This is the accessible text file for GAO report number GAO-03-397 
entitled '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' which was released on 
April 21, 2003.



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entitled ‘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’.



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Report to Congressional Requesters:



United States General Accounting Office:



GAO:



April 2003:



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 

Children’s Services:



GAO-03-397:



GAO Highlights:



Highlights of GAO-03-397, a report to Congressional Requesters



Why GAO Did This Study:



Recent news articles in over 30 states describe the difficulty many 

parents have in accessing mental health services for their children, 

and some parents choose to place their children in the child welfare or 

juvenile justice systems in order to obtain the services they need. GAO 

was asked to determine: (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.



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 mental health services, limited availability of 

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 to 

fund mental health services, improving access to mental health 

services, and expanding the array of available services. Few of these 

practices have been rigorously evaluated.



What GAO Recommends:



The Departments of Health and Human Services (HHS) and Justice (DOJ) 

should consider the feasibility of tracking children placed by their 

parents in the child welfare and juvenile justice systems to obtain 

mental health services. HHS, DOJ, and the Department of Education 

(Education) should develop an interagency working group to identify the 

causes of the misunderstandings at the state and local levels and 

create an action plan to address those causes. These agencies should 

also continue to encourage states to evaluate the programs that the 

states fund or initiate and determine the most effective means of 

disseminating the results of these and other available studies. 



www.gao.gov/cgi-bin/getrpt?GAO-03-397.



To view the full report, 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]



Contents:



Letter:



Results in Brief:



Background:



While No Formal Tracking Occurs, Available Estimates Indicate That Many 

Children Were Placed with the State--Primarily Adolescent Males--to 

Access Mental Health Services:



Multiple Factors Influence Decisions to Place Children:



States Have Developed a Range of Practices That May Reduce the Need for 

Some Mental Health-Related Child Welfare and Juvenile Justice 

Placements:



Conclusions:



Recommendations:



Agency Comments:



Appendix I: Scope and Methodology:



Appendix II: State Statutes Containing Language Allowing 

Voluntary Placement to Obtain Mental Health 

Services:



Appendix III: Comments from the Department of Education:



Appendix IV: Comments from the Department of Health and Human Services:



Appendix V: Comments from the Department of Justice:



Appendix VI: GAO Contacts and Acknowledgments:



GAO Contacts:



Acknowledgments:



Related GAO Products:



Tables:



Table 1: Characteristics of Key Agencies with Responsibilities for 

Children with a Mental Illness:



Table 2: States’ Estimated Number of Children Placed in the Child 

Welfare System to Obtain Mental Health Services in Fiscal Year 2001:



Table 3: Estimated Number of Children Placed in the Juvenile Justice 

System in 33 Counties to Obtain Mental Health Services in Fiscal Year 

2001:



Table 4: Key Features of Health Insurance Parity Laws in 6 States:



Table 5: Key Medicaid and SCHIP Programs for Children with Mental 

Illness in 6 States:



Table 6: Survey Numbers and Response Rates:



Table 7: Statutes in 11 States Allowing Parents to Place Children in 

Child Welfare Systems in Order to Obtain Mental Health Services While 

Retaining Custody of the Child:



Abbreviations:



ACF: Administration for Children and Families:



AFCARS: Adoption and Foster Care Analysis and Reporting System:



CMS: Centers for Medicare & Medicaid Services:



DOJ: Department of Justice:



EPSDT: Early Periodic Screening, Diagnostic and Treatment:



ERISA: Employee Retirement Income Security Act:



HCBS: Home and Community-Based Services:



HHS: Health and Human Services:



IDEA: Individuals with Disabilities Education Act:



IEP: Individualized Education Program:



JADE: Juvenile Alternative Defense Effort:



MHPA: Mental Health Parity Act:



OSERS: Office of Special Education and Rehabilitative Services:



OJJDP: Office of Juvenile Justice and Delinquency Prevention:



SAMHSA: Substance Abuse and Mental Health Services Administration:



SCHIP: State Children’s Health Insurance Program:



SED: serious emotional disturbances:



SSI: Supplemental Security Income:



TANF: Temporary Assistance for Needy Families:



TBS: Therapeutic Behavioral Services:



TEFRA: Tax Equity and Fiscal Responsibility Act:



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United States General Accounting Office:



Washington, DC 20548:



April 21, 2003:



The Honorable Susan M. Collins

United States Senate:



The Honorable Pete Stark

The Honorable Patrick Kennedy

House of Representatives:



Recent news articles in over 30 states and prominent mental health 

advocacy organizations have reported on the difficulty many parents 

have accessing mental health services for their children with severe 

mental illness.[Footnote 1] In some cases, parents must choose to keep 

their children at home without receiving the mental health and 

supportive services that they need or to remove them from their home 

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] Although the people 

and conditions described in the reports varied, all documented that 

many children with severe mental illness needed services such as 

psychiatric and family support services that are not readily accessible 

in their communities. Various federal laws require that state and local 

agencies provide services to disabled children, including children with 

a mental illness, in the least restrictive 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.



Several federal agencies have various responsibilities for children 

with mental health needs. For example, HHS’sSAMHSA provides funds and 

guidance to help states and localities address the needs of children 

with mental illness. HHS’s Centers for Medicare & Medicaid Services 

(CMS) administers both the Medicaid Program and the State Children’s 

Health Insurance Program (SCHIP). These programs provide funds to 

states for public health insurance programs, which can cover mental 

health services, for the approximately 26.5 million enrolled children 

who are members of low-income families and certain children with 

disabilities. Similarly, the Department of Education’s (Education) 

Office of Special Education and Rehabilitative Services (OSERS) 

provides funding and technical assistance to help states provide needed 

services, including mental health services, to disabled children with 

special education needs. Title IV-E of the Social Security Act provides 

reimbursement for foster care maintenance payments to states, which is 

available when child welfare agencies place eligible children in 

approved out-of-home settings, including some residential treatment 

facilities.[Footnote 3],[Footnote 4] In many cases, these costs are 

high; residential treatment facilities can cost over $250,000 a year 

for one child. Federal law does not require parents to relinquish their 

parental rights to place their children with child welfare agencies. 

However, after children have been in care for a specific period of 

time, the law requires the court to review the child’s status and 

determine the best interest of the child--which, in some cases, may 

include termination of parental rights.



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 5] 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 6] Laws in the 

remaining states are generally silent regarding voluntary placements 

for mental health. (See app. II for a description of state placement 

statutes.):



You asked us to determine: (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) promising state and local 

practices that may reduce the need for some child welfare and juvenile 

justice placements.



To address your questions, 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, rather than at the state level, because of the decentralized 

nature of the juvenile justice system. In addition, we researched state 

laws and regulations regarding voluntary placement and relinquishment 

of parental rights, and interviewed officials of child-serving 

agencies,[Footnote 7] caseworkers, and parents in 6 states (Arkansas, 

California, Kansas, Maryland, Minnesota, and New Jersey) and judges in 

5 states. We chose these states because they represented diversity in 

geographical location, legal requirements concerning children’s 

placement, use of Medicaid waivers and optional services,[Footnote 8] 

and the role of state and county agencies in administering child 

welfare and juvenile justice programs. Also, we observed programs that 

state officials identified as model programs in those 6 states and 

interviewed key federal officials and national experts. A more detailed 

discussion of our scope and methodology appears in appendix I. We 

conducted our work between March 2002 and February 2003 in accordance 

with generally accepted government auditing standards.



Results in Brief:



State child welfare officials in 19 states and county juvenile justice 

officials in 30 counties who responded to our surveys 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. However, this estimate understates the prevalence of these 

children for two reasons. First, 32 state 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 could not provide an estimate, such 

placements occurred in their state. Also, we surveyed juvenile justice 

officials in only 33 counties, 30 of which responded with an estimate. 

Moreover, no formal or comprehensive federal or state tracking of such 

placements occurs. According to the officials we interviewed, many of 

these children 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. For example, some parents found they were not able to meet 

the needs of other children in the family or fulfill job-related 

responsibilities.



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. Some parents we spoke to in all 6 states 

reported these factors often created delays or prevented them from 

obtaining the mental health services that their children needed. 

According to child welfare, child mental health, and juvenile justice 

officials, a number of parents placed children in the child welfare and 

juvenile justice systems because their health insurance had 

limitations, such as restrictions on mental health services. These same 

officials said some mental health services, such as child psychiatric 

and residential services, were in short supply. In all the states we 

visited, some parents who could not afford or access needed mental 

health services said they sought help from mental health agencies and 

schools but reported these agencies had limited resources. Parents 

seeking placements for children in residential treatment facilities 

faced further challenges. Mental health and education officials in the 

6 states we visited did not support residential placement for children 

except in extraordinary situations because federal law requires that 

mental health officials provide services for children in the least 

restrictive setting as possible and requires education officials to 

educate children with disabilities with children who are not disabled 

to the maximum extent possible. These officials believed providing 

services in a community-based program is a better option for children 

and families than providing services in residential treatment 

facilities. In addition, some parents in all 6 states said gaps in 

services occurred because child-serving agencies have different 

eligibility requirements for programs and this made it difficult for 

them to access the child mental health and family support services they 

needed from various agencies. For example, children who were eligible 

for psychological services under Medicaid could lose these services if 

their families’ income increases beyond eligibility thresholds. 

Finally, 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. Federal officials, experts, and service 

providers agreed that agencies must work together to meet the needs of 

children. Although federal officials work together on various advisory 

and information-sharing committees, co-sponsor programs designed to 

help children with a mental illness, and disseminate much guidance 

regarding their policies and programs, some state and local officials 

with responsibilities for children with a mental illness did not 

understand the program requirements and capacities of their agencies 

and other child-serving agencies.



