enables states to maintain and enhance mental health 
services; Sponsors the Systems of Care Initiative to help children and 
adolescents with serious mental illnesses and their families receive a 
variety of services from schools, community mental health centers, and 
social services organizations and facilitate coordination among these 
service providers; Awards formula and discretionary development and 
demonstration grants; Disseminates research; Provides technical 
assistance; Statute: Public Health Service Act; Population targeted 
and definition of mental illness: Individuals with substance abuse 
problems, mental illness, or at risk of substance abuse and mental 
illness; Children served meet the following criteria:; age 0 to 18 
and; have a diagnosed mental, behavioral, or emotional disorder of 
sufficient duration to meet diagnostic criteria that results in 
impairment that substantially interferes with or limits the child's 
functioning in family, school, or community activities.

Department and agency: DOJ (OJJDP); Key activities related to 
children's mental health: Helps oversee juvenile justice programs 
across the nation and supports states and local communities in their 
efforts to develop and implement effective and coordinated prevention 
and intervention programs. Helps improve the juvenile justice system's 
ability to protect public safety, hold offenders accountable, and 
provide mental health treatment and rehabilitative services; Funds 
formula and discretionary grants; Provides technical assistance; 
Disseminates research; Statute: Juvenile Justice and Delinquency 
Prevention Act; Population targeted and definition of mental illness: 
Children who commit crimes or are delinquent and children at risk for 
delinquency; Accepts mental illness classifications used by states 
to identify children with mental health needs.

Source: GAO.

Note: Other agencies, such as HHS's Social Security Administration, 
DOJ's Division of Civil Rights, and HHS's and Education's Office for 
Civil Rights, also have responsibilities for children with 
disabilities, including children with a mental illness.

[End of table]

Federal law does not require parents to relinquish their parental 
rights to place their children with child welfare agencies. However, 
after children are in care for a specific period of time, the law 
requires that the court be involved to determine if termination of the 
parents' rights are in the best interest of the child. State laws 
addressing the ability of parents to place their children in child 
welfare systems vary across states. Nationwide, laws in 11 states allow 
parents to place children in child welfare systems on a voluntary basis 
in order to access mental health services for as long as necessary 
without relinquishing custody of the child to the state.[Footnote 6] 
Child welfare directors in 8 other states and the District of Columbia 
advised us that their states do not allow parents to place children 
voluntarily in child welfare agencies to access such services.[Footnote 
7] Laws in the remaining states are generally silent regarding 
voluntary placements for mental health.

Federal agencies with responsibilities for children with mental illness 
support interagency collaboration at the federal and local level. For 
example, officials at SAMHSA are collaborating with officials at 
Education and OJJDP to improve mental health services for children with 
emotional and behavioral disorders who are at risk of violent behavior 
by developing and implementing a large grant program that targets these 
children. At the state and county level, a similar array of agencies 
provides or funds services for mentally ill children, and state and 
federal laws and policies often determine their roles and 
responsibilities. Importantly, federal agencies play a key role in 
funding research and evaluation studies and disseminating the findings 
of these efforts. For example, SAMSHA, OJJDP, and OSERS fund research 
and evaluation studies that target children with mental illness and 
disseminate the findings of these efforts, descriptions of promising 
practices, and other information through their clearinghouses, 
journals, and Web sites.

Despite their differences, programs run by agencies at all levels of 
government adhere to the principle of "least restrictive alternative." 
Under this principal, the state has the burden of demonstrating that 
state-funded out-of-home placements are necessary for the protection of 
the child or society. In 1999, the U.S. Supreme Court established this 
principle as a right for disabled children. In Olmstead v L.C., the 
Court held that under Title II of the Americans with Disabilities Act, 
states may be required to serve people with disabilities in community 
settings when such placements can be reasonably accommodated.

Mental health treatment can be very expensive, and most families rely 
upon insurance to help cover the cost of these services. For example, 
one outpatient therapy session can cost more than $100, and residential 
treatment facilities, which provides 24 hours of care, 7 days a week, 
can cost $250,000 a year or more. Nationwide, about 87 percent of 
American children are covered by private or public health insurance 
plans. Private plans, such as employer-sponsored or individually 
purchased plans, provide health insurance coverage to about 68 percent 
of American children, and public programs, such as Medicaid and SCHIP, 
provide health insurance coverage to about 19 percent.[Footnote 8]

Most private health insurance plans offer different coverage for mental 
health services than for physical health services. To ensure more 
comparable coverage, the federal government passed the federal Mental 
Health Parity Act (MHPA) of 1996. MHPA prohibited certain employer-
sponsored group plans from imposing annual or lifetime restrictions on 
mental health benefits that are lower than those imposed on other 
benefits. However, the act did not eliminate other restrictions and 
limitations on mental health coverage, such as limiting the number of 
treatments per year that are reimbursable. In addition, the law does 
not apply to plans sponsored by employers with 50 or fewer employees, 
group plans that experience an increase in plan claims costs of at 
least 1 percent because of compliance, and coverage sold in the 
individual market. According to the National Council of State 
Legislatures, as of November 2001, 46 states have passed mental health 
parity bills. Most of these laws meet or exceed the federal MHPA 
standard. However, the Employee Retirement Income Security Act of 1974 
preempts states from directly regulating self-funded, employer-
sponsored health plans; under such circumstances, states requirements 
usually do not apply.

For more than 30 years, Medicaid has provided comprehensive health 
insurance for children from low-income families. Although individual 
states determine many coverage, eligibility, and administrative 
details, the federal government sets certain requirements for state 
Medicaid programs. These requirements include coverage of screening and 
necessary treatment for children. Under Medicaid, states may apply for 
and receive approval from the federal government to waive certain 
provisions of the Medicaid statute in order to operate a specific 
program, change the benefits offered under Medicaid, or make 
comprehensive changes to their Medicaid or SCHIP programs. For example, 
states can use the Home and Community-Based Services (HCBS) (section 
1915(c) of the Social Security Act) waiver to provide home and 
community-based long-term care services to targeted groups of 
individuals who would otherwise require care in a hospital, skilled 
nursing facility, or intermediate care facility. To receive the HCBS 
waiver, states must demonstrate that the cost of the services to be 
provided under the waiver is no more than the cost of institutionalized 
care plus any other Medicaid services provided to institutionalized 
individuals. Additional flexibility is available to states under the 
"Katie Beckett" option, which enables states to use federal Medicaid 
funds more flexibly to cover the costs of health care services in the 
home and community rather than just in institutional settings, 
regardless of the income and assets of the family.[Footnote 9] States 
choosing this option provide Medicaid coverage for children under age 
19 who meet certain standards for disability, would be eligible for 
Medicaid if they were in an institution, and are receiving medical care 
at home that would be provided in an institution. Although family 
income and resources are not considered in determining eligibility for 
services under the Katie Beckett option, states can require families to 
contribute to the cost of the program. The Rehabilitation option allows 
states to provide optional Medicaid services such as psychiatric 
rehabilitation and other diagnostic, screening, and preventive services 
in nonmedical settings.

