Mental Health: A Report of the Surgeon General

treatment. MST was constructed around a set of
principles that were put into practice and then
expanded upon in a manual (Henggeler et al., 1998).
Elaborate training, supervision, and monitoring for
treatment adherence make this an exemplary approach.
Furthermore, publication of an MST manual and the
high level of clinical training in MST distinguish this
model from other types of family preservation services.
The efficacy of MST has been established in three
randomized clinical trials for delinquents within the
juvenile justice system. The first of these studies took
place in Memphis, Tennessee, and revealed that MST
was more effective than usual community services in
decreasing adolescent behavioral problems and in
improving family relations (Henggeler et al., 1986).
The second was conducted in Simpsonville, South
Carolina, and compared outcomes for 84 juvenile
offenders randomly assigned to either MST or usual
services. At 59 weeks after referral, youth who had
received MST had fewer arrests and self-reported
offenses and had spent an average of 10 fewer weeks
incarcerated than did the youth in usual services. In
addition, families served by MST reported increased
family cohesion and decreased youth aggression in peer
relations (Henggeler et al., 1992). In the third study,
MST was compared with individual therapy in
Columbia, Missouri, and was found to be more
effective in ameliorating adjustment problems in
individual family members. A 4-year followup of
rearrest data indicated that MST was more effective
than individual therapy in preventing future criminal
behavior, including violent offenses (Borduin et al.,
1995). Studies found improved behavior, fewer arrests,
and lower costs. These findings encouraged the
investigators to test the effectiveness of MST in other
organizational settings (e.g., child welfare and mental
health), allowing them to target other clinical
populations, including youthful sex offenders (Borduin
et al., 1990), abused and neglected youth (Brunk et al.,
1987), and child psychiatric inpatients (see Inpatient
Treatment section). Initial results are promising for
youth receiving  MST instead of psychiatric
hospitalizations (Henggeler et al., 1998). As expected,
some adjustments to MST are required to handle

children who are dangerous to themselves and who do
not respond as quickly to treatment as'the delinquent
youth in previous studies. The efficacy of MST was
demonstrated in real-world settings but only by one
group of investigators; thus, the results need to be
reproduced by others and future effectiveness research
needs to determine whether the same benefits can be
demonstrated with less support from experts.

Therapeutic Foster Care

Therapeutic foster care is considered the least
restrictive form of out-of-home therapeutic placement
for children with severe emotioni disorders. Care is
delivered in private homes with specially trained foster
parents. The combination of family-based care with
specialized treatment interventions creates "a
therapeutic environment in the context of a nurturant
family home" (Stroul & Friedman, 1988). These
programs, which are often funded jointly by child
welfare and mental health agencies, are responsible for
arranging for foster parent training and oversight.
Although the research base is modest compared with
`other widely used interventions, some studies have
reported positive outcomes, mostly related to
behavioral improvements and movement to even less
restrictive living environments, such as traditional
foster care or in-home placement.
While therapeutic foster care programs vary
considerably, they have some features in common.
Children are placed with foster parents who are trained
to work with children with special needs. Usually, each
foster home takes one child at a time, and caseloads of
supervisors in agencies overseeing the program remain
small. In addition, therapeutic foster parents are given
a higher stipend than that given to traditional foster
parents, and they receive extensive preservice training
and in-service supervision and support. Frequent
contact between case managers or care coordinators
and the treatment family is expected, and additional
resources and traditional mental health services may be
provided as needed.

Therapeutic foster care programs are inexpensive
to start (few requirements for facilities or salaried staff)
and have lower costs than more restrictive programs. In

176


Ontario, a study found that therapeutic foster care cost
half that of residential treatment center placement for
the same period of time (Rubenstein et al., 1978).
There have been four efficacy studies, each with
randomized, controlled designs. In the first study, 20
youths who had been previously hospitalized were
assigned to either therapeutic foster care or other out-
of-hospital settings, such as residential treatment
centers or homes of relatives. The youths in therapeutic
foster care showed more improvements in behavior and
lower rates of reinstitutionalization, and the costs were
lower than those in other settings (Chamberlain &
Reid, 1991). In another study, which concentrated on
youths with histories of chronic delinquency, those in
therapeutic foster care were incarcerated less frequently
and for fewer days per episode than youths in other
residential placements. Thus, at 2-year followup, 44
percent fewer children in therapeutic foster care were
incarcerated (Chamberlain & Weinrott, 1990). In a
third study, outcomes for children in therapeutic foster
care were compared with those of children in standard
foster care. Children in therapeutic foster care were less
likely during a 2-year study to run away or to be
incarcerated and showed greater emotional and
behavioral adjustment (Clark et al., 1994). In the most
recent study, therapeutic foster care was compared with
group care: children receiving the former showed
significantly fewer criminal referrals, returned to live
with relatives more often, ran away less often, and were
confined to detention or training schools less often
(Chamberlain & Reid, 1998).

  All four studies of treatment effectiveness showed
that youths in therapeutic foster care made significant
improvements in adjustment, self-esteem, sense of
identity, and aggressive behavior. In addition, gains
were sustained for some time after leaving the
therapeutic foster home (Bogart, 1988; Hawkins et al.,
1989; Chamberlain & Reid, 1991).

There are also promising indications from
uncontrolled studies. Looking at 18 reports from 12
therapeutic foster care programs across the country,
Kutash and Rivera (1996) concluded that between
about 60 and 90 percent of youth treated in therapeutic
foster homes are discharged to less restrictive settings.

Children and Mental Health

Three programs also reported followup data, indicating
that about 70 percent of youth treated in therapeutic
foster homes remained in less restrictive settings for a
substantial amount of time after treatment.

It is clear from these studies that therapeutic foster
care produces better outcomes at lower costs than more
restrictive types of placement. Furthermore, with the
fairly recent development of standards for therapeutic
foster care, as well as a standards review instrument
(Foster Family-Based Treatment Association, 1995),
services can be monitored for quality and fidelity to the
therapeutic approach, making it easier to ascertain if
the approach taken produces the favorable outcomes.

Therapeutic Croup Homes

For adolescents with serious emotional disturbances the
therapeutic group home provides an environment
conducive to learning social and psychological skills.
This intervention is provided by specially trained staff
in homes located in the community, where local
schools can be attended. Each home typically serves 5
to 10 clients and provides an array of therapeutic
interventions. Although the types and combinations of
treatment vary, individual psychotherapy, group
therapy, and behavior modification are usually
included.

There are two major models of therapeutic group
homes. The first is the teaching family model,
developed at the University of Kansas, then moved to
Boys Town in Omaha, Nebraska (Phillips et al., 1974).
The second is the Charley model, developed at the
Menninger Clinic. Both models use their staff as the
key agents for change in the disturbed youth; selection
and training of the staff are emphasized. Both models
employ couples who live at the homes 24 hours a day.
The teaching family model emphasizes structured
behavioral interventions through teaching new skills
and positively reinforcing improved behavior. Other
group homes use individual psychotherapy and group
interaction.

There is a dearth of research on the effectiveness of
therapeutic group home programs targeted toward
emotionally disturbed adolescents. These homes have
been developed primarily for children under the care of

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Mental Health: A Report of the Surgeon General

juvenile justice or social welfare. A dissertation
(Roose, 1987) studied the outcomes of 20 adolescents
treated in a group home. Adolescents with severe
character pathology or major psychiatric disorders were
not admitted. Twenty group home adolescents were
compared with 20 untreated adolescents. At an 18-
month followup, 90 percent of the treated group had
fair or good functioning, defined by improved
relationships with parents, peers, and fellow workers.
Only 45 percent of the untreated group achieved similar
functioning. The treated group experienced a
significant decrease in psychopathology, while the
untreated group did not.

