GAO-02-813, Mental Health Services: Effectiveness of Insurance Coverage and Federal Programs for Children Who Have Experienced Trauma Largely Unknown


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entitled 'Mental Health Services: Effectiveness of Insurance Coverage 
and Federal Programs for Children Who Have Experienced Trauma Largely 
Unknown' which was released on September 23, 2002.



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Report to Congressional Requesters:



August 2002:



Mental Health Services:



Effectiveness of Insurance Coverage and Federal Programs for Children 

Who Have Experienced Trauma Largely Unknown:



GAO-02-813:



Contents:



Letter:



Results in Brief:



Background:



Most Children Have Health Insurance Coverage, But Mental Health 

Coverage May Have Limits and Not Guarantee Access:



Federal Programs Can Help Children Who Have Experienced Trauma to 

Obtain Mental Health Services, But Extent of Assistance Is Largely 

Unknown and Little Evaluation Has Occurred:



Conclusions:



Recommendation for Executive Action:



Agency Comments and Our Evaluation:



Appendixes:



Appendix I: Scope and Methodology:



Appendix II: victimization Data:



Child Abuse and Neglect Data Collected by HHS’s Administration for 

Children and Families:



Child Access and Visitation Data Collected by HHS’s Administration for 

Children and Families:



Victimization Data Collected by the Department of Justice:



Appendix III: Information on SCHIP Program in the 50 States and the 

District of Columbia:	



Appendix IV: Selected Individual Insurers’ Coverage for Specified 

Mental Health Coverage in Six States as of 2002:



Appendix V: Summary of Selected Laws Regarding Mental Health Coverage 

in Six States:



Appendix VI: Selected Federal Grant Programs That May Be Used to Help 

Children Exposed to Trauma Obtain Mental Health Services: 



Appendix VII: State Crime Victim Compensation Benefits, May 2002:



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



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



Appendix X: Comments from the Department of Education:



Appendix XI: GAO Contact and Staff Acknowledgements:



Related GAO Products:



Tables:



Table 1: Type of Insurance Coverage for Children under Age 19 in 2000:



Table 2: Percentage of Health Plans Offered by Employers with More Than 

500 Employees That Limited Inpatient and Outpatient Mental Health 

Services in 2001:



Table 3: Number of Victims in Selected Categories Served by State 
Victim 

Assistance Programs in Four States, Fiscal Year 2001:



Table 4: Number of Referrals to Child Protective Services and 

Substantiated Cases of Child Maltreatment, by State, 1999:



Table 5: Information on Child Victims of Maltreatment, by State, 1999:



Table 6: Services Provided to Child Victims of Maltreatment, by State, 

1999:



Table 7: Number of Reports of Child Maltreatment, by Source of Report 

and State, 1999:



Table 8: Child Access and Visitation Grant Data, by State:



Table 9: Estimated Number of Persons Raped or Physically Assaulted by 
an 

Intimate Partner during Lifetime and Previous 12 Months, by Sex of 

Victim:



Table 10: Estimated Rates of Law Enforcement Actions, as Reported by 

Victims of Selected Intimate Partner Crimes:



Table 11: Instances of Forcible Rape of Women Reported to Police, All 

Ages, 2000:



Table 12: Sexual Assault Convictions in State Courts, 1998:



Table 13: Program Type, Maximum Income Eligibility Levels, and Fiscal 

Year 2001 Enrollment for SCHIP Programs in the 50 States and the 

District of Columbia:



Table 14: Summary of Parity Laws That Exceed Federal Standards in Three 

States:



Table 15: Summary of Selected Laws Related to Mental Health Coverage in 

Illinois:



Table 16: Selected Federal Grant Programs That May Be Used to Help 

Children Exposed to Trauma Obtain Mental Health Services:



Table 17: Crime Victim Compensation Maximum Overall Benefits and 
Maximum 

Mental Health Benefits:



Figures:



Figure 1: Comparison of State Medicaid and SCHIP Coverage for Selected 

Mental Health Treatments in California and Utah:



Figure 2: Public and Private Insurance Coverage Options in California 

and Illinois for a Hypothetical 5-Year Old Child Who Has Experienced 

Trauma:



Figure 3: Estimated Number of Victims of Intimate Partner Violence, by 

Sex, 1993 to 1998:



Figure 4: Selected Individual Insurers’ Coverage for Specified Mental 

Health Services Available to Children in Six States:



Abbreviations:



ACF: Administration for Children and Families:



CMS: Centers for Medicare & Medicaid Services:



DSM: Diagnostic and Statistical Manual of Mental Disorders:



EPSDT: Early and Periodic Screening, Diagnostic, and Treatment:



ERISA: Employee Retirement Income Security Act of 1974:



FEMA: Federal Emergency Management Agency:



HHS: Department of Health and Human Services:



HMO: health maintenance organization:



HRSA: Health Resources and Services Administration:



MHPA: Mental Health Parity Act of 1996:



OVC: Office for Victims of Crime:



POS: point of service:



PPO: preferred provider organization:



PTSD: posttraumatic stress disorder:



SAMHSA: Substance Abuse and Mental Health Services Administration:



SCHIP: State Children’s Health Insurance Program:



SED: serious emotional disturbance:



SMI: severe mental illness:



VOCA: Victims of Crime Act:



Letter:



August 22, 2002:



The Honorable Richard J. Durbin

The Honorable Edward M. Kennedy

The Honorable Paul Wellstone

United States Senate:



One-time traumatic events like natural disasters, terrorist incidents, 

and school shootings as well as ongoing exposure to trauma such as 

family and community violence can have serious psychological, 

emotional, and developmental repercussions for children. In the short 

term, children’s lives can be radically disrupted, and longer-term 

effects can include difficulties in school, work, and personal 

relationships. If children who have experienced trauma do not receive 

the care they need, these problems can continue into adulthood.



Large numbers of children are at risk for trauma-related mental health 

problems. The Department of Justice reported in 1997 that almost 9 

million children aged 12 to 17 had witnessed serious violence during 

their lifetimes; Justice has also reported that during the period of 

1993 through 1998, children under the age of 12 resided in 43 percent 

of households where intimate partner violence was known to have 

occurred. Further, the Department of Health and Human Services (HHS) 

reported that about 826,000 children and adolescents were found to be 

victims of abuse and neglect in 1999.



In response to your request for information on the ability of children 

who have experienced trauma to obtain mental health services, this 

report addresses (1) the extent to which private health insurance and 

the primary public programs that insure children--Medicaid and the 

State Children’s Health Insurance Program (SCHIP)--cover mental health 

services needed by children exposed to traumatic events and (2) other 

federal programs that help children who have experienced trauma receive 

needed mental health services.[Footnote 1] As requested, we are also 

providing national data that are available through federal agency 

sources on the incidence of child abuse and neglect, sexual assault, 

rape, intimate partner violence, and children’s witnessing such 

violence. (See app. II.):



To determine the extent of private and public insurance coverage of 

mental health services for children, we reviewed available employer 

survey data; reviewed the benefit design of health plans provided by 13 

insurers in the individual market as well as state Medicaid programs 

and SCHIP programs; and interviewed representatives of private insurers 

and public officials in California, Georgia, Illinois, Massachusetts, 

Minnesota, and Utah. We selected these states on the basis of variation 

in the number of beneficiaries covered, in geographic location, in the 

extent to which the insurance market is regulated, and in the design of 

the SCHIP program. To describe other federal programs that can help pay 

for mental health services for children who have experienced trauma or 

that try to ensure that these children receive needed services, we 

reviewed grant program documents obtained from officials of federal 

agencies, such as HHS, Justice, the Department of Education, and the 

Federal Emergency Management Agency (FEMA), and interviewed agency 

officials and representatives of national health care and child 

advocacy organizations. To gather information on services provided to 

children and on problems in obtaining needed services, we reviewed the 

relevant literature and contacted state and local mental health 

agencies, state crime victim compensation and assistance agencies, 

child welfare and protective service agencies, and other organizations 

receiving federal grants in California and Massachusetts, as well as 

additional service providers with federal grants in Colorado, Illinois, 

Minnesota, and Oregon. The programs and efforts we discuss in this 

report do not represent an exhaustive list of all federally funded 

programs that can address the mental health needs of children exposed 

to traumatic events; they highlight a range of programs that target 

varied populations, services, and systems that come into contact with 

this population. In addition, we obtained data on child abuse and 

neglect, intimate partner violence, and sexual assault that were 

collected and analyzed by HHS’s Administration for Children and 

Families (ACF) and Justice’s Bureau of Justice Statistics, National 

Institute of Justice, and Federal Bureau of Investigation. We did not 

verify the accuracy of these data. (For additional information on our 

methodology, see app. I.):



We conducted our work from September 2001 through August 2002 in 

accordance with generally accepted government auditing standards.



Results in Brief:



Eighty-eight percent of children nationwide, or over 67 million, have 

private or public health insurance that, to varying degrees, covers 

mental health services, including those that may be needed to help 

children recover from traumatic events. Despite the widespread 

prevalence of health insurance coverage for children, depending on 

their type of insurance coverage and where they live, children may face 

certain limitations in coverage or other barriers that could affect 

their access to needed services. Employer-sponsored health plans cover 

nearly two-thirds of children nationwide, or over 50 million, and 

federal law requires plans that cover more than 50 employees and 

include mental health benefits to cover mental health services to the 

same extent as other services in terms of annual or lifetime dollar 

limits. However, the federal law does not preclude these employer-

sponsored plans from including other features, such as day or visit 

limits, that are more restrictive for mental health services. In 

addition, the 4 percent of children, or over 3 million, covered by 

private-sector individual health insurance may face even greater 

coverage restrictions. For example, insurers in the individual market 

may offer only limited mental health coverage, such as a lifetime limit 

of $10,000 on mental health benefits; exclude specific disorders from 

coverage, such as posttraumatic stress disorder (PTSD); or offer no 

mental health coverage at all.



The 16 percent of children, or over 12 million, who are enrolled in 

Medicaid and SCHIP public insurance programs generally have coverage 

for a wide range of mental health benefits, and those enrolled in 

Medicaid are not subject to day or visit restrictions. In addition to 

any mental health services that states explicitly cover in their 

Medicaid programs, federal law requires states to provide all children 

enrolled in Medicaid with any service necessary to treat physical and 

mental conditions detected through Early and Periodic Screening, 

Diagnostic, and Treatment (EPSDT) screenings. Because EPSDT is not a 

mandatory component of SCHIP, however, states have more discretion in 

how they design their SCHIP programs, including the extent to which 

they cover mental health services. In states that model their SCHIP 

programs on private insurance plans rather than Medicaid, children may 

face day or visit limits, as in California and Utah. In addition, 

certain other factors, such as the availability of providers willing to 

participate in the Medicaid program or cost-sharing requirements of 

SCHIP, could also constrain the ability of some children to obtain 

needed services. The extent to which children enrolled in Medicaid and 

SCHIP receive covered mental health services is not fully known, but 

available evidence suggests that enrolled children in some states may 

not be obtaining services they need.



Beyond providing insurance that can give children access to mental 

health services, a range of federal programs can help children who have 

experienced trauma obtain needed services. We identified over 50 

programs--primarily in HHS, Justice, FEMA, and Education--that can be 

used by grantees to provide mental health and other needed services to 

children who have experienced trauma, although many of these programs 

have a broader focus and were not designed specifically for this 

purpose. Some federal programs pay for crisis counseling, such as the 

Crisis Counseling Assistance and Training Program to assist victims of 

disasters, which is administered by FEMA in collaboration with HHS’s 

Substance Abuse and Mental Health Services Administration (SAMHSA). 

Justice’s Victims of Crime Act (VOCA) Crime Victim Compensation grants 

to states are an important federal source of funding for mental health 

services for victims of crimes. However, children’s access to benefits 

may be constrained by states’ eligibility requirements or program 

limitations, such as caps on mental health services. In addition, other 

factors may also hamper some child victims’ ability to obtain financial 

assistance for needed mental health services. These include families’ 

lack of knowledge about state victim compensation programs and state 

program requirements such as filing a police report within 72 hours of 

a crime. Several federal grant programs encourage coordination among 

mental health and other service systems--such as child welfare, health 

care, and justice--so that children who have experienced trauma and 

their families can more easily gain access to the full range of 

services they need. Furthermore, some federal grants, such as Justice’s 

VOCA Crime Victim Assistance grants to states, can improve service 

providers’ ability to meet the needs of children who have experienced 

trauma by providing access to services, such as case management, that 

may not be covered by insurance.



While federal grant programs expand the number of children whose mental 

health services may be reimbursed or help increase the available 

services in a community, some children who need services may not 

benefit from such programs. For example, some grants are awarded to a 

relatively small number of communities and expire after a defined 

period. Moreover, little is known about the effectiveness of federal 

programs that can help children who have experienced trauma to obtain 

mental health services or about gaps in access to needed services. 

SAMHSA’s National Child Traumatic Stress Initiative, which is 

specifically designed to take a coordinated approach to improving 

mental health care for children who have experienced various kinds of 

trauma, plans to evaluate both its overall program and individual 

components. If carefully implemented, the SAMHSA evaluations have the 

potential to provide information on ways to effectively provide mental 

health services to children who have experienced trauma. Some key 

programs have not conducted evaluations to assess their effectiveness 

in helping traumatized children obtain needed mental health services, 

and others have lagged in establishing their evaluation frameworks. For 

example, FEMA and SAMHSA have not evaluated the effectiveness of the 

disaster crisis counseling program. Without evaluations of the 

effectiveness of federal programs that have a clear goal of helping 

children who experienced trauma obtain mental health services, federal 

managers and policymakers lack information that would help them assess 

which federal efforts are successful; determine which programs could be 

improved, expanded, or replicated; and effectively allocate resources 

to identify and meet additional service needs.



We are recommending that the Director of FEMA work with the 

Administrator of SAMHSA to evaluate the effectiveness of the disaster 

crisis counseling program. We provided a draft of this report to four 

departments and agencies for their review. FEMA and HHS concurred with 

our discussion of the Crisis Counseling Assistance and Training 

Program, agreed that evaluation of this program is needed to ensure 

program effectiveness, and stated that they have initiated additional 

evaluation activities. However, the activities they described do not 

constitute the programwide effectiveness evaluation we are recommending 

and FEMA did not indicate whether it intends to implement our 

recommendation to coordinate with SAMHSA to conduct such an evaluation. 

Both HHS and Education suggested that the report more fully address 

their concerns that the mental health workforce does not include enough 

appropriately trained providers to meet the service needs of children 

who have experienced trauma. We included additional information on this 

subject, but a detailed discussion of this issue is outside the scope 

of this report. HHS also suggested that the report treat in greater 

depth several other topics, including the role of stigma associated 

with mental health problems. We modified the report to acknowledge the 

role of stigma, but although we agree that this and other subjects are 

important, detailed discussion of them is outside the scope of this 

report. Justice provided technical comments.



Background:



Many children across the country have been victims of, or witnesses to, 

violence in their homes, schools, or communities. In 1999, according to 

the most recent edition of a joint Justice and Education report, 

students aged 12 through 18 were victims of about 186,000 violent 

crimes at school and about 476,000 violent crimes away from 

school.[Footnote 2] In addition, thousands of children have been 

exposed to natural disasters or terrorist acts such as those that 

occurred on September 11, 2001, placing them at risk for mental health 

problems. While many children respond to these situations with 

resilience, others suffer acute and chronic effects. Children’s 

reactions to trauma may appear immediately after the traumatic event or 

may appear days, weeks, months, or even years later. Researchers report 

that children who experience traumatic events show a wide range of 

reactions, and their nature and intensity vary on the basis of factors 

such as the type and frequency of trauma, whether a child knew the 

offender or victim, the strength of the family support system, and a 

child’s sex and age. For example, children age 5 and younger typically 

react to traumatic events with crying, screaming, and fear of being 

separated from a parent, while adolescents tend to have reactions 

similar to adults, such as flashbacks, nightmares, and suicidal 

thoughts.[Footnote 3] A child’s reactions to traumatic events, 

including disasters, may also vary based on how well their parents cope 

with the situation and on whether a child or parent has a preexisting 

mental disorder. Some children have a special vulnerability to the 

impact of traumatic events. Studies indicate that the impact is likely 

to be greatest for a child who had previously been victimized or 

already had a mental health problem.[Footnote 4]



Certain psychiatric diagnoses are associated with exposure to traumatic 

events, including acute stress disorder, PTSD, depression, and conduct 

disorder. Children with acute stress disorder can display multiple 

symptoms, including reexperiencing of the event, avoidance of 

situations that remind them of the traumatic event, sleep disturbances, 

poor concentration, and regressive behavior. The disorder is of short 

duration, with symptoms beginning within 4 weeks of a traumatic 

experience and lasting from 2 days to 4 weeks. If symptoms continue, 

the diagnosis may be reevaluated and changed to PTSD. PTSD is similar 

to acute stress disorder and shares many of the same symptoms, but 

lasts longer. It is diagnosed when symptoms persist more than a month, 

although the disorder may develop either immediately after a traumatic 

event or several months later. Exposure to traumatic events may also 

result in depression, which is generally characterized by changes in 

appetite, sleep disturbances, constant sadness, and irritability. 

Conduct disorder may also develop after experiencing a traumatic event. 

The disorder is identified by a persistent pattern of behavior that 

violates major age-appropriate societal norms, such as aggression 

toward people and animals or destruction of property.



The prevalence of different diagnoses varies based on factors such as 

age and sex. For example, a preliminary report on how the September 11, 

2001, attack affected New York City public school students found that 

children in grades 4 and 5 were more likely than children in grades 6 

to 12 to experience PTSD and other disorders involving intense fear and 

avoidance of usual activities, while the older children were more 

likely to have conduct disorder or depression. Similarly, girls had 

higher rates of PTSD, depression, and generalized anxiety than boys, 

who had higher rates of conduct disorder.[Footnote 5]



Depending on the nature and severity of a traumatized child’s 

condition, a variety of mental health treatment options and service 

settings may be recommended. These include outpatient individual, 

family, or group therapy; inpatient hospital care; and residential 

care. A range of service providers, including psychiatrists, 

psychologists, psychiatric nurses, counselors, and clinical social 

workers, may treat children who have experienced trauma. Optimal care 

of these children often requires participation by a variety of service 

systems, such as mental health and social services.



The Surgeon General has reported that there are not enough mental 

health professionals trained to work with children.[Footnote 6] 

Moreover, trauma experts report that even professionals who are trained 

to work with children may not have specialized training or experience 

in working with children who have experienced trauma. Children whose 

families do not speak English can have a particularly difficult time 

finding providers who can assist them.



Because the types of trauma that children experience vary considerably, 

numerous pathways can lead to the identification, referral, assessment, 

and treatment of traumatized children needing mental health services. 

These pathways include families; schools; day care; primary health 

care; and the law enforcement, juvenile justice, and child protective 

services systems. However, the professionals working in these systems 

may not be trained to identify children with trauma-related mental 

health problems. For example, a recent report by the Surgeon General 

noted that primary care providers often have little training on mental 

health services and vary in their capacity to recognize and diagnose 

disorders and to coordinate with mental health providers.[Footnote 7] 

In addition, the Institute of Medicine recently concluded that health 

professionals are not sufficiently educated about family 

violence.[Footnote 8] Further, not all teachers are aware of the 

connection between academic or behavioral problems and the possibility 

that they are related to a child’s exposure to violence. Justice has 

also reported that law enforcement personnel are generally not 

sufficiently aware of the psychological effects that witnessing 

violence can have on children.[Footnote 9]



At the national level, few data are available on the number of children 

who need mental health services as a result of exposure to trauma and 

the number who receive services. For example, there are no nationwide 

data on the number of children in foster care and the juvenile justice 

system--populations likely to have been exposed to trauma--who need 

mental health care, or on the number who have received 

treatment.[Footnote 10]



Private and Public Health Insurance Coverage for Children:



Access to health care services, including mental health services, is 

highly correlated to having health insurance coverage. According to 

March 2001 Current Population Survey data, over 67 million children 

nationwide have health insurance coverage. More than two-thirds of 

children under age 19--almost 54 million--obtain health insurance 

privately, either as a dependent under a parent’s or guardian’s 

employer-sponsored health plan or through the individual insurance 

market. In addition, almost 14 million children are enrolled in public 

programs such as Medicaid, SCHIP, or other federal insurance programs. 

Although most children have insurance coverage, over 9 million remain 

uninsured. (See table 1.):



Table 1: Type of Insurance Coverage for Children under Age 19 in 2000:



Type of insurance: Private; Employer-sponsored; Percentage of 

children under 19[A]: 65.9.



Type of insurance : Private/Individual; Percentage of 

children under 19[A]: Type of insurance : 4.1.



Type of insurance: Public; Medicaid (including SCHIP); Percentage of 

children under 19[A]: 16.3.



Type of insurance : Medicare[B]; Percentage of 

children under 19[A]: Type of insurance : 0.5.



Type of insurance : TRICARE[C]; Percentage of 

children under 19[A]: Type of insurance : 1.2.



Type of insurance: Uninsured; [Empty]; Percentage of 

children under 19[A]: 12.0.



[A] Some people may receive coverage from several sources. To avoid 

double counting, we assigned an individual reporting coverage from two 

or more sources to one source, based on a hierarchy in the following 

order: employer-sponsored, Medicare, Medicaid, TRICARE, private/

individual, and uninsured. Therefore, percentages for specific sources 

of coverage, such as Medicaid, may be underestimated.



[B] Children with a disability or End-Stage Renal Disease may be 

eligible for Medicare.



[C] TRICARE is a program administered by the Department of Defense for 

families of active duty, retired, and deceased service members.



Source: GAO analyses of March 2001 Current Population Survey.



[End of table]



Despite widespread health insurance coverage of children, private 

health insurance plans historically included greater restrictions on 

mental health benefits than on benefits for other health services. 

Consequently, federal and state laws have attempted to partially 

equalize benefit levels. The federal Mental Health Parity Act of 1996 

(MHPA) prohibits certain group health plans sponsored by employers with 

more than 50 employees from imposing annual or lifetime dollar limits 

on mental health benefits that are more restrictive than those imposed 

on other benefits.[Footnote 11] As of March 2000, more than half of the 

states had also passed laws that exceeded the federal law by requiring 

that certain health insurers not only have parity in dollar limits, but 

also in service limits and cost-sharing provisions. However, these 

state mental health parity provisions do not affect employers who pay 

their employees’ health expenses directly rather than by purchasing 

insurance. Federal law permits states to regulate insurance, but 

employers’ self-funded health plans, which covered almost half of all 

employees enrolled in employer-sponsored plans in 1999, are not 

affected by such state insurance regulations.[Footnote 12]



Medicaid operates as a joint federal-state program to finance health 

care coverage for certain categories of low-income individuals. Within 

guidelines established by federal law, states have considerable 

flexibility in how they structure their programs, including determining 

eligibility levels and what benefits to cover. For example, federal law 

requires states to offer Medicaid coverage to children age 5 and under 

if their family incomes are at or below 133 percent of the federal 

poverty level and to children ages 6 to 18 if their family incomes are 

at or below the federal poverty level.[Footnote 13] To offer coverage 

to additional children, many states have set family income eligibility 

thresholds beyond these minimum federal levels.



Benefits covered by state Medicaid programs are either mandatory or 

optional. For example, states are required to cover EPSDT services, 

which include comprehensive, periodic health and developmental 

evaluations or screenings. A state must cover any services necessary to 

treat physical and mental conditions detected through these screenings, 

regardless of whether the services are covered by the state’s Medicaid 

program.[Footnote 14] We have previously reported that the extent to 

which children actually receive EPSDT services is not fully known, 

largely because no reliable, national utilization data exist for these 

services.[Footnote 15] States also have the option to provide 

beneficiaries with a number of other services, such as inpatient 

psychiatric and psychological services. HHS’s Centers for Medicare & 

Medicaid Services (CMS), the federal agency that oversees Medicaid and 

SCHIP programs, does not have current data that comprehensively 

summarize the extent to which states cover mental health services; 

however, other available sources suggest that the majority of states 

provide some level of mental health coverage as an optional 

benefit.[Footnote 16]



In 1997, the Congress enacted SCHIP to provide health care coverage to 

low-income children living in families whose incomes exceed the 

eligibility limits for Medicaid.[Footnote 17] Although SCHIP is 

generally targeted to families with incomes at or below 200 percent of 

the federal poverty level, each state may set its own income 

eligibility limits within certain guidelines. As a result, SCHIP 

maximum income eligibility levels vary considerably among states, 

ranging from 100 to 350 percent of the federal poverty level. States 

have three options in designing SCHIP: expand their Medicaid programs, 

develop separate child health programs that function independently of 

the Medicaid programs, or do a combination of both. States that 

implement SCHIP by expanding Medicaid must use Medicaid’s enrollment 

structures and benefit packages (including EPSDT services); in 

contrast, separate SCHIP programs may depart from Medicaid requirements 

for benefits and for the plans, providers, and delivery systems 

available. (See app. III for a state summary of SCHIP programs.):



Federal Agencies with Responsibility for Assisting Children Who Have 

Experienced Trauma:



Several federal departments and agencies have responsibility for 

addressing the mental health needs of children who have experienced 

trauma. For example, HHS agencies have responsibility for improving the 

accessibility and delivery of mental health services, conducting 

research on children’s mental health issues, disseminating information 

on promising approaches for improving children’s mental health, and 

promoting the well-being of children. In addition to CMS, these 

agencies include ACF, the Health Resources and Services Administration 

(HRSA), the Indian Health Service, and SAMHSA. In addition, the 

National Institutes of Health, the Centers for Disease Control and 

Prevention, and the Agency for Health Care Research and Quality fund 

research on a range of topics related to child victims and trauma, 

including the effects of trauma on children and interventions to assist 

children who have experienced trauma. HHS’s Office of Public Health and 

Sciences coordinates programs across agencies and supports crosscutting 

initiatives involving children’s mental health.



FEMA is charged with providing financial and technical assistance to 

states and federally recognized Indian tribes for crisis counseling and 

other services to children and adults affected by presidentially 

declared disasters, which can include earthquakes, fires, floods, 

hurricanes, and terrorism. Justice seeks to mitigate the effects of 

violence on children, including by paying for mental health services 

for children who are victims of, or witnesses to, violent crimes. 

Offices within Justice that focus on this population include the Office 

of Juvenile Justice and Delinquency Prevention, the Violence Against 

Women Office, and the Office for Victims of Crime (OVC), all within the 

Office of Justice Programs. In addition, Education, through its Office 

of Elementary and Secondary Education, oversees programs that can help 

students obtain services to ensure that mental health problems do not 

interfere with their ability to learn.



Most Children Have Health Insurance Coverage, But Mental Health 

Coverage May Have Limits and Not Guarantee Access:



Private health insurance plans, such as employer-sponsored or 

individually purchased plans, and public programs, such as Medicaid or 

SCHIP, provide health insurance coverage to 88 percent of children. 

Although most children have health insurance, the level of mental 

health coverage available to children varies and depends largely on the 

type of insurance they have. While children enrolled in private 

insurance plans often face limitations in their mental health coverage, 

such as the exclusion of certain diagnoses from coverage or limits on 

the number of covered visits for outpatient therapy, children in 

Medicaid and SCHIP programs generally have coverage for a wide range of 

mental health services. The typically broader coverage of Medicaid 

programs and SCHIP programs that are Medicaid expansions is largely due 

to these programs being required to cover all necessary health care for 

problems detected through an EPSDT screening. Despite the availability 

of public insurance coverage, other factors, such as low Medicaid 

reimbursement rates that discourage provider participation or SCHIP 

cost-sharing requirements that may make services unaffordable for some 

families, could affect children’s access to services. Although little 

is known nationwide about the extent to which children in public 

insurance programs receive mental health services, available evidence 

suggests that children in some states may not be receiving services 

they need.



