This is the accessible text file for GAO report number GAO-09-935T entitled 'Hurricane Katrina: Barriers to Mental Health Services for Children Persist in Greater New Orleans, Although Federal Grants Are Helping to Address Them' which was released on August 4, 2009. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Testimony: Before the Ad Hoc Subcommittee on Disaster Recovery, Committee on Homeland Security and Governmental Affairs, U.S. Senate: United States Government Accountability Office: GAO: For Release on Delivery: Expected at 10:00 a.m. EDT: Tuesday, August 4, 2009: Hurricane Katrina: Barriers to Mental Health Services for Children Persist in Greater New Orleans, Although Federal Grants Are Helping to Address Them: Statement of Cynthia A. Bascetta: Director, Health Care: GAO-09-935T: Madam Chairman and Members of the Subcommittee: I am pleased to be here today to discuss the protection of children during disaster recovery and to provide highlights of our July 2009 report entitled Hurricane Katrina: Barriers to Mental Health Services for Children Persist in Greater New Orleans, Although Federal Grants Are Helping to Address Them.[Footnote 1] The greater New Orleans area has yet to fully recover from the effects of Hurricane Katrina, which made landfall on August 29, 2005. One issue of concern in the recovery is the availability of mental health services for children.[Footnote 2] In our report, we estimated that in 2008 about 187,000 children were living in the greater New Orleans area--which we defined as Jefferson, Orleans, Plaquemines, and St. Bernard parishes.[Footnote 3] Many children in the greater New Orleans area experienced psychological trauma as a result of Hurricane Katrina and its aftermath, and studies have shown that such trauma can have long-lasting behavioral, psychological, and emotional effects on children. Poor children in this area may also be at additional risk, because studies have also shown that children who grow up in poverty are at risk for the development of mental health disorders.[Footnote 4] In 2007 the poverty rate for each of the four parishes in the greater New Orleans area was higher than the national average, and in Orleans and St. Bernard parishes, the rate was at least twice the national average. Experts have found increases in the incidence of depression, post-traumatic stress disorder symptoms, risk-taking behavior, and somatic and psychosomatic conditions in children who experienced the effects of Hurricane Katrina. In addition, children in greater New Orleans may continue to experience psychological trauma because of the slow recovery of stable housing and other factors, such as the recurring threat of hurricanes. Data collected by Louisiana State University (LSU) Health Sciences Center researchers indicate that of the area children they screened in January 2008, 30 percent met the threshold for a possible mental health referral. Although this was a decrease from the 49 percent level during the 2005-06 school year screening, the rate of decline was slower than experts had expected. Experts have previously identified barriers both to providing and to obtaining mental health services for children.[Footnote 5] Barriers to providing services are those that affect the ability of health care organizations to provide services, such as a lack of providers; and barriers to obtaining services are those that affect the ability of families to gain access to services, such as concerns regarding the stigma often associated with mental health services for children. The devastation to the health care system in greater New Orleans caused by Hurricane Katrina may have exacerbated such barriers. Multiple federal agencies support the provision of mental health and related services for children in the greater New Orleans area through various programs. These agencies include the Department of Health and Human Services' (HHS) Administration for Children and Families (ACF), Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administration, and Substance Abuse and Mental Health Services Administration (SAMHSA) and the Departments of Education and Justice. For example, since Hurricane Katrina, the federal government has directed over $400 million toward restoring health services, including mental health services for children, in Louisiana and the greater New Orleans area. Other federal funding not targeted to Hurricane Katrina recovery, available through several grant programs, also supports the delivery of children's mental health services in the area. These programs provide funding through annual formula grants--noncompetitive awards based on a predetermined formula--to Louisiana and through various discretionary grants to state and local agencies and nongovernmental organizations.