States are pursuing a variety of approaches for expanding public health 
insurance for uninsured children from low-income families by 
implementing SCHIP programs. States have three options in designing 
SCHIP programs. For example, 24 states implement SCHIP by expanding 
Medicaid programs to include children from low-income families with 
earnings too high to qualify for Medicaid. Fourteen have developed a 
separate or independent child health insurance program with benefits 
that differ from those offered under Medicaid. Others use a combination 
of Medicaid and non-Medicaid plans to serve children in families at 
different income levels.

States operating Medicaid programs--including SCHIP Medicaid-
expansions--must offer the same benefit package to SCHIP beneficiaries 
as they do to Medicaid beneficiaries.[Footnote 10] These benefits 
include the Early and Periodic Screening, Diagnostic and Treatment 
(EPSDT) provision that requires states to provide children and 
adolescents under age 21 with access to comprehensive, periodic 
evaluations of physical and mental health and developmental and 
nutritional status, as well as vision, hearing, and dental needs. 
States must provide all services needed for conditions discovered 
through these routine pediatric screenings regardless of whether the 
service is covered by the state Medicaid plan for other beneficiaries. 
In 2000, more than 1 million children were enrolled in SCHIP Medicaid 
expansion programs and were, therefore, eligible for EPSDT screens.

While No Formal Tracking Occurs, Available Estimates Indicate That Many 
Children--Primarily Adolescent Males--Were Placed with the State to 
Access Mental Health Services:

State child welfare and county juvenile justice officials estimated 
that parents in their jurisdictions placed over 12,700 children in 
fiscal year 2001, generally adolescent males, in child welfare and 
juvenile justice agencies so that the children could receive mental 
health services. Nationwide, this number is likely higher because 
officials in 32 states, including the 5 states with the largest 
populations of children, did not provide us with estimates. Moreover, 
we surveyed juvenile justice officials in only 33 counties and three 
did not provide estimates. Only estimates were available because no 
federal or state agency tracked children placed to obtain mental health 
services in a formal or comprehensive manner. Officials in the 6 states 
we visited reported that placed children came from families of all 
financial levels and said that the seriousness of the children's 
illnesses strained families' abilities to function.

Some Officials Estimate That Parents Placed Over 12,700 Children to 
Access Mental Health Services:

State child welfare officials and county juvenile justice officials 
estimated that over 12,700 children entered the child welfare or 
juvenile justice systems in order to receive mental health services in 
fiscal year 2001. Of these children, about 3,700 entered the child 
welfare system. State child welfare officials reported estimates that 
ranged from 0 to 1,071 children, with a median of 71. Table 2 provides 
detailed information about the estimated number of children placed in 
the child welfare system. County juvenile justice officials reported 
estimates that totaled to approximately 9,000 children and ranged from 
0 to 1,750, with a median of 140. Table 3 provides details on the 
estimated number of children placed in the juvenile justice system.

Table 2: States' Estimated Number of Children Placed in the Child 
Welfare System to Obtain Mental Health Services in Fiscal Year 2001:

State: Alaska; Number of children placed: a.

State: Alabama; Number of children placed: 130.

State: Arkansas; Number of children placed: b.

State: Arizona; Number of children placed: b.

State: California; Number of children placed: c.

State: Colorado; Number of children placed: c.

State: Connecticut; Number of children placed: 738.

State: District of Columbia; Number of children placed: d.

State: Delaware; Number of children placed: 0.

State: Florida; Number of children placed: d.

State: Georgia; Number of children placed: d.

State: Hawaii; Number of children placed: d.

State: Iowa; Number of children placed: b.

State: Idaho; Number of children placed: 123.

State: Illinois; Number of children placed: a.

State: Indiana; Number of children placed: 0.

State: Kansas; Number of children placed: d.

State: Kentucky; Number of children placed: 14.

State: Louisiana; Number of children placed: a.

State: Massachusetts; Number of children placed: c.

State: Maryland; Number of children placed: 54.

State: Maine; Number of children placed: b.

State: Michigan; Number of children placed: c.

State: Minnesota; Number of children placed: 1,071.

State: Missouri; Number of children placed: d.

State: Mississippi; Number of children placed: 13.

State: Montana; Number of children placed: d, b.

State: North Carolina; Number of children placed: 440.

State: North Dakota; Number of children placed: b.

State: Nebraska; Number of children placed: c.

State: New Hampshire; Number of children placed: d.

State: New Jersey; Number of children placed: c.

State: New Mexico; Number of children placed: c.

State: Nevada; Number of children placed: 20.

State: New York; Number of children placed: c.

State: Ohio; Number of children placed: b.

State: Oklahoma; Number of children placed: 3.

State: Oregon; Number of children placed: 101.

State: Pennsylvania; Number of children placed: 71.

State: Rhode Island; Number of children placed: 279.

State: South Carolina; Number of children placed: a.

State: South Dakota; Number of children placed: b.

State: Tennessee; Number of children placed: b.

State: Texas; Number of children placed: d.

State: Utah; Number of children placed: b.

State: Virginia; Number of children placed: b.

State: Vermont; Number of children placed: 60.

State: Washington; Number of children placed: 423.

State: Wisconsin; Number of children placed: c.

State: West Virginia; Number of children placed: 135.

State: Wyoming; Number of children placed: 5.

Total; Number of children placed: 3,680.

Source: GAO survey.

[A] State did not respond to our survey.

[B] State did not provide the data requested, but indicated that 
voluntary placement happens.

[C] State did not provide the data requested.

[D] State officials said the practice of voluntary placement is not 
legal in the state.

[End of table]

Table 3: Estimated Number of Children Placed in the Juvenile Justice 
System in 33 Counties to Obtain Mental Health Services in Fiscal Year 
2001:

State: Arizona; County: Maricopa; Number of children placed: 60.

State: Arizona; County: Pima; Number of children placed: 1,750.

State: California; County: Los Angeles; Number of children placed: a.

State: California; County: San Diego; Number of children placed: 200.

State: Colorado; County: El Paso; Number of children placed: 40.

State: Colorado; County: Jefferson; Number of children placed: 100.

State: Florida; County: Broward; Number of children placed: 0.

State: Florida; County: Miami-Dade; Number of children placed: 999.

State: Georgia; County: Fulton; Number of children placed: 172.

State: Georgia; County: Gwinnett; Number of children placed: 100.

State: Illinois; County: Cook; Number of children placed: 0.

State: Illinois; County: DuPage; Number of children placed: 35.

State: Indiana; County: Lake; Number of children placed: 600.

State: Indiana; County: Marion; Number of children placed: 100.

State: Louisiana; County: Jefferson Parish; Number of children placed: 
50.

State: Michigan; County: Oakland; Number of children placed: 160.

State: Michigan; County: Wayne; Number of children placed: 400.

State: New Jersey; County: Bergen; Number of children placed: a.

State: New Jersey; County: Middlesex; Number of children placed: 999.

State: New York; County: Brooklyn; Number of children placed: 74.