Coverage Limitations in Private Health Insurance Plans Could Affect 

Children’s Ability to Obtain Mental Health Services:



The extent to which private health insurance plans cover mental health 

services varies. Most employer-sponsored health plans cover inpatient 

and outpatient mental health services, as do individual insurers, 

although to a lesser extent. However, private insurance plans often 

contain coverage or other restrictions, which may limit the 

availability of mental health services to enrollees, including children 

who have been exposed to trauma. For example, private plans may impose 

day or visit limits on mental health treatment, exclude certain 

diagnoses or benefits from coverage, or not offer mental health 

coverage at all.



Employer-Sponsored Group Health Plans:



Employer-sponsored group health plans, which cover over 50 million 

children, or 66 percent, typically include mental health benefits that 

children who have experienced trauma may need. However, many of these 

plans impose more restrictive limits, such as day or visit limits, on 

mental health benefits than on other benefits. For example, in a prior 

survey of nearly 900 employers, we found that 87 percent of employer 

plans complied with the dollar parity requirements of the MHPA but set 

other limits that were not prohibited by MHPA, such as the number of 

allowable outpatient visits or inpatient days for mental health 

treatment.[Footnote 18] In contrast, few plans imposed limits on 

hospital days or office visits for health conditions not related to 

mental health. In addition, a survey conducted by Mercer/Foster Higgins 

of 2,813 employers that sponsor health plans found that at least 73 

percent of preferred provider organization (PPO), point of service 

(POS), and health maintenance organization (HMO) health plans offered 

by employers with more than 500 employees imposed annual limits on 

mental health services.[Footnote 19] These plans most commonly imposed 

day and visit limits on mental health services, with median limits of 

30 inpatient days and 30 outpatient visits per year.[Footnote 20] (See 

table 2.) Although for some children these service levels are 

sufficient, these limits may not provide adequate coverage for some 

traumatized children who require long-term mental health treatment.



Table 2: Percentage of Health Plans Offered by Employers with More Than 

500 Employees That Limited Inpatient and Outpatient Mental Health 

Services in 2001:



Plans with annual inpatient day limits; Percentage of health plans: 

PPO: 78; Percentage of health plans: HMO: 77; Percentage of health 

plans: POS: 78.



Plans with annual outpatient visit limits; Percentage of health plans: 

PPO: 78; Percentage of health plans: HMO: 77; Percentage of health 

plans: POS: 73.



Note: Data for indemnity (fee-for-service) health plans were not 

reported in 2001 because sufficient data for these plans were not 

available. According to Mercer/Foster Higgins, only 6 percent of 

employees of large employers were enrolled in indemnity plans in 2001.



Source: Mercer/Foster Higgins National Survey of Employer-Sponsored 

Health Plans, 2001.



[End of table]



Individual Health Insurance Market:



Limitations in mental health coverage are more pronounced for the over 

3 million children covered by individual insurance plans. Unless 

precluded by state law, mental health benefits in the individual market 

can be more restrictive than other benefits in such areas as annual or 

lifetime dollar limits on what the plan will pay and service limits, 

such as fewer covered hospital days or outpatient office visits. The 

individual market may also have higher cost-sharing, such as 

deductibles, copayments, or coinsurance. We found such limitations 

among individual health plans we reviewed. For example, one insurer 

imposed a lifetime limit of $10,000 on mental health benefits, while 

another insurer that sells individual health plans in nearly 40 states 

includes mental health coverage only if required by state law. Another 

insurer limited annual mental health coverage to $1,500 for each 

member. (See app. IV for a summary of differences in individual market 

health plan coverage for certain mental health treatments available to 

children in six states.) In addition, few states require insurers in 

the individual market to guarantee access to health insurance coverage 

for people with mental disorders, leaving some children unable to 

obtain any health insurance. We recently reported that in several 

states, applicants for individual health insurance who had certain 

conditions, such as PTSD, would likely be denied coverage by five of 

the seven insurers reviewed.[Footnote 21]



State Responses to Limitations in Private Health Insurance Plans:



To address these and other limitations in mental health coverage, many 

states have passed laws that exceed the requirements of MHPA.[Footnote 

22] Among the six states we reviewed, three--California, Massachusetts, 

and Minnesota--mandated that health plans offer mental health benefits 

at the same level as other benefits. The other three states--Georgia, 

Illinois, and Utah--took varied approaches to requirements on mental 

health coverage. Laws in these states apply only to certain types of 

health plans or do not require health plans to include mental health 

coverage. However, self-funded employer group plans, which covered 

close to half of all private sector employees in group health plans in 

1999, are beyond the purview of state regulation and thus exempt from 

these reforms. (See app. V for a summary of selected laws related to 

mental health insurance coverage in these states.):



State Medicaid and SCHIP Programs Typically Cover a Wide Array of 

Mental Health Benefits, but Children May Encounter Difficulties 

Obtaining Covered Services:



The 16 percent of children enrolled in Medicaid and SCHIP typically 

have coverage for a wide range of mental health benefits. However, 

coverage limitations and other factors, such as Medicaid reimbursement 

rates to providers and SCHIP cost-sharing requirements, could affect 

children’s access to services and available data suggest that some 

enrolled children are not receiving mental health services they need.



Medicaid Program:



With few exceptions, the Medicaid programs in the six states we 

reviewed provided children with coverage for a wide range of mental 

health services. For example, all six states provided children with 

coverage for diagnostic assessments, outpatient therapy, medication 

management, and mental health treatment in residential care facilities, 

and did not impose day or visit limits or cost-sharing 

requirements.[Footnote 23] In addition to specified mental health 

services, Medicaid requires states to cover all necessary health 

treatment services when a health problem that could affect a child’s 

development is detected during an EPSDT screening, regardless of 

whether the condition or treatment is explicitly covered by the state’s 

Medicaid program. A required element of an EPSDT screening is a 

comprehensive history, which is supposed to include an assessment of a 

child’s mental health needs. Although many states have developed 

recommended screening protocols for health care providers to complete 

on specified schedules, CMS defines screenings very broadly and 

considers any encounter with a health care provider to be a screening 

sufficient to identify and require the provision of needed services.



One mental health service that can be important to families of children 

who have experienced trauma is respite care. Although respite care is 

not a mandatory Medicaid service, states may use flexibility available 

under the Medicaid statute to cover respite services, such as child 

care and weekend group home services, in order to provide some relief 

for an eligible child’s parent, guardian, or primary 

caregiver.[Footnote 24] By providing a temporary period of time apart 

for parents and their children, respite care services can decrease 

stress in the family and increase the likelihood that a child with a 

mental illness can continue to live at home and avoid placement in an 

institution. However, only one of the six state Medicaid programs we 

reviewed--Minnesota--explicitly covered respite services for some 

children with mental illness.[Footnote 25]



Despite having mental health coverage, children enrolled in Medicaid 

may face constraints when they attempt to obtain covered services. For 

example, children may have difficulty finding providers to treat their 

mental health needs. Officials in the six states we reviewed said that 

their states had shortages of mental health providers, especially child 

psychiatrists, and that these shortages were particularly acute in 

rural areas. In addition, some providers said that low Medicaid 

reimbursement rates, coupled with delayed payments from states, 

discourage providers from participating in Medicaid. Although not 

specifically focused on mental health services, studies have compared 

Medicaid fee-for-service reimbursement rates to Medicare and have shown 

that Medicaid rates are significantly lower.[Footnote 26] For example, 

in the six states we reviewed, Medicaid reimbursed physicians for a 

psychiatric diagnostic interview at rates that ranged from 28 to 78 

percent of the average national rate Medicare pays for the same 

service.[Footnote 27]



SCHIP:



The SCHIP programs in the six states we reviewed varied in their extent 

of mental health service coverage and the extent to which they have 

instituted cost-sharing requirements for covered beneficiaries. Four of 

the six SCHIP programs we reviewed covered generally the same extensive 

mental health benefits as Medicaid programs in their states. For 

example, SCHIP beneficiaries in Minnesota have coverage for the same 

unlimited mental health benefits as Medicaid beneficiaries and are not 

responsible for any out-of-pocket costs. Similarly, the SCHIP benefits 

of Illinois, Georgia, and Massachusetts generally mirror the benefits 

available under their state Medicaid programs, albeit with limited 

cost-sharing that Medicaid does not require. For example, Georgia 

families must pay a premium of $7.50 per month for each child over age 

six, with a monthly limit of $15 per family. Similarly, families in 

Illinois with incomes over 150 percent of the federal poverty level 

must pay $5 for each outpatient or inpatient mental health visit and a 

monthly premium of $15 for one child, $25 for two children, and $30 for 

three children.[Footnote 28]



In contrast to these four states, SCHIP beneficiaries in California and 

Utah generally have coverage for fewer benefits than Medicaid 

beneficiaries and may face limits on treatment days and visits. Unlike 

their state Medicaid programs, the SCHIP programs in each of these 

states are modeled after the private insurance plan available to public 

employees in the state.[Footnote 29] These SCHIP plans are not required 

to cover residential care or targeted case management services and are 

not required to provide all enrolled children with EPSDT screenings or 

coverage for services these screenings identify as necessary.[Footnote 

30],, (See fig. 1.) Also, children in Utah’s SCHIP program are allotted 

a maximum of 30 outpatient visits and 30 days of inpatient care per 

year and are not covered for family therapy visits.[Footnote 31] 

Similarly, California SCHIP allows participating health plans to limit 

children to 20 outpatient visits and 30 days of inpatient care per 

year. Some health plans have chosen not to impose these limits; health 

plans that do impose limits told us that children rarely reach them. In 

addition, these limits do not apply to children in California who are 

diagnosed with a serious emotional disturbance (SED) or one of nine 

severe mental illnesses (SMI).[Footnote 32] These children are eligible 

to receive unlimited mental health services. Whether limits in 

California and Utah SCHIP plans prevent children from obtaining needed 

services is unknown; however, these limits may not provide sufficient 

coverage to some traumatized children who require long-term mental 

health treatment.



Figure 1: Comparison of State Medicaid and SCHIP Coverage for Selected 

Mental Health Treatments in California and Utah:



[See PDF for image]



[A] SCHIP children in California who are diagnosed with SED have 

coverage for all of these services without limitations through the 

county mental health departments. In addition, day and visit limits do 

not apply to SCHIP children diagnosed with SMI.



[B] Health plans may limit outpatient care for non-SED/non-SMI children 

to 20 visits per year.



[C] Health plans limit enrollees to a maximum of 30 visits per year.



[D] Health plans may limit inpatient care for non-SED/non-SMI children 

to 30 days per year.



[E] Health plans limit enrollees to a maximum of 30 days per year and 

60 days in a 3-year period.



[F] The Medicaid programs in both states cover mental health services 

provided to enrollees in residential care facilities but not the cost 

of room and board.



Source: State Medicaid and SCHIP health plans.



[End of figure]



In addition to inpatient day and outpatient visit limits, children in 

California and Utah are also subject to cost-sharing requirements 

through SCHIP that may make mental health services unaffordable for 

some families. For example, depending upon the level of their income, 

families in California must pay $5 for each outpatient visit and must 

also pay a monthly premium of $4 to $9 for each child enrolled in the 

program, with a monthly limit of $27 per family.[Footnote 33] Although 

Utah’s SCHIP program does not charge monthly premiums, it requires 

families with incomes from 100 to 150 percent of the federal poverty 

level to pay a $5 copayment for each outpatient visit, and families 

with incomes from 151 to 200 percent of the federal poverty level to 

pay for half of the total cost of the outpatient service.[Footnote 34]



Utilization of Mental Health Services:



Little is known about the extent to which traumatized children with 

public insurance utilize mental health services, largely because no 

reliable, national utilization data exist for mental health services 

covered by Medicaid or SCHIP. While states are required by law to 

submit annual reports on the utilization of EPSDT services, CMS’s 

efforts to assemble reliable information about EPSDT participation in 

each state have been unsuccessful, despite 1999 revisions to the annual 

report that sought to clarify and simplify reporting requirements. 

State-reported data are often untimely or inaccurate, particularly in 

states where children receive services through managed care plans that 

are prospectively paid on a capitated basis, meaning the plans receive 

a flat payment per member, regardless of the cost of treating the 

patient.[Footnote 35] Moreover, states are not required to report 

mental health services provided under the EPSDT program. Limitations in 

other CMS data reporting requirements also make it difficult for the 

agency to determine the extent to which children are receiving mental 

health services. For example, periodic reports on health care 

utilization and expenditures that CMS requires states to submit do not 

collect consistent data on mental health services covered by Medicaid 

and SCHIP.



Although national data regarding publicly insured children’s use of 

mental health services are not available, numerous lawsuits alleging 

shortcomings in the provision of EPSDT services, coupled with 

individual state utilization data that were available from most of the 

states we reviewed, indicate that children enrolled in Medicaid or 

SCHIP may not be obtaining needed services. According to the National 

Health Law Program, a national public interest law firm, as of 

September 1, 2001, 49 court opinions had been rendered on challenges 

alleging a state’s failure to properly implement EPSDT or to provide 

access to necessary services. In several of these cases, courts have 

found that a state violated EPSDT requirements by not providing all 

necessary mental health services to children.[Footnote 36] For example, 

in response to a class action lawsuit alleging that children were not 

being provided with access to mental health services, the court 

approved a consent decree by the parties under which West Virginia 

agreed to ensure that all EPSDT screens and subsequent treatments 

include behavioral and mental health services.[Footnote 37]



In addition, statewide utilization data collected by four of the six 

states we reviewed--California, Illinois, Minnesota, and Utah--

indicated that a small percentage of children enrolled in the state’s 

Medicaid and SCHIP programs, ranging from 0.7 percent of children in 

Illinois to 6 percent of children in Minnesota, used mental health 

services.[Footnote 38] Utilization data collected by Massachusetts, 

however, indicated that close to 16 percent of the children enrolled in 

its Medicaid and SCHIP managed care program were using available mental 

health services.[Footnote 39] Based on their experience and their 

reviews of research, officials in California and Utah told us they 

would expect the proportion of children needing mental health services 

to be higher. State officials and providers told us that various 

factors, such as the difficulty associated with identifying children 

with mental illness, lack of parental awareness of mental illness, and 

the stigma associated with mental illnesses, could contribute to lower 

than expected utilization of services.



Type of Insurance Coverage and State of Residence Affect Mental Health 

Service Coverage and Costs:



A child’s type of health insurance and state of residence generally 

determine the extent of mental health coverage available. To 

demonstrate the variation between public and private insurance programs 

in the availability and cost of mental health services for children, as 

well as variation among states, the following example outlines the 

covered benefits and annual benefit limitations of various types of 

insurance available to a hypothetical 5 year-old child who has 

experienced trauma and resides in either California or Illinois. 

Depending on the recommended treatment, which may include individual, 

group, or family therapy; inpatient hospitalization; or care in a 

residential facility, the services available and their cost to the 

child’s family could vary considerably. (See fig. 2.):



For example, if enrolled in Medicaid, the child in California would 

have coverage for all these services at no cost; if enrolled in SCHIP, 

the child may not have coverage for residential care or transportation 

and could face limits on the number of inpatient days and outpatient 

visits allowed.[Footnote 40] In addition, the family of the SCHIP-

enrolled child would be responsible for a $5 copayment for each 

outpatient visit. This child would experience similar differences among 

types of coverage in Illinois. Under Illinois’ Medicaid and SCHIP 

programs, the child would have coverage for all these services without 

limitations. However, the family of the child enrolled in SCHIP would 

also have to pay a copayment for each outpatient visit, and depending 

on the family’s income, could be responsible for a monthly premium as 

well. In comparison, a child in Illinois who relied on coverage from 

the individual insurer specified would not have coverage for 

residential care and would be limited to 10 inpatient days and 20 

outpatient visits each year.



Figure 2: Public and Private Insurance Coverage Options in California 

and Illinois for a Hypothetical 5-Year Old Child Who Has Experienced 

Trauma:



[See PDF for image]



[A] The Medicaid programs in both states cover mental health services 

provided to enrollees in residential care facilities but not the cost 

of room and board.



[B] Some health plans in California do not choose to impose these 

limits on services. In addition, children in California who are 

diagnosed with SED have coverage for all the services included in 

figure 2, without limitations, through county mental health 

departments. Also, day and visit limits do not apply to SCHIP children 

diagnosed with SMI.



[C] Maximum of $27 premium per family per month.



[D] Maximum family copayment of $250 per year.. However, copayments are 

not required for services provided to SED children in county mental 

health centers.



[E] These data represent conditions and in-network costs for a sample 

of PPO plans of employers with 500 or more employees; these plans had a 

median family deductible of $600. The data represent the most common 

day and visit limitations and other costs, and the average employee 

premium portion for family coverage.



[F] Data are from a PPO that is one of the most popular health plans 

sold in the individual insurance market in California and has a $1,000 

deductible per person (maximum of $2,000 per family). Children who are 

diagnosed with a SED or one of nine SMI are eligible for unlimited 

benefits and pay 25 percent of service fees.



[G] This applies only to a child in a family whose income exceeds 150 

percent of the federal poverty level. For two children, the premium is 

$25; for three, the premium is $30.



[H] Maximum copayment per year per family is $100.



[I] This example represents conditions for a sample of HMO plans of 

employers with 500 or more employees. The data represent the most 

common day and visit limitations, and the average employee premium 

portion for family coverage and outpatient copayment costs.



[J] Data are from an HMO that is one of the most popular plans sold in 

the individual health insurance market in Illinois.



[K] A health plan official told us that this service is available to 

members who meet the plan’s medical necessity criteria.



Sources: State Medicaid and SCHIP health plans, Mercer/Foster Higgins 

National Survey of Employer-Sponsored Health Plans 2001, and individual 

insurers in California and Illinois.



[End of figure]



Federal Programs Can Help Children Who Have Experienced Trauma to 

Obtain Mental Health Services, But Extent of Assistance Is Largely 

Unknown and Little Evaluation Has Occurred:



Beyond insurance, a range of federal programs--including over 50 grant 

programs we identified--can help children who have experienced trauma 

obtain needed mental health services. (See app. VI for descriptions of 

selected federal grant programs.) Some federal programs pay for crisis 

counseling, such as the crisis counseling program for victims of 

disasters, which is administered by FEMA in collaboration with SAMHSA. 

Justice’s VOCA Crime Victim Compensation grants and Crime Victim 

Assistance grants to states help pay for mental health treatment needed 

by crime victims. However, factors such as state eligibility 

requirements and mental health service caps, as well as families’ lack 

of knowledge about the programs, may limit some child victims’ ability 

to benefit from these programs. Several federal grant programs 

encourage coordination among mental health and other service systems--

such as social services, health care, and justice--so that children who 

have experienced trauma and their families can more easily gain access 

to the full range of services they need. One such program is SAMHSA’s 

National Child Traumatic Stress Initiative, a recent effort 

specifically designed to take a coordinated approach to improving 

mental health care for children who have experienced various kinds of 

trauma. Some federal programs have a broader focus, such as general 

mental health, or are targeted to specific populations, such as 

children in foster care, but grantees can elect to use program funds to 

provide mental health and other needed services to children who have 

experienced trauma and their families. Little is known about the extent 

to which these broader programs assist these children. Moreover, little 

is known about the effectiveness of federal programs that help children 

who have experienced trauma to obtain mental health services. For 

example, FEMA and SAMHSA have not evaluated the effectiveness of the 

disaster crisis counseling program.



Federal Disaster Grants Provide Some Mental Health Services to 

Children:



Federal agencies provide financial and technical assistance to states 

and localities to meet crisis-related mental health needs of children 

and adults who are victims of natural disasters and mass violence. FEMA 

collaborates with SAMHSA’s Center for Mental Health Services to provide 

financial and technical assistance to states and federally recognized 

Indian tribes that request aid for crisis counseling[Footnote 41] and 

other services for children and adults affected by presidentially 

declared disasters.[Footnote 42] FEMA funds the program, and SAMHSA, 

through an interagency agreement, provides technical assistance, 

program guidance, and oversight. The Crisis Counseling Assistance and 

Training grant funds are generally available for up to

12 months after a disaster declaration. FEMA reported that in fiscal 

year 2001, it had obligated about $16.2 million in crisis counseling 

funds.



In addition to crisis counseling, program funds are used for such 

activities as training paraprofessionals to provide crisis counseling, 

distributing information to increase public awareness about the effect 

disasters can have on children, and helping identify and refer children 

who may need longer term mental health treatment.[Footnote 43] For 

example, New York and Virginia were declared disaster areas after the 

September 11, 2001, terrorist attacks and, as of May 2002, FEMA had 

approved about $160.6 million in crisis counseling grants.[Footnote 44] 

As of March 2002, New York had reported using the FEMA funds to provide 

free crisis counseling to approximately 10,000 children under age 18 

affected by the attacks. In addition, HHS has allocated over $28 

million for crisis counseling and other mental health and substance 

abuse services to help areas affected by the terrorist attacks, 

including $6.8 million that was awarded to eight states and the 

District of Columbia to help support crisis mental health services and 

to assist mental health and substance abuse systems in these locations. 

HHS also awarded $10 million to 33 New York City and New Jersey 

community health centers to support response-related services, 

including the provision of grief counseling and other mental health 

services. The Congress also appropriated $68.1 million to Justice to 

further meet the crisis counseling needs of victims, their families, 

and crisis responders. According to Justice, as of July 2002, the 

department had awarded more than $40 million of this amount to 

California, New Jersey, New York, Massachusetts, Pennsylvania, and 

Virginia.[Footnote 45]



According to federal officials, communities have generally found the 

12-month time frame sufficient for responding to all but the most 

serious types of disasters, and extensions of limited duration have 

occasionally been approved.[Footnote 46] However, SAMHSA officials and 

trauma experts told us that there are concerns about whether the crisis 

counseling grant’s time frame is sufficient for identifying all 

children who may require trauma-related mental health assistance as a 

result of a large-scale natural disaster or act of terrorism that 

results in mass casualties. These experts told us, for example, that in 

the case of the 1995 bombing of the Alfred P. Murrah Federal Building 

in Oklahoma City, the time frame was not sufficient to find, assess the 

mental health needs of, and provide assistance to the large number of 

children and adults who needed help. Although FEMA extended total grant 

funding to about 33 months, crisis counseling services were still 

needed after the funds had finally expired. As a result, Justice 

provided an additional $264,000 to Oklahoma’s Project Heartland to fund 

crisis counseling services needed by individuals with problems stemming 

from the bombing. Because there was a resurgence of mental health 

problems during the federal bombing trials, Justice also provided about 

$235,000 to help provide victims and other family members with needed 

crisis counseling services. According to a SAMHSA official, the 

September 11, 2001, attacks have led program officials to discuss 

whether changes are needed in the nature and duration of federal 

assistance available to address the special, longer-term mental health 

service needs that can arise from mass casualty disasters, especially 

those caused by terrorism.



SAMHSA is collaborating with the National Association of State Mental 

Health Program Directors on the association’s review of states’ 

emergency response plans to identify ways that states can better plan 

for the mental health care needs of disaster victims. According to 

trauma experts and SAMHSA officials, most states have dedicated few 

resources to planning for mental health needs that result from such 

events and most have insufficient capacity to coordinate and mobilize 

the mental health services needed for large-scale disasters. This could 

result in the loss of valuable time, duplicative efforts, and missed 

opportunities to identify children who could benefit from mental health 

assistance.



Another federal resource for crisis situations is Education’s School 

Emergency Response to Violence program, commonly known as Project SERV. 

Local school districts can apply for crisis response grants for 

generally up to 18 months to help deal with the aftermath of violent or 

traumatic events, such as school shootings and acts of 

terrorism.[Footnote 47] Education officials said school districts have 

used grants for children’s crisis counseling, school security, 

transportation to safe locations, and translation services.[Footnote 

48] In addition, under the program, Education can send trauma and 

violence experts to a school district to help school personnel handle 

disaster situations. In fiscal year 2001, Project SERV obligated nearly 

$9.8 million to school districts responding to violence and disasters, 

with nearly 90 percent of the funds awarded to schools in communities 

affected by the September 11, 2001, terrorist attacks.



Federal Crime Victims Fund Pays for Some Children’s Mental Health 

Services:



The federal Crime Victims Fund is an important federal funding source 

for meeting the mental health needs of children who are victims of 

violent crimes, including mass violence and terrorism. The fund is 

administered by Justice’s OVC, and most of the funds available[Footnote 

49] are used to support victim compensation grants and victim 

assistance grants to all states, the District of Columbia, Puerto Rico, 

and U.S. territories.[Footnote 50] Federal VOCA victim compensation 

grants supplement state funds to provide direct financial assistance 

and reimbursements to, or on behalf of, eligible crime victims or their 

survivors[Footnote 51] for a wide range of crime-related expenses, 

including those for mental health services.[Footnote 52] Federal victim 

assistance grants are provided to the states, which in turn award these 

funds to eligible public and private nonprofit organizations that work 

directly with crime victims to determine their needs and provide them 

with a range of free services, including mental health services. In 

fiscal year 2002, OVC allocated about $477 million to these two grant 

programs.[Footnote 53]



Victim Compensation:



States use federal victim compensation grants to supplement their 

efforts to compensate eligible crime victims or their survivors who 

file claims with state victim compensation programs for their crime-

related expenses.[Footnote 54] In some instances, children who witness 

crimes may be eligible for compensation.[Footnote 55] State victim 

compensation programs provide financial assistance and reimbursement to 

crime victims only to the extent that other financial resources, such 

as health insurance, do not cover a victim’s loss. Crisis counseling, 

individual and group therapy, psychiatric hospital care, and 

prescription drugs are among the mental health services covered by 

states. According to OVC, state victim compensation programs reimbursed 

approximately $50 million in mental health expenditures to children and 

adults in fiscal year 2000.[Footnote 56] The percentage of annual 

compensation expenditures that provides reimbursement for mental health 

services varies widely by state. For example, in fiscal year 2001, 91 

percent of California’s victim compensation funds that paid for 

services to children were for mental health services, while 14 percent 

of Illinois’s compensation funds that paid for children’s services were 

for mental health services.



State officials told us that the availability of victim compensation 

funds can be particularly helpful for uninsured children or children 

whose insurance does not cover all needed mental health services. For 

example, of the claims for children’s services reimbursed by 

California’s compensation program in fiscal year 2001, about 58 percent 

were for children who were uninsured, 21 percent for children with 

private insurance, 10 percent for children enrolled in Medicaid, and 

about 11 percent for children with other financial resources. 

Similarly, Illinois officials told us that the state’s compensation 

program serves many children who have no insurance.



Although crime victim compensation program guidelines require states to 

reimburse victims for mental health expenses, states are given 

discretion in setting program eligibility requirements and benefits. As 

a result, states have different rules for who can qualify to receive 

compensation benefits. In addition, states’ mental health benefits vary 

with respect to overall dollar limits, whether there are caps on mental 

health coverage within those limits and the amounts of those caps, the 

number of treatment sessions allowed, and the length of time that crime 

victims can receive mental health benefits through the victim 

compensation program. Furthermore, in most states when there are 

multiple victims of a crime, they typically must share the available 

overall maximum benefits. However, each family member or secondary 

victim is typically eligible for mental health counseling benefits up 

to specified caps, which generally apply to individuals and do not have 

to be shared. For example, the total maximum compensation in California 

for all victims of a crime is $70,000, with a $10,000 cap on mental 

health services for all direct victims, and Minnesota’s total maximum 

award limit is $50,000, with a $7,500 cap on mental health 

services.[Footnote 57] In Massachusetts and Illinois, the overall 

compensation ceilings are $25,000 and $27,000, respectively, with no 

mental health caps. New York has the most generous compensation 

benefit, with no overall maximum and no cap on reimbursement for 

victims’ mental health expenses. (See app. VII for a summary of state 

benefit information.):



Whether state eligibility requirements and caps on mental health 

services are preventing some children from obtaining needed services is 

largely unknown. Federal and state victim compensation program 

officials told us that most child claimants obtain reimbursement for 

needed mental health services and that many do not reach their benefit 

limits. The state victim compensation officials, however, also told us 

that eligibility requirements and benefit limits may exclude some 

children who need assistance to pay for mental health services. OVC has 

not undertaken a nationwide analysis of the effect of state 

requirements and benefit limits on meeting the mental health needs of 

child crime victims. Furthermore, OVC officials told us that there are 

no detailed data at the national level on state compensation programs’ 

payment for mental health services provided to children who have 

experienced trauma. While OVC requires states to submit annual reports 

on certain activities, including overall expenditures for mental health 

services, it does not require information on expenditures for 

children’s mental health services and the types of mental health 

services provided to these children. Therefore, the number of children 

who have benefited from the mental health coverage available through 

state victim compensation programs is uncertain.