Officials in all 6 states that we visited identified a range of 

practices in their states that they believe may help reduce the need 

for some child welfare and juvenile justice placements. Overall, these 

practices are consistent with those suggested by federal agencies and 

child mental health experts, and most parents we spoke with who had 

children in these programs found these practices helpful. However, the 

effectiveness of the practices is generally unknown because many were 

new and few were rigorously evaluated. In addition, many of these 

practices served a small number of children or only served children in 

specific locations. To fund mental health services, some state and 

county officials developed practices that increased the use of less 

expensive services and providers and distributed mental health costs 

among several agencies so no single agency paid the entire cost of a 

child’s care. For example, a program in Minnesota used experienced, 

masters-level staff to supervise less experienced, bachelor-level staff 

instead of using the more costly master’s level workers as the primary 

service provider. States and counties identified several practices that 

may improve access to mental health services, such as providing a 

variety of services for children in a convenient public facility and 

creating a single entity with responsibility for meeting children’s 

mental health needs. For example, a service provider in Kansas operated 

a facility that housed a variety of county child welfare, juvenile 

justice, and education service providers as well as county child mental 

health providers. States and counties also identified several practices 

that may improve the treatment of children with a mental illness, such 

as expanding the array of available mental health services for children 

and addressing the needs of the family to help the family maintain 

children with a mental illness at home. For example, in one city in 

Kansas, caseworkers from one mental health center worked with families 

of children with severe mental illness to identify community supports 

and services, such as mentors and after-school programs, which support 

the entire family.



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 are recommending that the Secretary of 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 

recommend that the Secretaries of HHS and Education and the Attorney 

General develop an interagency working group to identify the causes of 

these misunderstandings and create an action plan to address those 

causes. We further recommend that these agencies continue to encourage 

states to evaluate the child mental health programs that the 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 this report, 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 discussed in this report will 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 and DOJ suggested an existing 

group as the forum. HHS, however, said that such a group would do 

little to address the lack of resources. Education also said we should 

be more specific on the role of the interagency working group and added 

that such a group would not have the power to address congressional 

lawmaking.



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 depending on their type of coverage and where 

they lived.[Footnote 9]



At the federal level, several federal agencies--including HHS’s SAMHSA, 

CMS, and the Administration for Children and Families (ACF); DOJ’s 

Office of Juvenile Justice and Delinquency Prevention (OJJDP); and 

Education’s 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 

Children with a Mental Illness:



Department and agency: HHS (CMS); Key activities related to 

children’s mental health: Administers the Medicaid and SCHIP programs 

that provide health insurance coverage, including some coverage for 

severe mental illness; Awards research grants; Provides technical 

assistance to state agencies; [Empty]; Authorizing 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 

of 1997 (ASFA) 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; [Empty]; Authorizing Statute: Title IV, 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; [Empty]; Authorizing 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 provides 

block grant funding that enables the states to maintain and enhance 

mental health services; Sponsors the Systems of Care Initiative to 

help children and adolescents with severe 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; [Empty]; Authorizing 

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; [Empty]; Authorizing 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, 

Department of DOJ’s Division of Civil Rights, and HHS’s and Education’s 

Office of Civil Rights, also have responsibilities for children with 

disabilities, including children with a mental illness.



[End of table]:



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 Safe and Drug Free 

Schools 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. This program awarded 

grants--about $53.2 million in fiscal year 2001--to some local school 

districts that formed partnerships with local mental health and law 

enforcement agencies to provide comprehensive planning and services for 

children with emotional and behavioral disorders. In addition, ACF, 

Education, SAMHSA, and a private foundation are jointly administering a 

program that assesses the collaborative processes being used to provide 

multiagency services to very young children affected by mental illness 

and substance abuse. At the state and county level, a similar array of 

agencies provides or funds services for children with a mental illness, 

and state and federal laws and policies often determine their roles and 

responsibilities. In addition, federal agencies play an important 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 generally adhere to the principle of the “least restrictive 

environment.”[Footnote 10] This principle assumes that children, like 

adults, have liberty interests that include the right to live in a 

family situation. 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 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 provide 24 hours of care, 7 days a week, 

can cost $250,000 a year or more. Nationwide, 88 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 11]



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 heath 

parity bills. Most of these laws meet or exceed the federal MHPA 

standard. However, the Employee Retirement Income Security Act (ERISA) 

of 1974 preempts states from directly regulating self-funded, employer-

sponsored health plans; under such circumstances, state requirements 

usually do not apply.



For more than 30 years, Medicaid has provided comprehensive health 

coverage for children from low-income families. Although individual 

states determine many coverage, eligibility, and administrative 

details, the federal government has established certain requirements 

for state Medicaid programs. These requirements include providing 

preventive screening and necessary treatment of any detected health 

condition for children. Under Medicaid, a state may apply for waivers 

from the federal government, which exempt the state from 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 12] 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. Under this option, children can obtain services in nonmedical 

settings, including school-based or other day treatment and home-based 

services.



States can expand public health insurance for uninsured children from 

low-income families by implementing SCHIP programs. States have three 

options in designing SCHIP programs. They may (1) expand Medicaid 

programs to include children from low-income families with earnings too 

high to qualify for Medicaid, (2) develop a separate child health 

insurance program with benefits that differ from those offered under 

Medicaid, or 

(3) provide a combination of both. Twenty-four states are implementing 

SCHIP by expanding Medicaid. Fourteen states are enrolling children 

into separate non-Medicaid plans. Other states use a combination of 

Medicaid and non-Medicaid plans to serve children in families at 

different income levels. If a state elects to implement SCHIP by 

expanding Medicaid, it must offer the same benefit package to SCHIP 

beneficiaries as it does to Medicaid beneficiaries.



In addition, states operating SCHIP Medicaid-expansion or Medicaid-

combination programs must also screen children for various conditions 

so that health problems can be found early and treated before they 

worsen. This Medicaid requirement for Early and Periodic Screening, 

Diagnostic and Treatment services (EPSDT) requires states to provide 

children and adolescents under age 21 with access to comprehensive, 

periodic evaluations of health, developmental and nutritional status, 

as well as vision, hearing, and dental needs. States must provide all 

services needed for conditions discovered through routine pediatric 

screenings regardless of whether the service is covered for other 

beneficiaries by the state Medicaid plan. In 2000, more than 1 million 

children were enrolled in SCHIP Medicaid expansion programs and were, 

therefore, eligible for EPSDT screens.



Certain disabled children, including children with a mental illness, 

may qualify for monthly Supplemental Security Income (SSI) if they and 

their families have little or no income and resources and they meet 

SSI’s definition of disability. To meet SSI’s definition, a child must 

have a physical or mental condition or conditions that can be medically 

proven, and which result in marked and severe functional limitations; 

the condition or conditions must last or be expected to last at least 

12 months or be expected to result in death; and the child may not work 

at a job that is considered substantial work. The monthly SSI depends 

generally on where the child lives and his or her parents’ assets. 

However, the monthly SSI payment for children living in certain 

institutions throughout a month, where private health insurance paid 

for their care or when Medicaid paid more than half of the cost of 

their care, is currently capped at $30.[Footnote 13]



While No Formal Tracking Occurs, Available Estimates Indicate That Many 

Children Were Placed with the State--Primarily Adolescent Males--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, to child welfare and 

juvenile justice agencies so that the children could receive mental 

health services. Nationwide, the 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. 

Additionally, officials in 11 states that could not provide estimates 

indicated that such placements occurred in their state. Moreover, we 

surveyed juvenile justice officials in only 33 counties, with 30 

providing 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. For example, some 

parents are not able to meet the needs of children in the home and some 

found that they were less able to meet work demands.



Some Officials Estimate That Parents Placed Over 12,700 Children to 

Access Mental Health Services:



The state child welfare officials and county juvenile justice officials 

who responded to our surveys 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 number 

of children placed in the child welfare system.[Footnote 14] 

Approximately 9,000 children entered the juvenile justice system. 

County juvenile justice officials reported estimates that 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: [D].



State: Arizona; Number of children placed: [D].



State: California; Number of children placed: [B].



State: Colorado; Number of children placed: [B].



State: Connecticut; Number of children placed: 738.



State: District of Columbia; Number of children placed: [C].



State: Delaware; Number of children placed: 0.



State: Florida; Number of children placed: [C].



State: Georgia; Number of children placed: [C].



State: Hawaii; Number of children placed: [C].



State: Iowa; Number of children placed: [D].



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: [C].



State: Kentucky; Number of children placed: 14.



State: Louisiana; Number of children placed: [A].



State: Massachusetts; Number of children placed: [B].



State: Maryland; Number of children placed: 54.



State: Maine; Number of children placed: [D].



State: Michigan; Number of children placed: [B].



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



State: Missouri; Number of children placed: [C].



State: Mississippi; Number of children placed: 13.



State: Montana; Number of children placed: [C ,D].



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



State: North Dakota; Number of children placed: [D].



State: Nebraska; Number of children placed: [B].



State: New Hampshire; Number of children placed: [C].



State: New Jersey; Number of children placed: [B].



State: New Mexico; Number of children placed: [B].



State: Nevada; Number of children placed: 20.



State: New York; Number of children placed: [B].



State: Ohio; Number of children placed: [D].



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: [D].



State: Tennessee; Number of children placed: [D].



State: Texas; Number of children placed: [C].



State: Utah; Number of children placed: [D].



State: Virginia; Number of children placed: [D].



State: Vermont; Number of children placed: 60.



State: Washington; Number of children placed: 423.



State: Wisconsin; Number of children placed: [B].



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



State: Wyoming; Number of children placed: 5.



State: Total; Number of children placed: 3,680.



Source: GAO survey.



[A] State did not respond to our survey.



[B] State could not provide the data requested.



[C] State officials said the practice of voluntary placement is not 

legal in the state.



[D] State could not provide the data requested, but indicated that 

voluntary placement happens.



