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