Victim Assistance:



OVC’s victim assistance grants to the states are another vehicle that 

can help children and their families obtain needed mental health 

services. In fiscal year 2000, these grants were combined with state 

victim assistance funds to award grants to about 4,300 public and 

private nonprofit organizations that in turn provided crime victims 

with free medical, mental health, social service, and criminal justice 

advocacy services.[Footnote 58] In contrast to state victim 

compensation programs, which require crime victims to submit detailed 

applications and supporting documentation, local organizations that 

receive grants from state victim assistance programs typically do not 

require as much documentation from crime victims before providing them 

with needed assistance. State and local officials told us that some 

crime victims many obtain faster help through victim assistance 

programs than through filing compensation claims and waiting for 

reimbursement for their crime-related expenses--a process that took, on 

average, about 23 weeks in fiscal year 2000.



State victim assistance agencies reported allocating about $542.6 

million in fiscal year 2000 to provide a range of services to about 3 

million crime victims. For example, nearly 1.5 million of these victims 

received crisis counseling and about 230,000 received individual 

therapy.[Footnote 59] In the four states we reviewed, children 

benefiting from these grants included those who had been sexually or 

physically abused. (See table 3.):



Table 3: Number of Victims in Selected Categories Served by State 

Victim Assistance Programs in Four States, Fiscal Year 2001:



Type of victimization: Child physical abuse; California: 4,758; 

Illinois: 646; Massachusetts: 1,291; Minnesota: 4,769.



Type of victimization: Child sexual abuse; California: 21,817; 

Illinois: 5,742; Massachusetts: 3,380; Minnesota: 7,569.



Type of victimization: Adults molested as children; California: 5,327; 

Illinois: 945; Massachusetts: 1,351; Minnesota: 1,324.



Source: Statewide Victim Assistance Performance reports.



[End of table]



State victim assistance programs have reported to OVC that their 

programs helped children who have experienced trauma and their families 

in varied ways. For example, California, Illinois, and Massachusetts 

officials reported paying for individual and group therapy in cases 

where children either did not have insurance or their insurance 

provided reimbursement for fewer sessions than were needed. In 

addition, California and Massachusetts officials reported that victim 

assistance funds had helped provide comprehensive services to children 

and other family members, including case management, counseling 

services in their native languages, translation assistance, and help in 

filing claims for victim compensation.



Several Factors May Limit Some Children’s Use of Victim Compensation 

and Victim Assistance Benefits:



Although many children who are crime victims obtain mental health and 

other services through state victim compensation programs, federal, 

state, and local officials told us that many victims do not file 

compensation claims and that program limitations can constrain access 

to services. It is difficult to determine the exact number of 

victimized children who need trauma-related mental health services and 

who also need the financial assistance available through state victim 

compensation programs to obtain such services. Many crime victims may 

not need to file a claim for state victim compensation because they 

have not incurred any crime-related expenses or they have other 

resources, such as insurance, to help them pay for needed services. 

Nonetheless, California and Illinois victim compensation officials said 

that based on their analyses of claimant rolls and crime victim 

statistics in their states, they believe that many potentially eligible 

victims who could benefit from the assistance their programs offer had 

not applied for compensation. For example, an Illinois Crime Victim 

Compensation office analysis comparing 2000 county-level crime 

statistics with compensation claims received in 2001 showed that while 

there were 30,630 violent crimes reported in Chicago, the state victim 

compensation office received only 2,796 claims from victims in that 

city.[Footnote 60]



A 2001 Justice-funded report on state victim compensation and victim 

assistance programs indicated that several program-related factors 

might impede victims’ access to services supported by such programs. 

These factors included (1) lack of knowledge about the programs’ 

existence, (2) lack of information on how to obtain available benefits, 

and (3) state eligibility requirements that might make it difficult for 

some victims to qualify for benefits. For example, most states 
stipulate 

that to qualify for compensation, a victim must file a report with law 

enforcement authorities shortly after a crime occurs, generally within 

72 hours, and must cooperate with these authorities. However, victims 

of some crimes, such as sexual assault or domestic violence, may not 

report the crimes immediately and may be apprehensive about cooperating 

with authorities due to fear of retaliation by the offender. Other 

program barriers identified by state program managers surveyed for the 

report included (1) limited outreach and education, especially to 

racially and ethnically diverse populations and to rural communities, 

(2) lengthy and complex compensation award determination and payment 

processes, and (3) insufficient coordination between state victim 

compensation and victim assistance programs and with other agencies 

that work with these victims to eliminate gaps in assistance or 

duplicative services.[Footnote 61]



Efforts to address some of these problems are under way in the states 

we contacted. For example, the Los Angeles County District Attorney’s 

office placed victim advocates in county courts to inform victims of 

their right to benefit from the victim compensation and assistance 

programs and to help children and their families obtain needed 

services, including mental health care. In addition, California, 

Illinois, and Minnesota officials told us that they are now more 

flexible with their time frames for filing crime reports with police 

and will accept other official reports, such as those from child 

protective agencies and forensic sexual assault examinations. OVC 

published a report in 1998 that included a recommendation that state 

crime victim compensation programs reexamine their mental health 

benefits to ensure that they are adequate.[Footnote 62]



Federal Agencies Encourage Coordination to Meet the Needs of Children 

Who Experienced Trauma:



Coordination among mental health, child welfare, education, law 

enforcement, and juvenile justice systems can help ensure that children 

who have experienced trauma and their families obtain comprehensive, 

timely, and appropriate services. Several federal agencies have funded 

grant programs to promote collaborations within and across these 

systems--some of which have not traditionally worked together, such as 

police and mental health professionals. For example, although research 

has documented the frequent co-occurrence of domestic violence and 

child abuse,[Footnote 63] government officials and family violence 

experts report that the child welfare and domestic violence advocacy 

systems often fail to work together to devise safe, coordinated, and 

effective responses to family violence, due in part to differing 

missions, priorities, and perspectives. In some instances, child 

welfare officials want to remove a child from a home where domestic 

violence has allegedly occurred, while advocates for the nonoffending 

parent argue that taking the child out of the home would penalize that 

parent.



Justice awards grants to help support more than 350 Children’s Advocacy 

Centers, which assist children who come into contact with the court 

system as a result of being abused.[Footnote 64] The centers aim to 

bring together a multidisciplinary team and promote coordination among 

various service systems to ensure that a child’s multiple needs are 

met, including access to mental health services for the child and other 

family members. Typically consisting of law enforcement 

representatives, child protection workers, prosecutors, victim 

advocates, and mental health professionals, the teams work to ensure 

that the child does not have to recount the traumatizing event in 

multiple interviews, which could result in additional trauma.



To help communities minimize the adverse impact of family and community 

violence on young children, Justice initiated the Safe Start 

Demonstration Project in 1999. The grant program, which will last about 

5 years, is designed to improve access to, and the quality of, services 

for young children who are at high risk of exposure to violence or who 

have already been exposed to violence. The program’s goal is to help 

communities strengthen partnerships among key service systems such as 

Head Start, health care, mental health care, domestic violence shelters 

and advocacy organizations, child welfare, and law enforcement. In 

fiscal year 2000, the agency awarded grants to nine communities, with 

each receiving $250,000 for a first-year planning phase. In addition, 

grantees will receive up to $670,000 annually for implementation 

activities.



Another way federal agencies are trying to encourage service systems to 

work together is the Collaborations to Address Domestic Violence and 

Child Maltreatment Project, which is jointly funded and administered by 

eight agencies and offices within HHS and Justice.[Footnote 65] The 

one-time demonstration grant, commonly called the Greenbook Project, 

funds initiatives in six communities that are each receiving $350,000 

annually for 3 years, starting in fiscal year 2000.[Footnote 66] The 

project’s goal is to help communities develop partnerships among three 

key stakeholders--the child welfare system, domestic violence groups, 

and juvenile and family courts--to improve the delivery of services to 

victims of domestic violence and their children.[Footnote 67] For 

example, a grantee in Colorado has used program funds to hire a 

domestic violence advocate to work in the child welfare system to 

improve screening for domestic violence and assess the risk to 

children. The grantee has also used these funds to enhance an existing 

program that houses police and child protective personnel at one 

location, allowing them to jointly respond to domestic violence calls 

so they can deal with the needs of all family members, including 

children who have witnessed the violence.



Education, HHS, and Justice created the Safe Schools/Healthy Students 

demonstration project in 1999 to help schools and communities draw on 

three traditionally disparate service systems--education, mental 

health care, and justice--to promote the healthy development of 

children and address the consequences of school violence. The program, 

which through fiscal year 2001 had made awards totaling about $439 

million, requires local education agencies to establish formal 

partnerships with mental health providers and local law enforcement 

professionals. One of the project’s six core elements is the 

enhancement of school-and community-based mental health preventive and 

treatment services. In fiscal year 2001, the agencies awarded about 

$177 million to 97 urban, suburban, rural, and tribal community 

grantees.



SAMHSA’s National Child Traumatic Stress Initiative is a recent 

initiative specifically designed to take a coordinated approach to 

improving mental health care for children who have experienced various 

kinds of trauma. Launched in October 2001, the 3-year effort is 

designed primarily to 

(1) improve the quality, effectiveness, and availability of therapeutic 

services for all children and adolescents who experience traumatic 

events, (2) develop a national network of centers, programs, and 

stakeholders dedicated to improving the identification, assessment, and 

treatment of children, and (3) reduce the frequency and severity of 

negative consequences of traumatic events through greater public and 

professional understanding of childhood trauma and greater acceptance 

for child trauma intervention services. SAMHSA has taken a tiered 

approach in structuring the $30 million initiative by establishing 

three grantee categories: a National Center for Child Traumatic Stress 

to coordinate the overall initiative; 10 Intervention Development and 

Evaluation Centers, which plan to develop scientifically-based 

improvements in treatment and service delivery; and 25 Community 

Treatment and Services Centers, which focus on treating victims of 

various types of trauma.[Footnote 68] The initiative emphasizes 

partnerships and coordination among grantees at each level and across 

levels. It also encourages grantees to collaborate with professionals 

in various community service systems--including child protection, 

justice, education, and health care--that interact with children who 

have experienced trauma and their families. Because this initiative is 

in its early stages, information on the effectiveness of its efforts is 

not available.



Federal Programs with Broader Focus May Help Fund Services Needed by 

Children Who Experienced Trauma:



Other federal grant programs not specifically targeted to assisting 

children who have experienced trauma may also help fund mental health 

and other services needed by these children and their families. These 

federal grants focus on broader issues, such as general mental health 

or maternal and child health services or services for specific 

populations, such as children in foster care, homeless youth, or 

migrant farmworkers. (See app. VI for descriptions of selected federal 

grant programs.) Grantees can, if they choose, use these funds to 

provide a range of services beneficial to children who have been 

traumatized. For example, funds from the Indian Health Service’s Urban 

Indian Health Program, which provides health services to child and 

adult American Indians living in urban areas, can be used to screen, 

refer, and treat children who need mental health services due to 

trauma. ACF’s Transitional Living for Homeless Youth program, which 

operates transitional living projects and promotes self-sufficiency for 

homeless youth, requires grantees to offer mental health services, 

either directly or by referral. SAMHSA’s Comprehensive Community Health 

Services for Children and Their Families program, commonly known as the 

System-of-Care program, provides supportive services to children and 

adolescents with SED and their families. Many of the children served 

through this program have been exposed to violence in their homes and 

many have been referred by social service and law enforcement agencies. 

In fiscal year 2001, 45 communities received System-of-Care grants to 

fund a range of services, including case management, intensive home-

based treatment services, family counseling, and respite care. State 

officials and service providers told us that some of the broader 

federal grants improved their ability to meet the needs of traumatized 

children and their families because the grants can fund services that 

are not always eligible for insurance reimbursement, such as case 

management and ancillary services for parents, including child care and 

transportation.



Some of these broader federal grants also support screening and 

identification of children with trauma-related mental health problems. 

For example, ACF’s Head Start program, which promotes school readiness 

for low-income children, requires grantees to ensure that each child 

receives mental health screening within 45 days of entering the 

program. The grantees are required to consult with mental health or 

child development professionals, teachers, and family members in 

devising appropriate responses to address identified problems. In 1990, 

HRSA and CMS cosponsored the initiation of the Bright Futures project 

to help primary care health professionals promote the physical and 

mental well-being of children, recognize problems, and intervene early. 

Recently, HRSA funded the development of mental health practice 

guidelines outlining risk factors and potential interventions related 

to domestic and community violence.[Footnote 69] In addition, HRSA and 

the National Highway Traffic Safety Administration administer the 

Emergency Medical Services for Children program, which provides funds 

to ensure that children’s services are well integrated into the 

emergency medical system. Among its initiatives, the program provides 

training grants to improve the ability of emergency medical services 

workers and emergency department physicians and nurses to identify the 

mental health needs of children in emergency situations.



Because they are not specifically designed to assist the mental health 

needs of children who have experienced trauma, these grants’ data 

reporting requirements often do not produce information on the extent 

to which children have been screened for trauma-related problems and 

the number of children who have obtained mental health services as a 

result of trauma. In addition, program officials were generally unable 

to provide specific information on the portion of program funds used to 

serve these children.



Few Federal Programs Have Evaluated Their Effectiveness in Assisting 

Children Who Experienced Trauma:



Despite the many federal efforts that contribute to varying degrees to 

helping children who have experienced trauma and their families obtain 

mental health and other needed services, little is known about their 

effectiveness. Few programs have undertaken formal evaluations to 

assess program progress and results and to guide decisions to improve 

service to targeted beneficiaries. For example, FEMA and SAMHSA have 

not conducted an evaluation of the effectiveness of FEMA’s crisis 

counseling program. SAMHSA officials told us that there were no 

immediate plans to conduct such an evaluation. In 1995, FEMA’s Office 

of Inspector General recommended that the agency, in consultation with 

experts in disaster mental health and mental health outcomes research, 

evaluate the effectiveness and efficiency of the crisis counseling 

program.[Footnote 70] In its response to the recommendation, FEMA 

indicated that FEMA and SAMHSA monitored grantee activities through 

grantee reports and joint site visits. However, these activities do not 

constitute an evaluation of the crisis counseling program. For example, 

the site visits generally involve monitoring the grantee’s program to 

ensure that it is carrying out reported activities and providing 

technical assistance. SAMHSA recently developed guidance for grantees 

outlining recommended program evaluation strategies. An agency official 

told us that grantees are encouraged to conduct evaluations of their 

individual programs, but are not required to adhere to the guidance in 

managing their programs. According to HHS, the Department of Veterans 

Affairs’ National Center for Post-Traumatic Stress Disorder will 

conduct case studies of past and current crisis counseling program 

grantees’ programs and will make recommendations on programwide 

evaluation activities. The scope and nature of these efforts have not 

been fully determined. Education also has not evaluated Project SERV, 

which provides crisis response grants to schools, and ACF has not 

evaluated the Transitional Living for Homeless Youth program, which 

requires grantees to offer mental health services to homeless youth.



Justice has funded a multiyear evaluation of the Crime Victim 

Compensation and Victim Assistance programs. The study was designed to, 

among other things, evaluate how the victim compensation and assistance 

programs serve crime victims and how variations in program 

administration and operations affect the effectiveness and efficiency 

of services to victims. The initial report, issued in March 2001, 

primarily consisted of a survey of state program managers’ views on 

program operations and needed improvements.[Footnote 71] The final 

report, which is scheduled for issuance in fall 2002, will be based on 

case studies of six states’ compensation and assistance programs, 

including a survey of compensation claimants and a survey of assistance 

clients in those states. The results of the survey of compensation 

claimants will partly reflect the experience of child victims and of 

victims who used mental health services. Because the survey of 

assistance clients had less participation by adults who could comment 

on a child’s experience, the study may provide less information about 

child victims’ experience with the assistance program.[Footnote 72] The 

case studies also involved discussions with state administrators and 

service providers that received victim assistance funds on the 

programs’ ability to help child victims obtain mental health services.



Some federal grants include formal evaluation components, but have yet 

to establish their evaluation framework, including detailed outcome 

measures. For example, the Greenbook and Safe Start grants, which 

support coordination efforts, included a year-long planning process to 

develop their evaluation frameworks. However, as of May 2002, when 

these grants had been under way for almost 2 years, neither had 

finalized its evaluation process, including development of core 

performance measures. SAMHSA’s National Child Traumatic Stress 

Initiative also plans to undertake an evaluation of the overall 

initiative and individual grantee projects. As of May 2002, SAMHSA and 

the grantees had begun to discuss the evaluation framework but had not 

finalized it. In addition, other grants have established their 

evaluation frameworks and performance measures, but their evaluations 

have yet to yield results. For example, the Safe Schools/Healthy 

Students program is collecting data, with an interim report planned for 

fiscal year 2002 and a final report in fiscal year 2004.



Conclusions:



Many children who have experienced trauma are resilient and may suffer 

few ill effects. Others, however, require mental health services to 

help them cope and minimize long-term psychological, emotional, or 

developmental difficulties. While most children have health insurance 

that covers mental health services to varying degrees, coverage 

limitations are common and may constrain children’s ability to obtain 

care. Numerous federal grant programs could expand the number of 

children whose mental health services may be reimbursed or help 

increase the available services in a community, but some children who 

need services may not benefit from such programs. For example, some 

grants are awarded to a relatively small number of communities and 

expire after a defined period, and evidence suggests that families of 

some children who are eligible to benefit from Justice’s victim 

compensation and assistance programs may not be aware of the programs.



The effectiveness of federal programs that could help children who have 

experienced trauma remains largely unknown. Some programs with planned 

evaluations, such as the Greenbook Project, have lagged in establishing 

their evaluation frameworks. SAMHSA’s recent National Child Traumatic 

Stress Initiative, which focuses specifically on the mental health 

needs of these children, intends to evaluate the results of grantee 

projects and the overall program. This effort could develop information 

on ways to effectively provide mental health services to traumatized 

children, but because the initiative is new, it is too early to gauge 

its success. Justice’s current evaluation of its Crime Victim 

Compensation and Crime Victim Assistance programs should provide some 

information on the experience of child victims in using the victim 

compensation program to obtain needed mental health services, but may 

provide less information on children’s ability to obtain mental health 

services through the victim assistance program. FEMA and SAMHSA have 

not evaluated the effectiveness of the long-standing disaster crisis 

counseling program and have no immediate plans to conduct a programwide 

evaluation. Without evaluations of the effectiveness of federal 

programs that have a clear goal of helping children who experienced 

trauma to obtain mental health services, federal managers and 

policymakers lack information that would help them assess which federal 

efforts are successful; determine which programs could be improved, 

expanded, or replicated; and effectively allocate resources to identify 

and meet additional service needs.



Recommendation for Executive Action:



We recommend that, to provide federal policymakers and program managers 

with additional information on federal grant programs serving children 

who have experienced disaster-related trauma, the Director of FEMA work 

with the Administrator of SAMHSA to evaluate the effectiveness of the 

Crisis Counseling Assistance and Training Program, including its 

assistance to children who need mental health services as the result of 

a disaster.



Agency Comments and Our Evaluation:



We provided a draft of this report to four federal departments and 

agencies for their review. FEMA, HHS, and Education submitted written 

comments that are provided in appendixes VIII through X, respectively. 

HHS and Education also provided technical comments, as did Justice. We 

have modified the report, as appropriate, in response to written 

general and technical comments.



In general, HHS stated that the report will be a useful tool for 

policymakers and brings important attention to the needs of children 

exposed to traumatic events. HHS and FEMA both agreed with our 

description of the Crisis Counseling Assistance and Training Program 

and with our conclusions on the importance of evaluating the program’s 

effectiveness. HHS stated that it strongly agreed that evaluation 

activities are critical for this program and other child trauma 

programs to ensure program effectiveness and the appropriate use of 

resources. Both agencies said they have begun, or plan to take steps, 

to engage in additional evaluation activities, and HHS commented that 

it plans to continue ongoing evaluation efforts to assure that services 

are appropriate, efficient, and responsive to the needs of disaster 

victims. At their request, we modified the report to reflect additional 

information the agencies provided on current evaluation activities. 

However, neither the FEMA and HHS activities that we described nor 

those that they cited in their comments constitute the programwide 

evaluation of the program’s effectiveness that we are recommending. 

Furthermore, FEMA did not indicate in its response whether it intends 

to implement our recommendation to coordinate with SAMHSA to conduct 

such an evaluation, which is needed to help federal policymakers and 

program managers assess whether the Crisis Counseling Assistance and 

Training Program is effectively assisting children who have experienced 

disaster-related trauma.



HHS said that the draft report emphasized the lack of data on the 

prevalence of children exposed to trauma and their mental health needs 

but did not discuss National Institutes of Health and National 

Institute of Mental Health research data, including data from 

nationally representative surveys. The types of research studies HHS 

referred to in its comments generally focus on specific communities or 

certain defined populations, and existing nationwide surveys have 

limitations such as not covering certain age ranges or addressing the 

full range of traumatic situations that children may experience. 

Appendix II of our draft report included ACF’s nationwide data on 

children who have been abused and neglected and the number of those who 

received mental health services. However, for other kinds of trauma, 

there are few nationwide data estimating the number of children who 

need mental health services due to these traumas and the number who 

receive services.



HHS suggested that the report should more fully discuss the 

availability of providers trained to help children who have experienced 

trauma. The department said the country does not have a child mental 

health workforce with the capacity to meet the needs of children and 

that responding to PTSD in children requires even more specific 

training. The draft report did refer to workforce issues that could 

affect children’s access to needed mental health services, and we have 

included additional information in response to HHS’s comments. A 

detailed discussion of workforce issues, however, was not within the 

scope of this report. HHS also expressed concern that the report did 

not discuss the need for more research on specific mental disorders and 

effective treatments, the stigma often associated with mental health 

problems and its effect on the delivery of mental health services to 

children who have experienced trauma, or problems in the public mental 

health system. We agree that these are important issues and modified 

the report to acknowledge the potential role of stigma. However, a 

detailed discussion of these issues was also outside the scope of this 

report.



HHS further commented that the report should contain a more thorough 

discussion of HRSA’s grants to help meet the mental health needs of 

children. Appendix VI of the draft report described several HRSA 

grants, including the Maternal and Child Health Block Grant. Based on 

the department’s comments, we modified the appendix to describe 

additional HRSA grants.



HHS acknowledged that the report provides information on the limits 

insurance plans often place on mental health coverage, but said that 

the draft report did not address the ramifications of mental health 

parity. We added clarification that the federal mental health parity 

law does not require group health plans to offer mental health 

benefits, but otherwise believe the report provides ample information 

on the limits of federal and state mental health parity laws.



Education concurred with the information discussed in the report. Like 

HHS, the department raised concerns about the availability of mental 

health providers to serve children who have experienced trauma.



As arranged with your offices, unless you publicly announce its 

contents earlier, we plan no further distribution of this report until 

30 days after its issue date. We are sending copies of this report to 

the Secretary of Health and Human Services, the Attorney General, the 

Secretary of Education, the Director of the Federal Emergency 

Management Agency, appropriate congressional committees, and others who 

are interested. We will also make copies available to others who are 

interested upon request. In addition, the report will be available at 

no charge on the GAO Web site at http://www.gao.gov.



If you or your staffs have any questions, please contact me or Kathryn 

G. Allen, Director, Health Care--Medicaid and Private Insurance Issues, 

at (202) 512-7119. An additional contact and the names of other staff 

members who made contributions to this report are listed in appendix 

XI.



Janet Heinrich

Director, Health Care--Public Health Issues:



Signed by Janet Heinrich:



[End of section]



Appendix I: Scope and Methodology:



To do our work, we obtained program documents, pertinent studies, and 

data from the Department of Health and Human Services’ (HHS) 

Administration for Children and Families (ACF), Centers for Disease 

Control and Prevention, Centers for Medicare & Medicaid Services (CMS), 

Health Resources and Services Administration, Indian Health Service, 

National Institutes of Health, Office of the Secretary, Office of the 

Assistant Secretary for Planning and Evaluation, and Substance Abuse 

and Mental Health Services Administration (SAMHSA); the Department of 

Justice’s Bureau of Justice Statistics, National Institute of Justice, 

Office of Juvenile Justice and Delinquency Prevention, Office for 

Victims of Crime, and Violence Against Women Office; the Federal 

Emergency Management Agency; the Department of Education; and the 

Department of Agriculture. We also interviewed officials from these 

agencies. We also reviewed the relevant literature and interviewed 

officials or obtained information from national organizations including 

the American Academy of Child and Adolescent Psychiatry, American 

Academy of Pediatrics, American Psychiatric Association, American 

Psychological Association, American Public Human Services Association, 

Child Welfare League of America, Family Violence Prevention Fund, 

National Association of Crime Victim Compensation Boards, National 

Association of Social Workers, National Association of State Mental 

Health Program Directors, National Coalition Against Domestic Violence, 

National Council of Juvenile and Family Court Judges, and Prevent Child 

Abuse America.



To determine the extent to which private and public insurance programs 

cover mental health services for children, we reviewed national 

employer benefit surveys; reviewed the benefit design of health plans 

provided by 13 insurers in the individual market, state Medicaid 

programs, and State Children’s Health Insurance Programs (SCHIP); and 

interviewed representatives of private insurers and public officials in 

California, Georgia, Illinois, Massachusetts, Minnesota, and Utah. 

These states were selected on the basis of variation in the number of 

beneficiaries covered, in geographic location, in the extent to which 

the insurance market is regulated, and in the design of the SCHIP 

program. For information on the extent to which employers offer mental 

health benefits to employees, as well as the conditions under which 

coverage is made available, we relied on private employer benefit 

surveys conducted in 2001, specifically those of (1) William M. Mercer, 

Incorporated (formerly produced by Foster Higgins) and (2) the Health 

Research and Educational Trust, sponsored by the Kaiser Family 

Foundation. These surveys are distinguished from a number of other 

private ones largely because of their random samples, which allow their 

results to be generalized to a larger population of employers.



For the mental health services covered by private individual market 

insurers, we interviewed state insurance regulators in each of the six 

states to learn about state laws related to the provision of mental 

health benefits and to identify the insurers in the individual market 

in the state. We then reviewed the benefit designs of popular health 

plans sold in the individual market. To obtain information about the 

mental health coverage of the public insurance programs in these 

states, we reviewed state Medicaid and SCHIP plans, which specified 

program characteristics, including covered benefits and limitations, 

and we interviewed program officials to obtain information on income 

eligibility and service delivery models. In several of the states, we 

also interviewed Mental Health Department officials, providers, and 

consumer advocates.



To identify federal programs that help children who have experienced 

trauma receive mental health services, we reviewed the Catalog of 

Federal Domestic Assistance. After identifying programs, we interviewed 

and collected information from federal program officials to confirm 

whether these programs can support activities, such as mental health 

treatment, screening and referral services, educational outreach, 

training for medical and other professionals on the needs of children 

exposed to trauma, and research and evaluation of mental health 

services. The federal program officials also identified other programs 

and efforts that can address the mental health needs of children 

exposed to trauma and provided perspectives on barriers to these 

children receiving mental health services. We obtained additional 

information on grants that appeared to be most relevant to the 

population discussed in this report. The programs and efforts we 

discuss in this report do not represent an exhaustive list of all 

federally funded programs that can address the mental health needs of 

children exposed to trauma; they highlight a range of programs that 

target varied populations, services, and systems that come into contact 

with this population. We report that these programs can provide mental 

health services to this population because funds may be used for this 

purpose. We were not generally able to obtain information on the nature 

of the services provided or the level of service used by children 

exposed to trauma because some programs we identified do not collect 

information specifically on mental health services provided to children 

exposed to trauma.