[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 was unable to estimate 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 

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--confirmed 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 15] Information on 

the prevalence of children present in the juvenile justice system is 

also limited in this report since we surveyed only 33 counties. In 3 of 

those counties, juvenile justice officials reported that while they 

were not able to provide estimates, 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 track in a formal or comprehensive way 

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 database 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 could not provide 

information about the gender and ages of children placed in their 

system, most children in the juvenile justice population are male and 

range in age from 13 to 18.[Footnote 16]



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, their parents, 

or their siblings and often prevented their parents from meeting the 

needs of the other children in the family. For example, in Kansas, one 

parent reported that her three other children refused to remain in the 

home with her son who has bipolar disorder,[Footnote 17] is very 

aggressive, and has molested other children in the past. In Maryland, 

officials from both state and county child-serving agencies told us 

about a teenage boy who was mentally ill, developmentally disabled, 

autistic, 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 who are seriously mentally ill 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. One such child in Maryland was 

rejected by facilities that serve the developmentally disabled because 

he was mentally ill and rejected by facilities that serve the mentally 

ill because he was developmentally disabled. Moreover, parents and 

officials in 4 of the 

6 states that we visited also told us of youth who were not only 

mentally ill, but who also abused illegal drugs and alcohol as a way to 

self-medicate their mental illnesses.



Children who are placed or are at risk of placement come from families 

that span a variety of economic levels. Officials from state and county 

child-serving agencies in all 6 states that we visited reported that 

families of all economic levels have placed children or are at risk of 

doing so. Officials in child-serving agencies in all of the 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 for them. Private health insurance plans 

often have gaps and limitations in the mental health coverage they 

provide--for example, some may not cover certain mental illnesses and 

others may limit the amount and type of services that are covered--and 

not all children covered by Medicaid received needed services. Even 

when parents could afford mental health services, some could not access 

services--such as child psychiatric services--at times when they needed 

those services because of an inadequate supply of such services. In 

other instances, some mental health agencies and schools have limited 

resources to provide mental health services and are required to serve 

children in the least restrictive environment possible or to educate 

eligible disabled children with children who are not disabled to the 

maximum extent possible, respectively--which can limit the alternatives 

available to parents whose 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 18] 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 19] although mental health 

officials and service providers in the states that we visited said 

these services were often necessary to help families maintain their 

severely children with a mental illness in their homes. Furthermore, 

federal law[Footnote 20] preempts states from directly regulating self-

funded, employer-sponsored health insurance plans and in doing so 

exempted many families from the enhanced benefits and protections found 

in state parity laws. Table 4 shows the key features of these laws.



Table 4: Key Features of Health Insurance Parity Laws in 6 States:



State: Arkansas; Major provisions: * Does not apply to state employees 

and companies with less than 50 workers; * Exempts any group health 

plan whose costs increase 1 percent or more due to the act’s 

application; * Does not apply to health insurance plans if the act’s 

application to these plans will result in an increase in the cost of 

the health plan of at least 1.5 percent; Meets FMPHA: [Empty]; 

Exceeds: FMHPA: 3.



State: California; Major provisions: * Applies generally to all 

employers, regardless of size; * Applies to all health plans that 

provide benefits; * Coverage is limited to 20 outpatient visits and 30 

days of inpatient care for mental illnesses that do not meet the 

state’s SED criteria; * Covers severely emotionally disturbed children 

with certain categories of mental illness; Meets FMPHA: [Empty]; 

Exceeds: FMHPA: 3.



State: Kansas; Major provisions: * Applies to health insurance plans 

that provide mental health benefits; * Plans must provide coverage for 

psychotherapeutic drugs used for the treatment of mental health under 

conditions no less favorable than for other drugs; * Coverage is 

limited to 45 outpatient visits and 45 days of inpatient care; Meets 

FMPHA: [Empty]; Exceeds: FMHPA: 3.



State: Maryland; Major provisions: * Applies to all health insurance 

policies that provide coverage on an expense-incurred basis; * 

Includes drug and alcohol disorders; * Co-payments and deductibles 

must be equal to those for other conditions; * Outpatient coverage 

schedule provides for 80 percent coverage for the first five visits in 

a 12-month period, 65 percent for the 6-30th visits, and 50 percent for 

the 31st and subsequent visits; Meets FMPHA: [Empty]; Exceeds: FMHPA: 

3.



State: Minnesota; Major provisions: * Applies to all health plans that 

provide mental health benefits; * Applies to all health plans that 

provide benefits except self-insured health insurance plans; * Plans 

with 100 subscribers or more can limit mental health coverage to 80 

percent of the customary charge for the first 10 hours of treatment 

over a 12-month period and 

75 percent for additional treatment over the same 12-month period; 

Meets FMPHA: [Empty]; Exceeds: FMHPA: 3.



State: New Jersey; Major provisions: * Every individual health 

insurance policy must provide coverage for biologically based mental 

illness; * Covers biologically based mental illness under the same 

terms as other sicknesses; Meets FMPHA: [Empty]; Exceeds: FMHPA: 3.



Source: GAO analysis.



[End of table]



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. See table 5 for Medicaid and 

SCHIP programs used in the states that we visited.



Table 5: Key Medicaid and SCHIP Programs for Children with Mental 

Illness in 6 States:



State: Arkansas; Waivers: Home and Community-Based Services[A]: 

[Empty]; [Empty]; Types of optional services: Katie Beckett: Yes; Types 

of optional services: Rehabilitation: Yes; [Empty]; Types of SCHIP 

programs: Medicaid expansion: Yes; Types of SCHIP programs: Separate 

(non-Medicaid) program: [Empty]; Types of SCHIP programs: Combination 

(Medicaid 

expansion and separate) program: [Empty].



State: California; Waivers: Home and Community-Based Services[A]: Yes; 

[Empty]; Types of optional services: Katie Beckett: [Empty]; Types of 

optional services: Rehabilitation: Yes; [Empty]; Types of SCHIP 
programs: 

Medicaid expansion: [Empty]; Types of SCHIP programs: Separate 

(non-Medicaid) program: [Empty]; Types of SCHIP programs: Combination 

(Medicaid 

expansion and separate) program: Yes.



State: Kansas; Waivers: Home and Community-Based Services[A]: Yes; 

[Empty]; Types of optional services: Katie Beckett: [Empty]; Types of 

optional services: Rehabilitation: Yes; [Empty]; Types of SCHIP 
programs: 

Medicaid expansion: [Empty]; Types of SCHIP programs: Separate 

(non-Medicaid) program: Yes; Types of SCHIP programs: Combination 

(Medicaid 

expansion and separate) program: [Empty].



State: Maryland; Waivers: Home and Community-Based Services[A]: Yes; 

[Empty]; Types of optional services: Katie Beckett: Yes; Types of 

optional services: Rehabilitation: Yes; [Empty]; Types of SCHIP 
programs: 

Medicaid expansion: [Empty]; Types of SCHIP programs: Separate 

(non-Medicaid) program: [Empty]; Types of SCHIP programs: Combination 

(Medicaid 

expansion and separate) program: Yes.



State: Minnesota; Waivers: Home and Community-Based Services[A]: Yes; 

[Empty]; Types of optional services: Katie Beckett: Yes; Types of 

optional services: Rehabilitation: Yes; [Empty]; Types of SCHIP 
programs: 

Medicaid expansion: Yes; Types of SCHIP programs: Separate 

(non-Medicaid) program: [Empty]; Types of SCHIP programs: Combination 

(Medicaid 

expansion and separate) program: [Empty].



State: New Jersey; Waivers: Home and Community-Based Services[A]: 

[Empty]; [Empty]; Types of optional services: Katie Beckett: [Empty]; 

Types of optional services: Rehabilitation: Yes; [Empty]; Types of 
SCHIP 

programs: Medicaid expansion: [Empty]; Types of SCHIP programs: 

Separate 

(non-Medicaid) program: [Empty]; Types of SCHIP programs: Combination 

(Medicaid 

expansion and separate) program: Yes.



Source: GAO analysis.



[A] Of the 4 of the 6 states that we visited that had a HCBS waiver, 

only Kansas had a waiver specifically for children with serious 

emotional disturbances.



[End of table]



States used different approaches to expand Medicaid coverage. For 

example, 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 provides 60 days of 

community-based services and limited hospitalization.[Footnote 21] 

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’s program 

did not require parents to share program costs to receive services, but 

Minnesota’s program required parents to pay according to their ability 

as defined by a sliding scale.



While states chose to use different waivers and options to expand 

access to mental health services, all 6 states used SCHIP programs to 

extend health insurance coverage to low-income families whose incomes 

exceeded allowable limits under Medicaid. Kansas offered a separate 

child health (non-Medicaid) expansion program. Arkansas and Minnesota 

offered expanded Medicaid coverage and California, Maryland, and New 

Jersey offered both and Medicaid-expansion and separate child health 

programs to low-income families of different income levels. However, 

mental health officials in 3 states said that their separate SCHIP 

programs generally resemble many private insurance plans in terms of 

limits and restrictions. For example, New Jersey’s separate SCHIP plan 

limits some mental health services. California’s plan, however, 

entitles children who meet the state’s definition of severely 

emotionally disturbed to receive the same services from county mental 

health services as children covered by Medicaid.



Although Medicaid’s EPSDT provision requires Medicaid coverage for all 

medically necessary 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 previous report, we recommended that the 

Administrator of CMS work with states to develop criteria and time 

frames for consistently assessing and improving EPSDT reporting and 

provision of services.[Footnote 22] 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 mental health providers’ 

participation in the program 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 parents often 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. 

For example, state and local mental health officials in Arkansas, 

California, Kansas, Maryland, and Minnesota told us that some rural 

counties had very limited or no child mental health services. 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 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. Child welfare, 

mental health, and juvenile justice officials in California, Maryland, 

and New Jersey 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 counseling and therapy sessions and increase the length of 

waiting lists. In 3 of the states that we visited--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.



Other ways of controlling costs in the states that we visited included 

limiting placements of children in residential treatment facilities. 

Mental health officials said community-based services supported the 

right of children with a mental illness to receive services in the 

least restrictive setting, were more effective than residential 

services in helping children and their families, and cost less, thus 

allowing more children to receive services. To implement the limits and 

to ensure placements are necessary, states required interagency review 

boards to approve such placements or reduced the time spent in 

residential placements. For example, local mental health agency 

officials in Maryland explained that they could not place children in 

private residential facilities even if they presented a danger to 

themselves and others because the state did not allow them to pay for 

such placements. These officials further explained that private 

residential placements had to be approved by a county interagency 

coordinating committee and subsequently reviewed by a state 

coordinating committee that could return requests for further 

consideration. A parent in this county said the approval process took 

6 months. In New Jersey, child welfare officials said a goal of the new 

child mental health system is to reduce the average stay at residential 

treatment facilities from 18 to 6 months, and some parents in Maryland 

told us that funding limits, rather than the success of the treatment, 

determine the date children will be discharged from residential 

treatment.