Therapeutic group homes were compared with
therapeutic foster care in two studies. The first study
found equivalent gains for youth in the two
interventions, but group home placement was twice as
costly as therapeutic foster care (Rubenstein et al.,
1978). A second study, a randomized clinical trial,
compared the outcomes for 79 males with histories of
juvenile delinquency placed in either group homes or
therapeutic foster homes (Chamberlain & Reid, 1998).
The boys treated in therapeutic foster homes had
significantly fewer criminal referrals and returnedmore
often to live with relatives, suggesting this to be a more
effective intervention. The implication of these studies
is that if therapeutic foster care is available, and if the
foster parents are willing to take youth with serious
behavioral problems, therapeutic foster care may be a
better treatment choice for youth who previously would
have been placed in group homes.

Existing research suggests that therapeutic group
home programs produce positive gains in adolescents
while they are in the home, but the limited research
available reveals that these changes are seldom
maintained after discharge (Kirigin et al., 1982). The
conclusion may be similar to that for residential
treatment center placement: long-termoutcomes appear
to be related to the extent of services and support after
discharge. Adolescents who have been placed in
therapeutic group homes because of mental disorders
frequently have histories of multiple prior placements
(particularly in foster homes), a situation that is
associated with a poor prognosis. Thus, future

programs would benefit from assessing alternative
strategies for treatment after discharge from group
homes.

Crisis Services

Crisis services are used in emergency situations either
to furnish immediate and sufficient care or to serve as
a transition to longer term care within the mental health
system. These services are extremely important because
many youth enter the mental health service system at a
point of crisis. Crisis services include three basic
components: (1) evaluation and assessment, (2) crisis
intervention and stabilization, and (3) followup
planning. The goals of crisis services include
intervening immediately, providing brief and intensive
treatment, involving families in treatment, linking
clients and families with other community support
services, and averting visits to the emergency
department or hospitalization by stabilizing the crisis
situation in the most normal setting for the adolescent.
Crisis services include telephone hotlines, crisis group
homes, walk-in crisis intervention services, runaway
shelters, mobile crisis teams, and therapeutic foster
homes when used for short-term crisis placements.
Crisis programs are small in order to facilitate close
relationships among the staff, child, and family. Crisis
staff are required to have skills and experience in the
areas of assessment, emergency treatment, and family
support. Short-term services are provided, with the staff
meeting more frequently with the client at the outset of
the crisis. A typical treatment plan consists of 10
sessions over a period of 4 to 6 weeks. Crisis services
usually are available 24 hours a day, 7 days a week
(Goldman, 1988).

Research on crisis services consists exclusively of
uncontrolled studies. Kutash and Rivera (1996)
reviewed 12 studies with pre-postI designs. Positive
behavioral and adjustment outcomes for youth
presenting to crisis programs and emergency
departments across the country were reported in all of

I6 Pre-post design: a research design in which a measure is
compared on the same individual research subjects before and after
an intervention.

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Children and Mental Health

the studies. Most programs also demonstrated the
capacity to prevent institutionalization.
  The most recent studies examine three different
models: a mobile crisis team, short-term residential
services, and intensive in-home service. The first study
examined the Youth Emergency Services (YES)
program in New York. This program included amobile
crisis team that sent clinicians directly to the scene of
the crisis. The data showed that YES prevented
emergency department visits and out-of-home
placements (Shulman & Athey, 1993).
A second crisis program, in Suffolk County, New
York, involved short-term residential services. In a
study of 100 children served by the program over a 2-
year period, more than 80 percent were discharged in
less than 15 days. Most were diverted from inpatient
hospitalization, and inpatient admissions to the state
children's psychiatric center for Suffolk County were
reduced by 20 percent after the program was
established (Schweitzer & Dubey, 1994).
  In the third study, records were analyzed from a
large sample of youth (nearly 700) presenting to the
Home Based Crisis Intervention (HBCI) program in
New York over a 4-year period. Youth received short-
term, intensive, in-home emergency services. After an
average service episode of 36 days, 95 percent of the
youth were referred to, or enrolled in, other services
(Boothroyd et al., 1995). The HBCI program was
established at eight locations across the State of New
York. Overall, programs with more access to
community resources reported shorter average lengths
of services.

Although crisis and emergency services represent
a promising intervention, the research done so far only
includes uncontrolled studies, limiting the conclusions
that can be drawn. Kutash and Rivera (1996)
recommend additional effectiveness research using
controlled study designs and comparing differences
between the various types of crisis services. Finally,
there remains a need for investigation of cost-
effectiveness as well as an exploration of the
integration of crisis services into systems of care.

Service Delivery
The focus of this section is on service systems-their
origins, nature, and financing and also their
effectiveness, delivery, and utilization-rather than on
individual interventions and treatments, which were
covered in previous sections of this chapter.
About 20 years ago it became clear that children
and families were failing to receive adequate care from
the public sector, whose services were fragmented,
inadequate, and overreliant on institutional care. As a
result, the emphasis of service delivery has shifted to
systems of care that are designed to provide culturally
competent, coordinated se&ices; community-based
services; new financing arrangements in the private and
public sectors; family participation in decisionmaking
about care for their children; and individualized care
drawing on treatment and social supports called
wraparound services, described above. Thus, there has
been progress in transforming the nature of service
delivery and its financing, but the central question of
the effectiveness of systems of care has not yet been
resolved.

At the outset, it is important to note that while
systems of care are designed to provide the appropriate
level of services for all children, it is children with
serious emotional disturbances, particularly children
who are involved in multiple service sectors, who are
likely to benefit the most. There are approximately 6
million to 9 million children and adolescents in the
United States with serious emotional disturbances
(Friedman et al., 1996a; Lavigne et al., 1996),
accounting for 9 to 13 percent of all children (Friedman
et al., 1996a; Friedman et al., 1998).
The system for delivering mental health services to
children and their families is complex, sometimes to the
point of inscrutability-a patchwork of providers,
interventions, and payers. Much of the complexity
stems from the multiple pathways into treatment and
the multiple funding streams for services. However,
once care has begun, the interventions and settings
themselves are generally the same as those covered in
previous sections of this chapter.

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Mental Health: A Report of the Surgeon General

Service Utilization

This section presents research findings about the
utilization of mental health services by children and
adolescents. The foremost finding is that most children
in need of mental health services do not get them.
Another finding refutes the common perception that
children who do not need specialty mental health
services are more likely to receive such services than
those who really do need them. This section also
discusses children's high dropout rates from treatment
and the significance of this problem for children of
different cultural backgrounds.

Utilization in Relation to Need

The conclusion that a high proportion of young people
with a diagnosable mental disorder do not receive any
mental health services at all (Bums et al., 1995; Leaf et
al., 1996) reinforces an earlier report by the U.S. Office
of Technology Assessment ( 1986), which indicated that
approximately 70 percent of children and adolescents
in need of treatment do not receive mental health
services. Only one in five children with a serious
emotional disturbance used mental health specialty
services, although twice as many such children
received some form of mental health intervention
(Bums et al., 1995). Thus, about 75 to 80 percent fail to
receive specialty services, and the majority of these
children fail to receive any services at all, as reported
by their families. The most likely reasons for
underutilization relate to the perceptions that treatments
are not relevant or are too demanding or that stigma is
associated with mental health services; the reluctance
of parents  and children to seek treatment;
dissatisfaction with services; and the cost of treatment
(Pavuluri et al., 1996; Kazdin et al., 1997).