We obtained additional information on selected federally supported 

programs and problems children face in obtaining needed mental health 

services through site visits in California and Massachusetts. In these 

states, we interviewed officials or obtained data from state and local 

mental health agencies, state crime victim compensation and assistance 

programs, child welfare and protective service agencies, and other 

organizations receiving federal grants. We also contacted service 

providers with federal grants located in Colorado, Illinois, Minnesota, 

and Oregon. We selected these locations to visit or contact because 

they have organizations receiving federal grants focused on children 

and trauma, such as SAMHSA’s Child Traumatic Stress Initiative or HHS/

Justice’s Greenbook Project, or recognized experts in the field of 

child trauma.



We also obtained data on child abuse and neglect, domestic violence, 

and sexual assault that were collected and analyzed by HHS’s ACF and 

Justice’s Bureau of Justice Statistics, National Institute of Justice, 

and Federal Bureau of Investigation. We did not verify the accuracy of 

these data.



We conducted our work from September 2001 through August 2002 in 

accordance with generally accepted government auditing standards.



[End of section]



Appendix II: Victimization Data:



This appendix presents information on child maltreatment,[Footnote 73] 

intimate partner violence,[Footnote 74] and sexual assault. ACF data 

provide information on children’s entry into the child protective 

service system and the services that they and their families received 

(see tables 4 to 7); additional information was provided by ACF on a 

program to increase contact between children and their noncustodial 

parents. (See table 8.) Justice data provide information on individuals 

who were victims of intimate partner violence and sexual assault. (See 

tables 9 to 12 and fig. 3.) We did not confirm the accuracy of these 

data.



Child Abuse and Neglect Data Collected by HHS’s Administration for 

Children and Families:



In 1996, the Child Abuse Prevention and Treatment Act was amended to 

require states receiving a Child Abuse and Neglect State Grant to 

report to the National Child Abuse and Neglect Data System, to the 

extent practicable, 12 specific data items on child maltreatment, such 

as the number of victims of abuse and neglect and the number of 

children who received services. States can voluntarily report data in 

other categories, such as the number of children receiving mental 

health services. All states submitted data for 1999, the most recent 

year for which data are available. All states did not respond to all 

required items. For example, 10 states did not report information on 

the number of victims who received services. (See table 6.) ACF 

reported in Child Maltreatment 1999 that the required child 

maltreatment data had been validated for consistency and clarity, but 

ACF officials told us that state definitions vary, making comparisons 

between states difficult.



Table 4: Number of Referrals to Child Protective Services and 

Substantiated Cases of Child Maltreatment, by State, 1999:



State: Alabama; Child population (under 18)[A]: 1,066,177; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 24,586; Number of 

investigations[C]: 24,586; Number of investigations substantiating 

maltreatment[D]: 8,610; Percentage of investigations substantiating 

maltreatment[D]: 35.0.



State: Alaska; Child population (under 18)[A]: 196,825; Referrals 

screened out[B]: 1,767; Referrals screened in[B]: 7,806; Number of 

investigations[C]: 13,270; Number of investigations substantiating 

maltreatment[D]: 3,766; Percentage of investigations substantiating 

maltreatment[D]: 28.4.



State: Arizona; Child population (under 18)[A]: 1,334,564; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 32,635; Number of 

investigations[C]: 32,635; Number of investigations substantiating 

maltreatment[D]: 5,650; Percentage of investigations substantiating 

maltreatment[D]: 17.3.



State: Arkansas; Child population (under 18)[A]: 660,224; Referrals 

screened out[B]: 11,883; Referrals screened in[B]: 17,036; Number of 

investigations[C]: 17,036; Number of investigations substantiating 

maltreatment[D]: 5,482; Percentage of investigations substantiating 

maltreatment[D]: 32.2.



State: California; Child population (under 18)[A]: 8,923,423; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 227,561; Number of 

investigations[C]: 227,561; Number of investigations substantiating 

maltreatment[D]: 73,188; Percentage of investigations substantiating 

maltreatment[D]: 32.2.



State: Colorado; Child population (under 18)[A]: 1,065,510; Referrals 

screened out[B]: 17,325; Referrals screened in[B]: 28,774; Number of 

investigations[C]: [E]; Number of investigations substantiating 

maltreatment[D]: [E]; Percentage of investigations substantiating 

maltreatment[D]: [E].



State: Connecticut; Child population (under 18)[A]: 828,260; Referrals 

screened out[B]: 12,701; Referrals screened in[B]: 30,452; Number of 

investigations[C]: 30,452; Number of investigations substantiating 

maltreatment[D]: 11,281; Percentage of investigations substantiating 

maltreatment[D]: 37.1.



State: Delaware; Child population (under 18)[A]: 182,450; Referrals 

screened out[B]: 2,049; Referrals screened in[B]: 6,316; Number of 

investigations[C]: 5,965; Number of investigations substantiating 

maltreatment[D]: 1,346; Percentage of investigations substantiating 

maltreatment[D]: 22.6.



State: District of Columbia; Child population (under 18)[A]: 95,290; 

Referrals screened out[B]: 340; Referrals screened in[B]: 4,048; Number 

of investigations[C]: [E]; Number of investigations substantiating 

maltreatment[D]: [E]; Percentage of investigations substantiating 

maltreatment[D]: [E].



State: Florida; Child population (under 18)[A]: 3,569,878; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 152,989; Number of 

investigations[C]: 95,790; Number of investigations substantiating 

maltreatment[D]: 13,338; Percentage of investigations substantiating 

maltreatment[D]: 13.9.



State: Georgia; Child population (under 18)[A]: 2,056,885; Referrals 

screened out[B]: 22,917; Referrals screened in[B]: 47,032; Number of 

investigations[C]: 47,032; Number of investigations substantiating 

maltreatment[D]: 16,024; Percentage of investigations substantiating 

maltreatment[D]: 34.1.



State: Hawaii; Child population (under 18)[A]: 289,340; Referrals 

screened out[B]: 4,861; Referrals screened in[B]: 2,733; Number of 

investigations[C]: 4,646; Number of investigations substantiating 

maltreatment[D]: 2,669; Percentage of investigations substantiating 

maltreatment[D]: 57.5.



State: Idaho; Child population (under 18)[A]: 350,464; Referrals 

screened out[B]: 7,672; Referrals screened in[B]: 9,363; Number of 

investigations[C]: 9,363; Number of investigations substantiating 

maltreatment[D]: 835; Percentage of investigations substantiating 

maltreatment[D]: 8.9.



State: Illinois; Child population (under 18)[A]: 3,181,338; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 61,773; Number of 

investigations[C]: 61,773; Number of investigations substantiating 

maltreatment[D]: 18,779; Percentage of investigations substantiating 

maltreatment[D]: 30.4.



State: Indiana; Child population (under 18)[A]: 1,528,991; Referrals 

screened out[B]: 6,548; Referrals screened in[B]: 53,897; Number of 

investigations[C]: 91,625; Number of investigations substantiating 

maltreatment[D]: 21,608; Percentage of investigations substantiating 

maltreatment[D]: 23.6.



State: Iowa; Child population (under 18)[A]: 719,685; Referrals 

screened out[B]: 11,464; Referrals screened in[B]: 18,666; Number of 

investigations[C]: 18,666; Number of investigations substantiating 

maltreatment[D]: 6,716; Percentage of investigations substantiating 

maltreatment[D]: 36.0.



State: Kansas; Child population (under 18)[A]: 698,637; Referrals 

screened out[B]: 12,072; Referrals screened in[B]: 18,897; Number of 

investigations[C]: 18,974; Number of investigations substantiating 

maltreatment[D]: 5,894; Percentage of investigations substantiating 

maltreatment[D]: 31.1.



State: Kentucky; Child population (under 18)[A]: 965,528; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 37,285; Number of 

investigations[C]: 63,384; Number of investigations substantiating 

maltreatment[D]: 18,585; Percentage of investigations substantiating 

maltreatment[D]: 29.3.



State: Louisiana; Child population (under 18)[A]: 1,190,001; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 28,123; Number of 

investigations[C]: 26,868; Number of investigations substantiating 

maltreatment[D]: 7,244; Percentage of investigations substantiating 

maltreatment[D]: 27.0.



State: Maine; Child population (under 18)[A]: 290,439; Referrals 

screened out[B]: 11,058; Referrals screened in[B]: 4,450; Number of 

investigations[C]: 4,450; Number of investigations substantiating 

maltreatment[D]: 2,349; Percentage of investigations substantiating 

maltreatment[D]: 52.8.



State: Maryland; Child population (under 18)[A]: 1,309,432; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 31,220; Number of 

investigations[C]: 31,220; Number of investigations substantiating 

maltreatment[D]: 8,103; Percentage of investigations substantiating 

maltreatment[D]: 26.0.



State: Massachusetts; Child population (under 18)[A]: 1,468,554; 

Referrals screened out[B]: 22,654; Referrals screened in[B]: 38,715; 

Number of investigations[C]: 34,108; Number of investigations 

substantiating maltreatment[D]: 17,851; Percentage of investigations 

substantiating maltreatment[D]: 52.3.



State: Michigan; Child population (under 18)[A]: 2,561,139; Referrals 

screened out[B]: 58,596; Referrals screened in[B]: 69,133; Number of 

investigations[C]: 65,591; Number of investigations substantiating 

maltreatment[D]: 13,721; Percentage of investigations substantiating 

maltreatment[D]: 20.9.



State: Minnesota; Child population (under 18)[A]: 1,271,850; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 16,466; Number of 

investigations[C]: 16,466; Number of investigations substantiating 

maltreatment[D]: 7,228; Percentage of investigations substantiating 

maltreatment[D]: 43.9.



State: Mississippi; Child population (under 18)[A]: 752,866; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 18,389; Number of 

investigations[C]: 18,389; Number of investigations substantiating 

maltreatment[D]: 4,077; Percentage of investigations substantiating 

maltreatment[D]: 22.2.



State: Missouri; Child population (under 18)[A]: 1,399,492; Referrals 

screened out[B]: 51,362; Referrals screened in[B]: 46,269; Number of 

investigations[C]: 46,259; Number of investigations substantiating 

maltreatment[D]: 6,117; Percentage of investigations substantiating 

maltreatment[D]: 13.2.



State: Montana; Child population (under 18)[A]: 223,819; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 10,043; Number of 

investigations[C]: 10,043; Number of investigations substantiating 

maltreatment[D]: 1,262; Percentage of investigations substantiating 

maltreatment[D]: 12.6.



State: Nebraska; Child population (under 18)[A]: 443,800; Referrals 

screened out[B]: 2,964; Referrals screened in[B]: 8,456; Number of 

investigations[C]: 8,456; Number of investigations substantiating 

maltreatment[D]: 2,183; Percentage of investigations substantiating 

maltreatment[D]: 25.8.



State: Nevada; Child population (under 18)[A]: 491,476; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 13,384; Number of 

investigations[C]: 13,384; Number of investigations substantiating 

maltreatment[D]: 3,983; Percentage of investigations substantiating 

maltreatment[D]: 29.8.



State: New Hampshire; Child population (under 18)[A]: 304,436; 

Referrals screened out[B]: 6,150; Referrals screened in[B]: 6,107; 

Number of investigations[C]: 6,107; Number of investigations 

substantiating maltreatment[D]: 580; Percentage of investigations 

substantiating maltreatment[D]: 9.5.



State: New Jersey; Child population (under 18)[A]: 2,003,204; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 43,874; Number of 

investigations[C]: 74,585; Number of investigations substantiating 

maltreatment[D]: 9,222; Percentage of investigations substantiating 

maltreatment[D]: 12.4.



State: New Mexico; Child population (under 18)[A]: 495,612; Referrals 

screened out[B]: 6,802; Referrals screened in[B]: 6,846; Number of 

investigations[C]: 11,638; Number of investigations substantiating 

maltreatment[D]: 3,586; Percentage of investigations substantiating 

maltreatment[D]: 30.8.



State: New York; Child population (under 18)[A]: 4,440,924; Referrals 

screened out[B]: 179,879; Referrals screened in[B]: 139,564; Number of 

investigations[C]: 136,489; Number of investigations substantiating 

maltreatment[D]: 46,980; Percentage of investigations substantiating 

maltreatment[D]: 34.4.



State: North Carolina; Child population (under 18)[A]: 1,940,947; 

Referrals screened out[B]: [E]; Referrals screened in[B]: 75,013; 

Number of investigations[C]: 127,522; Number of investigations 

substantiating maltreatment[D]: 36,976; Percentage of investigations 

substantiating maltreatment[D]: 29.0.



State: North Dakota; Child population (under 18)[A]: 160,092; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 4,109; Number of 

investigations[C]: 4,109; Number of investigations substantiating 

maltreatment[D]: [ E]; Percentage of investigations substantiating 

maltreatment[D]: [E].



State: Ohio; Child population (under 18)[A]: 2,844,071; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 79,400; Number of 

investigations[C]: 79,400; Number of investigations substantiating 

maltreatment[D]: 8,749; Percentage of investigations substantiating 

maltreatment[D]: 11.0.



State: Oklahoma; Child population (under 18)[A]: 882,062; Referrals 

screened out[B]: 18,180; Referrals screened in[B]: 35,141; Number of 

investigations[C]: 35,141; Number of investigations substantiating 

maltreatment[D]: 9,864; Percentage of investigations substantiating 

maltreatment[D]: 28.1.



State: Oregon; Child population (under 18)[A]: 827,501; Referrals 

screened out[B]: 16,989; Referrals screened in[B]: 17,686; Number of 

investigations[C]: 17,686; Number of investigations substantiating 

maltreatment[D]: 8,073; Percentage of investigations substantiating 

maltreatment[D]: 45.7.



State: Pennsylvania; Child population (under 18)[A]: 2,852,520; 

Referrals screened out[B]: 6,135; Referrals screened in[B]: 13,175; 

Number of investigations[C]: 22,437; Number of investigations 

substantiating maltreatment[D]: 5,076; Percentage of investigations 

substantiating maltreatment[D]: 22.6.



State: Rhode Island; Child population (under 18)[A]: 241,180; Referrals 

screened out[B]: 4,342; Referrals screened in[B]: 7,882; Number of 

investigations[C]: 7,882; Number of investigations substantiating 

maltreatment[D]: 2,501; Percentage of investigations substantiating 

maltreatment[D]: 31.7.



State: South Carolina; Child population (under 18)[A]: 955,930; 

Referrals screened out[B]: 5,663; Referrals screened in[B]: 18,209; 

Number of investigations[C]: 18,209; Number of investigations 

substantiating maltreatment[D]: 5,518; Percentage of investigations 

substantiating maltreatment[D]: 30.3.



State: South Dakota; Child population (under 18)[A]: 198,037; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 2,770; Number of 

investigations[C]: 6,316; Number of investigations substantiating 

maltreatment[D]: 1,163; Percentage of investigations substantiating 

maltreatment[D]: 18.4.



State: Tennessee; Child population (under 18)[A]: 1,340,930; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 19,782; Number of 

investigations[C]: [E]; Number of investigations substantiating 

maltreatment[D]: [E ]; Percentage of investigations substantiating 

maltreatment[D]: [E].



State: Texas; Child population (under 18)[A]: 5,719,234; Referrals 

screened out[B]: 29,379; Referrals screened in[B]: 131,920; Number of 

investigations[C]: 110,837; Number of investigations substantiating 

maltreatment[D]: 26,978; Percentage of investigations substantiating 

maltreatment[D]: 24.3.



State: Utah; Child population (under 18)[A]: 707,366; Referrals 

screened out[B]: 7,792; Referrals screened in[B]: 17,514; Number of 

investigations[C]: 17,514; Number of investigations substantiating 

maltreatment[D]: 5,991; Percentage of investigations substantiating 

maltreatment[D]: 34.2.



State: Vermont; Child population (under 18)[A]: 139,346; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 2,263; Number of 

investigations[C]: 2,263; Number of investigations substantiating 

maltreatment[D]: 923; Percentage of investigations substantiating 

maltreatment[D]: 40.8.



State: Virginia; Child population (under 18)[A]: 1,664,810; Referrals 

screened out[B]: 15,538; Referrals screened in[B]: 32,270; Number of 

investigations[C]: 32,270; Number of investigations substantiating 

maltreatment[D]: 4,767; Percentage of investigations substantiating 

maltreatment[D]: 14.8.



State: Washington; Child population (under 18)[A]: 1,486,340; Referrals 

screened out[B]: 39,207; Referrals screened in[B]: 35,940; Number of 

investigations[C]: 35,940; Number of investigations substantiating 

maltreatment[D]: 5,128; Percentage of investigations substantiating 

maltreatment[D]: 14.3.



State: West Virginia; Child population (under 18)[A]: 403,481; 

Referrals screened out[B]: 5,791; Referrals screened in[B]: 17,274; 

Number of investigations[C]: 17,274; Number of investigations 

substantiating maltreatment[D]: 5,587; Percentage of investigations 

substantiating maltreatment[D]: 32.3.



State: Wisconsin; Child population (under 18)[A]: 1,348,268; Referrals 

screened out[B]: [E]; Referrals screened in[B]: 20,183; Number of 

investigations[C]: 34,311; Number of investigations substantiating 

maltreatment[D]: 9,791; Percentage of investigations substantiating 

maltreatment[D]: 28.5.



State: Wyoming; Child population (under 18)[A]: 126,807; Referrals 

screened out[B]: 2,305; Referrals screened in[B]: 2,505; Number of 

investigations[C]: 2,505; Number of investigations substantiating 

maltreatment[D]: 855; Percentage of investigations substantiating 

maltreatment[D]: 34.1.



State: Total for states reporting data; Child population (under 18)[A]: 

70,199,435; Referrals screened out[B]: 1,177,874; Referrals screened 

in[B]: 1,795,924; Number of investigations[C]: 1,838,427; Number of 

investigations substantiating maltreatment[D]: 486,197; Percentage of 

investigations substantiating maltreatment[D]: 26.5[F].



[A] Child population data are from the U.S. Bureau of the Census 1999 

population estimates, as reported by ACF.



[B] Referrals are screened out if the allegation does not warrant 

investigation. For example, the allegation may not meet the statutory 

definition of child maltreatment, may not contain sufficient 

information upon which to proceed, and/or may not pertain to the 

population served by the agency. Referrals alleging maltreatment are 

screened in if the child protective services agency decides that they 

are appropriate for investigation or assessment.



[C] ACF reports that the number of investigations may differ from the 

number of referrals screened in because referrals and investigations 

might not occur in the same year and there are variations in the way 

that states compile data. In most states, investigations may cover more 

than one child.



[D] An allegation is substantiated if the agency’s investigation 

concludes that the allegation of maltreatment or risk of maltreatment 

is supported, according to law or policy set by the state.



[E] State did not report data.



[F] Average for all reporting states.



Source: HHS, ACF, Child Maltreatment 1999: Reports from the States to 

the National Child Abuse and Neglect Data System (Washington, D.C.: 

2001).



[End of table]



Table 5: Information on Child Victims of Maltreatment, by State, 1999:



State: Alabama; Number of victims of maltreatment: 13,773; Percentage 

of victims by category of maltreatment[A]: Physically abused: 40.9; 

Percentage of victims by category of maltreatment[A]: Neglected: 46.0; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

23.1.



State: Alaska; Number of victims of maltreatment: 5,976; Percentage of 

victims by category of maltreatment[A]: Physically abused: 29.6; 

Percentage of victims by category of maltreatment[A]: Neglected: 60.5; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

15.2.



State: Arizona; Number of victims of maltreatment: 9,205; Percentage of 

victims by category of maltreatment[A]: Physically abused: 24.8; 

Percentage of victims by category of maltreatment[A]: Neglected: 58.4; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

5.6.



State: Arkansas; Number of victims of maltreatment: 7,564; Percentage 

of victims by category of maltreatment[A]: Physically abused: 27.2; 

Percentage of victims by category of maltreatment[A]: Neglected: 68.9; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

37.0.



State: California; Number of victims of maltreatment: 130,510; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 17.5; Percentage of victims by category of maltreatment[A]: 

Neglected: 56.3; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 9.1.



State: Colorado; Number of victims of maltreatment: 6,989; Percentage 

of victims by category of maltreatment[A]: Physically abused: 27.6; 

Percentage of victims by category of maltreatment[A]: Neglected: 70.7; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

15.1.



State: Connecticut; Number of victims of maltreatment: 14,514; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 16.2; Percentage of victims by category of maltreatment[A]: 

Neglected: 90.2; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 4.1.



State: Delaware; Number of victims of maltreatment: 2,111; Percentage 

of victims by category of maltreatment[A]: Physically abused: 25.3; 

Percentage of victims by category of maltreatment[A]: Neglected: 37.5; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

11.1.



State: District of Columbia; Number of victims of maltreatment: 2,308; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 14.4; Percentage of victims by category of maltreatment[A]: 

Neglected: 71.8; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 1.7.



State: Florida; Number of victims of maltreatment: 67,530; Percentage 

of victims by category of maltreatment[A]: Physically abused: 17.8; 

Percentage of victims by category of maltreatment[A]: Neglected: 39.8; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

6.5.



State: Georgia; Number of victims of maltreatment: 26,888; Percentage 

of victims by category of maltreatment[A]: Physically abused: 13.4; 

Percentage of victims by category of maltreatment[A]: Neglected: 63.1; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

8.4.



State: Hawaii; Number of victims of maltreatment: 2,669; Percentage of 

victims by category of maltreatment[A]: Physically abused: 6.5; 

Percentage of victims by category of maltreatment[A]: Neglected: 8.1; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

5.3.



State: Idaho; Number of victims of maltreatment: 2,928; Percentage of 

victims by category of maltreatment[A]: Physically abused: 29.0; 

Percentage of victims by category of maltreatment[A]: Neglected: 49.5; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

13.1.



State: Illinois; Number of victims of maltreatment: 33,125; Percentage 

of victims by category of maltreatment[A]: Physically abused: 11.2; 

Percentage of victims by category of maltreatment[A]: Neglected: 40.6; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

10.2.



State: Indiana; Number of victims of maltreatment: 21,608; Percentage 

of victims by category of maltreatment[A]: Physically abused: 31.1; 

Percentage of victims by category of maltreatment[A]: Neglected: 124.9; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

25.6.



State: Iowa; Number of victims of maltreatment: 9,763; Percentage of 

victims by category of maltreatment[A]: Physically abused: 25.2; 

Percentage of victims by category of maltreatment[A]: Neglected: 63.1; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

11.1.



State: Kansas; Number of victims of maltreatment: 8,452; Percentage of 

victims by category of maltreatment[A]: Physically abused: 30.8; 

Percentage of victims by category of maltreatment[A]: Neglected: 49.5; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

15.7.



State: Kentucky; Number of victims of maltreatment: 18,650; Percentage 

of victims by category of maltreatment[A]: Physically abused: 27.6; 

Percentage of victims by category of maltreatment[A]: Neglected: 63.7; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

7.7.



State: Louisiana; Number of victims of maltreatment: 12,614; Percentage 

of victims by category of maltreatment[A]: Physically abused: 20.9; 

Percentage of victims by category of maltreatment[A]: Neglected: 68.1; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

6.5.



State: Maine; Number of victims of maltreatment: 4,154; Percentage of 

victims by category of maltreatment[A]: Physically abused: 34.4; 

Percentage of victims by category of maltreatment[A]: Neglected: 59.2; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

21.5.



State: Maryland; Number of victims of maltreatment: 15,451; Percentage 

of victims by category of maltreatment[A]: Physically abused: [B]; 

Percentage of victims by category of maltreatment[A]: Neglected: [B]; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

[B].



State: Massachusetts; Number of victims of maltreatment: 29,633; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: [B]; Percentage of victims by category of maltreatment[A]: 

Neglected: [B]; Percentage of victims by category of maltreatment[A]: 

Sexually abused: [B].



State: Michigan; Number of victims of maltreatment: 24,505; Percentage 

of victims by category of maltreatment[A]: Physically abused: 20.9; 

Percentage of victims by category of maltreatment[A]: Neglected: 70.8; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

6.5.



State: Minnesota; Number of victims of maltreatment: 11,113; Percentage 

of victims by category of maltreatment[A]: Physically abused: 24.8; 

Percentage of victims by category of maltreatment[A]: Neglected: 77.4; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

7.3.



State: Mississippi; Number of victims of maltreatment: 6,523; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 26.6; Percentage of victims by category of maltreatment[A]: 

Neglected: 47.0; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 21.1.



State: Missouri; Number of victims of maltreatment: 9,079; Percentage 

of victims by category of maltreatment[A]: Physically abused: 24.1; 

Percentage of victims by category of maltreatment[A]: Neglected: 49.6; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

26.0.



State: Montana; Number of victims of maltreatment: 3,414; Percentage of 

victims by category of maltreatment[A]: Physically abused: 9.2; 

Percentage of victims by category of maltreatment[A]: Neglected: 62.0; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

9.2.



State: Nebraska; Number of victims of maltreatment: 3,474; Percentage 

of victims by category of maltreatment[A]: Physically abused: 21.6; 

Percentage of victims by category of maltreatment[A]: Neglected: 64.5; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

9.8.



State: Nevada; Number of victims of maltreatment: 8,238; Percentage of 

victims by category of maltreatment[A]: Physically abused: 14.6; 

Percentage of victims by category of maltreatment[A]: Neglected: 22.1; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

2.8.



State: New Hampshire; Number of victims of maltreatment: 926; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 27.5; Percentage of victims by category of maltreatment[A]: 

Neglected: 65.2; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 25.7.



State: New Jersey; Number of victims of maltreatment: 9,222; Percentage 

of victims by category of maltreatment[A]: Physically abused: 23.3; 

Percentage of victims by category of maltreatment[A]: Neglected: 62.7; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

8.0.



State: New Mexico; Number of victims of maltreatment: 3,730; Percentage 

of victims by category of maltreatment[A]: Physically abused: 22.3; 

Percentage of victims by category of maltreatment[A]: Neglected: 52.4; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

6.0.



State: New York; Number of victims of maltreatment: 64,045; Percentage 

of victims by category of maltreatment[A]: Physically abused: 24.8; 

Percentage of victims by category of maltreatment[A]: Neglected: 23.3; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

5.6.



State: North Carolina; Number of victims of maltreatment: 36,976; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 3.6; Percentage of victims by category of maltreatment[A]: 

Neglected: 87.8; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 3.7.



State: North Dakota; Number of victims of maltreatment: 1,284; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 12.5; Percentage of victims by category of maltreatment[A]: 

Neglected: 64.0; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 7.2.



State: Ohio; Number of victims of maltreatment: 55,921; Percentage of 

victims by category of maltreatment[A]: Physically abused: 28.0; 

Percentage of victims by category of maltreatment[A]: Neglected: 53.3; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

14.1.



State: Oklahoma; Number of victims of maltreatment: 16,210; Percentage 

of victims by category of maltreatment[A]: Physically abused: 24.9; 

Percentage of victims by category of maltreatment[A]: Neglected: 98.0; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

8.0.



State: Oregon; Number of victims of maltreatment: 11,241; Percentage of 

victims by category of maltreatment[A]: Physically abused: 13.2; 

Percentage of victims by category of maltreatment[A]: Neglected: 21.1; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

11.8.



State: Pennsylvania; Number of victims of maltreatment: 5,076; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 62.1; Percentage of victims by category of maltreatment[A]: 

Neglected: 3.8; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 80.4.



State: Rhode Island; Number of victims of maltreatment: 3,485; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 26.6; Percentage of victims by category of maltreatment[A]: 

Neglected: 84.6; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 8.9.