[Footnote 6] My statement today is based on our July 2009 report, in which we (1) identified barriers to providing and barriers to obtaining mental health services for children in the greater New Orleans area, and (2) described how federal programs, including grant programs, address barriers to providing and to obtaining mental health services for children. To do this work, we developed and used a structured interview and a written data collection instrument to gather views on barriers from 18 state and local stakeholder organizations selected on the basis of experts' referrals and the organizations' roles in children's mental health. The representatives of the 18 organizations we interviewed were asked, as a group, to identify the three greatest barriers to providing and to obtaining mental health services for children in the greater New Orleans area. Because the 18 organizations were not selected by random sample, their views cannot be generalized to all organizations or individuals working in the field of children's mental health services in the greater New Orleans area. To learn how federal programs address these barriers, we reviewed documents from and interviewed federal, state, and local officials involved in providing mental health services to children. Our work included a site visit to greater New Orleans. We conducted our work from April 2008 through June 2009 in accordance with all sections of GAO's Quality Assurance Framework that are relevant to our objectives. The framework requires that we plan and perform the engagement to obtain sufficient and appropriate evidence to meet our stated objectives and to discuss any limitations in our work. We believe that the information and data obtained, and the analysis conducted, provide a reasonable basis for any findings and conclusions in this product. A detailed explanation of our methodology is included in our July 2009 report. Barriers to Mental Health Services for Children Persist, Although Federal Grants Are Helping to Address Them: Stakeholder organizations most frequently identified a lack of mental health providers and sustainability of funding as barriers to providing mental health services to children in the greater New Orleans area, and they most frequently identified a lack of transportation, competing family priorities, and concern regarding stigma as barriers to families' obtaining mental health services for children. A range of federal programs are helping to address these barriers, but much of the funding they provide is temporary. Lack of Providers Was Most Frequently Identified Barrier to Providing Children's Mental Health Services, and Lack of Transportation Was Most Frequently Identified Barrier to Obtaining Services: Among the 18 stakeholder organizations that participated in our structured interviews, the most frequently identified barrier to providing mental health services was a lack of providers. (See table 1.) Fifteen of the 18 organizations identified a lack of mental health providers--including challenges recruiting and retaining child psychiatrists, psychologists, and nurses--as a barrier to providing services. In addition, 13 of the 18 organizations identified sustainability of funding, including difficulty securing reliable funding sources and limitations on reimbursement for services, as a barrier to providing services. Table 1: Most Frequently Identified Barriers to Providing Mental Health Services for Children in the Greater New Orleans Area: Barrier: Lack of mental health providers; Number of organizations identifying barrier: 15. Barrier: Sustainability of funding; Number of organizations identifying barrier: 13. Barrier: Availability of referral services; Number of organizations identifying barrier: 5. Barrier: Lack of coordination between mental health providers or other providers serving children; Number of organizations identifying barrier: 3. Barrier: Availability of physical space for programs; Number of organizations identifying barrier: 2. Source: GAO. Note: Data are from analysis of structured interview data collected from September through November 2008. Each of 18 stakeholder organizations was interviewed and asked to identify the three greatest barriers to providing mental health services for children. In some cases, organizations offered fewer than three barriers. Barriers named by only 1 organization were omitted from this table. [End of table] With regard to families' ability to obtain services for their children, 12 of the 18 organizations identified lack of transportation as a barrier.[Footnote 7] (See table 2.) In addition, 11 of the 18 organizations identified competing family priorities--such as housing problems, unemployment, and financial concerns--as a barrier to obtaining services. An equal number identified concern regarding the stigma associated with receiving mental health services as a barrier. Table 2: Most Frequently Identified Barriers to Obtaining Mental Health Services for Children in the Greater New Orleans Area: Barrier: Lack of transportation; Number of organizations identifying barrier: 12. Barrier: Competing family priorities; Number of organizations identifying barrier: 11. Barrier: Concern regarding stigma; Number of organizations identifying barrier: 11. Barrier: Lack of available services; Number of organizations identifying barrier: 8. Barrier: Not knowing where to go to obtain services; Number of organizations identifying barrier: 3. Barrier: Lack of health