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 three 

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 this 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, state officials in 2 of the states that we visited 

said children often remain hospitalized or in a shelter 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 2 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 

1 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 four districts told us that some children with a 

mental illness 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 23] and bipolar 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 son[Footnote 24] 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 25] 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.



Some parents bypass eligibility restrictions for special education 

services and procedures for receiving child welfare, mental health, and 

juvenile justice services by petitioning the court to provide mental 

health and specific education services for their child. These petitions 

have varying names. For example, Maryland refers to them as CINS 

(children in need of supervision) petitions and Arkansas refers to them 

as FINS (family in need of services) petitions. Three of the states 

that we visited--Arkansas, Maryland, and Minnesota--allowed parents to 

directly petition the court to order mental health services for the 

child. In Arkansas, a child in a court-ordered residential placement 

was automatically eligible for Medicaid regardless of his or her 

family’s income. In that state, a variety of officials told us that 

court-ordered placement was the most common way for parents to obtain 

residential mental health and education services for their child. 

Juvenile court officials told us that parents often come to court 

requesting residential treatment and lobbying judges for placement in a 

specific facility. Some state officials were concerned that this 

practice could result in inappropriate placements for some children 

because judges can make placement decisions with no clinical input. 

Mental health and juvenile justice officials told us staff from private 

residential facilities often evaluate children on a pro bono basis and, 

based on these evaluations, recommend that judges place the children in 

their facility. These officials said that they were concerned about the 

objectivity of such evaluations.



Misunderstandings of Agencies’ Responsibilities and Resources:



Program officials’ and service providers’ misunderstandings of 

agencies’ responsibilities and resources also affect service 

provision.[Footnote 26] 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 1 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 entitled to 

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. 

Many of these practices were developed to reduce treatment costs and 

provide a better way to treat children with a mental illness in their 

communities. 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 

appropriately 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 bachelor-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.



State officials in 5 states also recommended increasing the use of 

volunteer and charitable organizations to reduce the cost of services 

because these organizations can provide inexpensive or free supportive 

services to children with a mental illness and their families. While 

these services were not therapeutic, officials said that they helped 

families cope with problems associated with mental illness and kept 

some mental health problems from escalating. For example, the Four 

County Mental Health Center in Kansas used volunteers from churches, 

community agencies, and charities, such as the Salvation Army, to 

provide services such as mentoring and tutoring for children with a 

mental illness. A county in New Jersey increased its reliance on Big 

Brother-Big Sister volunteers and the local YMCA to provide after 

school supervision and mentoring for children with severe mental 

illness.



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 that 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. The Juvenile 

Alternative Defense Effort (JADE), a county juvenile justice diversion 

program in California, combines funds from a federal Juvenile 

Accountability Incentive Block Grant and the state Temporary Assistance 

for Needy Families Program (TANF)[Footnote 27] to provide the range of 

mental health services necessary to prevent a juvenile justice 

placement for mentally ill youths. In Kansas, the Family Service and 

Guidance Center blends funds from federal Medicaid and Department of 

Transportation programs, designated funds from the state’s Master 

Tobacco Settlement and Attorney General’s Office, funds from county 

juvenile justice and social services agencies, county general funds, 

the United Way, and several local philanthropic clubs to provide a wide 

range of mental health and supportive services for children who are 

seriously mentally ill in its county.



In addition to blending funds to pay for services, state officials in 4 

of the 

6 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 range of nontraditional supportive services and items to children 

with a mental illness and their families. Using these funds, the 

program provided services and items 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 some 

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. County officials 

from a variety of agencies told us that the center ended service 

fragmentation and prevented duplication of services for children with a 

mental illness and their families by implementing one intake procedure 

for all county social services. For example, case managers work with 

police to prevent the placement of children with mental illness in 

correctional facilities. If a mental illness is identified during the 

intake assessment, the intake workers immediately link the child with a 

mental health worker. Working collaboratively with juvenile justice, 

school, and other appropriate officials, the case manager develops a 

diversion[Footnote 28] plan all can agree to that is aimed at 

preventing the need for juvenile justice or child welfare custody, or 

residential or other out-of-home placements with the goal of keeping 

the child at home with the child’s own family.



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 California, Los Angeles 

county officials told us that integrating mental health services into 

the school system has been a very effective way of reaching poor 

families without transportation and working families, and helps to 

ensure regular participation in mental health services. In Harford 

County, Maryland, for example, mental health services are collocated at 

an elementary school specifically to improve access to care for 

students with 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 bachelor-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 

the Classroom Support Program, an intensive, in-school program for 

children with a mental illness staffed with a full-time school 

psychologist for individual counseling; the Teen 2000 program, a 

mentoring program for teens that uses paid school staff, high school 

students, and volunteer community members to provide a combination of 

homework support, play, and social skills development; the School 

Outreach Advocacy Program, a program that provides counseling, 

tutoring, recreation, social skills groups, home visits, referrals and 

some psychiatric rehabilitation services; Project Prepare, a program to 

identify mentally ill elementary school children 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, 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. State and county officials we 

spoke with in all 6 states stressed the importance of early 

identification of children at risk of mental illness and the provision 

of therapeutic services when they were young in hopes of preventing the 

need for extensive, and costly, residential services later on. 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’ 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 

include failures and successes, gang-related behaviors, 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 who makes the final decisions. 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 the 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. Red 

Wing officials told us that transition planning and reintegration 

efforts are very important in preventing recidivism and they take 

several steps to ensure a successful transition. The program is 

designed in levels that reward good behavior by allowing youth to move 

to lower levels of supervision. For instance, at level 4, youth begin 

to transition back to the community by making periodic visits, called 

furloughs, to their homes. Officials see furloughs as an opportunity 

for youth to try out the new positive behaviors that they have learned. 

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.



Out of frustration with the difficulties it had finding appropriate 

services for mentally ill youth who were aging out of child mental 

health programs, The Sycamores, a residential mental health facility in 

Los Angeles County, California, created community-based transitional 

homes for older teens who were leaving their facility and were unable 

to return to their own homes. Its Emancipated Youth Program provides an 

apartment for every two residents, a youth advocate worker to provide 

support, and case managers to coordinate services. For this program, 

the Sycamores uses reasonably priced private apartments in the 

community, instead of a group home that would house several mentally 

ill youths in the same building. When the youths become able to live 

independently, the Sycamores turns the leases over to them. They also 

started a business card company at one community center to provide 

vocational training for adolescents aging out of their program.



Crisis Intervention: Programs we reviewed in 4 states had a mobile 

crisis unit. These units consist 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 do an emergency petition 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 works 

extensively with parents of children who are seriously mentally ill at 

the facility and requires their participation. To help parents 

successfully prepare for and keep their child with a mental illness at 

home, The Sycamores provides a variety of supportive services--anything 

the family needs to make a child’s return home successful--including 

household items like refrigerators, washers, dryers, stoves, and car 

seats, and services such as transportation to and from the facility. In 

addition, as part of its transitional Home-Based Program, The Sycamores 

trains parents to use Therapeutic Behavioral Services (TBS), one-on-

one, in-home services provided whenever needed 24 hours a day, 7 days a 

week. TBS workers model good parenting skills so parents will be 

prepared for their child’s return home, such as modeling for the 

parents how to get their child with a mental illness who may have 

violent outbursts ready for the school bus in the morning without 

incident. The Four County Mental Health Center in Kansas’s provides 

free parenting classes designed to teach effective parenting skills for 

children with mental illness and a parent support coordinator who can 

provide support and information on mental health services for children. 

The Center also works with Kansas’s Keys for Networking, a statewide 

parent advocacy organization that educates parents about their child’s 

right to services and advocates on their behalf to obtain needed 

services.



Conclusions:



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.



Experts, agency officials, and service providers agree that agencies 

must work together to meet the needs of children who are severely 

mentally ill because these children have complex problems and are 

likely to need services from multiple community agencies, such as 

mental health and education, if they are to remain in their communities 

or if they are to successfully transition from a residential facility 

back to their community. 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. Opportunities exist for HHS, DOJ, and Education to 

determine the causes for these misunderstandings at the state and local 

level and to identify ways to reduce them.



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.



Recommendations:



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 recommend that the Secretary of 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 recommend 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 

create an action plan to address those causes. We further recommend 

that these agencies continue to encourage states to evaluate the child 

mental health programs that they 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.



Agency Comments:



We provided a draft of this report to Education, HHS, and DOJ to obtain 

their comments. Each agency provided comments, which are reproduced in 

appendixes III, IV, and V. These agencies also provided technical 

clarifications, which we incorporated when appropriate.



Education generally agreed with the findings of our report, but asked 

that we change some terminology to be consistent with terminology used 

in IDEA. We changed this terminology to reflect IDEA when needed. HHS 

also generally agreed with the findings and said that the report is 

comprehensive, interesting, and provides an informative overview of the 

concerns with which child welfare agencies and juvenile justice systems 

are confronted when children and youth do not receive adequate mental 

health services within the community. However, HHS also said that the 

report is relatively critical of state and local agencies for 

“inappropriately” using child welfare and juvenile justice placements 

to get services to children who need them and cannot access them 

through other channels. HHS further stated that a broader look at the 

status of children’s mental health services in general would be useful 

because the problems leading parents to place their children in child 

welfare and juvenile justice systems to obtain mental health services 

are part of the bigger problem of children’s mental health services in 

general, such as limited or non-existent services, a lack of access, 

and a lack of quality providers. Although a broad assessment of the 

availability and effectiveness of children’s mental health services was 

beyond the scope of this report, we have conducted studies relevant to 

these problems and reference to them can be found in the related 

products list at the end of this report. The purpose of this report was 

to shed light on the number of children placed in the two systems 

solely to receive mental health services and the factors that lead to 

those placements. In doing so, this report does not criticize state and 

local child welfare and juvenile justice agencies that place these 

children, but instead identifies the circumstances under which these 

agencies play a role in meeting mental health needs, as well as the 

roles that other agencies should play. DOJ also generally agreed with 

our findings but was concerned that the estimates of children placed 

provided by child welfare and juvenile justice officials would be taken 

as solid and conclusive and be used for policy changes without further 

study being undertaken. We explicitly acknowledged the limitations of 

these estimates in the report and we recommended that the Secretary of 

HHS and the Attorney General investigate the feasibility of obtaining 

more precise numbers by tracking these children. Doing so will allow 

the agencies to determine the extent of the problem.