State: South Carolina; Number of victims of maltreatment: 9,580; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 13.7; Percentage of victims by category of maltreatment[A]: 

Neglected: 54.8; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 6.3.



State: South Dakota; Number of victims of maltreatment: 2,561; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 25.1; Percentage of victims by category of maltreatment[A]: 

Neglected: 70.9; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 10.0.



State: Tennessee; Number of victims of maltreatment: 10,611; Percentage 

of victims by category of maltreatment[A]: Physically abused: 20.0; 

Percentage of victims by category of maltreatment[A]: Neglected: 43.5; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

21.0.



State: Texas; Number of victims of maltreatment: 39,488; Percentage of 

victims by category of maltreatment[A]: Physically abused: 29.3; 

Percentage of victims by category of maltreatment[A]: Neglected: 59.6; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

14.9.



State: Utah; Number of victims of maltreatment: 8,660; Percentage of 

victims by category of maltreatment[A]: Physically abused: 16.6; 

Percentage of victims by category of maltreatment[A]: Neglected: 28.8; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

21.8.



State: Vermont; Number of victims of maltreatment: 1,080; Percentage of 

victims by category of maltreatment[A]: Physically abused: 22.0; 

Percentage of victims by category of maltreatment[A]: Neglected: 43.7; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

40.4.



State: Virginia; Number of victims of maltreatment: 8,199; Percentage 

of victims by category of maltreatment[A]: Physically abused: 31.1; 

Percentage of victims by category of maltreatment[A]: Neglected: 64.7; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

14.4.



State: Washington; Number of victims of maltreatment: 8,039; Percentage 

of victims by category of maltreatment[A]: Physically abused: 27.1; 

Percentage of victims by category of maltreatment[A]: Neglected: 70.8; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

9.0.



State: West Virginia; Number of victims of maltreatment: 8,609; 

Percentage of victims by category of maltreatment[A]: Physically 

abused: 25.1; Percentage of victims by category of maltreatment[A]: 

Neglected: 43.8; Percentage of victims by category of maltreatment[A]: 

Sexually abused: 8.6.



State: Wisconsin; Number of victims of maltreatment: 9,791; Percentage 

of victims by category of maltreatment[A]: Physically abused: 21.9; 

Percentage of victims by category of maltreatment[A]: Neglected: 42.2; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

37.9.



State: Wyoming; Number of victims of maltreatment: 1,221; Percentage of 

victims by category of maltreatment[A]: Physically abused: 29.4; 

Percentage of victims by category of maltreatment[A]: Neglected: 63.9; 

Percentage of victims by category of maltreatment[A]: Sexually abused: 

9.0.



State: Total for states reporting data; Number of victims of 

maltreatment: 828,716; Percentage of victims by category of 

maltreatment[A]: Physically abused: 21.4[C]; Percentage of victims by 

category of maltreatment[A]: Neglected: 56.0[C]; Percentage of victims 

by category of maltreatment[A]: Sexually abused: 11.3[C].



[A] Percentages do not add up to 100 because some states reported 

additional types of maltreatment that are not included here.



[B] State did not report data.



[C] Average for all reporting states.



Source: HHS, ACF.



[End of table]



Table 6: Services Provided to Child Victims of Maltreatment, by State, 

1999:



State: Alabama; Number of victims of maltreatment: 13,773; Percentage 

of victims who received services, by type of service: Any services: 

15.6; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Alaska; Number of victims of maltreatment: 5,976; Percentage of 

victims who received services, by type of service: Any services: 30.7; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Arizona; Number of victims of maltreatment: 9,205; Percentage of 

victims who received services, by type of service: Any services: [D]; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: 27.3; Percentage of victims 

who received services, by type of service: Counseling services[C]: 

27.8.



State: Arkansas; Number of victims of maltreatment: 7,564; Percentage 

of victims who received services, by type of service: Any services: 

100.0; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: 1.9; Percentage of victims 

who received services, by type of service: Counseling services[C]: 

12.9.



State: California; Number of victims of maltreatment: 130,510; 

Percentage of victims who received services, by type of service: Any 

services: 53.3; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Colorado; Number of victims of maltreatment: 6,989; Percentage 

of victims who received services, by type of service: Any services: 

34.4; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: 24.0; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Connecticut; Number of victims of maltreatment: 14,514; 

Percentage of victims who received services, by type of service: Any 

services: 53.6; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Delaware; Number of victims of maltreatment: 2,111; Percentage 

of victims who received services, by type of service: Any services: 

62.9; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: 1.2; Percentage of victims 

who received services, by type of service: Counseling services[C]: 1.7.



State: District of Columbia; Number of victims of maltreatment: 2,308; 

Percentage of victims who received services, by type of service: Any 

services: 71.4; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Florida; Number of victims of maltreatment: 67,530; Percentage 

of victims who received services, by type of service: Any services: 

64.5; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: 25.3; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Georgia; Number of victims of maltreatment: 26,888; Percentage 

of victims who received services, by type of service: Any services: 

52.7; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Hawaii; Number of victims of maltreatment: 2,669; Percentage of 

victims who received services, by type of service: Any services: [D]; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: 9.0.



State: Idaho; Number of victims of maltreatment: 2,928; Percentage of 

victims who received services, by type of service: Any services: 30.6; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: 13.8; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Illinois; Number of victims of maltreatment: 33,125; Percentage 

of victims who received services, by type of service: Any services: 

15.1; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Indiana; Number of victims of maltreatment: 21,608; Percentage 

of victims who received services, by type of service: Any services: 

51.8; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: 0.1; Percentage of victims 

who received services, by type of service: Counseling services[C]: 

<0.1.



State: Iowa; Number of victims of maltreatment: 9,763; Percentage of 

victims who received services, by type of service: Any services: 65.2; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: 4.1; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Kansas; Number of victims of maltreatment: 8,452; Percentage of 

victims who received services, by type of service: Any services: 28.8; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: 34.7; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Kentucky; Number of victims of maltreatment: 18,650; Percentage 

of victims who received services, by type of service: Any services: 

53.5; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: 8.1; Percentage of victims 

who received services, by type of service: Counseling services[C]: 8.8.



State: Louisiana; Number of victims of maltreatment: 12,614; Percentage 

of victims who received services, by type of service: Any services: 

68.0; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: 13.6; Percentage of victims who received services, by 

type of service: Mental health services[B]: 1.6; Percentage of victims 

who received services, by type of service: Counseling services[C]: 1.5.



State: Maine; Number of victims of maltreatment: 4,154; Percentage of 

victims who received services, by type of service: Any services: 25.1; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Maryland; Number of victims of maltreatment: 15,451; Percentage 

of victims who received services, by type of service: Any services: 

[D]; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Massachusetts; Number of victims of maltreatment: 29,633; 

Percentage of victims who received services, by type of service: Any 

services: [D]; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Michigan; Number of victims of maltreatment: 24,505; Percentage 

of victims who received services, by type of service: Any services: 

81.0; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Minnesota; Number of victims of maltreatment: 11,113; Percentage 

of victims who received services, by type of service: Any services: 

84.2; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Mississippi; Number of victims of maltreatment: 6,523; 

Percentage of victims who received services, by type of service: Any 

services: 100.0; Percentage of victims who received services, by type 

of service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Missouri; Number of victims of maltreatment: 9,079; Percentage 

of victims who received services, by type of service: Any services: 

69.4; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: 11.3; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: 3.0.



State: Montana; Number of victims of maltreatment: 3,414; Percentage of 

victims who received services, by type of service: Any services: 41.3; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Nebraska; Number of victims of maltreatment: 3,474; Percentage 

of victims who received services, by type of service: Any services: 

[D]; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: 0.3; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: New Hampshire; Number of victims of maltreatment: 926; 

Percentage of victims who received services, by type of service: Any 

services: 65.7; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: New Jersey; Number of victims of maltreatment: 9,222; Percentage 

of victims who received services, by type of service: Any services: 

69.0; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: 0.1; Percentage of victims 

who received services, by type of service: Counseling services[C]: 

<0.1.



State: New Mexico; Number of victims of maltreatment: 3,730; Percentage 

of victims who received services, by type of service: Any services: 

60.8; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: 54.2; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: New York; Number of victims of maltreatment: 64,045; Percentage 

of victims who received services, by type of service: Any services: 

[D]; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: <0.1; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Nevada; Number of victims of maltreatment: 8,238; Percentage of 

victims who received services, by type of service: Any services: [D]; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: North Carolina; Number of victims of maltreatment: 36,976; 

Percentage of victims who received services, by type of service: Any 

services: 52.1; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: 0.3; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: 

20.0.



State: North Dakota; Number of victims of maltreatment: 1,284; 

Percentage of victims who received services, by type of service: Any 

services: [D]; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Ohio; Number of victims of maltreatment: 55,921; Percentage of 

victims who received services, by type of service: Any services: 50.5; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: 50.0; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Oklahoma; Number of victims of maltreatment: 16,210; Percentage 

of victims who received services, by type of service: Any services: 

56.2; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: 18.0; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: 3.0.



State: Oregon; Number of victims of maltreatment: 11,241; Percentage of 

victims who received services, by type of service: Any services: 32.6; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: 16.9; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Pennsylvania; Number of victims of maltreatment: 5,076; 

Percentage of victims who received services, by type of service: Any 

services: 63.2; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: 1.2; Percentage of victims 

who received services, by type of service: Counseling services[C]: 

78.4.



State: Rhode Island; Number of victims of maltreatment: 3,485; 

Percentage of victims who received services, by type of service: Any 

services: 100.0; Percentage of victims who received services, by type 

of service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: 34.5; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: South Carolina; Number of victims of maltreatment: 9,580; 

Percentage of victims who received services, by type of service: Any 

services: 99.9; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: South Dakota; Number of victims of maltreatment: 2,561; 

Percentage of victims who received services, by type of service: Any 

services: 60.3; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Tennessee; Number of victims of maltreatment: 10,611; Percentage 

of victims who received services, by type of service: Any services: 

[D]; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Texas; Number of victims of maltreatment: 39,488; Percentage of 

victims who received services, by type of service: Any services: [D]; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: 11.1; Percentage of victims who received services, by 

type of service: Mental health services[B]: 21.4; Percentage of victims 

who received services, by type of service: Counseling services[C]: 

29.9.



State: Utah; Number of victims of maltreatment: 8,660; Percentage of 

victims who received services, by type of service: Any services: 54.3; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: 5.2; Percentage of victims who received services, by 

type of service: Mental health services[B]: 20.6; Percentage of victims 

who received services, by type of service: Counseling services[C]: 9.4.



State: Vermont; Number of victims of maltreatment: 1,080; Percentage of 

victims who received services, by type of service: Any services: 35.8; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: 12.4; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Virginia; Number of victims of maltreatment: 8,199; Percentage 

of victims who received services, by type of service: Any services: 

74.8; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Washington; Number of victims of maltreatment: 8,039; Percentage 

of victims who received services, by type of service: Any services: 

84.5; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: 4.5.



State: West Virginia; Number of victims of maltreatment: 8,609; 

Percentage of victims who received services, by type of service: Any 

services: 48.7; Percentage of victims who received services, by type of 

service: Family preservation services in the 

past 5 years[A]: 7.6; Percentage of victims who received services, by 

type of service: Mental health services[B]: 0.1; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Wisconsin; Number of victims of maltreatment: 9,791; Percentage 

of victims who received services, by type of service: Any services: 

94.5; Percentage of victims who received services, by type of service: 

Family preservation services in the 

past 5 years[A]: [D]; Percentage of victims who received services, by 

type of service: Mental health services[B]: [D]; Percentage of victims 

who received services, by type of service: Counseling services[C]: [D].



State: Wyoming; Number of victims of maltreatment: 1,221; Percentage of 

victims who received services, by type of service: Any services: 37.3; 

Percentage of victims who received services, by type of service: Family 

preservation services in the 

past 5 years[A]: 22.0; Percentage of victims who received services, by 

type of service: Mental health services[B]: 0.7; Percentage of victims 

who received services, by type of service: Counseling services[C]: 8.1.



State: Total for states reporting data; Number of victims of 

maltreatment: 828,716; Percentage of victims who received services, by 

type of service: Any services: 55.8[E]; Percentage of victims who 

received services, by type of service: Family preservation services in 

the 

past 5 years[A]: 21.6[E]; Percentage of victims who received services, 

by type of service: Mental health services[B]: 8.3[E]; Percentage of 

victims who received services, by type of service: Counseling 

services[C]: 14.8[E].



[A] Family preservation services include services to prevent out-of-

home placement, support reunification of children with their families, 

support the continued placement of children in adoptive homes, or 

support other permanent living arrangements.



[B] Mental health services are provided by clinicians, physicians, and 

social workers in mental health agencies to address clinically 

diagnosed problems. Services are often time-limited and may include 

residential and/or outpatient treatment.



[C] Counseling refers to family and individual counseling services 

provided by case workers and clinicians in social services agency 

settings.



[D] State did not report data.



[E] Average for all reporting states.



Source: HHS, ACF.



[End of table]



Table 7: Number of Reports of Child Maltreatment, by Source of Report 

and State, 1999:



State: Alabama; Social services: 1,922; Medical: 2,283; Mental health: 

930; Legal/law enforcement: 4,149; Education: 4,017; Parents: 2,721; 

Other relatives and friends: 3,703; Total reports[A]: 24,586.



State: Alaska; Social services: 2,136; Medical: 1,112; Mental health: 

[B]; Legal/law enforcement: 1,962; Education: 2,471; Parents: 832; 

Other relatives and friends: 1,925; Total reports[A]: 13,270.



State: Arizona; Social services: 1,418; Medical: 3,294; Mental health: 

1,307; Legal/law enforcement: 5,717; Education: 5,405; Parents: 2,586; 

Other relatives and friends: 5,284; Total reports[A]: 32,635.



State: Arkansas; Social services: 1,898; Medical: 1,294; Mental health: 

1,041; Legal/law enforcement: 1,662; Education: 2,061; Parents: 676; 

Other relatives and friends: 3,125; Total reports[A]: 17,036.



State: California; Social services: 38,341; Medical: 19,118; Mental 

health: [B]; Legal/law enforcement: 33,333; Education: 39,386; Parents: 

3; Other relatives and friends: 26,129; Total reports[A]: 227,561.



State: Colorado; Social services: [B]; Medical: [B]; Mental health: 

[B]; Legal/law enforcement: [B]; Education: [B]; Parents: [B]; Other 

relatives and friends: [B]; Total reports[A]: [B].



State: Connecticut; Social services: 2,561; Medical: 3,140; Mental 

health: 2,408; Legal/law enforcement: 5,545; Education: 6,489; Parents: 

2,043; Other relatives and friends: 1,831; Total reports[A]: 30,452.



State: Delaware; Social services: 280; Medical: 515; Mental health: 

260; Legal/law enforcement: 1,628; Education: 955; Parents: 581; Other 

relatives and friends: 828; Total reports[A]: 6,316.



State: District of Columbia; Social services: 672; Medical: 192; Mental 

health: 156; Legal/law enforcement: 768; Education: 320; Parents: 96; 

Other relatives and friends: 788; Total reports[A]: 4,048.



State: Florida; Social services: 21,591; Medical: 12,142; Mental 

health: 6,037; Legal/law enforcement: 26,590; Education: 19,200; 

Parents: 14,375; Other relatives and friends: 24,609; Total reports[A]: 

152,989.



State: Georgia; Social services: 3,979; Medical: 3,660; Mental health: 

2,784; Legal/law enforcement: 7,445; Education: 8,677; Parents: 3,885; 

Other relatives and friends: 9,552; Total reports[A]: 47,032.



State: Hawaii; Social services: 630; Medical: 564; Mental health: [B]; 

Legal/law enforcement: 688; Education: 674; Parents: 193; Other 

relatives and friends: 510; Total reports[A]: 5,063.



State: Idaho; Social services: 500; Medical: 618; Mental health: 100; 

Legal/law enforcement: 1,425; Education: 1,726; Parents: 1,050; Other 

relatives and friends: 1,651; Total reports[A]: 9,363.



State: Illinois; Social services: 9,451; Medical: 8,695; Mental health: 

b; Legal/law enforcement: 9,989; Education: 10,265; Parents: 4,551; 

Other relatives and friends: 7,780; Total reports[A]: 61,773.



State: Indiana; Social services: [B]; Medical: [B]; Mental health: [B]; 

Legal/law enforcement: [B]; Education: [B]; Parents: [B]; Other 

relatives and friends: [B]; Total reports[A]: [B].



State: Iowa; Social services: 3,010; Medical: 1,386; Mental health: 

525; Legal/law enforcement: 2,237; Education: 2,804; Parents: 152; 

Other relatives and friends: [B]; Total reports[A]: 18,666.



State: Kansas; Social services: 3,279; Medical: 1,501; Mental health: 

181; Legal/law enforcement: 1,741; Education: 3,694; Parents: 1,957; 

Other relatives and friends: 2,344; Total reports[A]: 18,834.



State: Kentucky; Social services: 1,139; Medical: 683; Mental health: 

[B]; Legal/law enforcement: 2,164; Education: 2,355; Parents: 6,075; 

Other relatives and friends: 14,387; Total reports[A]: 63,384.



State: Louisiana; Social services: 3,631; Medical: 2,900; Mental 

health: [B]; Legal/law enforcement: 3,771; Education: 4,896; Parents: 

1,802; Other relatives and friends: 4,364; Total reports[A]: 28,123.



State: Maine; Social services: 503; Medical: 317; Mental health: 426; 

Legal/law enforcement: 503; Education: 765; Parents: 253; Other 

relatives and friends: 785; Total reports[A]: 4,450.



State: Maryland; Social services: [B]; Medical: [B]; Mental health: 

[B]; Legal/law enforcement: [B]; Education: [B]; Parents: [B]; Other 

relatives and friends: [B]; Total reports[A]: [B].



State: Massachusetts; Social services: [B]; Medical: [B]; Mental 

health: [B]; Legal/law enforcement: [B]; Education: [B]; Parents: [B]; 

Other relatives and friends: [B]; Total reports[A]: [B].



State: Michigan; Social services: 12,237; Medical: 3,353; Mental 

health: 6,136; Legal/law enforcement: 8,902; Education: 5,000; Parents: 

6,022; Other relatives and friends: 11,721; Total reports[A]: 69,133.



State: Minnesota; Social services: 1,456; Medical: 1,559; Mental 

health: 631; Legal/law enforcement: 3,685; Education: 3,716; Parents: 

1,458; Other relatives and friends: 1,993; Total reports[A]: 17,098.



State: Mississippi; Social services: 1,158; Medical: 2,106; Mental 

health: [B]; Legal/law enforcement: 2,517; Education: 3,187; Parents: 

809; Other relatives and friends: 5,162; Total reports[A]: 18,389.



State: Missouri; Social services: 5,136; Medical: 3,058; Mental health: 

2,364; Legal/law enforcement: 5,544; Education: 5,243; Parents: 1,738; 

Other relatives and friends: 13,813; Total reports[A]: 46,269.



State: Montana; Social services: 1,182; Medical: 548; Mental health: 

219; Legal/law enforcement: 1,504; Education: 1,687; Parents: 808; 

Other relatives and friends: 2,144; Total reports[A]: 10,043.



State: Nebraska; Social services: 464; Medical: 555; Mental health: 

280; Legal/law enforcement: 1,737; Education: 987; Parents: 593; Other 

relatives and friends: 1,245; Total reports[A]: 8,456.



State: Nevada; Social services: 937; Medical: 1,086; Mental health: 

438; Legal/law enforcement: 1,913; Education: 2,643; Parents: 1,111; 

Other relatives and friends: 2,707; Total reports[A]: 13,384.



State: New Hampshire; Social services: 749; Medical: 510; Mental 

health: 560; Legal/law enforcement: 799; Education: 1,217; Parents: 

172; Other relatives and friends: 1,157; Total reports[A]: 6,107.



State: New Jersey; Social services: 8,138; Medical: 9,358; Mental 

health: [B]; Legal/law enforcement: 11,874; Education: 14,564; Parents: 

6,617; Other relatives and friends: 10,903; Total reports[A]: 74,585.



State: New Mexico; Social services: 807; Medical: 893; Mental health: 

610; Legal/law enforcement: 3,957; Education: 2,616; Parents: 627; 

Other relatives and friends: 1,900; Total reports[A]: 11,638.



State: New York; Social services: 36,639; Medical: 13,025; Mental 

health: [B]; Legal/law enforcement: 7,797; Education: 13,128; Parents: 

9,520; Other relatives and friends: 14,784; Total reports[A]: 139,564.



State: North Carolina; Social services: 20,778; Medical: 10,056; Mental 

health: [B]; Legal/law enforcement: 12,623; Education: 22,727; Parents: 

9,855; Other relatives and friends: 32,262; Total reports[A]: 127,522.



State: North Dakota; Social services: 533; Medical: 217; Mental health: 

288; Legal/law enforcement: 817; Education: 780; Parents: 361; Other 

relatives and friends: 552; Total reports[A]: 4,109.



State: Ohio; Social services: 12,198; Medical: 4,990; Mental health: 

2,737; Legal/law enforcement: 12,260; Education: 8,974; Parents: [B]; 

Other relatives and friends: 20,124; Total reports[A]: 79,400.



State: Oklahoma; Social services: 4,191; Medical: 2,283; Mental health: 

2,223; Legal/law enforcement: 3,755; Education: 3,939; Parents: 2,021; 

Other relatives and friends: 7956; Total reports[A]: 35,141.



State: Oregon; Social services: 1,824; Medical: 1,721; Mental health: 

145; Legal/law enforcement: 5,043; Education: 2,650; Parents: 567; 

Other relatives and friends: 1,995; Total reports[A]: 17,686.



State: Pennsylvania; Social services: 3,011; Medical: 3,431; Mental 

health: 1,290; Legal/law enforcement: 1,725; Education: 5,067; Parents: 

2,210; Other relatives and friends: 1,940; Total reports[A]: 22,397.



State: Rhode Island; Social services: 1,020; Medical: 1,223; Mental 

health: [B]; Legal/law enforcement: 962; Education: 1,431; Parents: 

527; Other relatives and friends: 825; Total reports[A]: 9,168.



State: South Carolina; Social services: 1,724; Medical: 2,198; Mental 

health: 502; Legal/law enforcement: 2,763; Education: 3,558; Parents: 

1,433; Other relatives and friends: 2,785; Total reports[A]: 18,209.



State: South Dakota; Social services: [B]; Medical: 259; Mental health: 

172; Legal/law enforcement: 1,175; Education: 899; Parents: 284; Other 

relatives and friends: 903; Total reports[A]: 4,709.



State: Tennessee; Social services: 2,419; Medical: 2,906; Mental 

health: [B]; Legal/law enforcement: 6,352; Education: 4,187; Parents: 

1,454; Other relatives and friends: 9,251; Total reports[A]: 33,682.



State: Texas; Social services: 6,992; Medical: 14,637; Mental health: 

4,183; Legal/law enforcement: 15,944; Education: 24,322; Parents: 

13,450; Other relatives and friends: 27,380; Total reports[A]: 131,920.



State: Utah; Social services: 2,034; Medical: 937; Mental health: 454; 

Legal/law enforcement: 3,642; Education: 1,361; Parents: 755; Other 

relatives and friends: 2,981; Total reports[A]: 17,514.



State: Vermont; Social services: 160; Medical: 165; Mental health: 191; 

Legal/law enforcement: 393; Education: 502; Parents: 221; Other 

relatives and friends: 242; Total reports[A]: 2,273.



State: Virginia; Social services: 1,948; Medical: 2,626; Mental health: 

1,364; Legal/law enforcement: 4,951; Education: 6,430; Parents: 3,114; 

Other relatives and friends: 5,355; Total reports[A]: 32,270.



State: Washington; Social services: 6,822; Medical: 2,929; Mental 

health: 1,452; Legal/law enforcement: 3,844; Education: 5,908; Parents: 

2,804; Other relatives and friends: 6,656; Total reports[A]: 35,940.



State: West Virginia; Social services: 2,025; Medical: 913; Mental 

health: 699; Legal/law enforcement: 1,221; Education: 2,166; Parents: 

1,774; Other relatives and friends: 3,243; Total reports[A]: 17,274.



State: Wisconsin; Social services: 5,354; Medical: 1,868; Mental 

health: 1,628; Legal/law enforcement: 6,849; Education: 6,114; Parents: 

3,169; Other relatives and friends: 5,062; Total reports[A]: 36,295.



State: Wyoming; Social services: [B]; Medical: [B]; Mental health: [B]; 

Legal/law enforcement: [B]; Education: [B]; Parents: [B]; Other 

relatives and friends: [B]; Total reports[A]: [B].



State: Total for states reporting data; Social services: 238,877; 

Medical: 152,824; Mental health: 44,721; Legal/law enforcement: 

245,865; Education: 271,163; Parents: 117,305; Other relatives

and friends: 306,636; Total reports[A]: 1,805,756.



State: Percentage of total reports; Social services: 13.2; Medical: 

8.5; Mental health: 2.5; Legal/law enforcement: 13.6; Education: 15.0; 

Parents: 6.5; Other relatives and friends: 17.0; Total reports[A]: 
100.0.



Note: According to ACF officials, the number of reports is based on 

those reports of child maltreatment that resulted in an investigation, 

but there are variations in the way that states compile their data. 

Social services personnel, medical personnel, mental health personnel, 

legal and law enforcement personnel, educators, child day care 

providers, and foster care and adoption providers may, depending on 

state law, be legally required to report suspected maltreatment as part 

of their job.



[A] Total for each state also includes reports from other sources not 

listed in the table. Of the approximately 1.8 million reports 

nationwide, 3 percent of the reports came from child day care 

providers, foster care and adoption providers, alleged victims, or 

alleged perpetrators, and 20.7 percent of the reports came from another 

or unknown source. :



[B] State did not report data.



Source: HHS, ACF, Child Maltreatment 1999: Reports from the States to 

the National Child Abuse and Neglect Data System (Washington, D.C.: 

2001).



[End of table]



Child Access and Visitation Data Collected by HHS’s Administration for 

Children and Families:



The Personal Responsibility and Opportunity Act of 1996 authorized ACF 

to provide $10 million to states to establish and operate access and 

visitation programs. The overall goal of the program is to increase 

children’s contact with their noncustodial parents. Individual 

grantees, however, often have additional goals that relate to child 

well-being, such as providing a safe, stress-free environment in which 

children and noncustodial parents can interact, when a court has said 

that the child is at risk for harm. Most families either self-refer to 

access and visitation programs or are referred by courts, child support 

agencies, or child welfare agencies. Eligible services include, but are 

not limited to, mediation, counseling, education, development of 

parenting plans, visitation enforcement, and development of guidelines 

for visitation and alternative custody arrangements. These services are 

provided in urban, suburban, and rural locations and are administered 

by state and county agencies, courts, and nonprofit organizations. As a 

condition of receiving these funds, states must report annually on 

program activities funded through the grant and on funding priorities 

for the next fiscal year, one of which can be counseling. (See table 

8.):



Table 8: Child Access and Visitation Grant Data, by State:



State: Alabama; Parents served in

fiscal year 1998: 276; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Alaska; Parents served in

fiscal year 1998: 8; [Empty]; Counseling targeted as a priority area in 

fiscal year 2000: No.



State: Arizona; Parents served in

fiscal year 1998: [A]; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Arkansas; Parents served in

fiscal year 1998: 222; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: California; Parents served in

fiscal year 1998: 5,812; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: Yes.



State: Colorado; Parents served in

fiscal year 1998: 588; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Connecticut; Parents served in

fiscal year 1998: [A]; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Delaware; Parents served in

fiscal year 1998: 18; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: No.



State: District of Columbia; Parents served in

fiscal year 1998: 158; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: No.



State: Florida; Parents served in

fiscal year 1998: 6,668; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: No.