insurance; Number of organizations identifying barrier: 2. Source: GAO. Note: Data are from analysis of structured interview data collected from September through November 2008. Each of 18 stakeholder organizations was interviewed and asked to identify the three greatest barriers to obtaining mental health services for children. Barriers named by only 1 organization were omitted from this table. [End of table] Federal Programs Address Barriers by Supporting State and Local Efforts to Hire Providers; Assist Families; and Deliver Care through School- Based Health Centers: A range of federal programs address barriers to mental health services for children in the greater New Orleans area by supporting various state and local efforts--including hiring providers, assisting families, and utilizing schools as delivery sites--but much of the funding is temporary. Several federal programs support state and local efforts to hire or train mental health providers. For example, as of May 2008, CMS's Professional Workforce Supply Grant, created with the intent to recruit and retain health professionals in the greater New Orleans area, was used to provide financial incentives to 82 mental health providers who agreed to either take a new position or continue in a position in the area and to serve for at least 3 years. This funding will be available through September 2009. In addition, a few federal programs support training of children's mental health providers. For example, SAMHSA's National Child Traumatic Stress Initiative awarded two grants in October 2008 to providers in the greater New Orleans area to provide training on, implement, and evaluate trauma-focused treatment for children. Funding from several HHS programs has been used to transport children to mental health services. For example, Louisiana designated $150,000 in its fiscal year 2009 state plan for SAMHSA's Community Mental Health Services Block Grant for transportation for children in the greater New Orleans area, and funding from ACF's 2006 Supplemental Social Services Block Grant (SSBG) has also been used to supply transportation to mental health appointments for children.[Footnote 8] Federal programs also provide funding that is used to alleviate conditions that create competing family priorities--including dealing with housing problems, unemployment, and financial concerns--to help families more easily obtain children's mental health services. Federal programs address competing priorities, in part, by providing case management, information, and referral services,[Footnote 9] which can help families identify and obtain services such as health care, housing assistance, and employment assistance. For example, officials from a local organization that received funding from ACF's Head Start told us that the program had provided families with information and referrals for mental health services. Some federal programs also address competing family priorities by providing direct financial assistance, which may help alleviate family stress and make it easier for families to devote resources and effort to obtaining mental health services for their children. Although most of the federal programs we identified were not established as a direct result of Hurricane Katrina, the programs that are hurricane-related have been an important source of support for mental health services for children in greater New Orleans. However, much of this funding is temporary and does not fully address the sustainability barrier. For example, funds from three hurricane-related grant programs--CMS's Primary Care Access and Stabilization Grant (PCASG), its Professional Workforce Supply Grant, and ACF's 2006 SSBG supplemental funding--will no longer be available to grantees after 2010.[Footnote 10] Louisiana has used federal funds to help support school-based health centers (SBHC), which have emerged as a key approach in the greater New Orleans area to address barriers to obtaining mental health services for children. In general, SBHCs are located in schools or on school grounds and provide a comprehensive range of primary care services to children. Louisiana's SBHCs also provide mental health services and are required to have mental health staff on-site. Furthermore, some SBHCs in the greater New Orleans area have a psychiatrist on staff on a part- time basis. Although there is no federal program whose specific purpose is to support SBHCs, state programs have used various federal funding sources to support them. For example, a Louisiana official told us funds from HHS's Maternal and Child Health Services Block Grant and Community Mental Health Services Block Grant provide some of the support for SBHCs in greater New Orleans. During the 2007-08 school year, there were nine SBHCs in greater New Orleans, and state officials told us in February 2009 that at least four more were in the planning stages for this area. SBHCs can help address the top three barriers to obtaining services identified in our structured interviews--a lack of transportation, competing family priorities, and concern regarding stigma. For example, because SBHCs are