State: New York; County: Queens; Number of children placed: 49.

State: Ohio; County: Cuyahoga; Number of children placed: a.

State: Ohio; County: Franklin; Number of children placed: 363.

State: Pennsylvania; County: Montgomery; Number of children placed: 20.

State: Pennsylvania; County: Philadelphia; Number of children placed: 
500.

State: Texas; County: Dallas; Number of children placed: 200.

State: Texas; County: Harris; Number of children placed: 200.

State: Virginia; County: Fairfax; Number of children placed: 350.

State: Virginia; County: Prince William; Number of children placed: 
840.

State: Washington; County: King; Number of children placed: 575.

State: Washington; County: Pierce; Number of children placed: 0.

State: Wisconsin; County: Dane; Number of children placed: 120.

State: Wisconsin; County: Milwaukee; Number of children placed: 0.

State: Total; County: [Empty]; Number of children placed: 9,056.

Source: GAO survey.

[A] County did not provide an estimate of the number of children.

[End of table]

Nationwide, the number of children placed is likely to be higher. 
Eleven states reported that they could not provide us with an estimate 
of child welfare placements solely to obtain mental health services 
even though they were aware that such placements occurred. Moreover, 
officials in 9 additional states that responded to our survey did not 
provide an estimate and did not mention whether or not parents turned 
to the child welfare system to access mental health services. However, 
child welfare workers we interviewed in 2 of these 9 states--California 
and New Jersey--told us that these placements did in fact occur. 
Although some of the state child welfare officials that we visited in 
California said children do not enter that system to obtain mental 
health services, county child welfare workers said that they knew of 
such placements and explained how the cases were coded in their system. 
Four states did not respond to the survey.[Footnote 11] Information on 
the prevalence of children present in the juvenile justice system is 
also limited in this statement since we surveyed only 33 counties. In 3 
of those counties, juvenile justice officials reported that while they 
did not have an estimate to provide, they knew that children were 
entering the system to obtain mental health services because they were 
not able to access such services in other ways.

Federal and state systems that track children in the juvenile justice 
and child welfare systems do not formally or comprehensively track 
children placed to receive mental health services. For example, ACF's 
AFCARS, which contains data reported by states about children in foster 
care or adopted out of foster care, does not have a data element that 
identifies this population. Similarly, every 2 years OJJDP conducts the 
Census of Juveniles in Residential Placement, which gathers information 
on children in juvenile residential facilities and their 
characteristics but no data base variable exists to isolate children 
whose parents sought the help of the juvenile justice system to meet 
children's mental health needs from other children in the juvenile 
justice system who may also have mental health problems. OSERS 
maintains extensive data about children who receive special education 
services, but data are aggregated at the state level and do not include 
information about who has custody of the child.

Officials Said Placed Children Were Mostly Adolescent Males with Severe 
Mental Health Problems:

According to our survey of state child welfare directors, placed 
children are more likely to be boys than girls and are more likely to 
be adolescent. Child welfare directors in 19 states reported that, in 
fiscal year 2001, 65 percent of placed children were male and 67 
percent were between the ages of 13 and 18. While juvenile justice 
officials did not provide information about the gender and ages of 
children placed in their system, children in the juvenile justice 
population are mostly male and range in age from 13 to 18.[Footnote 12]

The officials from state and county child-serving agencies and parents 
we interviewed in the 6 states that we visited said that children who 
were placed had severe mental illnesses, sometimes in combination with 
other disorders, and their parents believed they required intense 
treatment that could not be provided in their homes. Many of these 
children were violent and had tried to hurt themselves or others, and 
often prevented their parents from meeting the needs of the other 
children in the family. For example, in Maryland, officials told us 
about a teenage boy who was mentally ill, developmentally disabled, 
autistic,[Footnote 13] and hospitalized. Because the boy was both 
violent and sexually aggressive, the county told his mother that if she 
brought him home from a stay in the hospital, they would remove her 
other children from the house. Caring for children with severe mental 
illness can also prevent parents from obtaining full-time work or cause 
disruptions in their work lives. For example, an Arkansas parent now 
raising her grandchild does not work because of the time necessary to 
care for her mentally ill granddaughter. State and county officials 
from child-serving agencies in 5 of the 6 states that we visited told 
us that finding placements for children who were mentally ill and who 
also had other developmental disabilities was particularly difficult. 
Children who are placed or are at risk of placement come from families 
that span a variety of economic levels. However, officials from state 
and county child-serving agencies in all 6 states that we visited said 
children from middle class families are more likely to be placed 
because they are not eligible for Medicaid and their families do not 
have the funds to pay for treatments not covered by insurance.

Multiple Factors Influence Decisions to Place Children:

Multiple factors influence parents' decisions to place their children 
in the child welfare and juvenile justice systems so that they can 
obtain mental health services. Private health insurance plans often 
have gaps and limitations in the mental health coverage they provide, 
and not all children covered by Medicaid received needed services. Even 
when parents could afford mental health services, some could not access 
services at times when they needed those services because supplies of 
such services were inadequate. In other instances, some mental health 
agencies and schools have limited resources to provide mental health 
services and are required to serve children with a mental illness in 
the least restrictive environment possible--which can limit the 
alternatives available to parents who believe their children need 
residential placements. In other instances, parents sometimes have 
difficulty obtaining all needed services for their children in their 
communities because eligibility requirements for services provided by 
various agencies differ. Furthermore, some officials and service 
providers have misunderstood the role of their own and other agencies 
and, therefore, gave parents inaccurate or incomplete information about 
available services for families. These misunderstandings created gaps 
in services for some children.

Limitations in Private and Public Insurance Often Restrict Access to 
Mental Health Care, and Some Services are Limited:

Almost all state child welfare directors and county juvenile justice 
officials who responded to our surveys reported that private health 
insurance limitations were increasing the number of child welfare and 
juvenile justice placements to obtain mental health services, and well 
over half reported Medicaid rules also increased such placements. For 
example, according to parents and state and local officials in all 6 
states that we visited, many private insurance plans and separate SCHIP 
plans offered limited coverage for traditional or clinical treatments, 
such as psychotherapy or psychiatric consultations,[Footnote 14] and 
did not cover residential treatment placements. In addition, state 
officials in 3 of the 6 states we visited said that Medicaid rules in 
some states that require the preauthorization of services could result 
in delays and denials of community-based services.

The legislatures in the 6 states that we visited passed health 
insurance parity laws to increase the coverage that was available for 
mental health services by requiring insurance companies to provide 
mental health coverage that was comparable to what they offered for 
physical health care. Although these laws met or exceeded the standard 
established by the federal MHPA, they did not require private plans to 
cover intensive, long term, and nontraditional services such as respite 
care and wrap-around services.[Footnote 15] Mental health officials and 
service providers in the states that we visited said these services 
were often necessary to help families maintain children with a severe 
mental illness in their homes. Furthermore, federal law preempts states 
from directly regulating self-funded, employer-sponsored health 
insurance plans and in doing so exempted many families from protection 
under state laws.