In commenting on the recommendations, Education said that it was not 

clear to them how collecting more data and tracking outcomes will 

increase the likelihood of progressive practices to provide children’s 

mental health services. 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. HHS 

also said we failed to identify to what end these data would be used 

and that a request for appropriate funding for states and federal 

agencies involved in tracking should accompany the recommendation for 

tracking. DOJ agreed that tracking should take place, but only in the 

short term, and that HHS should take the lead in such an effort. As we 

stated in our recommendation, we believe HHS and DOJ should determine 

the feasibility of tracking children to identify the extent and 

outcomes of the mental health placements discussed in the report. 

Knowledge of the extent of this practice is a necessary first step to 

determine what corrective actions might be taken and might be useful in 

identifying which progressive practices will most benefit these 

children. In addition, without this basic information, the agencies may 

unknowingly limit the action steps that they develop to alleviate state 

and local officials misunderstandings and thus fail to maximize access 

to and the use of existing resources. While the report recognizes that 

some mental health resources may be limited, it also describes the 

misunderstandings that exist among state and local officials regarding 

each agency’s service requirements, responsibilities, and resources. If 

such misunderstandings could be corrected, more children could possibly 

be served by the agencies better designed to meet their mental health 

needs. Since HHS and DOJ already track various characteristics of all 

children placed in the child welfare and juvenile justice systems, 

these agencies should determine the feasibility of adding data elements 

regarding placement solely to receive mental health services and 

determine appropriate time frames for collecting these data.



HHS also said that our estimate of the number of children placed was 

presented without context, and asked how the number compares with 

various groups--such as the total number of children placed in the two 

systems and the number of children who remain outside the system but 

are in need of the same kinds of services. We could not, however, make 

these comparisons because no agency was tracking these children and we 

necessarily relied on the estimates provided, which we believe to be an 

underestimate for the reasons stated in this report.



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. We believe several organizational 

entities may be appropriate and that the member agencies forming this 

group should determine the entity that is best suited. HHS, however, 

said that an interagency working group would do little to address the 

lack of resources. We believe that identifying the causes of the 

misunderstandings that are occurring is a first step toward addressing 

the lack of resources. Such a group, by promoting a more consistent 

understanding of the roles and resources of state and local agencies, 

may improve access to services and result in more effective utilization 

of existing resources. Education commented that we should be more 

specific on the role of the working group in addressing major 

differences in terminology and definitions across various legislation, 

enormous differences in local interpretation of federal definitions, 

and in local practices for establishing eligibility. Education added 

that such a group would not have the power to address congressional 

lawmaking and noted that no recommendations were made for increased 

grant spending to duplicate or disseminate the positive features of 

such practices. We believe that our recommendation is broad enough to 

encompass the list of issues Education mentions. We also believe that 

our recommendation does not preclude the group from recommending 

legislative changes as part of its action plan. Regarding Education’s 

comment on information dissemination, we added a recommendation to that 

effect.



DOJ also said that while evaluating child mental health programs is a 

worthwhile goal, states should consider evaluating their entire systems 

of care for children to determine (1) how many children with serious 

mental illness are in need of care but unable to obtain it, (2) how 

state and local child-serving agencies attempt to address the needs of 

these children, and (3) how effective these systemic efforts are in 

actually meeting these needs and those of their families. While we 

concur that such evaluations are worthwhile, including this suggestion 

is beyond the scope of our report.



We also provided a copy of our draft to state officials in the 6 states 

we visited (Arkansas, California, Kansas, Maryland, Minnesota, and New 

Jersey). Kansas provided technical clarifications, which we 

incorporated when appropriate. Minnesota made a general comment that 

required no changes in the report, and California said that it had no 

suggested corrections or edits.



We are sending copies of this report to the Secretaries of HHS and 

Education and the Attorney General, appropriate congressional 

committees, state child welfare directors, selected juvenile justice 

officials, and others who are interested. We will also make copies 

available to others upon request. In addition, the report will be 

available at no charge on GAO’s Web site at http://www.gao.gov.



If you or your staff have any questions, or wish to discuss this 

material further, please call me at (202) 512-8403 or Diana Pietrowiak 

at (202) 

512-6239. Key contributors to this report are listed in appendix VI.



Cornelia M. Ashby

Director, Education, Workforce, and Income Security Issues:



Signed by Cornelia M. Ashby



[End of section]



Appendix I: Scope and Methodology:



To obtain estimates of the number and characteristics of children 

voluntarily placed in the child welfare and juvenile justice systems to 

receive mental health services, we conducted two surveys. We sent the 

first survey to state child welfare directors in the 50 states and the 

District of Columbia. We conducted the second survey by telephoning 

directors of county juvenile justice agencies in large counties in the 

17 states with the largest populations of children under age 18. 

Overall, 71 percent of the children in juvenile justice facilities 

resided in these states. In most cases, we interviewed juvenile justice 

agencies in the two largest counties in each state. We chose to survey 

a sample of juvenile justice officials at the county level because, 

unlike child welfare, all states do not have a juvenile justice agency. 

Also, children who enter the juvenile justice system for mental health 

services are more difficult to identify than children who enter through 

child welfare systems because parents cannot directly place children in 

juvenile justice systems and children cannot enter juvenile justice 

solely to access mental health services. Telephone contacts with local 

juvenile justice officials allowed us to obtain information from 

individuals who were more likely than state officials to have direct 

knowledge of how children enter the juvenile justice system.



We asked both groups to estimate[Footnote 29] the number of children 

voluntarily placed in their system by actions of their parents in order 

to obtain mental health services, the characteristics of the children, 

and factors influencing the rate of placements. Table 6 provides survey 

numbers and response rates for the surveys.



Table 6: Survey Numbers and Response Rates:



Survey of: Child welfare directors; Number of 

surveys conducted: 51; Number of survey responses received: 47.



Survey of: Juvenile justice officials; Number of 

surveys conducted: 33; Number of survey responses received: 33.



Source: GAO.



Not all respondents to the surveys answered every survey question. For 

example, 19 respondents to the child welfare survey and 30 respondents 

to the juvenile justice survey provided estimates of number of children 

placed. Some respondents indicated that they were unable to access 

information to generate estimates.



[End of table]



Site Visits:



To determine the factors that influence child welfare and juvenile 

justice placements for mental health services, we included questions on 

these issues in our surveys and interviewed federal, state, and local 

officials and national child mental health experts. We interviewed 

officials at the Department of Health and Human Services (HHS), the 

Department of Justice (DOJ), and Education. We spoke with state and 

local officials in 

6 states--Arkansas, California, Kansas, Maryland, Minnesota, and New 

Jersey--and in one county in each of these states. The officials 

represented state and county agencies that were responsible for child 

welfare, child mental health, Medicaid, juvenile justice and education 

services. We also interviewed judges in 5 states and caseworkers and 

parents in all 6 states. Staff of community mental health centers and 

other programs serving families with children with a mental illness, 

such as a Family Support Organization and a residential treatment 

facility, selected parents of children with, or who had, severe mental 

illness and invited them to attend our interviews. We selected states 

that varied in geographical location, legal requirements concerning 

placement, the use of Medicaid options and waivers, and the authority 

of state and county agencies in administering child welfare and 

juvenile justice programs; and counties that varied in demographic 

characteristics.



To identify promising practices that may reduce the need for some child 

welfare and juvenile justice placements by meeting the needs of 

children with a mental illness and their families, we asked national 

experts and state and local officials to identify such practices in the 

states that we visited. We visited 16 programs that embodied these 

practices.



We conducted our work between March 2002 and February 2003 in 

accordance with generally accepted government auditing standards.



[End of section]



Appendix II: State Statutes Containing Language Allowing Voluntary 

Placement to Obtain Mental Health Services:



Table 7: Statutes in 11 States Allowing Parents to Place Children in 

Child Welfare Systems in Order to Obtain Mental Health Services While 

Retaining Custody of the Child:



State: Alaska; Statute citation: M.S.A. Section 260C.201 (3); Statute: 

Where a parent enters into a voluntary placement agreement, the 

agreement may not preclude the parent from regaining care of the child 

at any time.



State: Colorado; Statute citation: C.R.S.A. Section 19-3-701(1); 

Statute: Where a parent voluntarily places a child out of the home for 

the purpose of obtaining treatment for an emotional disability solely 

because the parent is unable to provide care, relinquishment of legal 

custody is not required.



State: Connecticut; Statute citation: C.G.S. A. Section 17a-129; 

Statute: Their shall be no requirement for the Department to seek 

custody or protective supervision of a child or youth who needs or is 

receiving voluntary services unless the child or youth is otherwise 

alleged to be neglected or abused.



State: Iowa; Statute citation: I.C.A. Section 232.1784 and 232.182 (5) 

(d); Statute: Petitions for voluntary placements shall describe the 

child’s emotional disability which requires care and treatment; the 

reasonable efforts to maintain the child in the child’s home; a 

determination of whether services or support provided to the family 

will enable the family to continue to care for the child in the child’s 

home; and the reason the child’s parent has requested a foster care 

placement. A court may only order foster care placement if it makes a 

determination that services or support provided to the family will not 

enable the family to continue to care for the child in the child’s 

home. If the court finds that reasonable efforts have not been made and 

that services or support are available to prevent placement, the court 

may order the services or support to be provided to the child.



State: Maine; Statute citation: 22 M.R.S.A. Section 4004-A(1) and (2); 

Statute: If certain conditions are met, a parent may enter into a 

voluntary placement agreement in which the parent retains legal custody 

of the child.