generally located in schools or on school grounds, students have less need for transportation to obtain care and parents have less need to take time from work to accompany a child to appointments. In addition, SBHC services may be provided at low or no cost to the patient, which lessens the financial burden on the family. Also, colocation of mental health and other primary care services may reduce concern regarding stigma because the type of service the child is receiving at the SBHC is generally not apparent to an observer. Agency Comments and Our Evaluation: We provided a draft of our July 2009 report to HHS and Education for their review. In its comments, HHS provided additional information on mental health services provided in schools other than through SBHCs and emphasized the effect of a lack of stable housing on children's mental health. In addition, both HHS and Education provided technical comments. We incorporated HHS's and Education's comments in the report as appropriate. Madam Chairman, this completes my prepared remarks. I would be happy to respond to any questions you or other members of the subcommittee may have at this time. GAO Contacts and Staff Acknowledgments: For further information about this statement, please contact Cynthia A. Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. Key contributors to this statement were Helene F. Toiv, Assistant Director; Roseanne Price; Julie Thomas Stewart; Laurie F. Thurber; and Malissa G. Winograd. [End of section] Footnotes: [1] GAO, Hurricane Katrina: Barriers to Mental Health Services for Children Persist in Greater New Orleans, Although Federal Grants Are Helping to Address Them, [hyperlink, http://www.gao.gov/products/GAO-09-563] (Washington, D.C.: July 13, 2009). [2] For the purposes of this statement, such services include inpatient and outpatient counseling or mental health treatment; related ancillary services like transportation, translation, and case management; mental health education and prevention services; and substance abuse prevention and treatment services. [3] For details regarding the computation of our estimate, see [hyperlink, http://www.gao.gov/products/GAO-09-563], appendix I. [4] See GAO, Catastrophic Disasters: Federal Efforts Help States Prepare for and Respond to Psychological Consequences, but FEMA's Crisis Counseling Program Needs Improvements, [hyperlink, http://www.gao.gov/products/GAO-08-22] (Washington, D.C.: Feb. 29, 2008); V. Murali and F. Oyebode, "Poverty, Social Inequality and Mental Health," Advances in Psychiatric Treatment, vol. 10 (2004), 216-224; and K.A.S. Wickrama et al., "Family Antecedents and Consequences of Trajectories of Depressive Symptoms from Adolescence to Young Adulthood: A Life Course Investigation," Journal of Health and Social Behavior, vol. 49, no. 4 (2008), 468-483. [5] See, for example, the President's New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America (Rockville, Md., 2003). [6] See [hyperlink, http://www.gao.gov/products/GAO-09-563], appendixes II and III, for detailed information on selected federal programs that support mental health and related services for children. [7] For information on transportation services to hurricane victims, see GAO, Disaster Assistance: Federal Efforts to Assist Group Site Residents with Employment, Services for Families with Children, and Transportation, [hyperlink, http://www.gao.gov/products/GAO-09-81] (Washington, D.C.: Dec. 11, 2008). [8] SSBG supplemental funds were appropriated to ACF for allocation to states for expenses related to the 2005 hurricanes under the Department of Defense, Emergency Supplemental Appropriations to Address Hurricanes in the Gulf of Mexico, and Pandemic Influenza Act, 2006, Pub. L. No. 109-148, div. B, title I, ch. 6, 119 Stat. 2680, 2768 (2005). Additional SSBG supplemental funding was allocated to Louisiana in January 2009 and is available through September 2009 from an appropriation made by the Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009, Pub. L. No. 110-329, div. B, title I, ch. 7, 122 Stat. 3574, 3594-95 (2008). [9] For more information on case management services provided after Hurricane Katrina, see GAO, Disaster Assistance: Greater Coordination and an Evaluation of Programs' Outcomes Could Improve Disaster Case Management, GAO-09-561 (Washington, D.C.: July 8, 2009). We reported that federal agencies provided millions of dollars to support disaster case management services to assist victims of hurricanes Katrina and Rita, but a key barrier to providing case management services was a lack of reliable, continuous funding. [10] For additional information about the PCASG and the Professional Workforce Supply Grant, see GAO, Hurricane Katrina: Federal Grants Have Helped Health Care Organizations Provide Primary Care, but Challenges Remain, GAO-09-588 (Washington, D.C.: July 13, 2009). [End of section] GAO's Mission: The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO's commitment to good government is reflected in its core values of accountability, integrity, and reliability. 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