State: Georgia; Parents served in

fiscal year 1998: 213; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Hawaii; Parents served in

fiscal year 1998: 200; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Idaho; Parents served in

fiscal year 1998: 230; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Illinois; Parents served in

fiscal year 1998: 359; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Indiana; Parents served in

fiscal year 1998: 1,166; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: Yes.



State: Iowa; Parents served in

fiscal year 1998: 189; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Kansas; Parents served in

fiscal year 1998: 329; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: [A].



State: Kentucky; Parents served in

fiscal year 1998: 1,630; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: Yes.



State: Louisiana; Parents served in

fiscal year 1998: 290; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: No.



State: Maine; Parents served in

fiscal year 1998: 774; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Maryland; Parents served in

fiscal year 1998: 156; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Massachusetts; Parents served in

fiscal year 1998: 265; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Michigan; Parents served in

fiscal year 1998: 456; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: [A].



State: Minnesota; Parents served in

fiscal year 1998: 314; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: [A].



State: Mississippi; Parents served in

fiscal year 1998: 305; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Missouri; Parents served in

fiscal year 1998: 1,051; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: Yes.



State: Montana; Parents served in

fiscal year 1998: 389; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Nebraska; Parents served in

fiscal year 1998: 211; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Nevada; Parents served in

fiscal year 1998: 248; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: New Hampshire; Parents served in

fiscal year 1998: 112; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: New Jersey; Parents served in

fiscal year 1998: 6,363; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: Yes.



State: New Mexico; Parents served in

fiscal year 1998: 539; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: New York; Parents served in

fiscal year 1998: 1,021; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: Yes.



State: North Carolina; Parents served in

fiscal year 1998: [B]; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: North Dakota; Parents served in

fiscal year 1998: [A]; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: [A].



State: Ohio; Parents served in

fiscal year 1998: 1,045; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: [A].



State: Oklahoma; Parents served in

fiscal year 1998: 56; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Oregon; Parents served in

fiscal year 1998: 464; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Pennsylvania; Parents served in

fiscal year 1998: 878; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Rhode Island; Parents served in

fiscal year 1998: 71; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: [A].



State: South Carolina; Parents served in

fiscal year 1998: 166; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: South Dakota; Parents served in

fiscal year 1998: 264; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: [A].



State: Tennessee; Parents served in

fiscal year 1998: 3,622; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: [A].



State: Texas; Parents served in

fiscal year 1998: 3,649; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: Yes.



State: Utah; Parents served in

fiscal year 1998: 392; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: [A].



State: Vermont; Parents served in

fiscal year 1998: 1,079; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: Yes.



State: Virginia; Parents served in

fiscal year 1998: 1,108; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: Yes.



State: Washington; Parents served in

fiscal year 1998: 1,061; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: [A].



State: West Virginia; Parents served in

fiscal year 1998: [A]; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Wisconsin; Parents served in

fiscal year 1998: 276; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Wyoming; Parents served in

fiscal year 1998: [A]; [Empty]; Counseling targeted as a priority area 

in fiscal year 2000: Yes.



State: Total for states reporting data; Parents served in

fiscal year 1998: 44,691; [Empty]; Counseling targeted as a priority 

area in fiscal year 2000: [Empty].



Note: The most recent year for which states reported data on parents 

served is fiscal year 1998. Information on the provision of counseling 

services comes from state descriptions of their proposed activities and 

funding priorities for fiscal year 2000, not the services they actually 

provided. This table includes only those programs that reported serving 

parents. States may not have reported these data for some service 

programs or may have funded additional programs for purposes other than 

serving parents, such as general training.



[A] State did not report data.



[B] North Carolina reported that the fiscal year 1998 money was 

returned to ACF, so there are no data to report.



Source: HHS, ACF, Child Access and Visitation Grants: State Profiles 

(Washington, D.C.: Oct. 2001) http://www.acf.dhhs.gov/programs//cse/

pol/im-01-03a/index.html (downloaded March 4, 2002).



[End of table]



Victimization Data Collected by the Department of Justice:



Data that Justice has collected on victimization include information on 

intimate partner violence and sexual assault. Justice’s Bureau of 

Justice Statistics’ National Crime Victimization Survey provided 

estimates on intimate partner violence over time (see figure 3), while 

the National Violence Against Women Survey, jointly conducted by the 

National Institute of Justice and HHS’s Centers for Disease Control and 

Prevention, provided more detailed descriptions of intimate partner 

violence and victim behavior. (See tables 9 and 10.) Justice’s Federal 

Bureau of Investigation collects data on the forcible rape[Footnote 75] 

of women using the Uniform Crime Reporting Program. (See table 11.) The 

program collects annual counts of reported criminal activity from city, 

county, and state law enforcement agencies; incidents not reported to 

law enforcement are not included in counts. In addition, the Bureau of 

Justice Statistics collects information on sexual assault convictions 

using the National Judicial Reporting Program. (See table 12.):



Figure 3: Estimated Number of Victims of Intimate Partner Violence, by 

Sex, 1993 to 1998:



[See PDF for image]



Source: Department of Justice, Bureau of Justice Statistics, Bureau of 

Justice Statistics Special Report: Intimate Partner Violence 

(Washington, D.C.: 2000).



[End of figure]



Table 9: Estimated Number of Persons Raped or Physically Assaulted by 

an Intimate Partner during Lifetime and Previous 12 Months, by Sex of 

Victim:



Type of violence: Rape; Lifetime: Women: 7,754,000; Lifetime: Men: 

278,000; [Empty]; Previous 12 months: Women: 201,000; Previous 12 

months: Men: [A ].



Type of violence: Physical assault; Lifetime: Women: 22,254,000; 

Lifetime: Men: 6,863,000; [Empty]; Previous 12 months: Women: 

1,309,000; Previous 12 months: Men: 835,000.



Note: Based on estimates of men and women in the United States aged 18 

years and older, U.S. Bureau of Census, Current Population Survey, 

1995.



[A] The number of male rape victims was insufficient to calculate a 

reliable estimate.



Source: Department of Justice, National Institute of Justice and HHS, 

Centers for Disease Control and Prevention, Prevalence, Incidence, and 

Consequences of Violence Against Women: Findings from the National 

Violence Against Women Survey (Washington, D.C.: 1998). The federal 

National Violence Against Women Survey consisted of a nationally 

representative sample of 8,000 U.S. women and 8,000 U.S. men. The 

survey was conducted from November 1995 to May 1996.



[End of table]



Table 10: Estimated Rates of Law Enforcement Actions, as Reported by 

Victims of Selected Intimate Partner Crimes:



Total crime victims (n); Rape victims[A]: Women: 441; [Empty]; Physical 

assault victims: Women: 1,149; Physical assault victims: Men: 541; 

[Empty]; Stalking victims: Women: 343; Stalking victims: Men: 47.



Reported to police (%); Rape victims[A]: Women: 17.2; [Empty]; Physical 

assault victims: Women: 26.7; Physical assault victims: Men: 13.5; 

[Empty]; Stalking victims: Women: 51.9; Stalking victims: Men: 36.2.



Did not report to police (%); Rape victims[A]: Women: 82.8; [Empty]; 

Physical assault victims: Women: 73.3; Physical assault victims: Men: 

86.5; [Empty]; Stalking victims: Women: 48.1; Stalking victims: Men: 

63.8.



Crime victims reporting to police (n)[B]; Rape victims[A]: Women: 75; 

[Empty]; Physical assault victims: Women: 370; Physical assault 

victims: Men: 73; [Empty]; Stalking victims: Women: 178; Stalking 

victims: Men: 17.



Police took report (%); Rape victims[A]: Women: 77.6; [Empty]; Physical 

assault victims: Women: 76.2; Physical assault victims: Men: 64.4; 

[Empty]; Stalking victims: Women: 67.4; Stalking victims: Men: 64.7.



Police arrested or detained attacker (%); Rape victims[A]: Women: 47.4; 

[Empty]; Physical assault victims: Women: 36.4; Physical assault 

victims: Men: 12.3; [Empty]; Stalking victims: Women: 28.7; Stalking 

victims: Men: [C].



Police referred victim to prosecutor or court (%); Rape victims[A]: 

Women: 10.5; [Empty]; Physical assault victims: Women: 33.9; Physical 

assault victims: Men: 23.3; [Empty]; Stalking victims: Women: 28.1; 

Stalking victims: Men: [C].



Police referred victim to services (%); Rape victims[A]: Women: [C]; 

[Empty]; Physical assault victims: Women: 25.1; Physical assault 

victims: Men: 17.8; [Empty]; Stalking victims: Women: 21.3; Stalking 

victims: Men: [C].



Police gave victim advice on self-protective measures (%); Rape 

victims[A]: Women: [C]; [Empty]; Physical assault victims: Women: 26.1; 

Physical assault victims: Men: 17.8; [Empty]; Stalking victims: Women: 

23.1; Stalking victims: Men: 35.3.



Police did nothing (%); Rape victims[A]: Women: [C]; [Empty]; Physical 

assault victims: Women: 11.1; Physical assault victims: Men: 19.2; 

[Empty]; Stalking victims: Women: 18.5; Stalking victims: Men: [C].



Note: Estimates are based on the most recent intimate partner 

victimization since age 18. :



[A] Estimates not calculated for male rape victims due to the small 

sample size.



[B] Estimates are based on responses from victims whose victimization 

was reported to police and exceed 100 percent because some victims 

reported multiple police responses.



[C] Estimates not calculated because fewer than five in sample cell.



Source: Department of Justice, National Institute of Justice and HHS, 

Centers for Disease Control and Prevention, Extent, Nature, and 

Consequences of Intimate Partner Violence: Findings from the National 

Violence Against Women Survey (Washington, D.C.: 2000). The federal 

National Violence Against Women Survey consisted of a nationally 

representative sample of 8,000 U.S. women and 8,000 U.S. men. The 

survey was conducted from November 1995 to May 1996.



[End of table]



Table 11: Instances of Forcible Rape of Women Reported to Police, All 

Ages, 2000:



State: Alabama; Forcible rape: 1,482.



State: Alaska; Forcible rape: 497.



State: Arizona; Forcible rape: 1,577.



State: Arkansas; Forcible rape: 848.



State: California; Forcible rape: 9,785.



State: Colorado; Forcible rape: 1,774.



State: Connecticut; Forcible rape: 678.



State: Delaware; Forcible rape: 424.



State: District of Columbia; Forcible rape: 251.



State: Florida; Forcible rape: 7,057.



State: Georgia; Forcible rape: 1,968.



State: Hawaii; Forcible rape: 346.



State: Idaho; Forcible rape: 384.



State: Illinois; Forcible rape: 4,090.



State: Indiana; Forcible rape: 1,759.



State: Iowa; Forcible rape: 676.



State: Kansas; Forcible rape: 1,022.



State: Kentucky; Forcible rape: 1,091.



State: Louisiana; Forcible rape: 1,497.



State: Maine; Forcible rape: 320.



State: Maryland; Forcible rape: 1,543.



State: Massachusetts; Forcible rape: 1,696.



State: Michigan; Forcible rape: 5,025.



State: Minnesota; Forcible rape: 2,240.



State: Mississippi; Forcible rape: 1,019.



State: Missouri; Forcible rape: 1,351.



State: Montana; Forcible rape: 301.



State: Nebraska; Forcible rape: 436.



State: Nevada; Forcible rape: 860.



State: New Hampshire; Forcible rape: 522.



State: New Jersey; Forcible rape: 1,357.



State: New Mexico; Forcible rape: 922.



State: New York; Forcible rape: 3,530.



State: North Carolina; Forcible rape: 2,181.



State: North Dakota; Forcible rape: 169.



State: Ohio; Forcible rape: 4,271.



State: Oklahoma; Forcible rape: 1,422.



State: Oregon; Forcible rape: 1,286.



State: Pennsylvania; Forcible rape: 3,247.



State: Rhode Island; Forcible rape: 412.



State: South Carolina; Forcible rape: 1,511.



State: South Dakota; Forcible rape: 305.



State: Tennessee; Forcible rape: 2,186.



State: Texas; Forcible rape: 7,856.



State: Utah; Forcible rape: 863.



State: Vermont; Forcible rape: 140.



State: Virginia; Forcible rape: 1,616.



State: Washington; Forcible rape: 2,737.



State: West Virginia; Forcible rape: 331.



State: Wisconsin; Forcible rape: 1,165.



State: Wyoming; Forcible rape: 160.



State: Total; Forcible rape: 90,186.



Source: Department of Justice, Federal Bureau of Investigation, Crime 

in the United States 2000 (Washington, D.C.: 2001).



[End of table]



Table 12: Sexual Assault Convictions in State Courts, 1998:



Sexual assault; Estimated number of convictions: 29,693; Percentage 

of felons

sentenced to incarceration: 82; Mean maximum sentence for felons 

sentenced to incarceration: 94 months.



Rape; Estimated number of convictions: 11,622; Percentage 

of felons

sentenced to incarceration: 84; Mean maximum sentence for felons 

sentenced to incarceration: 125 months.



Other assault; Estimated number of convictions: 18,071; Percentage 

of felons

sentenced to incarceration: 80; Mean maximum sentence for felons 

sentenced to incarceration: 74 months.



All felony offenses; Estimated number of convictions: 927,717; 

Percentage 

of felons

sentenced to incarceration: 68; Mean maximum sentence for felons 

sentenced to incarceration: 39 months.



Source: Department of Justice, Bureau of Justice Statistics, Felony 

Sentences in State Courts, 1998 (Washington, D.C.: 2001).



[End of table]



[End of section]



Appendix III: Information on SCHIP Programs in the 50 States and the 

District of Columbia:



States have flexibility in the way they design their SCHIP program. 

They may expand their Medicaid programs, develop a separate child 

health program that functions independently of the Medicaid program, or 

do a combination of both. Although SCHIP is generally targeted to 

families with incomes at or below 200 percent of the federal poverty 

level, each state may set its own income eligibility limits within 

certain guidelines. (See table 13.):



Table 13: Program Type, Maximum Income Eligibility Levels, and Fiscal 

Year 2001 Enrollment for SCHIP Programs in the 50 States and the 

District of Columbia:



State: Alabama; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 200; 

Enrollment - fiscal year 2001: 68,179.



State: Alaska; SCHIP program type: Medicaid expansion: X; SCHIP program 

type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 21,831.



State: Arizona; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 86,863.



State: Arkansas; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

100; Enrollment - fiscal year 2001: 2,884.



State: California; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: [Empty]; SCHIP program type: 

Combination: X; Maximum income eligibility by percent federal poverty 

level: 250; Enrollment - fiscal year 2001: 693,048.



State: Colorado; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

185; Enrollment - fiscal year 2001: 45,773.



State: Connecticut; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: [Empty]; SCHIP program type: 

Combination: X; Maximum income eligibility by percent federal poverty 

level: 300; Enrollment - fiscal year 2001: 18,720.



State: District of Columbia; SCHIP program type: Medicaid expansion: X; 

SCHIP program type: Separate SCHIP: [Empty]; SCHIP program type: 

Combination: [Empty]; Maximum income eligibility by percent federal 

poverty level: 200; Enrollment - fiscal year 2001: 2,807.



State: Delaware; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 5,567.



State: Florida; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 200; 

Enrollment - fiscal year 2001: 298,705.



State: Georgia; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

235; Enrollment - fiscal year 2001: 182,762.



State: Hawaii; SCHIP program type: Medicaid expansion: X; SCHIP program 

type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 7,137.



State: Idaho; SCHIP program type: Medicaid expansion: X; SCHIP program 

type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

150; Enrollment - fiscal year 2001: 16,896.



State: Illinois; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 185; 

Enrollment - fiscal year 2001: 83,510.



State: Indiana; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 200; 

Enrollment - fiscal year 2001: 56,986.



State: Iowa; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 200; 

Enrollment - fiscal year 2001: 23,270.



State: Kansas; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 34,241.



State: Kentucky; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 200; 

Enrollment - fiscal year 2001: 66,796.



State: Louisiana; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

150; Enrollment - fiscal year 2001: 69,579.



State: Maine; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 200; 

Enrollment - fiscal year 2001: 27,003.



State: Maryland; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 300; 

Enrollment - fiscal year 2001: 109,983.



State: Massachusetts; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: [Empty]; SCHIP program type: 

Combination: X; Maximum income eligibility by percent federal poverty 

level: 200; Enrollment - fiscal year 2001: 105,072.



State: Michigan; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 200; 

Enrollment - fiscal year 2001: 76,181.



State: Minnesota; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

280; Enrollment - fiscal year 2001: 49[A].



State: Mississippi; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: [Empty]; SCHIP program type: 

Combination: X; Maximum income eligibility by percent federal poverty 

level: 200; Enrollment - fiscal year 2001: 52,436.



State: Missouri; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

300; Enrollment - fiscal year 2001: 106,594.



State: Montana; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

150; Enrollment - fiscal year 2001: 13,518.



State: Nebraska; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

185; Enrollment - fiscal year 2001: 13,933.



State: Nevada; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 28,026.



State: New Hampshire; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: [Empty]; SCHIP program type: 

Combination: X; Maximum income eligibility by percent federal poverty 

level: 300; Enrollment - fiscal year 2001: 5,982.



State: New Jersey; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: [Empty]; SCHIP program type: 

Combination: X; Maximum income eligibility by percent federal poverty 

level: 350; Enrollment - fiscal year 2001: 99,847.



State: New Mexico; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

235; Enrollment - fiscal year 2001: 10,347.



State: New York; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 250; 

Enrollment - fiscal year 2001: 872,949.



State: North Carolina; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 98,650.



State: North Dakota; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: [Empty]; SCHIP program type: 

Combination: X; Maximum income eligibility by percent federal poverty 

level: 140; Enrollment - fiscal year 2001: 3,404.



State: Ohio; SCHIP program type: Medicaid expansion: X; SCHIP program 

type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 158,265.



State: Oklahoma; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

185; Enrollment - fiscal year 2001: 38,858.



State: Oregon; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

170; Enrollment - fiscal year 2001: 41,468.



State: Pennsylvania; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 141,163.



State: Rhode Island; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

250; Enrollment - fiscal year 2001: 17,398.



State: South Carolina; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

150; Enrollment - fiscal year 2001: 66,183.



State: South Dakota; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: [Empty]; SCHIP program type: 

Combination: X; Maximum income eligibility by percent federal poverty 

level: 200; Enrollment - fiscal year 2001: 8,937.



State: Tennessee; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

100; Enrollment - fiscal year 2001: 8,615.



State: Texas; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

X; Maximum income eligibility by percent federal poverty level: 200; 

Enrollment - fiscal year 2001: 500,950.



State: Utah; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 34,655.



State: Vermont; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

300; Enrollment - fiscal year 2001: 2,996.



State: Virginia; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 73,102.



State: Washington; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

250; Enrollment - fiscal year 2001: 7,621.



State: West Virginia; SCHIP program type: Medicaid expansion: [Empty]; 

SCHIP program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

200; Enrollment - fiscal year 2001: 33,144.



State: Wisconsin; SCHIP program type: Medicaid expansion: X; SCHIP 

program type: Separate SCHIP: [Empty]; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

185; Enrollment - fiscal year 2001: 57,183.



State: Wyoming; SCHIP program type: Medicaid expansion: [Empty]; SCHIP 

program type: Separate SCHIP: X; SCHIP program type: Combination: 

[Empty]; Maximum income eligibility by percent federal poverty level: 

133; Enrollment - fiscal year 2001: 4,652.



State: Total; SCHIP program type: Medicaid expansion: 16; SCHIP program 

type: Separate SCHIP: 16; SCHIP program type: Combination: 19; Maximum 

income eligibility by percent federal poverty level: [Empty]; 

Enrollment - fiscal year 2001: 4,601,098.



[A] Minnesota’s SCHIP program covers children under age 2 who are in 

families with incomes that are from 275 to 280 percent of the federal 

poverty level. Minnesota has a state-funded insurance program that 

covers most non-Medicaid children in families with incomes up to 275 

percent of the federal poverty level.



Source: Centers for Medicare & Medicaid Services, The State Children’s 

Health Insurance Program Annual Enrollment Report: Federal Fiscal Year 

2001 (Baltimore, Md.: Feb. 6, 2002), p. 10, www.hcfa.gov/init/chip-

map.htm (downloaded on March 6, 2002). Since the CMS report did not 

have year-end data available for Idaho, we contacted the state SCHIP 

program. :



[End of section]



Appendix IV: Selected Individual Insurers’ Coverage for Specified 
Mental 

Health Coverage in Six States as of 2002:



The over 3 million children who are covered by an individual insurance 

plan may face limitations in mental health coverage, largely because 

federal and most state parity laws do not apply to health plans sold in 

this market. Unless precluded by state law, restrictions on mental 

health benefits in the individual market can include limitations on 

hospital days or outpatient office visits or higher out-of-pocket 

expenses. Figure 4 summarizes differences in individual market 

preferred provider organization (PPO) and health maintenance 

organization (HMO) health plan coverage for certain mental health 

treatments available to children in six states.



Figure 4: Selected Individual Insurers’ Coverage for Specified Mental 

Health Services Available to Children in Six States:



[See PDF for image]



[A] Under California’s parity law, limits do not apply to children with 

severe mental illnesses (SMI) or those diagnosed with a serious 

emotional disturbance (SED).



[B] Maximum of 20 total outpatient visits per year.



[C] Patient is responsible for additional cost-sharing after the 48th 

individual or family therapy visit each year. For group therapy, one 

visit is equal to half of an individual or family therapy visit, and 

enrollees are responsible for the full treatment cost after the 96th 

group therapy visit each year.



[D] Maximum of 30 outpatient visits per year with a maximum of 100 

visits per lifetime.



[E] Maximum of 15 outpatient visits per year.



[F] All mental health services are limited to a total benefit of $1,500 

per member per year.



[G] One family therapy session is equal to two outpatient visits.



[H] Maximum of 30 inpatient days per year.



[I] Maximum of 45 inpatient days per year. One residential treatment 

day is counted as one inpatient day.



[J] Patient is responsible for additional cost-sharing after the 30th 

inpatient day each year.



[K] Maximum of 10 inpatient days per year.



[L] Care received in a residential treatment center (a licensed 24-hour 

facility that offers mental health treatment).



[M] Room and board costs are not covered.



[N] One day of residential care is equal to two inpatient days.



Source: Individual insurers in each of the six states. We obtained this 

information from insurers from February through April 2002.



[End of figure]



[End of section]



Appendix V: Summary of Selected Laws Regarding Mental Health Coverage 
in 

Six States:



Many states have sought to equalize mental health and other benefits 

beyond the requirements of the federal Mental Health Parity Act of 1996 

(MHPA), which prohibited certain group health plans that are sponsored 

by employers with more than 50 employees and include mental health 

benefits from imposing annual or lifetime dollar limits on mental 

health benefits that are more restrictive than those imposed on other 

benefits. Laws in the six states we reviewed differed in the extent to 

which they addressed mental health coverage and limitations.



Three states we reviewed--California, Massachusetts, and Minnesota--

enacted laws that are more comprehensive than the federal parity law, 

requiring certain health plans to offer mental health benefits to 

certain populations with parity in service limits and cost-sharing. For 

example, California law requires all health plans to provide mental 

health coverage with the same restrictions and limits as other benefits 

to members with severe mental illnesses (SMI) and children with serious 

emotional disturbances (SED). (See table 14.) While states have primary 

responsibility for regulating the business of insurance, they are 

preempted by the Employee Retirement and Income Security Act of 1974 

(ERISA) from regulating employer-sponsored health plans. Therefore, 

state laws that have sought to equalize mental and other benefits 

beyond MHPA do not apply to self-funded employer-sponsored plans, 

through which close to 50 percent of employees with employer-sponsored 

coverage obtain health insurance.



Table 14: Summary of Parity Laws That Exceed Federal Standards in Three 

States:



Health plan applicability[D]; California[A]: Every health care service 

plan that provides hospital, medical, or surgical coverage; 

Massachusetts[B]: Any individual, group, and HMO plan; Minnesota[C]: 

All HMOs; all individual and group plans that provide mental health or 

chemical benefits.



Population covered; California[A]: All plan members with SMI and 

children with SED[E]; Massachusetts[B]: Plan members (1) with 

biologically based mental illness, (2) in need of rape-related 

services, and (3) who are children under 19 with certain non-

biologically based mental illnesses[ F]; Minnesota[C]: All enrolled 

individuals.



State law requires; California[A]: Mental health benefits must be 

provided and have the same limits and restrictions as physical 

benefits; Massachusetts[B]: No mental health service limitation can be 

less than those imposed for physical conditions[G]; Minnesota[C]: 

Mental health benefits must be provided and have the same limits as 

medical condition benefits.



[A] See California Health & Safety Code § 1374.72 (2002).



[B] See General Laws of Massachusetts, Chapter 175, Section 47B (2002).



[C] See Minnesota Statutes §§ 62Q.47(a); 62A.152; 62E.06 (2001).



[D] These state laws generally apply to group health plans that 

employers purchase for their employees but not to employers who self-

fund their plans, meaning they pay their employees’ health expenses 

directly.



[E] SMI is defined as (1) schizophrenia, (2) schizoaffective disorder, 

(3) bipolar disorder (manic-depressive illness), (4) major depressive 

disorders, (5) panic disorder, (6) obsessive-compulsive disorder, (7) 

pervasive developmental disorder or autism, (8) anorexia nervosa, and 

(9) bulimia nervosa. SED children are generally defined as having 

mental disorders identified in the most recent edition of the 

Diagnostic and Statistical Manual of Mental Disorders (DSM) that result 

in behavior inappropriate to their age. As a result of their mental 

disorders, SED children will also (1) have substantial impairment in at 

least two specified areas, such as self-care or family relationships, 

and one of the following must occur-child must be at risk of removal 

from the home or have already been removed or the child must have 

mental disorders and impairments present for more than 6 months; 

(2) display psychotic features or have risk of suicide or violence; or 

(3) meet special education eligibility requirements.



[F] Biologically based mental illnesses are defined as (1) 

schizophrenia, (2) schizoaffective disorder, 

(3) major depressive disorder, (4) bipolar disorder, (5) paranoia and 

other psychotic disorders, 

(6) obsessive-compulsive disorder, (7) panic disorder, (8) delirium and 

dementia, (9) affective disorders, and (10) any biologically based 

mental disorders appearing in the DSM that are scientifically 

recognized and approved by certain state officials. Rape-related 

services include the diagnosis and treatment of rape-related mental or 

emotional disorders for victims of a rape or an assault with intent to 

commit rape. Covered services for children under 19 include the 

diagnosis and treatment of non-biologically based mental, behavioral, 

or emotional disorders that substantially interfere with or 

substantially limit the functioning and social interactions of such 

child or adolescent, evidenced by 

(1) inability to attend school as a result of the disorder; (2) need to 

hospitalize as a result of the disorder; or (3) a pattern of conduct or 

behavior caused by the disorder that poses a serious danger to self or 

others.



[G] State law also mandates medically necessary minimum benefits of 60 

inpatient days and 24 outpatient visits for members over 19 with non-

biologically based mental disorders.



Source: Individual state laws.



[End of table]



Illinois’s mental health coverage laws do not apply to all health 

plans; further, Illinois’s laws allow health plans to limit the number 

of visits or days of mental health treatment for children and require 

parity only for serious mental illness.[Footnote 76] For example, 

Illinois law requires HMOs to offer mental health coverage with annual 

minimums of 10 inpatient days and 20 individual outpatient visits for 

each member. Similar requirements, however, do not exist for other 

types of health plans, such as PPOs. In addition, Illinois requires 

group health plans with more than 50 employees to provide coverage for 

serious mental illnesses under the same conditions as coverage for 

other illnesses. (See table 15.):



Table 15: Summary of Selected Laws Related to Mental Health Coverage in 

Illinois:



Population covered; All HMOs[A]: All enrolled individuals; Group health 

plans[B]: Members with serious mental illnesses[C].