State: Minnesota; Statute citation: M.S.A. Section 260C.201(3); 

Statute: If a court determines a child is in need of special services 

to treat a mental disability, the court may order the child’s parent or 

health plan company to provide such services. If the parent or the 

health plan is unable to provide care, the court may order that 

treatment be provided. If the child’s disability is not the result of 

abuse or neglect by the parent, the court shall not transfer legal 

custody of the child in order to obtain treatment solely because the 

parent is unable to provide care.



State: North Dakota; Statute citation: N.D.C.C. 50-06-06.13; Statute: 

The Department of Human Services may not require a parent to relinquish 

legal custody in order to have the child voluntarily placed.



State: Oregon; Statute citation: O.R.S. Section 418.312(1)and (2); 

Statute: To have a child placed in a foster home, group home, or 

institutional child care setting for the sole purpose of obtaining 

services for the child’s emotional or mental disorder, a parent is not 

required to transfer legal custody. Rather, the child is placed 

pursuant to a voluntary placement agreement that specifies the rights 

and obligations of the parent, the child, and the Department of Human 

Services.



State: Rhode Island; Statute citation: R.I.S.T. Section 14-1-11.1; 

Statute: Where a parent voluntarily places a child with an emotional 

disorder with the Department of Human services for the purpose of 

accessing an out-of-home program, relinquishment of legal custody is 

not required.



State: Wisconsin; Statute citation: W.S.A. Section 48.13(4) and 

938.34(6)(a) and (ar); Statute: Where a parent is financially unable to 

provide treatment for a child, the parent may sign a petition giving a 

court exclusive jurisdiction. The court may then order an appropriate 

agency to provide treatment whether or not legal custody has been taken 

from the parent.



State: Vermont; Statute citation: 33 V.S.A. Section 4305(g); Statute: A 

child with an emotional disorder may receive services, including an 

out-of-home placement, without a parent surrendering legal custody.



Source: GAO analysis.



[End of table]



[End of section]



Appendix III: Comments from the Department of Education:



UNITED STATES DEPARTMENT OF EDUCATION:



OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES:



MAR 19 2003:



THE ASSISTANT SECRETARY:



Ms. Cornelia Ashby:



Director, Education, Workforce, and Income Security Issues:



General Accounting Office 441 G Street, NW Washington, DC 20548:



Dear Ms. Ashby:



Thank you for the opportunity to review Draft Report GAO-03-397, 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. I am pleased to respond on behalf of the 

Department of Education.



We have shared with your staff a range of comments, suggestions and 

editorial observations, some of which we consider significant. It would 

be desirable in our view for your final report to use terminology 

consistent with the terminology used in the Individuals with 

Disabilities Education Act (IDEA) and supporting regulations when 

discussing special education and related services, and educational 

settings. Many of our comments are directed at increasing technical 

accuracy and hopefully reducing confusion in recognition of the fact 

that “children with mental illness” is not a term used in IDEA.	

“Emotional disturbance” is defined at 34 CFR 300.7(c)(4), however. 

“Autism” and “other health impairment” are also defined at 300.7. 

Similarly, the term “mental health services” is not used in IDEA, but 

certain “related services” such as counseling services or psychological 

services may be provided to students in special education.



In addition to my program responsibilities at the Department I have 

been representing Secretary Rod Paige on the President’s New Freedom 

Commission on Mental Health, which is mentioned in the draft report. 

The Commission has considered information about the relinquishment 

issue and a reference to this may be found on the Commission’s website 

at:



http://www mentalhealtheommission.gov/subcommittee/rights022803.doc:



The Department would, of course, participate in any interagency working 

group to be established according to the recommendation on page 38 of 

the draft report.



I hope our comments have been helpful.



Signed by Robert H. Pasternack, Ph.D



Child Welfare and Juvenile Justice Draft Report:



Substantive Changes:



1. Page ii in the list of abbreviations, IEP is incorrectly defined. 
IEP 

stands for “Individualized Education Program.” Also make correction on 

Table on page 8. 



2. Eligibility for special education and related 

services (including mental health services) needs to be clarified. It 

needs to be clear that a diagnosis of mental illness does not 

necessarily qualify a child for special education and related services. 

The student must be a “child with a disability” as defined by IDEA. The 

following pages in the document need clarification in this regard:



a. Page 2, middle of the page. The sentence that reads: “Similarly, the 

Department of Educations’ (Education) Office of Special Education and 

Rehabilitative Services (OSERS) provides funding and technical 

assistance to help states provide needed services to disabled children 

with special education needs - including those with mental illness.”:



b. Page 28, second paragraph:



c. Page 8 identifies the children IDEA serves as “children with mental 

illness. That terminology is not in the IDEA statute or regulations. A 

child with “emotional disturbance” (ED) is defined in the regulations 

and should be used here. Further, the definition of eligibility used in 

this table indicates that “Only children who fail to make adequate 

progress because of their disability are eligible for special education 

or related services such as mental health services.” This is NOT 

consistent with the IDEA. Many students with ED are relatively high 

functioning and, especially when they receive necessary supports and 

services, can be academically successful. Furthermore, many students 

“with mental illness” in terms of other funding agencies are actually 

served under different (from ED) categories within IDEA, notably 

“autism” and “other health impaired.” See attached page for specific 

revisions to this table. Be sure the table is revised consistent with 

IDEA.



d. Page 19, section on “Multiple Factors Influence Decisions to Place 

Children.”:



e. Page 30, second paragraph, “Also, some parents and professionals 

misunderstood that IDEA gives all disabled children, including mentally 

ill children, the right to a free and appropriate education....” This 

sentence is confusing and unclear. IDEA requires that FAPE be made 

available to all children eligible under IDEA. It should be noted that 

“free appropriate public education does not contain the word “and.”:



3. Page 28, first full paragraph: It should be noted that the use of 
the 

terms “adequate educational progress,” “adequate progress” and 

“educational progress” is not consistent with the provisions of the 

IDEA and the regulations. The 

standard used in the regulations is whether the disability “adversely 

affects a child’s educational performance.” See 34 CFR 300.7. A student 

can be making 

progress and advancing from grade to grade but may still require and be 

eligible for special education or related services.



4. The “least restrictive environment” and the individualized nature of 

special education services need to be clarified. The sentence “... did 

not support residential placement for children except in extraordinary 

situations because federal law requires that they provide services for 

all disabled children including mentally ill children in the least 

restrictive setting as possible...” (page 5, first sentence) does not 

accurately reflect the individualized nature of special education. The 

requirement under IDEA is not the “least restrictive environment” as 

possible. Rather, under IDEA, to the maximum extent appropriate, 

children with disabilities are to be educated with children who are not 

disabled, based on the needs of the child. Although this conception is 

attributed to the “officials,” it may convey an impression that the 

IDEA requires the most “possibly” LRE. Similarly, the reference to 

“least restrictive alternative” on page 9 (second paragraph), 

oversimplifies the construct of LRE under IDEA which includes a broad 

range of appropriate service locations/levels. See also, Page 19, 

section on “Multiple Factors Influence Decisions to Place Children.”:



5. The “large grant program” [$52 million] (p. 9, 1st par.) with 

collaboration across OJJDP, SAMHSA, and Education is managed, within 

the Dept. ED, by Safe and Drug Free Schools (SDFS), without involvement 

by OSERS. That should be noted, since OSERS is the only Dept. ED POC/

program identified in the document.



6. “Wrap-around services....” described in Footnote 15, p. 20, should 

include education, or “instruction.” Which is an important component of 

wrap-around services for children and their families.



7. Page 17, last sentence regarding OSERS data base. It should be noted 

that OSERS does collect data (number and percent) of children with 

disabilities age 6 through 21 served in correctional facilities by 

state and by race.



8. Page 29, second paragraph, first sentence, refers to “specialized 

education services.” Is this different than “special education”?



9. Page 30, second paragraph, should make clear that it is not a 
federal 

requirement that referrals for special education must be in writing.



10. Throughout the document, numerous references are made to 

“misunderstandings” on the part of state and local personnel in 

interpreting Federal law (example, p. 38, middle paragraph, last 

sentence). This characterization may be both 

prejudicial and, in many instances, incorrect. Most of the various 

federal laws concerning this population are purposely vague, open to 

interpretation, and (in the case of IDEA) actively supportive of State 

determination of actual procedures and how they will be interpreted. 

This is particularly apparent for students with emotional disturbance. 

Each State defines eligibility for these students, using the federal 

definition as guidance. States vary greatly in terms of the labels they 

use for this population. More States use variants of “emotional and 

behavioral disorders” than the terminology of “emotionally disturbed,” 

which is generally considered pejorative. If the term 

“misunderstandings” is retained the following phrase should be added: 

“regarding the roles of the various agencies that provide mental health 

services...”:



11. The recommendations do not well address the findings of the report. 

For example-The conclusion and recommendations sections talk a lot 

about tracking data on placements and outcomes (though outcomes are not 

defined). However, the bulk of the report speaks to the real issues of 

the logistical, policy, and resource limitations that limit the 

availability of and access to MH services for kids. Starting on page 
31, 

several positive examples of more effective practices are also 

featured. It is not clear how collecting more data and tracking 

unspecified outcomes will increase likelihood of these more progressive 

practices. The recommendations do little to build on these strong 

practices, and no recommendations are made for increased grant spending 

to duplicate or disseminate these positive features.



At a minimum, the report should be more specific about some of the 

objectives that the workgroup should address and include key issues 

like major differences in terminology and definition across various 

legislation, enormous differences in local interpretation of federal 

definitions and in local practices for establishing eligibility.



Similarly, attention should be given to the multiplicity, 

fractionalization, and incongruity of legislation and funding for these 

populations as a major impediment to any cohesive coordination of 

services across agencies, at Federal, State, and local levels. A 

federal (executive) panel is not the sort of body empowered, or 

appropriate, to address Congressional law-making on these services, but 

can the GAO recommend an independent organization for that guidance, 

and explicitly suggest that they examine inconsistencies and other 

problems in the multiple pieces of legislation and programs?