Studies do, however, demonstrate a clear and
strong relationship between use of services and
presence of a diagnosis and/or presence of impaired
functioning. In the study by Leaf and colleagues
(1996), young people with both a diagnosis and
impaired functioning were 6.8 times more likely to see
a specialist than were those with no diagnosis and a
higher level of functioning.

The study by Bums and colleagues also showed
where children were receiving treatment. Of those who
received services and had both a diagnosis and
impaired functioning, about 40 percent received
services in the specialty mental health sector, about 70
percent received services from the schools, about 11
percent from the health sector, about 16 percent from
the child welfare sector, and about 4 percent from the
juvenile justice sector. For nearly half the children with
serious emotional disturbances who received services,
the public school system was the sole provider (Bums
et al., 1995). After reviewing thFse findings and the
findings from other studies, Hoagwood and Erwin
(1997) also concluded that schools were the primary
providers of mental health services for children.

Early Termination of Treatment

Among children and adolescents who begin treatment,
the dropout rate is high, although estimates vary
considerably. According to Kazdin and colleagues
(1997), 40 to 60 percent of families who begin
treatment terminate it prematurely. Armbruster and
Fallon (1994) found that the great majority of children
who enter outpatient treatment attend for only one or
two sessions. One of the explanations for the high
dropout rate and for failure to keep the first
appointment is that referrals are often made not by
children and adolescents or their families, but by
schools, courts, or other agencies. Most of the research
on dropping out has focused exclusively on examining
demographic or diagnostic correlates of dropping out,
and few researchers have directly asked the children or
their parents about their reasons for discontinuing
treatment.

  There are a number of effective interventions to
reduce dropout from treatment and to increase
enrollment and retention (Szapocznik et al., 1988;
McKay et al., 1996; Santisteban et al., 1996). Offering
services in the schools improves treatment access
(Catron & Weiss, 1994). A variety of case management
approaches can also improve engagement of low-
income families in the treatment of their children
(Bums et al., 1996; Koroloff et al., 1996a; Lambert &
Guthrie, 1996).

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poverty and Utilization

poverty status has been associated with both dropping
out of services and shorter lengths of treatment
(Hoberman, 1992). This relationship between
underutilization of mental health services and poverty
is especially significant for minority children and
families. Youths receiving community mental health
services supported by public agencies tend to be male,
poor, and referred by social agencies (Canino et al.,
1986; Costello & Janiszewski, 1990). Furthermore,
investigators have found this pattern particularly true
for African Americans as compared with Caucasians.
Hoberman (1992) has found that 90 percent of African
American youths entering the mental health systemlive
in poverty.

Culture and Utilization

Although it is clear that an insufficient number of
children receive mental health services, it is not clear
whether utilization of services varies by race or
ethnicity. The majority of studies have found that
African Americans tend to use some mental health
services, particularly inpatient care, more than would
be expected from their proportion in the population.
However, research findings are conflicting, probably
due to divergent methodological approaches (Attkisson
et al., 1995; McCabe et al., 1998; Quinn & Epstein,
1998). Furthermore, as Attkisson and colleagues (1995)
point out, consistent with the study by McCabe and
colleagues (1998), it is difficult to interpret these
findings in the absence of epidemiologic data on the
prevalence of a mental disorder in different racial and
ethnic groups. Recent reviews of epidemiological
findings concluded that present data are inadequate to
determine the relationship between race or ethnicity
and prevalence of a mental disorder (Friedman et al.,
1996b; Roberts et al., 1998).

The task of understanding treatment patterns is
made even more difficult because there are racial and
ethnic differences in family preferences and family-
initiated patterns of help-seeking (see also Culturally
Appropriate Social Support Services). For example,
parents from various cultural backgrounds have been
found to differ in the degree to which they identify

Children and Mental Health

child behavioral and emotional problems as disturbed
(Weisz & Weiss, 1991). Differences also have been
found across cultural groups in their beliefs about
whether these child problems are likely to improve in
the absence of professional support. Weisz and Weiss
(1991) have also identified cultural differences in the
power of various children's behavioral and emotional
problems to motivate a parent's search for professional
help.

Differences also arise indirectly from the
multiplicity of service systems with authority and
responsibility for protecting the well-being of children.
These systems have different `criteria for initiating
treatment and different patterns of utilization. African
American children and youth are considerably more
likely than those of other ethnic groups to enter the
child welfare system (National Research Council,
1993). Their greater chances of having parents
compelled to surrender them or of suffering abuse or
neglect lead them in greater numbers to be referred to
child welfare authorities, to be placed out-of-home, and
to be involved with the child welfare system longer.
Studies in one California county have found that
African American youths are overrepresented in
arrests, detention, and incarceration in the juvenile
justice system,  and in the schools they are
overrepresented in educational classes for the severely
emotionally disturbed. Hispanic/Latin0 children and
youths are no more likely than whites to come under
supervision of the child welfare system but, once
involved, remain longer. They are also more likely than
whites to be detained in juvenile justice facilities
(McCabe et al., 1998).

As a group, Hispanic/Latin0 and African American
children more often leave mental health services
prematurely than do Caucasian children (Sue et al.,
1991; Bui & Takeuchi, 1992; Takeuchi et al., 1993;
Viale-Val et al., 1984). Many factors contribute to
premature termination, such as insensitivity of mental
health providers to the culture of children and families
(Woodward et al., 1992). In general, even after
demonstrated success with middle-class Caucasians,
mental health treatments should not be applied without

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Mental Health: A Report of the Surgeon General

culturally appropriate modification to people from
other cultures and races (Rosado & Elias, 1993).
Specialized programs and supports linked with the
culture of the community being served have been found
to be successful in promoting favorable patterns of
service utilization for all ages (Snowden & Hu, 1997).
It is becoming clear that the children and families
served by mental health programs designed to be linked
to community cultures are less ,likely to drop out of
treatment compared with similar families in mainstream
programs (Takeuchi et al., 1995). For example, Asian
American children at an Asian community- or culture-
focused program were found to use more services, drop
out less often, and improve more than did Asian
American children at mainstream programs (Yeh et al.,
1994).

In summarizing the relationship between race and
ethnicity, need for service, and use of service, Isaacs-
Shockley and colleagues (1996) raised the concern that
minority children are less likely to receive the care they
need than nonminority children-a concern that should
energize advocacy for the development of systems of
care tailored to the needs of distinct cultures (Cross et
al., 1989; Hemandez & Isaacs, 1998).

Service Systems and Financing
In the past, mental health services paid for by the
private sector were viewed as separate entities from
those funded by the public sector, particularly since the
public sector only paid for services that it itself
delivered. As this section explains below, the
distinction between public and private sectors has been
blurred by the advent of publicly supported payment
systems such as Medicaid and grants of public funds to
private organizations and providers. Now in the public
sector, services are paid for with governmental
resources but delivered either by public or private
organizations in institutional or community-based
settings.

Private Sector

The private sector uses a health insurance model that
reimburses for acute medical problems. Under this
traditional model, mental health coverage usually

entails outpatient counseling, medication treatments,
and short-term inpatient hospitalization. Under more
generous insurance plans, including some managed
care plans, intermediate services, such as crisis respite
and day hospitalization (also called partial
hospitalization or day treatment), are becoming more
popular although more traditional insurance plans
continue to restrict their use. The drive to reduce the
cost of inpatient care is sparking an expansion in the
range of services supported by the private sector.
When children and adolescents have complex and
long-term mental health problems, required services are
not usually covered by private sector insurance plans.
Families must either pay for the services themselves or
obtain the services through the public sector. In many
states, parents are forced to give up custody of their
children to the state child welfare system in order to
obtain needed residential services (Cohen et al., 1991).
This unfortunate choice results from a limited supply of
public sector services and special requirements for
gaining access to them.