In the 6 states that we visited, state and local mental health 
officials agreed that Medicaid had far fewer restrictions and 
limitations than private health insurance plans. In addition, mental 
health officials in Arkansas, California, and Maryland told us that 
differences between private insurance and Medicaid programs had created 
two distinct systems of child mental health services. Under these 
systems, children covered by Medicaid had greater coverage for mental 
health services than children covered by private insurance.

All 6 of the states that we visited covered optional Medicaid and SCHIP 
services by expanding their programs for children with mental illness 
who were ineligible for Medicaid on the basis of their families' 
income. These included the HCBS waivers, Katie Beckett option, 
Rehabilitation option, and SCHIP programs.

For example, states used different approaches to expand Medicaid 
coverage. Medicaid officials in Kansas received permission from CMS to 
implement a HCBS waiver to expand coverage for community-based mental 
health services for a limited number of children who are chronically 
mentally ill. Although Medicaid officials in New Jersey financed its 
new child mental health system through a Medicaid Rehabilitation 
option, the option extends Medicaid coverage to only a limited number 
of children who have exhausted benefits under other insurance and who 
have chronic and severe mental illness. This option generally provides 
60 days of community-based services and limited 
hospitalization.[Footnote 16] Arkansas, Maryland, and Minnesota used 
Medicaid's Katie Beckett option to expand Medicaid coverage to 
physically or mentally disabled children who meet CMS's requirements 
for institutional care. Arkansas' program did not require parents to 
pay into the program to receive services, but Minnesota's program 
required parents to pay according to their ability as defined by a 
sliding scale.

Although Medicaid's EPSDT provision requires Medicaid coverage for all 
necessary physical and mental health services that are identified 
during routine periodic screening as long as the treatment is 
reimbursable under federal Medicaid guidelines, some state officials 
said many eligible children are unable to access necessary services 
through Medicaid because practitioners in the states implement EPSDT 
unevenly. For example, a Medicaid official in Maryland told us that the 
implementation of EPSDT varied from county to county. Medicaid 
officials in California said implementation varied from practitioner to 
practitioner although access to EPSDT services was increasing as a 
result of litigation. These officials explained that some practitioners 
are reluctant to recommend services if such services are not available, 
some do not have the time to question parents about their child's 
mental health, and others are not well informed about children's mental 
health issues. In a July 2001 report, we recommended that the 
Administrator of CMS work with states to develop criteria and timelines 
for consistently assessing and improving EPSDT reporting and provision 
of services.[Footnote 17] As we stated in that report, comprehensive 
national data on the implementation of EPSDT are needed to judge 
states' success in implementing EPSDT requirements.

Low Medicaid reimbursement rates may restrict the participation of some 
practitioners and thus further restrict services. In all 6 states, 
officials from a variety of agencies said Medicaid rates for some 
services are lower than the usual and customary rates in their areas 
and, in some areas, psychiatrists and psychotherapists will not accept 
Medicaid patients or expand the number that they are presently seeing 
because of low Medicaid reimbursements. For example, a psychologist in 
Minnesota told us that Medicaid reimbursement for a psychotherapy 
session is about half the customary rate, and a mental health official 
in New Jersey said that Medicaid reimburses only $5 per visit for 
monitoring the use and effects of psychotherapeutic medication.

Even when insurance covered the costs of mental health services, some 
mental health officials and parents indicated all parents could not 
access services or placements in their community because the supplies 
of these services were limited. Fifteen of the 28 child welfare 
officials and 9 of the 23 juvenile justice officials who responded to 
our survey question on the relationship between community mental health 
services and voluntary placements indicated that the lack of such 
services increased voluntary placements. In every site we visited, 
officials of state and local child-serving agencies and parents 
reported inadequate supplies of mental health service providers and 
specialized mental health placements. Many of these officials said that 
shortages of child psychiatrists, child psychologists, respite care 
workers, and behavior therapists existed on statewide levels and were 
worse in rural areas. Also, specialized, out-of-home mental health 
placements, such as psychiatric in-patient services and residential 
treatment facilities, were often not available or had long waiting 
lists. For example, Arkansas officials said that the state has no 
state-run psychiatric hospital placements for children under age 12, 
and, in California, some children have to wait about 8 months for a 
residential placement. Officials in 3 states noted that relatively 
fewer residential placements are available for girls than are available 
for boys and that few placements would accept children with histories 
of arson and sexual aggression. Moreover, these officials noted 
children placed in the child welfare or juvenile justice systems 
received preference for services, particularly when the services were 
court-ordered.

Difficulties Accessing Services through Certain Agencies, Difficulties 
in Meeting Service Eligibility Requirements, and Misunderstandings 
among Officials and Service Providers Can Influence Placements:

In the 6 states that we visited, limited resources in mental health 
agencies and public schools to fund mental health services and agency 
officials' attempts to minimize the use of residential services posed 
additional challenges for parents seeking services and placements for 
their children. In addition, some children who needed multiple supports 
experienced gaps in services because of differences in the eligibility 
requirements for obtaining such services. Moreover, some officials and 
service providers often misunderstood the responsibilities and 
resources of their own and other agencies and communicated the 
misunderstandings to parents, compounding service gaps and delays.

Difficulties Accessing Services through Mental Health or Education 
Agencies:

According to some mental health and education officials, budgetary 
shortfalls in the 6 states that we visited contributed to agencies' 
attempts to cut or control costs, including the cost of mental health 
services. Mental health agencies used a variety of strategies to 
control costs, such as reducing spending, requiring that services 
covered by Medicaid be approved before they are provided, and limiting 
the number of children served. In each state we visited, some parents 
believed the strategies affected the quality of the services their 
children received and created unnecessary delays in getting services. 
In Arkansas, private, nonprofit mental health providers that contract 
with the state to provide community mental health said that state 
officials cut their funding and, as a result, they had to reduce the 
length of treatment sessions and increase the length of waiting lists. 
In Arkansas, Maryland, and New Jersey, state officials said that they 
contracted with private, nonprofit agencies to authorize the medical 
necessity of mental health services covered by Medicaid. Arkansas 
required preauthorization of all Medicaid-financed mental health 
services, including those that were legally required, such as the 
screening of foster children for mental health services. A variety of 
officials in this state and a parent reported that the preauthorization 
agency often denied services for children because they had not 
benefited from similar services in the past. For example, this parent 
said the preauthorization agency refused her son's therapist's request 
to hospitalize him to treat his suicidal behavior because past 
hospitalizations for suicide attempts had not reduced the behavior. In 
New Jersey, state mental health officials reduced the number of 
counties that had been targeted to implement the state's new child 
mental health system and limited the number of children served by the 
system. For example, officials from a variety of county agencies 
reported that the new system of care limited the number of children 
receiving the highest level of care in their county to 180 a year, 
although juvenile justice officials said that at least 500 children in 
their system alone needed such services. Officials from child welfare, 
mental health, and juvenile justice agencies said eligible children who 
did not receive the highest level of care were placed on waiting lists 
and provided less intensive services.