12. The draft report does not mention the Independent Living Services 

Program administered by the Rehabilitation Services Administration 

(RSA), a component of OSERS. We believe that independent living 

programs are a potential resource for supportive services for children 

with mental illness and their families.



[End of section]



Appendix IV: Comments from the Department of Health and Human Services:



DEPARTMENT OF HEALTH & HUMAN SERVICES	Office of Inspector General:



Washington, D.C. 20201:



APR 3 2003:



Ms. Cornelia M. Ashby Director, Education, Workforce, and Income 

Security Issues United States General Accounting Office Washington, 

D.C. 20548:



Dear Ms. Ashby:



Enclosed are the department’s comments on your draft report entitled, 

“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.” The comments represent the 

tentative position of the department and are subject to reevaluation 

when the final version of this report is received.



The department also provided several technical comments directly to 

your staff.



The department appreciates the opportunity to comment on this draft 

report before its publication.



Sincerely,



Dennis J. Duquette:



Signed by Dennis J. Duquette:



Acting Principal Deputy Inspector General:



Enclosure:



The Office of Inspector General (OIG) is transmitting the department’s 

response to this draft report in our capacity as the department’s 

designated focal point and coordinator for General Accounting Office 

reports. The OIG has not conducted an independent assessment of these 

comments and therefore expresses no opinion on them.



Comments of the Department of Health and Human Services on the General 

Accounting Office’s Draft 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):



The Department of Health and Human Services (department) appreciates 

the opportunity to comment on this draft report which addresses the 

causes for and possible solutions to the high number of children placed 

in the child welfare and juvenile justice systems solely to obtain 

mental health services.



General Comments:



The department agrees that this report is comprehensive, interesting 

and provides an informative overview of the concerns with which child 

welfare agencies and juvenile justice systems are confronted when 

children and youth do not receive adequate mental health services 

within the community. The family scenarios are realistic, presenting 

the challenges families face in obtaining mental health services for 

severely, emotionally disturbed children.



The GAO’s use of multiple methods to highlight the deficiencies in how 

these clients are currently served increases our federal understanding 

of the problems.



The GAO’s major concern appears to be access to and availability of 

mental health services for adolescents outside of state child welfare 

systems. The GAO identifies and illustrates the core issue well; mental 

health services, particularly community based alternatives, are under-

funded and it is the scarcity of these resources that causes parents to 

seek placement to meet the mental health needs of their children. Thus, 

the problem is not really with the child welfare or juvenile justice 

systems, but caused by a lack of appropriate mental health services at 

the state and local levels, and the inadequacy of mental health 

insurance coverage in general. The report is relatively critical of 

state and local agencies for “inappropriately” using child welfare and 

juvenile justice placements to get services to children who need them 

and who cannot access them through other channels. The department is 

concerned that unless or until alternative ways of accessing services 

are available, condemning agencies that do what they can to meet 

families’ needs may further impede access for families seeking 

treatment for children’s serious mental health conditions.



The GAO identifies in its report that child welfare agencies often have 

the same difficulty accessing services that parents face. Committing a 

child to the custody of child welfare does not assure his/her mental 

health needs will be met. Such commitments are often made in order to 

access the funds that child welfare or juvenile justice has available 

to pay for residential treatment services, and may not address other 

mental health services.



The Administration for Children and Families (ACF) uses the child and 

family services review (CFSR) process to identify states’ success in 

meeting children’s mental health:



needs. In part, the CFSRs allow ACF and states to evaluate the outcomes 

for children involved with the child welfare agency and develop plans 

to improve the outcomes when they are inconsistent with federal 

standards and requirements. The CFSRs are comprehensive, focusing on 

all children receiving child welfare services in their own homes or in 

foster care placements. Many of the findings in the GAO report mirror 

what the CFSRs have found to date:



* Mental health services are in short supply and often inaccessible to 

the children and families who need them.



* Children with mental health problems are often committed to the 

custody of the child welfare system which is ill equipped to serve 

them.



* State Systems of Care offer effective means of serving children with 

high-end needs.



Some of the findings of the CFSRs with regard to mental health services 

include:



* All 32 states reviewed to date will need to enter into Program 

Improvement Plans (PIP) to strengthen the quality of needs assessment 

and service delivery to children and families. This is a critical issue 

since caseworkers often fail to identify important needs of children, 

including mental health needs, when they develop case plans and provide 

services.



* Thirty-one of the 32 states failed to achieve positive ratings on the 

indicator in the CFSR that addresses the provision of physical and 

mental health services. Most often, it is the mental health area that 

is lacking.



* Access to services is one of the weakest areas of performance 

identified among the 32 states reviewed. Most often, the more 

specialized services, such as children’s mental health services and 

substance abuse treatment, are among the services that are either 

lacking or inaccessible due to wait lists, location, etc.



GAO Recommendations for Executive Action:



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 recommend that the Secretary of HHS and the 

Attorney General investigate the feasibility of tracking these children 

to identify the extent and outcomes of these placements. To help reduce 

misunderstanding at the state and local levels, we also recommend that 

the Secretaries of HHS and Education, and the Attorney General develop 

an interagency working group to identify the causes of these 

misunderstandings and create an action plan to address those causes. We 

further recommend that these agencies continue to encourage states to 

evaluate the child mental health programs they fund or initiate.



Department Response:



The report articulates significant problems already identified, yet 

basically recommends further study. The recommendation to track this 

population of children in foster care:



does not address the larger point of lack of mental health resources 

for families and communities and does not address the problems of the 

children or their parents. While the department is not fundamentally 

opposed to collecting data on the number of children who enter foster 

care solely for mental health reasons, GAO fails to identify to what 

end this data would be used. Appropriate funding for states and the 

federal agencies involved in tracking should accompany the request for 

further tracking.



We are not opposed to meeting with our federal counterparts and have, 

in fact, identified it as an activity that ACF needs to undertake to 

further the goals of the CFSR. We require interagency coordination at 

the state level and ACF intends to model such behavior at the federal 

level. We would be glad to participate in a special workgroup or 

utilize one of the interagency bodies already established such as the 

Public-Private Partnership on Mental Health Services for Children and 

Youth to thoroughly examine the issue. If a special workgroup were 

chosen as the best way to examine the problem, ACF would agree to co-

chair this activity with appropriate staff from the Substance Abuse and 

Mental Health Services Administration (SAMHSA). However, once again, we 

fail to see how GAO’s recommendation will truly address the core issue. 

Forming an interagency group to look at state and local 

misunderstandings of agency roles and program requirements and 

educating state agencies with respect to federal requirements, roles, 

and responsibilities will do little to address the lack of resources.



Other comments:



In order to address the specific problem under study, a broader look at 

the status of children’s mental health services in general would be 

useful. The report could go further in stating explicitly that the 

problems in children’s mental health that lead to parents committing 

their children to the child welfare or juvenile justice system in order 

to obtain services are part of the bigger problem of children’s mental 

health services in general, i.e., limited or non-existent services, 

lack of access, lack of quality providers, etc.



The data on the Highlights page are presented without context, i.e., 

12,700 children were placed in order to receive mental health services. 

What percentage is that of the total number of children placed in these 

two systems? And how many children remained “outside” the system but in 

need of the same kind of deep-end, seriously emotionally disturbed-type 

services? Without a comparison group there is no sense of proportion or 

scale. Is this a relatively small percentage/low base rate occurrence? 

Is this number “bad” or a traumatic decision for any parent to make, or 

is it an unnecessary drain on the public coffers?



The report would benefit from the inclusion of more detail about the 

terms “voluntary placement” and “custody relinquishment.” What is the 

exact meaning of these terms and what are the legal and other 

implications for parents and children? In a few pages, e.g., on page 

27, the question of “custody relinquishment” is mentioned.



The GAO stated that, “Although Federal law does not require custody 

relinquishment to obtain mental health services, state child welfare 

officials in two states that they visited:



said that their state required parents to relinquish custody of their 

child to the state after the voluntary placement period ended.” 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. 

We would like to see a more fundamental and basic discussion on such 

questions as whether relinquishment of custody may be permanent or 

reversible, how this may differ from state to state, or exactly how 

custody relinquishment may affect parents and children. It would be 

helpful if these terms and questions were defined and discussed in a 

discrete section in the beginning of the report.



Input provided by SAMHSA concerning “voluntary” placement was not 

accurately reflected in the report. Voluntary placement is a legal term 

(in the states that allow this process to be used) which allows custody 

to automatically return to the parents at the end of the treatment for 

the mental health issues. This term is used in the report as an act on 

the part of the parents.



We have some concern about the completeness of the study and the 

conclusions it draws based on the sample, to the extent they were 

included in the study, that a large group of vested individuals--the 

parents of the children who were relinquished--could have provided 

additional information regarding their motivations and the outcomes of 

their decisions to place children within the child welfare system. 

Responses to the questions below could provide valuable insight into 

this issue:



* Who helped the parents to see this relinquishment as a solution to 
the 

problem? 



* How did the parents approach the child welfare agency or did 

the agency approach them?



* Were they satisfied, e.g. did their child receive the services they 

needed or the services that the parents wanted for them?



* Did those services help their child and did things get better 

(whatever measure the parents used) for their child?



* Did parents try to “undo” these relinquishments?



* Did agencies actually deliver on the services?



* Did the kids get what they needed to have better lives?



The report gives a short view of the system’s placement record with 

these children. This missing outcome piece gives an incomplete picture 

of the problem.



The GAO mentioned two big caveats, but did not address them as such in 

the conclusions. The conclusions should at least include caveats, e.g., 

there are no formal or comprehensive federal or state tracking 

placement occurrences and the findings may not have any statistical 

significance. Data was not provided from the five states that have the 

largest populations of children.



[End of section]



Appendix V: Comments from the Department of Justice:



U.S. Department of Justice Office of Justice Programs:



Office of the Assistant Attorney General

Washington, D. C. 20531:



Cornelia M. Ashby Director:



Education, Workforce, and Income Security Issues General Accounting 

Office:



441 G Street, NW, Room 5928 Washington, DC 20548:



APR 07 2003:



Dear Ms. Ashby:



This letter is in response to the General Accounting Office (GAO) draft 

report entitled, “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).