Over the past decade, managed care has become a
major payer for private health care. Managed care
provision of mental health services emerged partially in
response to the overutilization of costly inpatient
hospitalization by adolescents in the 1980s (Lourie et
al., 1996). The purpose of managed care has been to
control spiraling mental health service costs, mostly by
limiting hospital stays and rigorously managing
outpatient service usage (Stroul et al., 1998). Managed
care can offer advantages in terms of cost-effective
services to meet the needs of children with flexible
benefits. It may also lead to denial of needed treatment.
While its potential negative effect on the efficacy of
mental health care delivered under its aegis is a hotly
debated issue, for the most part managed care furnishes
the same traditional services available under fee-for-
service insurance. The drive for efficiency, however,
has led to the introduction of intermediate services
designed to divert children from hospitalization.
Managed care has shortened hospital stays and
increased the use of short-term therapy models (Eisen
et al., 1995; Merrick, 1998). Managed care also has
lowered reimbursements for services provided by both

182


individual professionals and institutions. This has been
accompanied by the construction of provider networks,
under which professionals and institutions agree to
accept lower than customary fees as a tradeoff for
access to patients in the network.

Public Sector

Mental health services provided by the public sector are
more wide-ranging than those supported by the private
sector, and the types of payers are more diverse. Some
public agencies, such as Medicaid and state and local
departments of mental health, are mandated to support
mental health services. Others provide mental health
services to satisfy mandates in special education,
juvenile justice, andchild welfare, among others.
Medicaid is a major source of funding for mental
health and related support services. For the most part,
Medicaid has supported the traditional mix of
outpatient and inpatient services. However, unlike
private sector insurance, Medicaid also funds long-term
services for those children who need more intensive or
restrictive services, often through hospitalizations and
residential treatments. Some states cover in-home
services, school-based services, and case management
through a variety of Medicaid options. Medicaid also
supports the Early Periodic Screening, Diagnosis, and
Treatment (EPSDT) program.

without individualized wraparound provisions, early
intervention programs, crisis stabilization, in-home
therapy, and day programs. Since there has never been
a mandate to states to provide mental health services to
children and adolescents, the state or local support for
such services has been variable; Thus, one might find
a well-supported, innovative array of mental health
services for children in one state or community, and
almost no services in the next. The new State Child
Health Insurance Program (CHIP) is an attempt by
Congress to address the health care needs of low-
income, uninsured children. States have great flexibility
in their approach to coverage, and it remains to be seen
how they will deal with mental health services.
States and communities have sweeping mandates to
serve children and adolescents in schools and under
child welfare and juvenile service auspices. Many of
these state and community programs, however, lack the
expertise to recognize, refer, or treat mental health
problems that trigger mandated services, When they do
recognize problems, some of the needed mental health
services are paid for by Medicaid, by the federal
Maternal and Child Block Grant, or by a state or local
mental health authority; often, however, they are not.
Under these circumstances, the school, welfare, or
juvenile justice agency ends up paying the bill for the
mental health services.

Trapped between the private and public sectors is
a group of uninsured individuals and families who do
not qualify for the public sector programs, cannot
afford to pay for services themselves, and have no
access to private health insurance. The American
Academy of Pediatrics estimates that in 1999 there will
be 11 million uninsured children, about 3 million of
whom do not qualify for existing public programs
(American Academy of Pediatrics website
www.aap.org). State and local mental health authorities
fund some mental health services for these children,
often offered through the same community mental
health centers that are funded by Medicaid. Mental
health departments in some jurisdictions also fund a
broader array of mental health services than the
traditional acute service package. These "intermediate"
services include intensive case management with and

183

Children and Mental Health

Under the Federal special education law, the
Individuals with Disabilities Education Act" (IDEA;
see also New Roles for Families in Systems of Care),
school systems are mandated to provide special
education services to children and adolescents whose
disabilities interfere with their education, When these
disabilities take the form of serious emotional or
behavioral disturbances, school systems are required to
respond through assessment, counseling, behavior
management, and special classes or schools. When
school systems lack sufficient capacity to meet such
needs directly, school funds are used to send children
and youths to specialized private day schools or to
long-term residential schools, even if such schools are
out of the child's state or community. In this way,

" Public Law 94-142; Public Law 101-476; Public Law 10517.


Mental Health: A Report of the Surgeon General

school systems support an extensive array of mental
health services in the public and private sectors.

Preschool children with developmental and
emotional disabilities are covered by some state and
local legislation. Services for them also are mandated
under IDEA. Whereas some states coordinate this
education-based mandate through school systems,
others administer the preschool programs through
mental health or developmental disability agencies, an
interagency coordinating body, or other state agency.

Child welfare agencies in states and communities
also have powerful mandates to protect children and to
ensure that they receive the services they need;
including mental health services. Child welfare
agencies primarily serve poor children who are
separated from their parents because they are orphaned,
abandoned, abused, or neglected. Although many
mental health services are provided either under
Medicaid or through state and locally supported
community mental health centers, many are not and are
paid for directly by child welfare agencies. This
happens most often when children and adolescents have
severe, complicated conditions. As with education
agencies, when funding is not available through
Medicaid or other mental health funds, child'welfare
agencies directly pay for group home care, therapeutic
foster care, or residential treatment.

The same is true for juvenile justice agencies,
which have strong mandates to protect children and the
public. Many children and adolescents in the juvenile
justice system have serious mental health problems.
Beyond the more traditional "training schools" and
"detention centers," run by state and local juvenile
authorities, respectively, these agencies also purchase
care from the same group home, therapeutic foster care,
and residential providers as do child welfare agencies.

Children Served by the Public Sector
Children needing services are identified under the
auspices of five distinct types of service sectors:
schools, juvenile justice, child welfare, general health,
and mental health agencies. These agencies are mostly
publicly supported, each with different mandates to
serve various groups and to provide somewhat varied

levels of services. Many of these agencies arose
historically for another purpose, only to recognize later
that mental disorders cause, contribute to, or are effects
of the problem being addressed. In the past, these
sectors operated somewhat autonomously, with little
ongoing interaction. Catalyzed by the NMHA's
Invisible Children's Project (NMHA, 1987, 1993), the
combined impetus of Federal policies and managed
care more recently has begun to forge their integration.
Two recent review articles examined the
characteristics of children served in public systems.
Based on an appraisal of six prior studies, it was
concluded that, in addition to emotional and behavioral
functioning, these young people have problems in life
domains such as intellectual and educational
performance and social and adaptive behavior
(Friedman et al., 1996b). Frequently, such children and
their families have contact not only with the mental
health system, but also with special education, child
welfare, and juvenile justice (Landrum et al., 1995;
Duchnowski et al., 1998; Greenbaumet al., 1998; Quinn
& Epstein, 1998).

It is estimated that in a l-year period more than
700,000 children nationwide are in out-of-home
placements, mostly under the supervision of either the
child welfare or to some extent the juvenile justice
system (Glisson, 1996). Also, during the 1996-1997
school year more than 400,000 emotionally disturbed
children and youths between the ages of 6 and 2 1 were
served in the public schools nationwide (U.S.
Department of Education, 1997). This is just under
1 percent of the school enrollment for ages 6 to 17, and
8.5 percent of all children with disabilities receiving
any kind of special education service (Oswald &
Coutinho, 1995; U.S. Department of Education, 1997).
These figures and percentages have remained relatively
constant since national data were first collected about
20 years ago, although there are great variations
between states. For example, in 1992-1993,0.4 percent
of school-enrolled children in Mississippi were
identified as having a serious emotional disturbance
compared with 2.08 percent in Connecticut (Coker et
al., 1998).