Officials from a variety of county agencies and some parents also 
reported that public schools in their county--in order to control 
costs--were often reluctant to provide individualized mental health 
services for special education children beyond services that are 
routinely available. For example, child welfare officials in 3 
locations we visited said schools fit children with a mental illness 
into preexisting programs, and school officials in two of these 
locations agreed, stating that children's IEPs could only contain 
services that were available in the schools. Almost all the parents 
that we interviewed said that school officials were reluctant to 
evaluate their children to determine eligibility for special education 
services or provide specialized services for them. For example, a 
parent of a child with a mental illness in Kansas said officials in her 
daughter's school refused to evaluate the child for a year and a half. 
After the evaluation, the school recommended that the child work with a 
learning disability specialist for 30 minutes a week, even though the 
parent said this service was insufficient and did not address her 
daughter's destructive, violent, and aggressive behavior.

As a result of the difficulties encountered at both mental health 
agencies and schools, some parents could not access the community-based 
services they needed to care for their child at home nor place their 
child in a residential treatment facility. In 4 of the 6 states that we 
visited, some teachers and mental health service providers encouraged 
parents to refuse to bring their child home from a hospital or other 
supervised placement, such as a detention center, when they were 
informed their child was being discharged in order to obtain mental 
services from child welfare agencies. Although these parents realized 
they were abandoning their child and, as a result, could be arrested 
and lose custody, they believed that this was the only alternative that 
remained to obtain services. Some parents that we interviewed told 
child welfare workers they would physically abuse their child in their 
presence to force them to place the child in their system if they could 
not get help for their child any other way, and juvenile justice 
officials told us other parents asked the police to arrest their 
children. However, officials in 2 of the states that we visited said 
children often remain hospitalized for months without appropriate 
services because child welfare agencies did not have the resources to 
provide the needed level of services or specialized placement, could 
not obtain resources from other agencies, or could not access 
appropriate services or placements that had the capacity to treat 
another child. In addition, although federal law does not require 
custody relinquishment to obtain mental health services, state child 
welfare officials in two states that we visited said that their state 
required parents to relinquish custody of their child to the state 
after the voluntary placement period ends. In one state, these 
officials misconstrued federal requirements and believed that they 
required relinquishment and in the other state, officials said 
relinquishment enabled them to have more control over the child's care.

Difficulties Meeting Eligibility Requirements for Mental Health 
Services:

Eligibility requirements for obtaining mental health services pose 
several challenges for parents. For example, state and local Medicaid 
officials in 3 states told us that some children lose their eligibility 
for Medicaid-funded services because their families' income increased 
beyond Medicaid's threshold or move in and out of eligibility as their 
families' income fluctuates. Also, some child welfare officials said 
some children receive Medicaid because they are in foster care and lose 
their eligibility when they return home if the family is not eligible. 
Alternatively, juvenile justice officials in 6 states said that 
children in juvenile justice correctional or detention facilities lose 
Medicaid eligibility and have to reapply to resume coverage when they 
are released from the facility.

In addition, in all 6 of the school districts we visited, schools used 
different eligibility criteria for mental health services than mental 
health or other child-serving agencies in their area. For example, 
school officials in 4 districts told us that some mentally ill children 
are not eligible for mental health services through their special 
education programs because they were making adequate educational 
progress or because behavior problems--rather than mental illness--
prevented them from making adequate progress. However, mental health 
officials who work with children attending some of these schools 
reported that schools often have a narrow definition of educational 
progress and do not recognize that inappropriate behavior might be a 
symptom of mental illness. For example, a parent of a child with 
attention deficit[Footnote 18] and bipolar[Footnote 19] disorders said 
her son's school refused to provide special education services for him 
because his lack of educational progress was due to his failure to pay 
attention and to get his work done, rather than his mental illness, and 
a parent of a bipolar, schizophrenic[Footnote 20] son said school 
officials told her that she was responsible for her son's behavior and 
poor school performance.

Although a variety of officials said schools had more restrictive 
eligibility requirements for mental health than other child-serving 
agencies, school officials in a county in California said that their 
county mental health agency used a more restrictive definition than the 
schools. In California, state law required that county mental health 
agencies treat children covered by Medicaid and SCHIP who were 
diagnosed as SED or who were eligible for special education 
services.[Footnote 21] California also requires that children be 
evaluated by county mental health agencies and fit a statutory 
definition of SED. School officials said that these children get 
priority and their services consumed all available county child mental 
health resources. According to these officials, other children, 
including children with dual diagnoses of mental illness and substance 
abuse, mental retardation, or autism-related disorders and children 
without the required diagnoses have to wait for county mental health 
services or might not receive services at all, although some may 
receive services through their school guidance counselors or social 
workers.

Misunderstandings of Agencies' Responsibilities and Resources:

Program officials' and service providers' misunderstandings of 
agencies' responsibilities and resources also affect service provision. 
For example, misunderstandings about Medicaid coverage created gaps and 
delays in services. In 3 states, some state and county officials did 
not know the Katie Beckett option could expand Medicaid coverage for 
children with a mental illness regardless of family status. In one of 
these states, a parent told us that county Medicaid officials 
incorrectly told her that her son was ineligible for coverage under 
this option because he had a two-parent family. In 2 other states, 
county mental health officials erroneously told us that this option 
applied only to children with very severe medical conditions. In 
another state, a Medicaid official did not know that children enrolled 
in SCHIP Medicaid expansion programs were eligible for EPSDT services. 
Furthermore, state child welfare officials in 2 states and mental 
health workers in a third did not know Medicaid's EPSDT provision 
includes mental health screenings, diagnosis, and treatment and thought 
the provision covered only physical health services.

In all 6 states, some parents, a variety of state and local officials, 
mental health service providers, caseworkers, and judges misunderstood 
the role and responsibilities of schools in implementing IDEA. For 
example, some parents we interviewed in 5 of these states said that 
their children waited over a year to receive special education services 
because they and the mental health professionals they worked with did 
not understand the procedures IDEA required schools to follow. For 
example, some parents were told that referrals for special education 
had to be in writing. Also, some parents and professionals 
misunderstood that IDEA gives all eligible children, including children 
with a mental illness, the right to a free appropriate education and 
parents did not know that they could appeal a school's decision about 
providing special education services. For example, a parent in Kansas 
agreed to home-school her 10-year old, sexually aggressive, child with 
a mental illness because the school would not put the child in a 
setting that would ensure the safety of his classmates. Despite her 
long-term involvement with a community mental health agency, this 
parent believed home schooling was her child's only option.

States Have Developed a Range of Practices That May Reduce the Need for 
Some Mental Health-Related Child Welfare and Juvenile Justice 
Placements:

Although few strategies were developed specifically to prevent mental 
health-related child welfare and juvenile justice placements, state and 
local officials identified a range of practices that they believe may 
prevent such placements by addressing key issues that have limited 
access to child mental health services in their state. State and local 
practices focused on three main areas: finding new ways to reduce costs 
or to fund services, consolidating services in a single location, and 
expanding community mental health services and supporting families. 
Although some programs were modeled on practices that had been 
evaluated in other settings, the effectiveness of the practices is 
unknown because many of them were implemented on a small scale in one 
location or with a small target group or were too new to be rigorously 
evaluated.