It is clear from this report that GAO conducted an in-depth and 

comprehensive review under very difficult circumstances. None of the 

states surveyed collected data on these children and their families, 

and information provided by state officials was most often offered in

anecdotal form. While we consider the draft report to be both thorough 

and well-written, we believe that it could be further refined and 

strengthened.



In general, we are concerned that the report presents the information 

provided by state officials as being solid and conclusive, when, in 

fact, it is highly speculative. The danger here is that readers of the 

report will conclude that state officials’ statements are sufficiently 

accurate 

and reliable to form the basis for recommended changes in policy and 

practice. We believe that the tenuous nature of the data precludes its 

use as a sound basis for policy change. Instead, we would recommend 

that the report emphasize both the lack of empirical support for state 

officials’ statements, as well as the urgent need for state and local 

jurisdictions to develop and implement plans for the collection of 

reliable, valid, and relevant data.



A number of statements in the report suggest that the evidence base 

regarding voluntary custody relinquishment is sufficiently strong to 

support recommendations for policy change. The reality, however, is 

that data on this issue are minimal, if not non-existent. On the 

“Highlights” page, for example, a sentence in the first paragraph 

states, “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.” If no agency maintains relevant data, 

then it is unclear how officials could have developed such specific 

characterizations of these children. The report should

provide some information regarding how officials have reached these 

conclusions in the absence of reliable statistics.



The report contains recommendations that apply specifically to the 

Attorney General. While we concur with the general outline of these 

recommendations, we believe that certain revisions are appropriate. The 

report recommends, “...that the Secretary of [Health and Human 

Services] and the Attorney General investigate the feasibility of 

tracking these children to identify the extent and outcomes of these 

[inappropriate] placements.” As noted in the enclosure, we strongly 

encourage the collection of relevant data to determine the nature and 

extent of these inappropriate placements. Institution of a long-term 

tracking program, however, appears premature, as we currently have no 

data regarding the true scope of the problem. Our ultimate goal is to 

eliminate any need for parents to place their children in the child 

welfare or juvenile justice systems to obtain needed mental health 

services. Tracking inappropriate placements does little to further this 

goal.



Because the primary source of the problem appears to be a lack of 

available mental health care services, Health and Human Services (HHS) 

should take the lead in this investigation. The Attorney General should 

also play a role, especially in data collection from within the 

juvenile justice system. Special considerations (e.g., 

confidentiality, coordination with defense and prosecuting attorneys) 

may apply to data obtained from youth and families involved with the 

juvenile court, and Department of Justice (DOJ) will be glad to assist 

HHS in understanding the complexities of data collection in juvenile 

justice settings.



The second recommendation involves the creation of an interagency 

working group by the Secretaries of HHS and Education and the Attorney 

General “to help reduce misunderstandings at the state and local level 

..... [and] to identify the causes of these misunderstandings and 

create an action plan to address those causes.” We agree with the 

importance of an interagency effort to elucidate the causes of this 

problem, and to identify policy and programmatic changes that would 

address those causes. We recommend that the existing, statutorily 

mandated Coordinating Council on Juvenile Justice and Delinquency 

Prevention’, which contains representatives from all the identified 

Federal agencies, serve as the vehicle for implementing this 

recommendation.



GAO concludes the report by recommending that, “...these agencies 

continue to encourage states to evaluate the child mental health 

programs that they fund or initiate.” Although the evaluation of child 

mental health programs is a worthwhile goal, it does not appear to 

address the specific issues raised by this report. The report does not 

identify ineffectiveness of existing mental health programs as a source 

of inappropriate placement. Rather, the key issue is a lack of 

placement opportunities in existing mental health facilities. States 

should consider evaluating their entire systems of care for children, 

in order to determine: a) how many children with serious mental illness 

are in need of care but unable to obtain it; b) how the state and local 

child-serving agencies (e.g. education, child welfare, mental health, 

juvenile justice) attempt to

address the needs of these children; and c) how effective these 

systemic efforts are in actually meeting the mental health needs of 

these youth and their families.



We appreciate the opportunity to provide comments to the draft report. 

Additional specific comments are enclosed for GAO’s consideration. If 

you have any questions concerning this response, please contact me on 

(202) 307-5933, or LeToya Johnson, Office of Justice Programs Audit 

Liaison, on (202) 514-0692.



Sincerely,



Deborah J. Daniels Assistant Attorney General:



Signed by Deborah J. Daniels:



Enclosure:



cc:	J. Robert Flores, Administrator:



Office of Juvenile Justice and Delinquency Prevention:



Cynthia J. Schwimer Comptroller, OJP:



LeToya A. Johnson Audit Liaison, OJP:



Vickie L. Sloan Audit Liaison, DOJ:



OAAG Executive Secretariat Control No. 20030602:



[1] 42 U.S.C. § 5616.



[End of section]



Appendix VI: GAO Contacts and Acknowledgments:



GAO Contacts:



Diana Pietrowiak (202) 512-6239

Kathleen D. White (202) 512-8512

:



Acknowledgments:



In addition to those named above, Karen A. Brown, Erin Williams, and 

Katherine L. Wulff made key contributions to the report. Rebecca Shea, 

Patrick Dibattista, Alice London, Behn Miller, and Carolyn Yocom 

provided key technical assistance.



[End of section]



Related GAO Products:



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, DC: 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.



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” throughout this report. 



[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 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--that is, according to the Department of 

Justice (DOJ), behaviors that are law violations only if committed by 

juveniles. However, parents sometimes request that police arrest their 

children for delinquent behaviors or status offenses that are related 

to or stem from their mental illness when they cannot obtain services 

through other means. In this report, 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] In commenting on a draft of this report, HHS said that federal 

reimbursement is only available for children placed by a juvenile 

justice agency when that agency has an agreement with a child welfare 

agency under Title IV-E. HHS also said that many facilities that treat 

children with serious mental health issues are not considered within 

the scope of foster care and the Title IV-E program. Some states have 

developed procedures for using Title IV-E funding for the residential 

placement of children with mental health needs by arranging for courts 

to make similar findings in these cases as are required for the 

placement of children removed for safety reasons in situations of abuse 

and neglect.



[4] A residential treatment facility is an inpatient facility, other 

than a hospital, that provides psychiatric services to individuals 

under age 21.



[5] The 11 states are: Alaska, Colorado, Connecticut, Iowa, Maine, 

Minnesota, North Dakota, Oregon, Rhode Island, Wisconsin, and Vermont.



[6] The 8 states are: Florida, Georgia, Hawaii, Kansas, Missouri, 

Montana, New Hampshire, and Texas.



[7] Child-serving agencies include mental health, Medicaid and SCHIP, 

juvenile justice, education, and child welfare.



[8] Medicaid is a federal-state health financing program for certain 

low-income individuals established by Title XIX of the Social Security 

Act; under Medicaid, states must meet minimum federal rules of coverage 

in order to receive federal matching dollars. People eligible for 

Medicaid can generally be divided into three categories: (1) the 

mandatory categorically needy, (2) the optional categorically needy, 

and (3) the medically needy. States have several methods by which they 

can customize their Medicaid program to meet the needs of these 

enrollees. States can choose to cover certain optional services, such 

as prescription drugs, or certain optional populations; for example, 

several states have expanded eligibility for Medicaid to certain groups 

of children who would not otherwise qualify for the program because 

their families’ incomes are too high. A limited number of states can 

also request that HHS waive certain statutory requirements for a 

specified period of time.



[9] 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).



[10] IDEA requires that, to the maximum extent possible, children with 

disabilities are to be educated with children who are not disabled, 

based on the needs of the child.



[11] U.S. General Accounting Office, Health Insurance: States’ 

Protections and Programs Benefit Some Unemployed Individuals, 

GAO-03-191 (Washington, D.C.: Oct. 25, 2002).



[12] 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 (TEFRA) of 1982. 



[13] Not all severely limited children with a mental illness who meet 

SSI’s income requirements are eligible for SSI payments because of 

SSI’s strict definition of disability. Federal SSI payments for 

disabled children range from $1 to $545 and some states supplement 

these payments. Although most children who receive SSI payments are 

eligible for Medicaid, some are not. 



[14] Twenty-eight states provided estimates. Nine states could not 

provide the data requested, 9 states said the practice of voluntary 

placement is not legal in their states, 11 states could not provide the 

data requested, but indicated that voluntary placement happens. Four 

states did not respond to our survey.



[15] These 4 states were Alaska, Illinois, Louisiana, and South 

Carolina.



[16] In commenting on a draft of this 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.



[17] 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.



[18] These services are generally provided by licensed or certified 

psychiatrists, psychologists, or master’s level social workers.



[19] 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. 



[20] See ERISA, 29 U.S.C. sections 1001-1461.



[21] In commenting on a draft of this report, Kansas said that services 

the state provides under the Rehabilitation option are not limited to 

60 days, but are based on the individual clinical and medical needs of 

a child.



[22] 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).



[23] Attention deficit disorder is a syndrome characterized by serious 

and persistent difficulties in attention span, impulse control, and, 

sometimes, hyperactivity.



[24] Schizophrenia is a cluster of disorders characterized by 

delusions, hallucinations, disordered thinking, and emotional 

unresponsiveness.



[25] The California legislature transferred the responsibility for 

providing mental health services to children in special education from 

schools to counties in the late 1980s. 



[26] In commenting on a draft of this report, Education said that most 

of the federal laws concerning this population are purposely vague, 

open to interpretation, and (in the case of IDEA) actively supportive 

of state determination of actual procedures and how they will be 

interpreted.



[27] TANF, created by the Personal Responsibility and Work Opportunity 

Reconciliation Act of 1996, provides assistance and work opportunities 

to needy families by granting states federal funds and flexibility to 

develop and implement their own welfare programs.



[28] Diversion programs attempt to prevent or reduce the time children 

spend in inappropriate placements.



[29] Child welfare directors and juvenile justice officials used a 

variety of means to estimate the numbers of children placed. For 

example, some child welfare directors spoke to their counterparts at 

the local level and asked them to provide estimates. In other 

instances, the directors estimated based on the number of children 

receiving the highest level of mental health services.



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