184


  In addition to children with a serious emotional
disturbance served by the special education system,
children served by child welfare and juvenile justice
systems also have need for mental health services
(Friedman & Kutash, 1986; Cohen et al., 1990;
Greenbaumet al., 1991,1998; Otto et al., 1992; Glisson,
1996; Claussen et al., 1998), because they are much
more likely to have emotional and behavioral disorders
than is the general population (Duchnowski et al.,
1998; Quinn & Epstein, 1998). Thus, the emphasis on
interagency community-based systems of care is
warranted and essential (see Integrated SystemModel).

Managed Care in the Public Sector
Since 1992, managed care has begun to penetrate the
public sector (Essock & Goldman, 1995). The prime
impetus for this has been an attempt to control the costs
of Medicaid, in both the general health and mental
health arenas. Since Medicaid appears, on the surface,
to be similar to a private health insurance plan,
administrators of state Medicaid programs have
recently implemented managed care approaches and
structures to reduce health care costs. However,
Medicaid populations tend to have a higher prevalence
of children with serious emotional disturbance than that
seen in privately insured populations. Those children
generally need longer-term care (Friedman et al.,
1996b; Broskowski & Harshbarger, 1998). Managed
care strategies, which developed in the private sector,
are geared toward a relatively low utilization of mental
health services by a population whose mental health
needs tend to be short term and acute in nature. As a
result, the kinds of cost-cutting measures used by
managed care organizations, such as reduction of
hospital days and encouragement of short-term
outpatient therapies, have not worked as well in the
public sector with seriously emotionally disturbed
children as they have in the private sector (Stroul et al.,
1998).

Advocates express concern that the restrictions of
public managed care on mental health services shift
costs of diagnosis and treatment to other agencies, a
process known as cost-shifting. Under public managed
care, hospitalization for mental disorders is being

Children and Mental Health

substantially cut, with youths being discharged from
the hospital before adequate personal and/or
community safety plans can be instituted. Child welfare
and juvenile justice agencies have been compelled to
create and pay for services to support those children
who are no longer kept in hospitals. Thus, while
Medicaid's mental health costs may be decreasing in
such cases, there may be a substantial cost increase to
the other agencies involved, resulting in little if any
overall cost saving (Stroul et al., 1998).
Similarly, management of only the Medicaid
portion of a complex funding system that includes
Medicaid, mental health, special education, child
welfare, and juvenile justice funds not only creates the
cost-shifting described above, but also underestimates
the need to manage the funds spent by all agencies.
Demonstration programs of managed care strategies for
children and adolescents with severe emotional
disturbances have included the creation of an
interagency funding pool, shared by all affected
agencies, to meet the full range of needs of this
population. Under the demonstration program, the
funds in such a pool are capitated" to ensure that the
most appropriate services are purchased, regardless of
which agency's mandate they come under. In this way,
long-term, complex care can be offered in an efficient
way that reduces costs for all of the involved child and
youth agencies.

An excellent example of an approach in a managed
care setting is "Wraparound Milwaukee," one of the
Center for Mental Health Services' Comprehensive
Community Mental Health Services for Children and
Their Families Programs (Stroul et al., 1998; Goldman
& Faw, 1998). Wraparound Milwaukee, a coordinated
system of community-based care and resources for
families of children with severe emotional, behavioral,
and mental health problems, is operated by the Children
and Adolescent Services Branch of the Milwaukee
County Mental Health Division. The features of this
care management model are a provider network that
furnishes an array of mental health and child welfare
services; an individualized plan of care; a care

" Capitation: a fixed sum per individual per month.

185


Mental Health: A Report of the Surgeon General

coordinator management system to ensure that services
are coordinated, monitored, and evaluated; a Mobile
Urgent Treatment Team to provide crisis intervention
services;  a managed care approach including
preauthorization of services and service monitoring;
and a reinvestment strategy in which dollars saved from
decreased use of inpatient or residential care are
invested in increased service capacity.
Since its inception in 1994, one of the goals of the
program has been to blend funding streams.
Wraparound Milwaukee operates as a behavioral health
care "carve-out"" that blends funds from a monthly
capitation rate from Medicaid, a case rate from county
child welfare and juvenile justice funds, and a Center
for Mental Health Services child mental health services
grant. The Wraparound Milwaukee capitated rate of
approximately $4,300 covers all mental health and
substance abuse services,  including inpatient
hospitalization. Additional funds from child welfare
and/or juvenile justice are used for children with
serious emotional disturbances in the child welfare and
juvenile justice systems in Milwaukee County to cover
residential treatment, foster care, group home and
shelter care costs, and nontraditional mental health
community services (e.g., mentors, job coaches, after-
school programs). Wraparound Milwaukee is at "full
risk" for all services costs, meaning it is responsible for
charges in excess of the capitated rate. The average
monthly costs, including administrative costs, are
$3,400 per child. Medicaid-eligible children constituted
80 percent of the population served by the program in
1998.

Culturally Appropriate Social Support
Services

One of the fundamental requirements of culturally
appropriate services is for mental health providers to
identify and then to work in concert with natural
support systems within the diverse communities they
serve (Greenbaum, 1998). (Background information on
cultural diversity and culturally competent services is

I9 Carve-out: separation of funding for mental health services and
their management from those of general health.

186

provided in Chapter 2.)  If they are culturally
appropriate, services can transcend mental health's
focus on the "identified client" to embrace the
community, cultural, and family context of a client
(Szapocznik & Kurtines, 1993; Hemandez et al., 1998).
According to Greenbaum (1998), considering a client's
context is important because people who live close to
each other frequently have developed ways of coping
with similar personal problems. Becoming aware of
these natural systems and adapting formal services to
be congruent with them are ways to make services more
accessible and useful to diverse populations.

Community- and neighborhood-based social net-
works act as important resources for easing emotional
stress and for facilitating the process of seeking
professional help (Saunders, 1996). Often natural social
supports ameliorate emotional distress and have been
found to reduce the need for formal mental health
treatment (Linn & McGranahan, 1980; Birkel &
Reppucci, 1983; Cohen & Wills, 1985). According to
Saunders (1996), obtaining social support is not a
single event but rather an ongoing process. In general,
people use their neighborhood and familial supports
many times before they decide they have a problem and
determine what type of help they will seek (Rew et al.,
1997). A key to the success of mental health programs
is how well they use and are connected with
established, accepted, credible community supports.
The more this is the case, the less likely families view
such help as threatening and as carrying stigma; this is
particularly true for families who are members of racial
and ethnic minority groups (Bentelspacher et al., 1994).

Minority parents are more likely than nonminority
parents to seek input regarding their children from
family and community contacts (Briones et al., 1990;
Hoberman, 1992). In a study by McMiller and Weisz
(1996), two-thirds of the parents of minority children
did not seek help from professionals and agencies as
their first choice. For example, in Hispanic/Latin0
families, important decisions related to health and
mental health are often made by the entire family
network rather than by individuals (Council of
Scientific Affairs, 1991). According to Ruiz (1993),
health care settings that are not modified to work with


Hispanic/Latin0 family networks find that their clients
do not comply with medical advice; as a result, their
health status can be compromised.
In sum. mental health programs attempting to serve
diverse populations must incorporate an understanding
of culture, traditions, beliefs, and culture-specific
family interactions into their design (Dasen et al., 1988)
and form working partnerships with communities in
order to become successful (Kretzman & McKnight,
1993). Ultimately, the solution offered by professionals
and the process of problem resolution or treatment
should be consistent with, or at least tolerable to, the
natural supportive environments that reflect clients'
values and help-seeking behaviors (Lee, 1996).
Such partnerships sometimes fail, however,
because they concentrate on neighborhood and
community problems. According to Kretzman and
McKnight (1993), this approach often reinforces the
negative stereotypes of violent, drug- and gang-ridden,
and poverty-stricken communities. A more effective
alternative approach to working with communities is to
focus on community strengths (Kretzman & McKnight,
1993). This approach works best when community
residents themselves are interested in participating in
the partnership. Mental health providers who approach
minority communities in a paternalistic manner fail to
engage residents and fail to recognize whether the
community wants their assistance (Gutierrez-Mayka &
Contreras-Neira, 1998). Service providers who attend
to the wishes of community residents are more likely to
be respectful in their delivery of services, a respect that
is a prerequisite to cultural responsiveness and
competence in service planning and delivery to diverse
communities (Gutierrez-Mayka & Contreras-Neira,
1998).