Finding New Ways to Reduce Costs or to Fund Services May Help Agencies 
Pay for Mental Health Treatment:

According to officials in the 6 states that we visited, one way to 
reduce the cost of services is to better match children's needs to the 
appropriate level of service. One goal of some of the programs we 
reviewed was to ensure that children with lower-level needs were served 
with lower-level and less expensive services, reserving the more 
expensive services for children with more severe mental illnesses. 
Under New Jersey's Systems of Care Initiative, the state contracted 
with a private, nonprofit organization for a variety of services, such 
as mental health screenings and assessments to determine the level of 
care needed, authorization of service, insurance determination, 
billing, and care coordination across all agencies involved with the 
children. When the Initiative is fully implemented statewide, the 
contractor in each county will use standardized tools to assess 
children's mental health and uniform protocols to determine appropriate 
levels of care. Children requiring lower levels of care will be 
referred to community-based providers, while children requiring a 
higher level of care will be approved to receive services from local 
Care Management Organizations specifically created to serve them. 
Presently, the System of Care Initiative has been implemented in 5 of 
the state's 21 counties.

As another cost-saving method, some programs substituted expensive 
traditional mental health providers with nontraditional and less 
expensive providers. Many state and local officials we interviewed in 5 
of the states we visited told us that the historic way to treat 
children with a mental illness included psychiatrists and residential 
placements. However, officials in New Jersey, Kansas, and Minnesota 
said their states had switched their focus to using less expensive 
providers such as using nurses to distribute medicines instead of 
psychiatrists or nontraditional bachelors-level workers for case 
management instead of masters-level social workers. For example, 
Uniting Networks for Youth--a private, county-based provider in 
Minnesota--used two commercially available, highly structured programs 
that allowed them to substitute lower-credentialed bachelor-level staff 
under the supervision of a masters-level clinician as the primary 
service provider instead of using higher-level clinicians. County 
officials told us this structured program has many safeguards, 
including the collection of extensive data from providers, teachers, 
and families that allow masters-level clinicians to review the 
appropriateness and effectiveness of provided mental health services.

In addition to reducing the cost of services, state officials in all 6 
states identified the blending of funds from multiple sources as 
another way to pay for services, thus working around agencies' 
limitations on the types of mental health services and placement 
settings each can fund. For example, in a county in Maryland, a local 
Coordinating Council blends funds from multiple agencies to provide 
community-based services to children with a mental illness involved 
with the judicial, child welfare, and mental health systems and with 
district special education programs. The Council, headed by a judge, 
leveraged funding by inviting key decision makers--those who could 
commit resources--from a variety of child-serving agencies and 
organizations, including the local departments of social services and 
juvenile justice, the public defenders office, prosecutors, attorneys, 
and Catholic Charities, to serve on the Council.

In addition to blending funds to pay for services, state officials in 4 
of the 6 the states that we visited identified the use of flexible 
funds, with few restrictions, to pay for nontraditional services that 
are not generally allowable under state guidelines. For example, 
Arkansas's Together We Can Program used flexible funds from a federal 
Social Services Block Grant, state general revenue, and the Title IV-B 
program to provide a wide array of nontraditional supportive services, 
such as in-home counseling, community activities, respite care, 
mentoring, tutoring, clothing, and furniture that helped the family 
care for the child at home and supported the child in his community.

Bringing Mental Health Services into a Single Location May Improve 
Access:

To improve access to mental health services and bring clarity to a 
confusing mental health system, 3 of the states that we visited 
developed a facility to be a single point of entry into the mental 
health system. Typically, several agencies are represented at the 
facility and children are assessed with a common instrument and 
eligible for the same services regardless of what agency had primary 
responsibility. Kansas's Shawnee County Child and Family Resource 
Center is a one-stop facility and, according to state mental health 
officials, a model for the rest of the state. The center houses workers 
from 11 social services agencies, including mental health, child 
welfare, juvenile justice, and education. All children with mental 
health needs, regardless of which agency first encountered the child, 
are referred to the center. Case managers at the Center assess the 
child's psychological, educational, and functional needs, determine 
appropriate services and placements, make referrals, provide direct 
counseling services, and determine how to pay for services. The 
facility includes four bedrooms for children who need to be removed 
from their homes for short periods of time and a secure juvenile 
justice intake suite that is staffed 24 hours a day.

State officials in all 6 of the states that we visited also identified 
co-locating services in public facilities such as schools and community 
centers as another way to improve access. In Harford County, Maryland, 
for example, mental health services are collocated at an elementary 
school specifically to improve access to care for students with a 
mental illness. Using county health and mental health funds, the school 
developed an in-house mental health clinic that provides mental health 
services through a bachelors-level social worker, a nurse practitioner, 
and consultative services from a physician and a psychiatrist. In 
addition, the school has a variety of internal support staff available 
to children with a mental illness, including a guidance counselor, a 
behavior specialist, a home visitor who supports families and assesses 
the home situation, and a pupil personnel worker who visits homes and 
helps with transportation issues. The school has several programs 
available to children with a mental illness, including an intensive, 
in-school program staffed with a full-time school psychologist; a 
mentoring program that is run by paid school staff, high school 
students, and volunteer community members; a program that provides 
counseling, tutoring, recreation, social skills groups, home visits, 
referrals, and some psychiatric rehabilitation services; a program to 
identify elementary school children with a mental illness and increase 
their access to services; and two collaborative programs with 
contracted mental health providers that provide community support and 
prevention services and intensive case management services.

Expanding Community Mental Health Services and Supporting Families May 
Improve Treatment for Children with a Mental Illness:

Officials from child-serving agencies in all 6 states we visited 
identified the expansion of the number and range of community-based 
services to provide an entire continuum of care as a way to improve 
treatment for children with a mental illness. Some programs we reviewed 
developed a complete range of community-based mental health services 
for children, including early intervention, diversion,[Footnote 22] 
transitional services, and crisis intervention. In addition, some 
programs supported families of children with a mental illness and 
encouraged parent involvement in their children's care. Examples of 
these programs follow.

Early Intervention: Working with local hospitals, workers from the 
Family Service and Guidance Center in Shawnee County, Kansas, screen 
newborns in local hospitals. If babies appear at-risk, social workers 
conduct home visits and refer families to health care professionals or 
others for support. The Center also developed a therapeutic preschool 
practice directed at 3-5 year old children, with or without a mental 
illness diagnosis, who were likely to need special education services 
when they entered kindergarten. The program serves 32-36 children and 
provides a half-day of services.