State law requires; All HMOs[A]: Plans must offer an annual minimum of 

10 inpatient days and 20 individual outpatient visits of mental health 

coverage; Group health plans[B]: Mental health benefits must be under 

the same conditions as coverage for other illnesses with a minimum of 

45 inpatient days and 35 outpatient visits annually.



Note: These state laws generally apply to group health plans that 

employers purchase for their employees but not to employers who self-

fund their plans, meaning they pay their employees’ health expenses 

directly.



[A] See 50 Illinois Administrative Code § 5421.130 (2002).



[B] See 215 Illinois Compiled Statutes Annotated § 5/370c (2001).



[C] Serious mental illness means the following psychiatric illnesses as 

defined in the most current edition of the DSM published by the 

American Psychiatric Association: (1) schizophrenia; (2) paranoid and 

other psychotic disorders; (3) bipolar disorders (hypomanic, manic, 

depressive, and mixed); (4) major depressive disorders (single episode 

or recurrent); (5) schizoaffective disorders (bipolar or depressive); 

(6) pervasive developmental disorders; (7) obsessive-compulsive 

disorders; 

(8) depression in childhood and adolescence; and (9) panic disorder. 

See 215 Illinois Compiled Statutes Annotated § 5/370c (2001).



Source: Illinois state law.



[End of table]



The remaining two states--Georgia and Utah--address mental health 

coverage similarly. State laws in Georgia and Utah do not require 

health plans to include a minimum level of mental health coverage. 

Rather, both of these states require health plans to offer an 

additional plan that exclusively covers mental health services and can 

be purchased in addition to the standard health plan. For example, 

Georgia’s mandated offer requirement applies to individual, small 

group, and large group major medical health plans, and requires 

coverage for annual and lifetime dollar mental health benefits to be 

equal to or greater than coverage for physical illnesses.[Footnote 77] 

Utah’s law requires only that group health plans offer mental health 

coverage as an option.



[End of section]



Appendix VI: Selected Federal Grant Programs That May Be Used to Help 

Children Exposed to Trauma Obtain Mental Health Services:



Table 16 is a nonexhaustive list of federal grants that may be used to 

help children who were exposed to trauma obtain mental health services. 

The list includes 15 formula grants and 38 discretionary grants from 

seven departments and agencies.



Table 16: Selected Federal Grant Programs That May Be Used to Help 

Children Exposed to Trauma Obtain Mental Health Services:



[See PDF for image]



[A] All funding is amount appropriated unless otherwise noted.



[B] In this column, the term “state” includes the District of Columbia, 

the Commonwealth of Puerto Rico, the United States Virgin Islands, and 

generally any other territory or possession of the United States unless 

otherwise noted.



[C] Estimated fiscal year 2002 obligations.



[D] This program description includes Head Start and Early Head Start. 

Head Start and Early Head Start programs are for children from birth to 

the age when the child enters the school system, which will vary by 

child. Head Start and Early Head Start must serve children until 

kindergarten or first grade if kindergarten is not available in the 

child’s community.



[E] Community Health Centers, Health Center Grants for Homeless 

Populations, Health Centers Grants for Migrant and Seasonal 

Farmworkers, Health Centers Grants for Residents of Public Housing, and 

Healthy Schools, Healthy Communities are all part of HRSA’s 

Consolidated Health Centers Program. Under this program there have been 

periodic opportunities for existing grantees to compete for additional 

program funds to help them expand and enhance specific services, such 

as mental health/substance abuse services.



[F] This program is jointly administered with the Department of 

Transportation’s National Highway Traffic Safety Administration.



[G] Estimated fiscal year 2001 obligations.



[H] This program is not currently accepting new applications.



[I] The localities and nonprofit organizations/agencies that are 

designated to act on behalf of a larger coalition may apply. The 

coalition must consist of at least seven organizations or agencies.



[J] Fiscal year 2002 allocation.



[K] Victims must be determined to be eligible under the state victim 

compensation statute, which may declare that coverage extends generally 

to any crime resulting in injury, or may list all specific crimes that 

can be covered. :



[L] Fiscal year 2000 obligation.



[M] This grant was awarded to the Child Development-Community Policing 

Program at the Yale Child Study Center at the Yale University School of 

Medicine, in collaboration with the New Haven Department of Police 

Service, New Haven, Connecticut.



[N] Fiscal year 2002 obligation.



[O] Units of local or state governments and nonprofit agencies may 

apply for the grant on behalf of a collaboration of community groups.



[P] States designated as rural are Alaska, Arizona, Arkansas, Colorado, 

Idaho, Iowa, Kansas, Maine, Montana, Nebraska, Nevada, New Mexico, 

North Dakota, Oklahoma, Oregon, South Dakota, Utah, Vermont, and 

Wyoming.



[Q] This program is more commonly referred to as the “Greenbook 

Project,” and is a one-time demonstration initiative.



[R] Funds are not separately appropriated for this program, rather, 

they are allocated by the participating agencies from discretionary 

accounts.



[S] Fiscal year 2001 obligation.



[T] Estimated fiscal year 2002 obligation as of July 22, 2002.



[U] The departments participating in this initiative, which is 

administered by HHS’s Indian Health Service, have identified several 

grant programs that will be coordinating in this effort, including 

Justice’s Community-Oriented Policing Services Public Safety 

Partnership and Community Policing Grants, funded in cooperation with 

Education, and HHS’s American Indian and Alaskan Native Community 

Planning program. The initiative also involves Justice’s Tribal Youth 

Program, Mental Health Project and HHS’s Circles of Care Program, which 

are described in this table, respectively, under Justice’s Office of 

Justice Programs discretionary grants and HHS’s SAMHSA discretionary 

grants. 



Sources: Agency program officials, GAO analysis of agency grant 

documents, and the Catalog of Federal Domestic Assistance (Washington, 

D.C.: General Services Administration, 2002), http://www.cfda.gov, 

(downloaded at various times between September 2001 and August 2002).



[End of section]



Appendix VII: State Crime Victim Compensation Benefits, May 2002:



The federal Crime Victims Fund, administered by Justice’s Office for 

Victims of Crime, provides annual crime victim compensation grants to 

the states’ crime victim compensation programs. Federal victim 

compensation funds can help crime victims who file claims with state 

victim compensation agencies obtain reimbursement for mental health 

expenses, as well as lost wages, loss of support, and medical, dental, 

and funeral expenses. Federal law requires that states provide certain 

benefits, including mental health counseling benefits. However, states 

have discretion in setting program eligibility requirements and benefit 

amounts. According to the National Association of Crime Victim 

Compensation Boards, most states’ overall maximum benefit is linked to 

the individual crime rather than to individual primary victims, family 

members, or other persons affected by the crime. When there are 

multiple secondary victims of an individual crime, they typically must 

share the available maximum benefits. However, maximum mental health 

counseling benefits are typically linked to individual victims, with 

each family member or secondary victim typically eligible for mental 

health counseling benefits up to specified caps, unless otherwise 

stated. (See table 17.):



Table 17: Crime Victim Compensation Maximum Overall Benefits and 

Maximum Mental Health Benefits:



State: Alabama; Maximum overall per crime: $15,000; Maximum mental 

health counseling benefits per crime: Up to 50 outpatient treatment 

sessions in 2 years ($6,250 cap); $15,000 cap for inpatient treatment..



State: Alaska; Maximum overall per crime: $40,000; $80,000 in death 

cases with multiple victims; Maximum mental health counseling benefits 

per crime: $2,600 cap for primary victims; $600 cap for secondary 

victims; $1,200 cap for custodial parents of sexually abused victims.



State: Arizona; Maximum overall per crime: $20,000; Maximum mental 

health counseling benefits per crime: Up to 36 months.



State: Arkansas; Maximum overall per crime: $10,000; $25,000 for 

catastrophic injuries[A]; Maximum mental health counseling benefits per 

crime: $3,500 cap outpatient; $3,500 cap inpatient.



State: California; Maximum overall per crime: $70,000; Maximum mental 

health counseling benefits per crime: $10,000 cap for direct victims, 

family of homicide victims, custodial parents or primary caretakers of 

minor victims, and per relative in homicides; $3,000 cap for other 

secondary victims.



State: Colorado; Maximum overall per crime: $20,000 (each judicial 

district in the state may set lower maximum)[B]; Maximum mental health 

counseling benefits per crime: Determined by district compensation 

programs (each district can specify limits).



State: Connecticut; Maximum overall per crime: $15,000; $25,000 in 

homicides; Maximum mental health counseling benefits per crime: $15,000 

cap; $25,000 cap in homicides (up to six sessions for family of 

homicide victims without submitting application for compensation).



State: Delaware; Maximum overall per crime: $25,000; $50,000 for 

catastrophic injuries[A]; Maximum mental health counseling benefits per 

crime: $25,000 cap; $50,000 cap in catastrophic cases.



State: District of Columbia; Maximum overall per crime: $25,000; 

Maximum mental health counseling benefits per crime: $25,000 cap.



State: Florida; Maximum overall per crime: $25,000; $50,000 in 

catastrophic cases[A]; Maximum mental health counseling benefits per 

crime: $2,500 cap or up to 3 years for adults; $10,000 cap for minor 

victims; $2,500 cap for child witnesses.



State: Georgia; Maximum overall per crime: $25,000; Maximum mental 

health counseling benefits per crime: $3,000 cap.



State: Hawaii; Maximum overall per crime: $20,000; Maximum mental 

health counseling benefits per crime: $5,000 cap.



State: Idaho; Maximum overall per crime: $25,000; Maximum mental health 

counseling benefits per crime: $2,500 cap for direct victims; $500 cap 

per family member in homicide and sexual assault victims (maximum of 

$1,500 per family).



State: Illinois; Maximum overall per crime: $27,000; Maximum mental 

health counseling benefits per crime: $27,000 cap.



State: Indiana; Maximum overall per crime: $15,000; Maximum mental 

health counseling benefits per crime: $1,500 cap for direct victims if 

therapist charges sliding scale fees based on victims’ income and 

$1,000 cap if no sliding scale used; $1,000 cap per family member in 

homicide, sexual assault, and domestic violence cases.



State: Iowa; Maximum overall per crime: No overall limit; maximums for 

each expense category, e.g., $15,000 medical; Maximum mental health 

counseling benefits per crime: $3,000 cap for nonmedical therapy; 

therapy under psychiatrist’s supervision is considered under medical 

benefits category with $15,000 cap for primary victims and $3,000 limit 

for survivors of homicide victims; $1,000 cap per family member of non-

homicide victims.



State: Kansas; Maximum overall per crime: $25,000; Maximum mental 

health counseling benefits per crime: $3,500 cap; $1,000 cap per family 

member in homicides.



State: Kentucky; Maximum overall per crime: $25,000; Maximum mental 

health counseling benefits per crime: $25,000 cap.



State: Louisiana; Maximum overall per crime: $10,000; $25,000 when 

injuries result in total and permanent disability; Maximum mental 

health counseling benefits per crime: Up to 26 sessions or 6 months, 

whichever comes first, with $5,000 cap for direct victims, $2,000 cap 

for indirect victims.



State: Maine; Maximum overall per crime: $15,000; Maximum mental health 

counseling benefits per crime: $15,000 cap.



State: Maryland; Maximum overall per crime: $45,000; Maximum mental 

health counseling benefits per crime: $5,000 cap; $1,000 cap for each 

family member up to $5,000.



State: Massachusetts; Maximum overall per crime: $25,000; Maximum 

mental health counseling benefits per crime: $25,000 cap.



State: Michigan; Maximum overall per crime: $15,000; Maximum mental 

health counseling benefits per crime: Up to 26 sessions.



State: Minnesota; Maximum overall per crime: $50,000; Maximum mental 

health counseling benefits per crime: $7,500 cap for direct victims; up 

to 20 sessions for each secondary victim.



State: Mississippi; Maximum overall per crime: $15,000; Maximum mental 

health counseling benefits per crime: $3,000 cap.



State: Missouri; Maximum overall per crime: $25,000; Maximum mental 

health counseling benefits per crime: $2,500 cap.



State: Montana; Maximum overall per crime: $25,000; Maximum mental 

health counseling benefits per crime: $2,000 cap or 12 months with 

possibility of extension (based on review by a mental health 

professional working with the Crime Victims Unit Board of Control) for 

primary victims; for secondary victims, $2,000 cap or 12 months per 

person for spouse, parent, child, or sibling of a homicide victims and 

for the parent or sibling of a minor who is the victim of a sex crime.



State: Nebraska; Maximum overall per crime: $10,000; Maximum mental 

health counseling benefits per crime: $2,000 cap.



State: Nevada; Maximum overall per crime: $50,000; Maximum mental 

health counseling benefits per crime: $3,500 cap; additional $5,000 in 

extreme cases.



State: New Hampshire; Maximum overall per crime: $10,000 per primary 

victim and secondary victim for each victimization occurring on or 

after July 1, 1997; $5,000 otherwise; Maximum mental health counseling 

benefits per crime: $2,000 cap.



State: New Jersey; Maximum overall per crime: $25,000; $50,000 for 

catastrophic injuries[A]; Maximum mental health counseling benefits per 

crime: Up to 100 sessions or $10,000 cap, whichever is greater.



State: New Mexico; Maximum overall per crime: $20,000; $50,000 for 

catastrophic injuries[A]; Maximum mental health counseling benefits per 

crime: Up to 30 sessions; preauthorization required for additional 

sessions.



State: New York; Maximum overall per crime: No medical maximum; $30,000 

lost wages/support; Maximum mental health counseling benefits per 

crime: No categorical limit.



State: North Carolina; Maximum overall per crime: $30,000; $33,500 in 

homicides; Maximum mental health counseling benefits per crime: Up to 1 

year for adults; 2 years for children age 10 and under.



State: North Dakota; Maximum overall per crime: $25,000; Maximum mental 

health counseling benefits per crime: 80% of charges.



State: Ohio; Maximum overall per crime: $50,000 per victim per 

incident; Maximum mental health counseling benefits per crime: $50,000 

cap; $2,500 cap per immediate family member.



State: Oklahoma; Maximum overall per crime: $20,000; Maximum mental 

health counseling benefits per crime: $3,000 cap for primary victims 

may be waived in extreme cases. For families of homicide victims, $500 

cap per person and $3,000 cap per family. Complex or lengthy therapy is 

reviewed by panel composed of mental health professionals working with 

the Crime Victims Compensation Board..



State: Oregon; Maximum overall per crime: $44,000; Maximum mental 

health counseling benefits per crime: $20,000 cap for direct victims 

and family in homicides; $10,000 cap for children who witness domestic 

violence; limited family therapy in child sexual abuse cases.



State: Pennsylvania; Maximum overall per crime: $35,000; Maximum mental 

health counseling benefits per crime: $35,000 cap.



State: Puerto Rico; Maximum overall per crime: $3,000 per person; 

$5,000 per family; Maximum mental health counseling benefits per crime: 

$3,000 cap per person; $5,000 per family.



State: Rhode Island; Maximum overall per crime: $25,000; Maximum mental 

health counseling benefits per crime: $25,000 cap.



State: South Carolina; Maximum overall per crime: $15,000; $25,000 for 

catastrophic injuries per Crime Victims’ Advisory Board approval[A]; 

Maximum mental health counseling benefits per crime: Up to 180 days of 

treatment or 20 sessions, whichever is greater.



State: South Dakota; Maximum overall per crime: $15,000; Maximum mental 

health counseling benefits per crime: Up to 24 sessions for primary 

victims; 18 sessions for family members in homicides; 6 sessions for 

parents of juvenile victims and spouses of rape victims.



State: Tennessee; Maximum overall per crime: $30,000; Maximum mental 

health counseling benefits per crime: $30,000 cap.



State: Texas; Maximum overall per crime: $50,000; with additional 

$75,000 for catastrophic injuries[A]; Maximum mental health counseling 

benefits per crime: $3,000 cap; $400 per day, 30-day limit on inpatient 

psychiatric care.



State: Utah; Maximum overall per crime: $25,000; $50,000 medical in 

homicide, attempted homicide, aggravated assault, drunk driving; 

Maximum mental health counseling benefits per crime: $2,500 cap for 

primary victims; $1,000 cap for secondary victims (immediate family 

members, individuals residing in the household at the time of the 

crime, and other individuals essential to well-being and treatment of 

primary victims); may be extended after review by mental health 

professionals working with the Office of Crime Victim Reparations.



State: Vermont; Maximum overall per crime: $10,000; Maximum mental 

health counseling benefits per crime: Up to 20 sessions with treatment 

plan, may request extensions at 20-session increments for crime-related 

symptoms still needing treatment.



State: Virginia; Maximum overall per crime: $15,000; Maximum mental 

health counseling benefits per crime: $15,000 cap for direct victims; 

$2,500 cap for survivors of homicide victims.



State: Virgin Islands; Maximum overall per crime: $25,000; Maximum 

mental health counseling benefits per crime: Up to 10 sessions.



State: Washington; Maximum overall per crime: $150,000 for medical and 

mental health costs, which may be waived in special circumstances; 

$30,000 for nonmedical expenses; $40,000 for pension and death 

benefits, less other nonmedical expenses paid; Maximum mental health 

counseling benefits per crime: Up to 40 sessions for children; reports 

are required after 6 sessions and after 15 sessions; report to the 

state Crime Victim Compensation Program and preauthorization required 

for more sessions..



State: West Virginia; Maximum overall per crime: $25,000 in personal 

injury cases; $35,000 in homicides; Maximum mental health counseling 

benefits per crime: $25,000 cap for direct victims; $1,000 cap for 

secondary victims.



State: Wisconsin; Maximum overall per crime: $40,000; plus additional 

$2,000 for funeral expenses; Maximum mental health counseling benefits 

per crime: $40,000 cap.



State: Wyoming; Maximum overall per crime: $15,000; $25,000 for 

catastrophic injuries[A]; Maximum mental health counseling benefits per 

crime: $15,000 cap direct victims; $1,500 cap for associated victims.



[A] Each state uses its own definition of catastrophic injuries.



[B] In Colorado, each of the 22 judicial districts has a victim 

compensation program.



Source: National Association of Crime Victim Compensation Boards, 2002.



[End of section]



Appendix VIII: Comments from the Federal Emergency Management Agency:



Federal Emergency Management Agency Washington, D.C. 20472:



Ms. Janet Heinrich:



Director, Health Care --Public Health Issues General Accounting Office:



Washington, D. C. 20548:



Dear Ms. Heinrich:



Thank you for the opportunity to respond to your draft report entitled, 

MENTAL HEALTH SERVICES: Effectiveness ofInsurance Coverage and Federal 

Programs for Traumatized Children Largely Unknown (GAO-02-813).



Following a review of the report, we conclude that the report is 

generally correct in the description of services of the Federal 

Emergency Management Agency (FEMA) and the Crisis Counseling Assistance 

and Training Program. The FEMA Crisis Counseling Assistance and 

Training Program is conducted through a partnership of FEMA and the 

Center for Mental Health Services (CMHS) within the U.S. Department of 

Health and Human Services.



The GAO report accurately states that there has not been a 

comprehensive evaluation of the Crisis Counseling Assistance and 

Training Program since the program’s inception. This is factually 

correct; however, there are evaluation methods that have been and are 

currently being used to measure program effectiveness. The Crisis 

Counseling Assistance and Training Program has been piloting data 

collection procedures-which are currently being utilized by States (New 

Jersey, New York and Virginia) affected by September 1 1th-to develop a 

standardized toolkit. The data collection standardized toolkit will 

provide an evaluation component to enhance data collection services and 

help monitor the quality of services being offered. This service was 

initially developed by evaluation experts and program administrators 

and will continue to be provided as program guidance to future 

grantees.



We agree with the GAO report that evaluation is an important tool for 

program effectiveness. 1t is our intent to continue developing 

evaluation and implementation methods to ensure that the Crisis 

Counseling Assistance and Training Program is administered to the 

highest degree of effectiveness to disaster victims.



Thank you again for the chance to provide clarification on this issue. 

If you have any further questions, please feel free contact me at 202-

646-3692 or my staff at 202-646-3683.



Sincerely,



John R. D’Araujo, Jr. Assistant Director Response and Recovery 

Directorate:



Signed by John R. D’Araujo, Jr.:



[End of section]



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



DEPARTMENT OF HEALTH & HUMAN SERVICES:



Office of Inspector General:



Washington, D.C. 20201:



JUL 29 2002:



Ms. Janet Heinrich:



Director, Health Care - Public Health Issues United States General 
Accounting 

Office: 



Washington, D.C. 20548:



Dear Ms. Heinrich:



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

“Mental Health Services: Effectiveness of Insurance Coverage and 

Federal Programs for Traumatized Children Largely Unknown.” 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,



Janet Rehnquist Inspector General:



Signed by Michael Manzam for Janet Rehnquist:



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 U.S. 

General Accounting Office’s Draft Report, “Mental Health Services: 

Effectiveness of Insurance Coverage and Federal Programs for 

Traumatized Children Largely Unknown”:



General Comments:



The Department of Health and Human Services (HHS) appreciates the 

opportunity to comment on this draft report. Based on our review, the 

GAO Report on Child Trauma Emergency Services and Insurance will be a 

useful tool for policy makers and brings important attention to the 

needs of children exposed to traumatic events. The report includes 

extensive information describing services provided through the Crisis 

Counseling Assistance and Training Program, which is conducted through 

a partnership of the Federal Emergency Management Agency (FEMA) and the 

Center for Mental Health Services (CMHS), which is a subcomponent of 

the Substance Abuse and Mental Health Services Administration (SAMHSA) 

within HHS.



The report is generally accurate in its description of the structure 

and operations of the Crisis Counseling Program and in its description 

of the services provided through the program. The report accurately 

notes that a program-wide evaluation has not been conducted for the 

Crisis Counseling Program and asserts that evaluation activities are 

critical for this program and for other child trauma programs. However, 

HHS would like to provide additional information regarding evaluation 

activities that have been conducted in the program and are planned for 

the future.



The HHS strongly agrees that evaluation activities are critical to 

ensure program effectiveness and appropriate use of resources, and have 

instituted a number of evaluations in recent years. Based on input from 

evaluation experts and program administrators, SAMHSA/CMHS recently 

developed new guidance for grantees regarding recommended evaluation 

activities for grantees.



After significant review, new evaluation guidance materials were 

developed and released in September of 2001, shortly before the 

September 11 terrorist attacks. These materials have been used by 

grantees in New York, New Jersey, and Virginia, to develop data 

collection and evaluation plans. Data collected through these 

evaluation activities are being used for ongoing quality assurance 

purposes and we expect that the evaluation activities conducted by 

these grantees will provide important information for future programs.



Based on the data collection approaches and evaluation activities being 

conducted through these programs, the Crisis Counseling Program is 

currently developing a standardized data toolkit, which will result in 

additional cross-site evaluation and improved monitoring of services. 

Improved data collection processes will be critical in conducting high 

quality evaluation activities in the future.



In addition, CMHS, through an interagency agreement with the National 

Center for Post Traumatic Stress Disorder (NCPTSD) within the U.S. 

Department of Veterans Affairs, has requested additional guidance from 

leading researchers in the field of disaster mental health regarding 

needs assessment and program-wide evaluation approaches that can be 

implemented in the program. Among the activities to be conducted in the 

upcoming year in this interagency agreement, NCPTSD staff will be 
conducting 

“case studies” of current and past programs. The Department has also 
asked 

NCPTSD to consult with research experts and recommend additional 

evaluation activities in the Crisis Counseling Program. We plan to 

continue ongoing evaluation planning and implementation to assure that 

services are appropriate, efficient, and responsive to the needs of 

disaster victims and appreciate the attention the GAO has brought to 

this issue.



Several places in the report emphasize the lack of data on the 

prevalence of mental health needs and services for child trauma 

victims/survivors. It should be noted that several components of the 

National Institutes of Health (NIH) as well as other HHS agencies have 

significant research programs in this area. For example, the NIH Child 

Abuse and Neglect Working Group coordinates NIH and other agency 

research on victims of child abuse and neglect. The National Institute 

of Mental Health (NIMH) Traumatic Stress Research Program supports 

research, including post 9/11/01 studies, on the prevalence of child 

trauma exposure, how such experiences increase risk for adverse mental 

health outcomes, and interventions to prevent mental disorders. 

Additionally, NIMH supports nationally representative surveys, some 

down to age 13, on the prevalence of mental disorders, adverse life 

events/trauma, service need and use, medication use, functional 

impairments and disability. Some of these efforts were in the field 

prior to September 2001 and are therefore able to address pre-post 9-

11-01 trauma exposure. Collectively, these programs are helping us to 

better understand the needs of traumatized children and effective 

methods for organizing and delivering care. Moreover, building on 

significant advances in biological and behavioral research, and with a 

significant scientific push, these programs have the potential to 

rapidly advance our understanding of and interventions to reduce 

trauma-related mental health disorders, including posttraumatic stress 

disorder.



In addition, SAMHSA agrees with NIH that this report assumes that well-

trained mental health providers capable of delivering these services to 

a child population are available. In reality, a child mental health 

workforce with the capacity to meet the mental health needs of the 

children and adolescents in this country does not exist. Responding to 

post traumatic stress in children requires even more specialized 

training. Unless this gap is addressed, the knowledge that we have 

already acquired related to the delivery of effective mental health 

services will not be implemented, and services will not be available to 

those who need them most, the nation’s children. The gap between what 

we know works in mental health treatment and what services are actually 

delivered was clearly documented in Mental Health: A Report of the 

Surgeon General in 1999 and further elaborated upon in a Report of the 

Surgeon General’s Conference on Children’s Mental Health: A National 

Action Agenda in 2000. Both of these reports recognized the need for 

public education to reduce stigma and for training of frontline 

providers to recognize and manage mental healthcare issues, as well as 

the need to educate mental health providers about scientifically-proven 

prevention and treatment services.



It is vitally important for us as a nation to be able to provide 

quality mental health care to every child who may need such care in our 

communities. The report should emphasize that this requires that 

adequately trained mental health practitioners, including 

psychiatrists, clinical psychologists, psychiatric social workers, 

nurses and other relevant professionals, are in fact available and 

accessible to those who need them. Providing good care also assumes 

the availability of in-patient and out-patient facilities in the 
community, 

along with a range of effective diagnostic and treatment tools and 

procedures.Moreover, it also assumes that non-psychiatric physicians 

(general practitioners, internists, pediatricians and others) in the 

community are all sufficiently informed about trauma-related 

psychiatric disorders and able to diagnose and treat these conditions, 

or to refer these patients to knowledgeable specialists who can provide 

appropriate treatment.



The report should note that even if sufficient human and material 

resources are made available for the mental health services needed, 

there remain some fundamental questions concerning the effectiveness of 

some present-day approaches to the treatment and prevention of such 

highly misunderstood and stigmatized illnesses as depression, panic and 

anxiety disorders, posttraumatic stress and conduct disorders. This is 

due to the simple fact that at the present stage of the scientific 

development in this field, our knowledge of the neurobiological nature, 

cause, pathogenesis and treatment of many of these conditions is 

extremely limited. We currently know how to manage and ameliorate some 

of these problems but the fundamental knowledge needed to cure or 

prevent them is simply not available to us at the present time. Several 

reasons include:



1) In the past we have not recognized the full magnitude of the social, 

economic and health burdens of mental disorders in comparison with 

other diseases and adverse events which threaten human life or diminish 

its quality.



2) Another issue is the need to increase the understanding of the 

etiology and pathogenesis of specific mental disorders and to increase 

the availability of effective treatments for them. Therefore, two 

specific goals must be addressed in this area: a) to increase our 

knowledge through comprehensive programs of empirical research that 

target the genetic and other biochemical, psycho-social and 

environmental causes of brain-behavior disorders and b) to develop 

additional new, effective methods of treatment and prevention to reduce 

or eliminate the suffering and disabilities of our patients and their 

families and to reduce the profound social and economic costs of mental 

illness to society.