Support and Assistance for Families
Any parent or guardian of a child with an emotional or
behavioral disorder can testify to the challenging,
sometimes overwhelming, task of caring for and raising
such a child. In the past, support from public agencies
has been inadequate and disjointed. Compounding the
problem was the view that parents were partly, if not
completely, to blame for their child's condition

Children and Mental Health

(Friesen 8z Stephens, 1998). In 1982, a particularly
incisive description of the problems faced by families
raising children with emotional or behavioral disorders
was published. It concluded that parents received little
assistance in finding services for their children and
.were either ignored or coerced by public agencies;
respite and support services to relieve the stress on
parents were unavailable; parents with children needing
residential care were compelled to give up custody to
get them placed; and few advocacy efforts were aimed
at relieving their problems (Knitzer, 1982).
Over the past two decad$s, however, recognition
and response to the plight of families have become
increasingly widespread. The role of families has been
redefined as that of a partner in care. Furthermore,
there was growing awareness of the difficulties families
faced because services are provided by so many
different public sources. In addition to problems with
coordination, parents and caregivers encountered
conflicting requirements, different atmospheres and
expectations, and contradictory messages from system
to system, office to office, and provider to provider
(Knitzer, 1982). Although some agencies began to
provide families with training, information, education,
and financial assistance, there was often a gap between
what families needed and what agencies provided.
Also, service agencies themselves began to recognize
that putting children into institutions may not have
served the child, the family, or the state and that
keeping a child with his or her family could reduce the
ever-growing costs of institutionalization (Stroul,
1993a, 1993b). Emerging awareness of these foregoing
problems galvanized advocacy for a better way to care
for children with emotional and behavioral disorders.
Reforms were instituted in many Federal programs, as
discussed later in this section.

According to Knitzer andcolleagues (1993), family
participation promotes four changes in the way children
are served: increased focus on families; provision of
services in natural settings; greater cultural sensitivity;
and a community-based system of care. Research is
accumulating that family participation improves the
process of delivering services and their outcomes. For
example, Koren and coworkers (1997) found that, for

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Mental Health: A Report of the Surgeon General

children with serious mental health problems, the more
the family participates in planning services, the better
family members feel their children's needs are being
met; participation in service planning also helps service
coordination. Curtis and Singh (1996) and Thompson
and colleagues (1997) also found that family
involvement in services was a determinant of the level
of parental empowerment, that is, how much control
parents felt they had over their children's treatment.

New Roles for Families in Systems of Care
Over the past two decades, the Federal government
established a series of initiatives to support families.
Parents were given progressively greater roles as
decisionmakers with the passage of the Education of
the Handicapped Act in 1975 and its successor
legislation, the Individuals with Disabilities Education
Acts of 1991 and 1997. For simplicity, these pieces of
legislation are collectively referred to hereinafter as the
IDEA Act. This act requires parent involvement in
decisions about educating children with disabilities. It
guarantees that all children with disabilities receive
free and appropriate public education. It also provides
funding assistance to states for implementation.
A novel approach taken by some community-level
systems of care to encouraging involvement of.families
is to train and hire family members into a wide range of
well-paying, career-ladder jobs as outreach workers,
service coordinators (sometimes called case managers),
and direct support services providers. These positions
are critical to achieving major program goals because
they make it possible for children and families to
remain together and to participate in the more clinical
components of their service plan. Family members are
also employed as supervisors of services, involved in
hiring staff, providing them with orientation and on-
the-job training (e.g., of case managers), overseeing
their work, and evaluating their performance. They also
participate in research.

Beginning in 1989, the Child and Adolescent
Service System Program, a component of the Center for
Mental Health Services, began providing some support
for statewide family organizations through a series of
funding and technical assistance mechanisms (Koroloff

et al., 1991; Briggs et al., 1994; also see Integrated
System Model). Such organizations were funded to
develop statewide networks of information and support
for families, to coordinate with other organizations that
shared common goals, and to promote needed changes.
Currently, Federal funding for 22 statewide family
organizations is provided through the Child and Family
Branch, Center for Mental Health Services, Substance
Abuse and Mental Health Services Administration.
Support and technical assistance to community-level
family organizations are also provided by the
Federation of Families for Children's Mental Health,
the National Alliance for the M&tally Ill, and other
family-run consumer organizations.

Family Support

Family support is defined here as the assistance given
to families to cope with the extra stresses that
accompany caring for a child with emotional
disabilities. In addition to the stress of raising a child
with an emotional disability, families often face other
difficulties such as poverty, joblessness, substance
abuse, and victimization. Family support often helps
keep families together by assisting them with the
practicalities of living and by attending to the needs of
all family members (Will, 1998). The main goal of
family support services is to strengthen adults in their
roles as parents, nurturers, and providers (Weissbourd
& Kagan, 1989). Too often, family support services are
not available within local communities.
Natural support systems are often diminished for
families of children with serious emotional, behavioral,
or physical disorders or handicaps because of the
stigma of, or embarrassment about, their child's
problems, or because caregivers have insufficient
energy to reach out to others. Not surprisingly, most
parents report that limited social support decreases
their quality of life (Crowley & Kazdin, 1998) and that
they feel less competent, more depressed, worried, and
tired and have more problems with spouses and other
family relationships than other parents (Farmer et al.,
1997). although a few families do feel enriched by
caring for these children (Yatchmenoff et al., 1998).

188


In a national survey of parents of children with an
emotional or behavioral disorder, 72 percent of
respondents indicated that emotional support
(irrespective of its form) was the most helpful aspect of
family support services (Friesen, 1990). Benefits
included increased access to information, improved
problem-solving skills, and more positive views about
parenting and their children's behavior (Friesen &
Koroloff, 1990).

Family support services occur in several forms:
assistance with daily tasks and psychosocial support
and counseling; informal or professional provision of
services; and practical support such as housing
assistance, food stamps, income support, or respite care
(i.e., temporary relief for family members caring for
individuals with disabilities).

Efforts to stop blaming parents for children's
problems have resulted in parents becoming viewed
less as patients than as partners, actively involved in
every phase of the treatment process (e.g., home-based
care, case management) and as a resource for their
children, as discussed above. For the self-help and
professionally led family support services described
subsequently, parents may function either as partners or
as providers. As "partners," parents act as a resource,
active contributor, or decisionmaker; as "providers,"
they are viewed as contributing to the welfare and
growth of other members of the family.

Results of research on the effectiveness of family
services are only beginning to appear, in the form of
some controlled studies and evaluations of support
services for families of children with emotional and
behavioral disorders (although there is a larger
literature on families whose children have other types
of disability and illness). Although this database on
family support programs is still limited, many positive
effects have been reported. The following paragraphs
cover family support groups as well as concrete
services. For the latter, only two types of interventions,
respite care and the family associate, are included.
Family therapy is covered in this chapter under
Outpatient Treatment. Furthermore, several forms of
parent training were found to be effective for individual

Children and Mental Health

diagnoses, such as conduct disorder (see section on
Selected Mental Disorders in Children).