Diversion: Los Angeles' Juvenile Alternative Defense Effort (JADE) was 
designed to prevent or reduce the time of expensive juvenile justice 
placements for youths with mental illness, by arranging assessments, 
providing referrals to mental health providers and advocating for these 
youth to ensure they receive the treatment they need. Upon referral to 
JADE, a psychiatric social worker performs an extensive psychosocial 
evaluation, including a developmental history, family history, and 
educational history that includes failures and successes, delinquency 
behaviors, and a mental health status exam. Based on the evaluation, 
the social worker makes placement and service recommendations to the 
juvenile court judge. JADE officials said that the evaluations and 
recommendations give the judges the information they need to consider 
alternatives to incarceration.

Transitional Services: State and county juvenile justice and mental 
health officials in all 6 states we visited stressed the importance of 
including transitional services in a continuum of care. These services 
are typically provided to a child leaving a residential setting and 
returning to his or her home or community. For example, Minnesota's Red 
Wing facility is a secure juvenile justice facility that provides in-
house mental health services and places a strong focus on transitional 
services so youth can successfully reenter their own community. The 
transition program is designed with various levels that allow youth who 
exhibit good behavior to move to lower levels of supervision. For 
instance, at level 4, youth begin to transition back to the community 
by making periodic visits to their homes. At level 5, youth move to a 
transitional living unit at Red Wing that focuses on applying new 
skills to activities in their homes and communities. After youth leave 
Red Wing, a county juvenile justice worker monitors them for 90 days.

Crisis Intervention: Programs we reviewed in 4 states had a mobile 
crisis unit consisting of teams of staff that visit homes to stabilize 
crisis situations. Funding, staffing, and authority of these teams 
vary. Some of the crisis teams can provide direct mental health 
services; others conduct assessments and make emergency petitions to 
psychiatric hospitals on behalf of the family. One of the difficulties 
noted by program officials is determining how to pay for crisis 
services since these services may not be covered by insurance and 
families may not have the ability to pay. In Harford County, Maryland, 
the mobile crisis team is not a fee-for-service provider but is funded 
by a grant. The team--a psychiatrist, a psychologist, and a licensed 
social worker--provide direct mental health services and are authorized 
to make emergency petitions to get a child with a mental illness 
admitted to a hospital psychiatric unit.

A second way some states improve treatment for children with a mental 
illness is to provide services to support families and encourage 
parental involvement in their child's care. State and local officials 
in all 6 states pointed out that involving parents was a fundamental 
change in philosophy. Previously, services were provided solely to the 
children and parents were not included in the decisions about their 
child's care. Now, the focus is on providing the services parents need 
to maintain the child in the home and helping parents make informed 
decisions about their child's care. For example, The Sycamores, a 
residential mental health facility in Los Angeles County, California, 
works extensively with parents of children with severe mental illness 
at its facility and requires their participation. The Sycamores also 
provides a variety of supportive services, including household items 
and services such as transportation to and from the facility. In 
addition, as part of its transitional program, The Sycamores uses 
Therapeutic Behavioral Services (TBS), one-on-one services provided 
whenever needed 24 hours a day, 7 days a week to assist youth in 
maintaining their current living situation and in developing the coping 
and problem-solving skills needed.

Concluding Observations:

Some parents are placing their children, mostly adolescent boys with 
severe mental illness, in the child welfare and juvenile justice 
systems to access mental health services. Although these children may 
not have been abused or neglected, or may not have committed a criminal 
or delinquent act, parents are turning to these agencies because they 
see no alternatives for obtaining comprehensive services for them. 
Because federal, state, and local agencies do not systematically track 
these children, the extent and outcomes of these placements are not 
fully known. To determine the extent to which children may be placed 
inappropriately in the child welfare and juvenile justice systems in 
order to obtain mental health services, we recommended in our April 
2003 report that the Secretary of HHS and the Attorney General 
investigate the feasibility of tracking these children to determine the 
extent and outcomes of these placements. In commenting on a draft of 
that report, DOJ agreed that tracking should take place, but only in 
the short term, and that HHS should take the lead in such an effort. 
HHS said that asking agencies to track this population does not address 
the lack of mental health resources for families and communities and 
does not address the problems of the children and their families. 
However, we believe that knowledge of the extent of this practice is a 
necessary first step to determine what corrective actions might be 
taken and may be useful in identifying which progressive practices will 
most benefit these children.

Experts, agency officials, and service providers agree that agencies 
must work together to meet the needs of children with severe mental 
illness because these children have complex problems and are likely to 
need services from multiple agencies if they are to remain in their 
communities or if they are to successfully transition from a 
residential facility back to their communities. However, in some cases, 
state and local officials' misunderstandings of each agency's service 
requirements, responsibilities, and resources prevent the provision of 
interagency services that have the potential to address the needs of 
these children and their families. In our April 2003 report, we 
recommended that the Secretaries of HHS and Education and the Attorney 
General develop an interagency working group (including representatives 
from CMS, SAMHSA, and ACF) to identify the causes of these 
misunderstandings and to create an action plan to address those causes. 
All three agencies said they would participate in any interagency 
working group that might be established based on our recommendation and 
DOJ recommended using the existing Coordinating Council on Juvenile 
Justice and Delinquency Prevention for the purposes we stated. We 
believe several organizational entities may be appropriate and that the 
member agencies forming this group should determine the entity that is 
best suited.

Although states and counties are implementing practices that may reduce 
the need for parents to place their children with child welfare or 
juvenile justice agencies, many of the programs are new, small, and 
only serve children in specific localities. Furthermore, their 
effectiveness in achieving their multiple goals--such as reducing the 
cost of mental health services, supporting families, and helping 
children overcome their mental illnesses--has not yet been fully 
evaluated. Given that states and localities are developing new 
approaches to meeting the needs of children with mental illness, it is 
important that the federal government continue its role in supporting 
evaluations of these programs and disseminating the results. To further 
such efforts, we recommended in the report that the agencies continue 
to encourage states to evaluate the child mental health programs that 
the states fund or initiate. In commenting on a draft of our April 2003 
report, Education said that no recommendations were made for increased 
grant spending to duplicate or disseminate the positive features of the 
practices we highlighted. As a result, we added a recommendation that 
the Secretaries of HHS and Education and the Attorney General determine 
the most effective means of disseminating the results of these and 
other available studies to state and local entities.

Madam Chairman, this concludes my prepared statement. I would be 
pleased to respond to any questions that you or other members of the 
Committee may have.

GAO Contact and Acknowledgments:

For further contacts regarding this testimony, please call Cornelia M. 
Ashby at (202) 512-8403. Individuals making key contributions to this 
testimony include Diana Pietrowiak and Kathleen D. White.

[End of section]

Related GAO Products:

Child Welfare and Juvenile Justice: Federal Agencies Could Play a 
Stronger Role in Helping States Reduce the Number of Children Placed 
Solely to Obtain Mental Health Services. GAO-03-397. Washington, D.C.: 
April 21, 2003.

Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's 
Access to Care. GAO-03-222. Washington, D.C.: January 14, 2003.

Mental Health Services: Effectiveness of Insurance Coverage and Federal 
Programs for Children Who Have Experienced Trauma Largely Unknown. GAO-
02-813. Washington, D.C.: August 22, 2002.