3) A third fundamental problem is the general public’s misconception 

about causes of mental disorders and the prejudice, shame and stigma 

that seem universally associated with them. The education of the public 

with regard to the biological and behavioral bases of mental disorders 

will go a long way toward removing stigma and prejudice and 

facilitating a more realistic and appropriate response to individuals 

with mental illness in the community, a response similar to that 

afforded to persons with, for example, arthritis, diabetes or heart 

disease.



The GAO’s draft report should include a more thorough discussion of the 

Health Resources and Services Administration’s (HRSA) funding of 

programs to meet the mental health needs of uninsured and underserved 

children. Specifically, on page four of the report, the section on 

other Federally supported mental health services should include HRSA’s 

Consolidated Health Center program. In FY 2001, under this program, 

health centers (Community Health Centers, Migrant Health Centers, 

Health Care for the Homeless programs, Public Housing Health Centers 

and School-based Health Centers) provided primary health care services, 

including mental health services, to nearly four million children. 

Among these health center users, visits for mental health services were 

one of the most frequently reported encounters.



HRSA’s Bureau of Primary Health Care (BPHC), which administers the 

Comprehensive Community Health Center Program, has initiated the 

“Mental Health/Substance Abuse Service Expansion Grant program.” The 

purpose of this grant program is to fund on-site primary mental health 

and substance abuse service delivery within federally-funded Community 

Health Centers in order to 1) improve patient access to these services 

on-site, and; 2) to reduce health disparities among the poor and 

uninsured populations seen in health centers and the U.S. population in 

general. Through a competitive grant process the BPHC “Mental Health/

Substance Abuse Service Expansion Grant” program provides annual 

funding of $100,000 to federally-funded community health centers to 

provide on-site primary mental health/substance abuse services. Over 

the past 4 years, nearly 237 health centers have been funded to provide 

expanded primary mental health/substance abuse services to health 

center patients. These funds are used to hire mental health and/or 

substance abuse providers to practice as a member of the health 

center’s primary care team, and to deliver their services in 

collaboration with the primary medical providers within the community 

health center’s primary care clinics. This funding offers health 

centers the opportunity to begin to serve their patients’ mental health 

needs within the privacy and confidentiality of the primary care clinic 

setting, thereby increasing patient access to mental health services 

and improving the health outcomes of patients with a history of trauma 

and other mental health problems.



While the GAO’s draft report states that most insurance plans place 

limits on mental health coverage (including very limited coverage on 

the types of mental health services, the number of visits, the number 

of days of hospitalization, and the type of mental health provider), 

GAO does not portray the very limited access that even insured children 

have to mental health services. For example, GAO’s draft report does 

not discuss the ramifications of discontinuous coverage of children 

under Medicaid and the State Children’s Health Insurance Program, and 

does not address the ramifications of other complex issues such as 

‘mental health parity.’:



The GAO report should contain a discussion of problems within the 

public mental health system. This system, funded in part by the 

SAMHSA’s Mental Health Block Grant, serves Medicaid and uninsured 

populations, and focuses their service delivery on the seriously 

mentally ill only. But access to mental health services within this 

State-based system has been deteriorating nationwide for many years. 

Without adequate funding, State public mental health systems have been 

unable to hire enough providers and have been unable to support the 

requests for services that are being made by the populations they are 

supposed to serve. As this system has deteriorated, access to mental 

health services by uninsured populations has disappeared.



The GAO draft report does not reference research highlighting problems 

of underserved populations in accessing mental health for children, 

i.e., according to the Rand Research Brief 2001, “the majority of 

troubled youth do not get the mental health services they need.”



The GAO’s draft report should include a discussion of stigma as an 

important reason why families do not access mental health services for 

traumatized children. The fact that most pediatric and primary care 

service providers offer little if any direct access to mental health 

screening and service delivery should also be discussed. In general, 

parents must request these services. But to actually obtain mental 

health services, the child must be referred to a separate mental health 

provider, usually at another physical location, often at some distance 

from their pediatric or primary care provider. This is a significant 

barrier to many families seeking mental health care for their children.



Furthermore, it should mention the influences of familial ethnicity and 

cultural background on attitudes of mental disorders and the use of 

mental health services. Frequently, other family members’ symptoms of 

trauma may interfere with their ability to obtain help for their 

children. This is especially important, as it has been found that the 

family support environment has a critical influence on recovery.



Primary care clinicians could serve as an important portal of entry to 

specialty mental health services for traumatized children. The large 

majority of children do visit primary care providers at least once a 

year. In addition, primary care providers are an important part of 

family’s support systems. Graduate medical education programs should 

ensure that primary care clinicians receive education and training on 

identifying, treating as appropriate, and working with mental health 

specialists to better help children with mental health problems and 

their families. Furthermore, GAO should cite the influences of familial 

ethnicity and cultural background on attitudes of mental disorders and 

the use of mental health services.



Certain populations of youth are at risk for acquiring HIV and AIDS as 

a result of sexual exploitation. Many of these children face life long 

disability due to physical and emotional abuse. Some consideration 

should be given within the report to this largely unknown population of 

children. Approximately 16 percent of new HIV infections worldwide in 

2001 occurred among children less than 15 years of age (UNAIDS, AIDS 

Epidemic Update, December 2001). Although virtually all the pediatric 

AIDS in this country is a result of perinatal transmission, it is 

necessary to consider the global epidemic when reviewing service needs 

within the U.S.



The inadequate availability of mental health personnel for services to 

children in trauma may be successfully ameliorated through the use of 

telehealth mental health services. However, funding problems limit the 

use of such services. 1t may be advantageous for GAO’s report to 

suggest that the States look more closely at such an approach.



[End of figure]



[End of section]



Appendix X: Comments from the Department of Education:



UNITED STATES DEPARTMENT OF EDUCATION:



OFFICE OF ELEMENTARY AND SECONDARY EDUCATION:



THE ASSISTANT SECRETARY:



JUL 26 2002:



Ms. Janet Heinrich, Director Health Care, Public Health Issues United 

States General Accounting Office Washington, DC 20548:



Dear Ms Heinrich:



Thank you for providing an opportunity for us to review your draft 

report, Mental Health Services: Effectiveness of lnsurance Coverage and 

Federal Programs for Traumatized Children Largely Unknown.



Generally, we believe that the information that you have included in 

the report concerning activities administered by the US Department of 

Education accurately describes those programs and initiatives. We have 

included information about recommended minor technical revisions as an 

enclosure to this letter.



While the report provides a thorough discussion of the various Federal 

programs that may address the needs of traumatized children, I believe 

that the report would be strengthened by including some discussion that 

addresses the issue or whether or not the pool of qualified mental 

health service providers trained to deal with the needs of children, 

and more particularly children experiencing trauma, is sufficient. We 

have worked closely with several school districts that have been the 

site of school shootings or other traumatic events, and this issue has 

emerged repeatedly.



Again, thank you for providing a copy of this draft report for our 

review.



Sincerely,



Susan B. Neuman:



Signed by Susan B. Neuman:



Enclosure:



600 INDFPENDENCE AVE.. S.W. WASHINGTON, D.C.20202-6100 Our mission is 

to ensure equal access to education and to promote educational 

excellence throughout the Nation.



[End of section]



Appendix XI: GAO Contact and Staff Acknowledgments:



GAO Contact:



Helene F. Toiv, (202) 512-7162:



Staff Acknowledgments:



In addition to the person named above, key contributors to this report 

were Susan Anthony, Alice L. London, Janina Austin, Sari Bloom, Emily 

Gamble Gardiner, William D. Hadley, Christi Turner, and Behn Miller.



[End of section]



Related GAO Products:



Private Health Insurance: Access to Individual Market Coverage May Be 

Restricted for Applicants with Mental Disorders. GAO-02-339. 

Washington, D.C.: February 28, 2002.



Bioterrorism: Public Health and Medical Preparedness. GAO-01-915. 

Washington, D.C.: September 28, 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.



Health and Human Services: Status of Achieving Key Outcomes and 

Addressing Major Management Challenges. GAO-01-748. Washington, D.C.: 

June 15, 2001.



Major Management Challenges and Program Risks: Department of Health and 

Human Services. GAO-01-247. Washington, D.C.: January 1, 2001.



Mental Health Parity Act: Despite New Federal Standards, Mental Health 

Benefits Remain Limited. T-HEHS-00-113. Washington, D.C.: May 18, 2000.



FOOTNOTES:



[1] In this report the term children encompasses both younger children 

and adolescents.



[2] Phillip Kaufman et al., Indicators of School Crime and Safety: 2001 

(Washington, D.C.: U.S. Departments of Education and Justice, 2001).



[3] See, for example, Joy Osofsky, The Impact of Violence on Children 

(Los Altos, Calif.: The David and Lucile Packard Foundation, Winter 

1999).



[4] See, for example, Betty Pfefferbaum, “Posttraumatic Stress 

Disorder,” Child and Adolescent Psychiatry, 3RD ed. (forthcoming).



[5] Applied Research and Consulting, Columbia University Mailman School 

of Public Health, and the New York State Psychiatric Institute, Effects 

of the World Trade Center Attack on NYC Public School Students: Initial 

Report to the New York City Board of Education, for the New York City 

Board of Education (New York, N.Y.: May 2002).



[6] HHS, SAMHSA, Center for Mental Health Services, Mental Health: A 

Report of the Surgeon General (Rockville, Md.: 1999); HHS, Report of 

the Surgeon General’s Conference on Children’s Mental Health: A 

National Action Agenda (Washington, D.C.: 2000); HHS, SAMHSA, Center 

for Mental Health Services, Mental Health: Culture, Race, and 

Ethnicity--A Supplement to Mental Health: A Report of the Surgeon 

General (Rockville, Md.: 2001).



[7] HHS, Public Health Service, Office of the Surgeon General, The 

Integration of Mental Health Services and Primary Health Care: Report 

of a Surgeon General’s working meeting on the integration of mental 

health services and primary health care, November 30-December 1, 2000, 

Atlanta, Georgia (Rockville, Md.: 2001).



[8] Institute of Medicine, Confronting Chronic Neglect: The Education 

and Training of Health Professionals on Family Violence (Washington, 

D.C.: 2001).



[9] See, for example, Steve Marans and Miriam Berkman, Community 

Development--Community Policing: Partnership in a Climate of Violence 

(Washington, D.C.: Department of Justice, Mar. 1997).



[10] See, for example, Bradley Stein et al., “Violence Exposure Among 

School-Age Children in Foster Care: Relationship to Distress Symptoms,” 

Journal of the American Academy of Child and Adolescent Psychiatry, 

vol. 40, no. 5 (2001).



[11] 29 U.S.C. § 1185a (2000). However, MHPA does not require these 

group health plans to offer mental health benefits.



[12] The Employee Retirement Income Security Act of 1974 (ERISA) 

generally preempts states from regulating employee health plans, 

although state governments maintain the ability to regulate health 

insurance sold in their states. 29 U.S.C. § 1144 (2000).



[13] In 2002, the federal poverty level was $18,100 for a family of 

four. Medicaid eligibility is mandatory for all children born after 

September 30, 1983 whose family incomes are less than or equal to the 

federal poverty level. By September 2002, mandatory Medicaid 

eligibility will apply to all children (under age 19) who meet the 

income requirements. 

See 42 U.S.C. § 1396a(a)(10)(A)(i)(VII), (l)(1)(D) and (l)(2)(C).



[14] 42 U.S.C § 1396(r)(5).



[15] See 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).



[16] For example, see Bazelon Center for Mental Health Law, Recovery in 

the Community: Funding Mental Health Approaches for Rehabilitative 

Approaches Under Medicaid (Washington, D.C.: Nov. 2001) and Commerce 

Clearing House Incorporated, Medicaid and Medicare Guide Volume 4, 

Medicaid State Plans, Medicare and Medicaid Laws (Chicago, Ill.: Nov. 

1996). However, these sources do not fully capture the extent to which 

states cover mental health services for children. Since states report 

their provision of mental health services to CMS differently, summary 

information of state coverage of these services is difficult to 

compile. For example, a state may report these services as 

psychological services, rehabilitation services, clinical services, or 

as part of its managed care program.



[17] The Balanced Budget Act of 1997 (Pub. L. No. 105-33) established 

SCHIP as Title XXI of the Social Security Act. SCHIP is set out at 42 

U.S.C. § 1397aa et seq.



[18] U.S. General Accounting Office, Mental Health Parity Act: Despite 

New Federal Standards, Mental Health Benefits Remain Limited, GAO/HEHS-

00-95 (Washington, D.C.: May 10, 2000).



[19] Mercer/Foster Higgins, National Survey of Employer-Sponsored 

Health Plans 2001: Report on Survey Findings (New York, N.Y.: 2002). 

The Mercer/Foster Higgins survey is representative of all employers in 

the United States with at least 10 employees, and results are often 

reported separately for employers with 500 or more employees.



[20] Another employer benefit survey by the Kaiser Family Foundation 

and Health Research and Educational Trust, Employer Health Benefits 

2001 Annual Survey, (Menlo Park, Calif. and Chicago, Ill.: 2001), found 

similar benefit limits among workers enrolled in employer-sponsored 

health plans it surveyed. Nearly half of employees enrolled in surveyed 

health plans were limited to mental health services of 30 or fewer 

inpatient days or outpatient visits. Eighty-seven percent lacked 

coverage for unlimited, annual outpatient mental health visits, while 

84 percent lacked coverage for unlimited inpatient days for mental 

health treatment.



[21] See, U.S. General Accounting Office, Private Health Insurance: 

Access to Individual Market Coverage May Be Restricted for Applicants 

with Mental Disorders, GAO-02-339 (Washington, D.C.: Feb. 28, 2002). 

Some states do not allow insurers in the individual market to deny 

coverage to applicants. We reported that 11 states required individual 

market carriers to guarantee applicants access to health insurance 

coverage, and certain carriers guaranteed access voluntarily in an 

additional 5 states and the District of Columbia. In the remaining 34 

states, carriers may deny coverage to high-risk individuals. However, 

27 of these 34 states have high-risk pools, which are typically state-

created, not-for-profit associations that offer comprehensive health 

insurance benefits to high-risk individuals and families who have been 

or would likely be denied coverage. High-risk pool coverage typically 

costs 125 to 200 percent of standard rates for healthy individuals.



[22] In May 2000, we reported that 43 states and the District of 

Columbia had laws that addressed mental health coverage in employer-

sponsored group plans; 29 were more comprehensive than the federal law, 

requiring parity not only in dollar limits but also in service limits 

or cost-sharing provisions. Ten states required that mental health 

benefits be on par with other benefits for all coverage sold in the 

individual market. See U.S. General Accounting Office, Mental Health 

Parity Act: Despite New Federal Standards, Mental Health Benefits 

Remain Limited, GAO/HEHS-00-95 (Washington, D.C.: May 10, 2000).



[23] A residential treatment center is a licensed 24-hour facility that 

offers mental health treatment.



[24] Under section 1915 (c) of the Social Security Act, 42 U.S.C. 

§1396n(1) (2000), states may request waivers of certain federal 

requirements in order to develop Medicaid-financed, community-based 

services, including respite care.



[25] Minnesota has a waiver that provides coverage for home and 

community-based services, including respite care for some persons with 

disabilities. However, according to a CMS official, only a small group 

of children--those with mental illness who are at risk of being placed 

in a nursing facility--are eligible for these waiver services. Although 

the Medicaid programs in the remaining five states we reviewed do not 

explicitly cover respite care, providers in these states may rely on 

other sources of funding to provide these services to Medicaid 

enrollees. For example, according to a Utah official, the state 

provides community mental health centers with funds specifically 

earmarked for respite services.



[26] See, American Academy of Pediatrics, Division of Health Policy 

Research, Department of Practice and Research, Medicaid Reimbursement 

Survey, 2001-50 States and the District of Columbia (Elk Grove Village, 

Ill.: 2001), and the Lewin Group, Comparing Physician and Dentist Fees 

Among Medicaid Programs, June 2001, a special report prepared at the 

request of the Medi-Cal Policy Institute (Oakland, Calif.: 2001).



[27] These rates do not apply to mental health services provided 

through capitated, managed care plans. To varying degrees, four of the 

six states we reviewed--California, Massachusetts, Minnesota, and Utah-

-provide mental health services to Medicaid or SCHIP children through a 

managed care plan that is prospectively paid a capitated per-member 

per-month rate or through other risk arrangements.



[28] The maximum annual copayment for outpatient or inpatient mental 

health visits in Illinois is $100 per family.



[29] California’s SCHIP program has two components: a separate, stand-

alone child health program that functions independently of the state 

Medicaid program and an expansion of the state Medicaid program. 

According to data provided by the state, most California SCHIP 

children--over 506,000 in January 2002---were enrolled in the separate, 

stand-alone component of the program, while about 33,000 children were 

enrolled in the Medicaid expansion component in June 2001.



[30] SCHIP children in California diagnosed with severe emotional 

disturbance are eligible for these services through the county mental 

health departments.



[31] A Utah state official said that by creating a separate SCHIP plan 

with certain benefit limitations (rather than expanding the state 

Medicaid program), the state was able to offer SCHIP coverage to 

significantly more children.



[32] California law defines severe mental illness as (1) schizophrenia, 

(2) schizoaffective disorder, (3) bipolar disorder (manic-depressive 

illness), (4) major depressive disorders, 

(5) panic disorder, (6) obsessive-compulsive disorder, (7) pervasive 

developmental disorder or autism, (8) anorexia nervosa, or (9) bulimia 

nervosa.



[33] The annual copayment amount in California is limited to a maximum 

of $250 per family for each benefit year. Copayments are not required 

for services provided to SED children at county mental health centers.



[34] Annual copayment amounts in Utah are limited to a maximum of $500 

for families with incomes from 100 to 150 percent of the federal 

poverty level and $800 for families with incomes from 151 to 200 

percent of the federal poverty level.



[35] For additional information, see 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).



[36] See Emily Q. v. Belshe, No. CV-98-4181-WDK, C.D., Cal., May 5, 

1999 (court held that therapeutic behavioral services were required to 

be provided under EPSDT); French v. Concannon, No. 97-CV-24-B-C, D. 

Me., July 16, 1998 (in response to lawsuit challenging state’s failure 

to provide notice of mental health services availability, state agreed 

to modify its EPSDT materials to include specific information about 

mental health screening and treatment).



[37] See Sanders v. Lewis, No. 2:92-0353, S.D.W.Va., March 1, 1995.



[38] In states that provided mental health services to Medicaid or 

SCHIP children through both prepaid managed care plans and traditional 

fee-for-service arrangements, utilization data provided were the most 

recent available (all were from state fiscal years 2000 or 2001) and 

were for the delivery system that covered the majority of children. For 

Illinois and Minnesota, the data included children in both Medicaid and 

SCHIP. Medicaid utilization rates in California and Utah were 

approximately 5 percent. Utilization data were not available from 

Georgia.



[39] In Massachusetts, at least 85 percent of children in the Medicaid 

and SCHIP programs are covered through a managed care program. 

Utilization data provided were from fiscal year 2001.



[40] The California Medicaid program covers mental health services 

provided to enrollees in residential care facilities but not the cost 

of room and board.



[41] The goals of crisis counseling include helping disaster survivors 

understand their current situation and reactions, mitigating additional 

stress, developing coping strategies, providing emotional support, and 

encouraging links with other individuals and agencies who can help 

survivors return to their predisaster level of functioning. Services 

may be provided by mental health professionals and trained 

paraprofessionals.



[42] States and tribes must demonstrate that existing state and local 

resources are inadequate to provide for these services. Individuals are 

eligible to obtain crisis counseling services if they were residents of 

the designated disaster area or were located in the area at the time of 

the disaster and are experiencing mental health problems caused or 

aggravated by the disaster.



[43] FEMA crisis counseling grant funds cannot be used to provide 

treatment for substance abuse, mental illnesses, developmental 

disabilities, or any preexisting mental health conditions.



[44] In addition, at the request of New York and Virginia, a portion of 

their crisis counseling grant funds was provided by FEMA directly to 

Connecticut, the District of Columbia, Massachusetts, New Jersey, and 

Pennsylvania.



[45] The fiscal year 2002 Defense Emergency Supplemental Appropriations 

Act provided funds to Justice for these additional crisis counseling 

grants.



[46] Most extensions have been primarily for administrative purposes 

and have generally been for periods of 3 months or less.



[47] Project SERV awards in fiscal year 2001 ranged from $50,000 to 

$4,225,000.



[48] By statute, Project SERV funds may not be used for medical 

services or drug treatment or rehabilitation, except for pupil services 

or referral to treatment for students who are victims of, or witnesses 

to, crime. 20 U.S.C. § 7164(2). Pupil services are provided by school 

counselors, school social workers, school psychologists, and other 

qualified professional personnel involved in providing assessment, 

diagnosis, counseling, educational, therapeutic, and other necessary 

services (including certain services defined in section 602 of the 

Individuals with Disabilities Education Act). 20 U.S.C. § 7801(36)(B). 

Education officials report that services have included individual, 

group, and family counseling.



[49] The Congress has placed a cap on the amount of money in the Crime 

Victims Fund available to OVC for funding crime victim-related programs 

and activities. In fiscal year 2001, $537.5 million of the 

approximately $776.5 million in the Crime Victims Fund was made 

available to OVC for allocation. In addition to funding its two formula 

grant programs, OVC is authorized to use the Crime Victims Fund 

allocation to fund other victim-related activities, such as providing 

grants to help Indian tribes improve the handling of child abuse cases, 

funding projects to identify ways for improving the delivery of victim 

services, and supporting a special compensation program for child and 

adult victims of international terrorism, as required by the Victims of 

Trafficking and Violence Prevention Act of 2000. OVC is authorized to 

set aside up to $50 million from Crime Victims Fund allocations for an 

emergency reserve fund to assist victims of terrorism or mass violence 

and fund the International Terrorism Victim Compensation Program.



[50] OVC provides federal Victim Compensation grants and Victim 

Assistance grants to all 50 states, the District of Columbia, Puerto 

Rico, the U.S. Virgin Islands, and Guam. OVC also provides Victim 

Assistance grants to American Samoa and the Northern Mariana Islands.



[51] Survivors of homicide victims are also eligible for state victim 

compensation.



[52] VOCA requires states, at a minimum, to award compensation for 

victims’ medical and dental costs, mental health counseling and care, 

lost wages, and funeral expenses. VOCA compensation program guidelines 

give states flexibility to offer compensation for other crime-related 

expenses, such as for crime scene cleanup, forensic sexual assault 

examinations, and loss of support, to the extent authorized by state 

statute or policy.



[53] In addition, in fiscal year 2001, OVC used its emergency reserve 

fund to allocate $16.6 million in supplemental victim compensation 

grants and victim assistance grants to New York, Pennsylvania, and 

Virginia to assist children and adults affected by the September 11, 

2001, terrorist attacks.



[54] Claims for child victims can be filed on their behalf by their 

parents or other guardians; children can also file on their own behalf 

when they reach the age of 18.



[55] Although providing victim compensation to children who witness 

violence is not specifically required by VOCA, the National Association 

of Crime Victim Compensation Boards told us that most states consider 

children who have witnessed violence to be victims of a crime and thus 

potentially eligible for victim compensation.



[56] OVC could not provide separate reimbursement data for children and 

adults. We were able to obtain selected data on some children’s 

services in some states.



[57] In California, family members of homicide victims and custodial 

parents or primary caretakers of child victims are also subject to the 

$10,000 cap. However, other victims have a $3,000 cap for mental health 

benefits. In Minnesota, each secondary victim can obtain reimbursement 

for up to 20 counseling sessions.



[58] State victim assistance agencies provide grants to such entities 

as mental health agencies; domestic violence shelters; rape crisis 

centers; child abuse programs; and victim service units in law 

enforcement agencies, prosecutors’ offices, hospitals, and social 

service agencies.



[59] Data were not available on the number of children who received 

mental health services.



[60] Separate analyses were not done on children and adult crime 

victims.



[61] Urban Institute, The National Evaluation of State Victims of Crime 

Act Compensation and Assistance Programs: Findings and Recommendations 

from a National Survey of State Administrators, for the Department of 

Justice, National Institute of Justice (Washington, D.C.: Mar. 2001).



[62] Department of Justice, OVC, New Directions from the Field: 

Victims’ Rights and Services for the 21st Century (Washington, D.C.: 

May 1998).



[63] See, for example, Jeffrey L. Edelson, The Overlap Between Child 

Maltreatment and Woman Abuse (St. Paul, Minn.: Minnesota Center Against 

Violence and Abuse, Apr. 1999).



[64] Through a cooperative agreement, Justice provides funds to the 

National Children’s Alliance, a not-for-profit organization that 

assists communities seeking to plan, establish, and improve Children’s 

Advocacy Centers, which in turn administers grants that fund the 

establishment and expansion of Children’s Advocacy Centers.



[65] HHS participants are the Office of the Secretary (Office of the 

Assistant Secretary for Planning and Evaluation); ACF (Children’s 

Bureau and the Family Violence Program); and Centers for Disease 

Control and Prevention (National Center for Injury Prevention and 

Control). Justice participants are all in the Office of Justice 

Programs--Violence Against Women Office, OVC, Office of Juvenile 

Justice and Delinquency Prevention, and National Institute of Justice.



[66] The sites are located in El Paso County, Colorado; Grafton County, 

New Hampshire; Santa Clara County, California; Lane County, Oregon; St. 

Louis County, Missouri; and San Francisco County, California.



[67] The project was developed in response to recommendations presented 

in a report published in 1999 by the National Council of Juvenile and 

Family Court Judges, entitled Effective Intervention In Domestic 

Violence & Child Maltreatment Cases: Guidelines for Policy and Practice 

(Reno, Nev.: 1999).



[68] The program was initially funded at $10 million and those funds 

were awarded to 18 grantees. The National Center for Child Traumatic 

Stress, which is a partnership between the University of California, 

Los Angeles, and Duke University, received about $3.1 million. Five 

Intervention Development and Evaluation Centers received grants ranging 

from about $568,000 to $600,000, and 12 Community Treatment and 

Services Centers received grants ranging from about $285,000 to about 

$348,000. In fiscal year 2002, the Congress appropriated an additional 

$20 million. In June 2002, SAMHSA awarded 5 additional Intervention 

Development and Evaluation Center grants, ranging from about $600,000 

to about $1.8 million, and 13 additional Community Treatment and 

Services Center grants, ranging from about $117,000 to about $1 

million. These additional grants totaled about $11.4 million.



[69] Michael Jellinek, Bina P. Patel, and Mary C. Froehle (eds.), 

Bright Futures in Practice: Mental Health Practice Guide, Volume 1 

(Arlington, Va.: National Center for Education in Maternal and Child 

Health, 2002).



[70] FEMA, Office of Inspector General, Inspection of FEMA’s Crisis 

Counseling Assistance and Training Program, Inspection Report I-01-95 

(Washington, D.C.: June 1995).



[71] Findings of that survey were discussed earlier in this report.



[72] Minors could not participate in either survey. Participants in the 

compensation survey included adults who filed claims on behalf of 

children.



[73] ACF defines child maltreatment as including physical abuse, 

neglect, medical neglect, sexual abuse, and psychological maltreatment.



[74] CDC defines intimate partner violence as actual or threatened 

physical or sexual violence, or psychological or emotional abuse by a 

spouse, ex-spouse, boyfriend, girlfriend, ex-boyfriend, ex-girlfriend, 

or date.



[75] Forcible rape includes assaults or attempts to commit rape by 

force or threat of force, but does not include statutory rape or other 

sex offenses.



[76] For individuals who do not suffer serious mental illness, Illinois 

law requires group plans to offer coverage for reasonable and necessary 

treatment and services, but permits the plan to require the insured to 

pay up to 50 percent of treatment expenses.



[77] However, Georgia law permits individual and small group major 

medical health plans to impose annual limits on the number of inpatient 

treatment days and outpatient treatment visits for mental health 

benefits that differ from those imposed for physical illnesses.



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