Family Support Croups

The primary focus of family support groups is to
provide information and emotional support to members
&ho share a common problem or concern (e.g.,
disability, substance abuse, bereavement). Support
groups for families of children with emotional or
behavioral disorders are expanding. Although there is
a wide variation in membership, format, and duration
of these groups, most share some characteristics.
Usually, from 4 to 20 parents meet regularly to discuss
the problems and issues associated with parenting a
child with emotional and behavioral disorders and to
provide mutual encouragement and suggestions for
dealing with problematic situations. Support services
may be informal, organized, and parent led and are
often associated with organizations such as the
National Mental Health Association, Children and
Adults with Attention Deficit Disorders, the National
Alliance for the Mentally Ill, or the Federation of
Families for Children's Mental Health. Mental health
professionals may also participate in support groups
(Koroloff & Friesen, 1991).

It was found that support groups for parents of
children hospitalized with mental illness make parents
feel more positive about themselves and increase their
understanding of and communication with their
children (Dreier & Lewis, 1991). Participation in a six-
session education and support group for parents of
adolescents with schizophrenia led to increased
relaxation and concentration, less worry, changed
attitudes toward discipline, and greater ease in
discussing feelings. The support from parents in similar
situations was highly valued (Sheridan & Moore,
1991).

Another approach to support for parents of children
receiving mental health services is education:
knowledge of the services; skills needed to interact
with the system; and the caregivers' confidence in their
ability to collaborate with service providers (self-
efficacy). A training curriculum for parents was tested
in a randomized controlled trial involving more than

189


Mental Health: A Report of the Surgeon General

200 parents who either did or did not receive the
training curriculum. Three-month and 1 -year followup
results demonstrated significant improvement in
parents' knowledge and self-efficacy with the training
curriculum, whereas there was no effect on the mental
health status of their children, service use, or caregiver
involvement in treatment (Heflinger & Bickman, 1996;
Bickman et al., 1998).

Practical Support

Respite care is a type of concrete support that provides
temporary relief to family caregivers. An investigation
of the benefit of respite care is under way in New York
in families with children at risk of hospital placement.
When respite care was available, families preferred in-
home to out-of-home care. The younger the children,
the greater the child's functional impairment, and the
fewer the social supports (Boothroyd et al., 1998), the
more respite care was used. Outcomes have not yet
been reported.

Another form of concrete support is exemplified by
the Family Associate Intervention, which was
developed in Oregon. It appears to be an inexpensive
way to assist children in actually obtaining care after
they have been identified as needing care. The goal is
to use paraprofessionals (known as family associates),
rather than professionals, to facilitate entry into an
often intimidating service system. In a controlled study,
family associates were found to be effective in helping
families initiate mental health service use. Families
receiving this support service were more likely to make
and keep a first appointment at the mental health clinic.
The effectiveness of the intervention was moderate but
sufficient to encourage further development of such a
low-cost intervention (Koroloff et al., 1996b; Elliot et
al., 1998).

Integrated System Model

Within the public mental health system, the 1980s and
1990s have seen an increased emphasis on developing
interagency community-based systems of care (Stroul
& Friedman, 1986). This focus is driven by awareness
that a large number of children are served in systems
other than mental health, as well as by children's

complex and interrelated needs, as indicated earlier
(Friedman et al., 1996a, 1996b; Quinn & Epstein,
1998). In 1984, the Child and Adolescent Service
System Program (CASSP) was launched to respond to
the fragmentation of public services (Stroul &
Friedman, 1986). It was funded by the services
component of the National Institute of Mental Health,
which later became the Center for Mental Health
Services under the Alcohol and Drug Abuse and
Mental Health Administration Reorganization Act of
1992 (Public Law 102-321).

CASSP recognized the need for public sector
programs to become more integrated in their attempts
to meet more fully and efficiently the needs of children
and adolescents with a serious emotional disturbance
and their families. This Federal program pioneered the
concept of a "system of care" for this population, as
delineated by Stroul and Friedman (1986, 1996). A
system of care, described further below, is a
comprehensive approach to coordinating and delivering
a far-reaching array of services from multiple agencies.
All 50 states and numerous communities have received
CASSP grants to improve the organization of their
response to the mental health needs of the most
severely affected children and adolescents. Although
CASSP principles have become a standard for program
design, many communities do not offer comprehensive
services according to the CASSP model.

CASSP provided the conceptual framework for the
Robert Wood Johnson Foundation's Mental Health
Services Program for Youth and the Annie E. Casey
Foundation's Urban Mental Health Initiative. These
foundation programs were devoted to the development
of local interagency models (Cole, 1990). They were
followed in 1992 by the authorization for what was to
become the largest Federal program for child mental
health, the Comprehensive Community Mental Health
Services for Children and Their Families Program (also
known as the Children's Services Program), sponsored
by the Center for Mental Health Services (Public Law
102-321).

The Children's Services Program provides grants
to states, communities, territories, and Indian tribes and
tribal organizations to improve and expand systems of

190


cue to meet the needs of approximately 6.3 million
children and adolescents with serious emotional
disturbance and their families. The program now
s~pp~rts 45 sites across the country.
Built on the principles of CASSP, the Children's
Services Program promotes the development of service
delivery systems through a "system of care" approach.
The systemof care approach embraced by this initiative
is defined as a comprehensive spectrum of mental
health and other services and supports organized into a
coordinated network to meet the diverse and changing
needs of children and adolescents with serious
emotional disturbance and their families (Stroul &
Friedman, 1996). The system of care model is based on
three main elements: (1) the mental health service
system must be driven by the needs and the preferences
of the child and family; (2) the locus and management
of services must be within a muhiagency collaborative
environment, grounded in a strong community base;
and (3) the services offered, the agencies participating,
and the programs generated must be responsive to
children's different cultural backgrounds. The
Children's Services Program requires a national cross-
site evaluation,  which has been continuously
implemented since the spring of 1994. Preliminary
evidence from the uncontrolled evaluation indicates
some improvements in outcomes, such as fewer law
enforcement contacts and better school grades, living
arrangements, and mental health status. As part of the
evaluation, comparisons are being made between
system of care sites and comparable communities
without systems of care (Holden et al., 1999).

Effectiveness of Systems of Care

The previous sections have highlighted the trans-
formations that have taken place since the early 1980s
to create comprehensive, interagency, community-
based systems of care. This section reviews the
findings of research into the effectiveness of such
systems of care as compared with more traditional
systems.

Several studies on the effectiveness of systems of
care have been conducted in recent years (Stroul,
1993a, 1993b; Bruns et al., 1995; Rosenblatt, 1998).

Children and Mental Health

Although findings are encouraging, their effectiveness
has not yet been demonstrated conclusively, largely
because evaluation studies have not had a control
group. Most evaluations indicate that systems of care
reduce rates of reinstitutionalization after discharge
from residential settings, -reduce out-of-state place-
`ments of children, and improve other individual
outcomes such as number of behavior problems and
satisfaction with services. After reviewing findings
from the demonstration project of the Robert Wood
Johnson Foundation, their own work in Vermont,
research in California and. Alaska, and early findings
from the Fort Bragg evaluatidn, Bruns, Burchard, and
Yoe (1995) conclude that "initial findings are encourag-
ing, especially with the history of disappointing results
of outcome studies for child and adolescent services"
(p. 325). Details are available in the individual studies
(Attkisson et al., 1997; Illback et al., 1998; Santarcan-
gelo et al., 1998).