Medicaid and SCHIP: Recent HHS Approvals of Demonstration Waiver 
Projects Raise Concerns. GAO-02-817. Washington, D.C.: July 12, 2002.

Foster Care: Recent Legislation Helps States Focus on Finding Permanent 
Homes for Children, but Longstanding Barriers Remain. GAO-02-585. 
Washington, D.C.: June 28, 2002.

Long-term Care: Implications of Supreme Court's Olmstead Decision Are 
Still Unfolding. GAO-01-1167T. Washington, D.C.: September 24, 2001.

Medicaid and SCHIP: States' Enrollment and Payment Policies Can Affect 
Children's Access to Care. GAO-01-883. Washington, D.C.: September 10, 
2001.

Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health 
Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001.

Medicaid Managed Care: States' Safeguards for Children With Special 
Needs Vary Significantly. GAO/HEHS-00-169. Washington, D.C.: September 
29, 2000.

Children with Disabilities: Medicaid Can Offer Important Benefits and 
Services. GAO/T-HEHS-00-152. Washington, D.C.: July 12, 2000.

Mental Health Parity Act: Employer's Mental Health Benefits Remain 
Limited Despite New Federal Standards. GAO/T-HEHS-00-113. Washington, 
D.C.: May 18, 2000.

Mental Health Parity Act: Despite New Federal Standards, Mental Health 
Benefits Remain Limited. GAO/HEHS-00-95. Washington, D.C.: May 10, 
2000.

Medicaid Managed Care: Challenges in Implementing Safeguards for 
Children with Special Needs. GAO/HEHS-00-37. Washington, D.C.: March 3, 
2000.

Children's Health Insurance Program: State Implementation Approaches 
are Evolving, GAO/HEHS-99-65. Washington, D.C.: May 14, 1999.

FOOTNOTES

[1] Federal agencies and states have varying definitions for children 
with serious emotional disturbances (SED). For example, the Department 
of Health and Human Services' (HHS) Substance Abuse and Mental Health 
Services Administration (SAMHSA) defines SED as a diagnosable mental 
disorder found in persons from birth to 18 years of age that is so 
severe and long lasting that it seriously interferes with functioning 
in family, school, community, or other major life activities. Because 
of these differences, we use the term "children with severe mental 
illness" to describe such children throughout this statement.

[2] Child welfare systems are designed to protect children who have 
been abused or neglected by, for example, placing children in foster 
care or providing family preservation services; and juvenile justice 
systems are designed to rehabilitate children who have committed 
criminal or delinquent acts or status offenses--that is, according to 
the Department of Justice (DOJ), behaviors that are law violations only 
if committed by juveniles--and to prevent such acts from occurring. 
Consequently, the goals of these systems and the background and 
training of their staff reflect these purposes. In addition, parents 
cannot voluntarily place their children in the juvenile justice system. 
Children are detained in this system as a result of their delinquent 
acts or status offenses. However, parents sometimes request that police 
arrest their children for behaviors that are related to or stem from 
their mental illness when they cannot obtain services through other 
means. In this statement, we use the term "placed" to refer both to 
children who have been voluntarily placed in the child welfare system 
and children who enter the juvenile justice system to receive mental 
health services. Because information was not available, we were not 
able to report on whether parents relinquished custody of their 
children to obtain the services.

[3] Child-serving agencies include mental health, Medicaid and State 
Children's Health Insurance Program (SCHIP), juvenile justice, 
education, and child welfare.

[4] We did not interview judges in Minnesota primarily due to 
scheduling conflicts.

[5] U.S. General Accounting Office, Mental Health Services: 
Effectiveness of Insurance Coverage and Federal Programs for Children 
Who Have Experienced Trauma Largely Unknown, GAO-02-813 (Washington, 
D.C.: Aug. 22, 2002).

[6] The 11 states are: Alaska, Colorado, Connecticut, Iowa, Maine, 
Minnesota, North Dakota, Oregon, Rhode Island, Wisconsin, and Vermont.

[7] The 8 states are: Florida, Georgia, Hawaii, Kansas, Missouri, 
Montana, New Hampshire, and Texas.

[8] U.S. General Accounting Office, Health Insurance: States' 
Protections and Programs Benefit Some Unemployed Individuals, 
GAO-03-191 (Washington, D.C.: Oct. 25, 2002).

[9] This waiver authority for seriously ill children was inspired by 
the case of a ventilator dependent child, Katie Beckett. Katie's mother 
successfully argued that the nursing services her daughter required 
could be provided in her home and at a cost less than that of providing 
the same care in a hospital. What resulted was the so-called "Katie 
Beckett Waiver," enacted as part of the Tax Equity and Fiscal 
Responsibility Act of 1982. 

[10] A state that chooses a stand-alone or combination SCHIP program 
may introduce limited cost sharing and base its benefit package on one 
of several benchmarks specified in the statute, such as the Federal 
Employees Health Benefit program, or state coverage. See 42 U.S.C. 
1397cc(a) and (b) and U.S. General Accounting Office, Children's 
Health Insurance Program: State Implementation Approaches are Evolving, 
GAO/HEHS-99-65 (Washington, D.C.: May 14, 1999).

[11] These four states were Alaska, Illinois, Louisiana, and South 
Carolina.

[12] In commenting on a draft of our April 2003 report, DOJ said that, 
in the absence of formal tracking and official data, describing with 
any certainty the characteristics of youth placed voluntarily by their 
parents in the juvenile justice system is impossible.

[13] Autism is a developmental disability typically affecting the 
processing, integrating, and organizing of information that 
significantly impacts communication, social interaction, functional 
skills, and educational performance.

[14] These services are generally provided by licensed or certified 
psychiatrists, psychologists, or masters-level social workers.

[15] Respite care refers to the supervision of mentally ill or other 
disabled children by a trained caretaker for brief periods of time in 
order to provide parents relief from the strain of caring for a child 
with serious mental illness. Wrap-around services encompass a variety 
of community supports, including counseling, mentoring, tutoring, and 
economic services that are designed to meet the individual needs of 
children and their families. 

[16] In commenting on a draft of our April 2003 report, a Kansas 
official said that the state had expanded the services the state 
provides under the Rehabilitation option and does not limit the 
services to 60 days, but bases services on the individual clinical and 
medical needs of the child.

[17] U.S. General Accounting Office, Medicaid: Stronger Efforts Needed 
to Ensure Children's Access to Health Screening Services, GAO-01-749 
(Washington, D.C.: July 13, 2001).

[18] Attention deficit disorder is a syndrome characterized by serious 
and persistent difficulties in attention span, impulse control, and, 
sometimes, hyperactivity.

[19] Bipolar disorder is characterized by the occurrence of one or more 
major depressive episodes accompanied by at least one manic episode 
over a brief time interval.

[20] Schizophrenia is a cluster of disorders characterized by 
delusions, hallucinations, disordered thinking, and emotional 
unresponsiveness.

[21] The California legislature transferred the responsibility for 
providing mental health services to children in special education from 
schools to counties in the late 1980s. 

[22] Diversion programs attempt to prevent or reduce the time children 
spend in inappropriate placements.