Reviews (Stroul, 1993a, 1993b; Rosenblatt, 1998) of
uncontrolled studies of community-based systems of
care showed that young people with serious emotional
disturbances who were served under community-based
systems of care consistently showed improvement
across a range of outcomes. However, most of these
studies used a so-called pre-post evaluation design that
does not answer the question of whether the changes
occurring over time (pre to post) are a consequence of
the intervention or of the passage of time itself. Indeed,
when comparison groups are studied, such as in the
Fort Bragg demonstration project, results tend to be
less favorable (see below).

The Fort Bragg Study

The Fort Bragg study, conducted by Bickman and his
colleagues (Bickman et al., 1995; Bickman, 1996a;
Hamner et al., 1997), merits detailed discussion
because of the basic issues it raises and the controversy
it engendered. The Fort Bragg study is an evaluation of
a large-scale system change project initiated by the
State of North Carolina and the Department of Defense
in the early 1990s; it was designed to determine what
systemic, clinical, and functional outcomes could be

191


Mental Health: A Report of the Surgeon General

achieved if a wide range of individualized and family-
centered services were provided without any barriers to
their availability. The project involved replacing the
traditional CHAMPUS benefit for children who were
military dependents in the Fort Bragg area with a
continuum of care that included a broad range of
services, a single point of entry, comprehensive
assessments, and no copayment. or benefit limit. The
provider agency at Fort Bragg was reimbursed for
costs. The impact of this change on children was
assessed by comparing outcomes at Fort Bragg with
those at two other military installations in the Southeast
where the traditional CHAMPUS benefit package
remained in effect. The comparison sites restricted
services to outpatient treatment, placement in a
residential treatment center, or treatment in an inpatient
hospital setting; regular copayment and benefit limits
were in effect at the comparison sites.
  Over a 3-year period, the evaluators collected
service use, cost, satisfaction, clinical, and functional
data for 984 young people served either at Fort Bragg
(574) or the comparison sites (410). Overall, there were
a number of favorable findings for the demonstration
site at Fort Bragg: access for children was increased;
children referred for services were indeed in need.of
help; parents and adolescents were more satisfied with
the services they received than were parents and
adolescents at the comparison sites; children received
services sooner; care was provided in less restrictive
environments; there was heavy use of intermediate-
level services; fewer clients received only one session
of outpatient treatment; overall, children stayed in
treatment longer (although the length of stay in
hospitals and residential treatment centers was shorter);
and there were fewer disruptions in services (Bickman,
1996a). Thus, the major findings were that the
expanded continuum of care resulted in greater access,
higher satisfaction with services by patients, and less
use of inpatient hospitalization and residential
treatment. Bickman also concluded, however, that
despite the fact that the intervention was well
implemented at Fort Bragg, there were no differences
between sites in clinical outcomes (emotional-

behavioral functioning), and the cost was considerably
greater at Fort Bragg.

The interpretation of the results by the project's
principal investigator has generated much discussion
and controversy in the children's mental health field,
both in support of and questioning the study's
conclusions (Friedman & Bums, 1996; Behar, 1997;
Feldman, 1997; Hoagwood, 1997; Laurie, 1997; Pires,
1997; Saxe & Cross, 1997; Se&rest,& Walsh, 1997;
Weisz et al., 1997). Most of the controversy surrounds
study interpretation, implementation, methodology, and
the interpretation of the cost data (Behar, 1997;
Feldman, 1997; Heflinger & Northrup, 1997;
Langmeyer, 1997). Furthermore, it has been pointed out
that Fort Bragg was not a multiagency community-
based system of care (Friedman & Burns, 1996), a
point that has been acknowledged by the principal
investigator of the study (Bickman, 1996b). Overall,
despite the controversy surrounding it, the Fort Bragg
evaluation has challenged the notion that changes at the
system level have consequences at the practice level
and, ultimately, improve outcomes for children and
families. The results have stimulated an increased focus
on practice-level issues.

The Stark County Study

The shift in focus to the practice level is being re-
inforced by results from another study by Bickman and
colleagues (1997, 1999) of children with emotional
disturbances who were served in Stark County, Ohio.
In this study, participating children were served within
the public mental health system by a multiagency
system of care; this was in contrast to the Fort Bragg
sample of military dependents seen in a mental health-
funded and -operated continuum of care. Children and
families who consented to participate in the study were
randomly assigned to one of two groups. The first
group was immediately eligible to receive services
within the existing community-based system of care in
Stark County. Families in the second group were
required to seek services on their own rather than to
receive them within the system of care. The major
differences in services provided were that significantly


more children and families in the system of care group
received case management and home visits than those
in the comparison group. Findings indicate no
differences in clinical or functional status 12 months
after intake. These results are similar to those of the
Fort Bragg study and suggest that attention should be
paid to the effectiveness of services delivered within
systems of care rather than only to the organization of
these systems.

Summary: Effectiveness of Systems of Care
Collectively, the results of the evaluations of systems
of care suggest that they are effective in achieving
important system improvements, such as reducing use
of residential placements, and out-of-state placements,
and in achieving improvements in functional behavior.
There also are indications that parents are more
satisfied in systems of care than in more traditional
service delivery systems. The effect of systems of care
on cost is not yet clear, however. Nor has it yet been
demonstrated that services delivered within a system of
care will result in better clinical outcomes than services
delivered within more traditional systems. There is
clearly a need for more attention to be paid to the
relationship between changes at the system level and
changes at the practice level.

Conclusions

1.









2.






3.

Childhood is characterized by periods of transition
and reorganization, making it critical to assess the
mental health of children and adolescents in the
context of familial, social, and cultural
expectations about age-appropriate thoughts,
emotions, and behavior.
The range of what is considered "normal" is wide;
still, children and adolescents can and do develop
mental disorders that are more severe than the "ups
and downs" in the usual course of development.
Approximately one in five children and adoles-
cents experiences the signs and symptoms of a
DSM-IV disorder during the course of a year, but
only about 5 percent of all children experience
what professionals term "extreme functional im-
pairment."

4.

5.

6.

7.

8.

9.

Children and Mental Health

Mental disorders and mental health problems
appear in families of all social classes and of all
backgrounds. No one is immune. Yet there are
children who are at greatest risk by virtue of a
broad array of factors. These include physical
problems; intellectual disabilities (retardation); low
birth weight; family history of mental and addictive
disorders; multigenerational poverty; and caregiver
separation or abuse and neglect.
Preventive interventions have been shown to be
effective in reducing the impact of risk factors for
mental disorders and improving social and
emotional development by providing, for example,
educational programs for young children, parent-
education programs, and nurse home visits.
A range of efficacious psychosocial and
pharmacologic treatments exists for many mental
disorders in children, including attention-
deficit/hyperactivity disorder, depression, and the
disruptive disorders.
Research is under way to demonstrate the
.effectiveness of most treatments for children in
actual practice settings (as opposed to evidence of
"efficacy" in controlled research settings), and
significant barriers exist to receipt of treatment.
Primary care and the schools are major settings for
the potential recognition of mental disorders in
children and adolescents, yet trained staff are
limited, as are options for referral to specialty care.
The multiple problems associated with "serious
emotional disturbance" in children and adolescents
are best addressed with a "systems" approach in
which multiple service sectors work in an
organized, collaborative way. Research on the
effectiveness of systems of care shows positive
results for system outcomes and functional
outcomes for children; however, the relationship
between changes. at the system level and clinical
outcomes is still unclear.

10. Families have become essential partners in the
delivery of mental health services for children and
  adolescents.

11. Cultural differences exacerbate the general
problems of access to appropriate mental health

193


Mental Health: A Report of the Surgeon General

services. Culturally appropriate services have been
designed but are not widely available.

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