Almost 4 years after Hurricane Katrina, the children living in the greater New Orleans area may be at particular risk for needing mental health services, but certain barriers may impede the delivery of such care. Since Hurricane Katrina, there has been increasing emphasis on providing community-based, rather than hospital-based, mental health services for low-income and uninsured children in the greater New Orleans area. Multiple federal agencies support the provision of mental health and related services for these children through various programs. Children in the greater New Orleans area may be at particular risk for needing mental health services. Researchers at LSU Health Sciences Center have conducted semiannual mental health screenings in selected schools in the greater New Orleans area since Hurricane Katrina. One of the lead LSU Health Sciences Center researchers told us that they had screened about 12,000 area children as of January 2008; of the children screened in January 2008, 30 percent met the threshold for a possible mental health referral. Although this was a decrease from the 49 percent level during the 2005-06 school year screening, the rate of decline was slower than experts had expected. The LSU Health Sciences Center lead researcher we spoke with interpreted this slower-than-expected decline as indicating that the mental health needs of children in the greater New Orleans area continue to be significant. The effects of a traumatic event can persist for years. For example, a 2006 study on the use of counseling services by people affected by the 2001 World Trade Center attack found that some people first sought counseling services more than 2 years after the event. Research has shown that children who grow up in poverty as well as those who are exposed to violence during or after a catastrophic disaster are at risk for the development of mental health disorders. In 2007 the poverty rate for each of the four parishes in the greater New Orleans area was higher than the national average, and in Orleans and St. Bernard parishes, the rate was at least twice the national average. People who have experienced or witnessed certain incidents, including serious physical injury, during or after a catastrophic disaster can face an array of psychological consequences. The LSU Health Sciences Center lead researcher we spoke with told us that January 2008 data showed that 16 to 21 percent of children screened had a family member who had been injured in Hurricane Katrina, and 13 to 18 percent of children screened had a family member who had been killed in the hurricane. The President’s 2003 New Freedom Commission on Mental Health determined that many barriers can impede delivery of services for people with mental illness. The commission specifically identified stigma, cost, not knowing where or how to obtain services, unavailable services, workforce shortages, and a fragmented mental health delivery system as barriers. The stigma surrounding mental illness—negative attitudes and beliefs about mental illness that can deter people from seeking treatment—was described as a pervasive barrier preventing Americans from understanding the importance of mental health. The commission also noted that there was a national shortage of mental health providers and a lack of providers trained in evidence-based practices. The commission recommended early intervention, education, and screening in low-stigma settings—such as primary care and school settings—as ways to prevent mental health problems in children from worsening. Before Hurricane Katrina, health care services for low-income and uninsured children and families in the greater New Orleans area were primarily hospital-based. These individuals had access to mental health services through Charity and University hospitals, which were a major source of psychiatric care for the area. About half of the patients served by these hospitals were uninsured, and about one-third were covered by Medicaid. Since Hurricane Katrina and the subsequent reduction in hospital capacity, according to state and local officials, there has been an increasing emphasis on providing community-based mental health services, including through school-based health centers (SBHC) and other programs that provide mental health services in schools. In general, SBHCs are located in schools or on school grounds and provide a comprehensive range of primary care services to children. Louisiana’s SBHCs provide mental health services in addition to other primary care services. The LDHH Office of Public Health operates the Adolescent School Health Initiative, which facilitates the establishment of SBHCs in Louisiana, establishes standards for SBHCs, and monitors their quality of care. Each SBHC is administered by a sponsor organization, such as a hospital or school, and is required to have a mental health provider on staff. A parent or guardian must sign a written consent form for a student to receive services at an SBHC. Some children can gain access to mental health services through the regional human services districts, to which LDHH’s Office of Mental Health, Office for Addictive Disorders, and Office for Citizens with Developmental Disabilities give funding to provide services in certain areas of the state. The regional human services districts operate and manage community-based programs and services, including mental health services. In the greater New Orleans area, the Jefferson Parish Human Services Authority serves Jefferson Parish, and the Metropolitan Human Services District serves Orleans, Plaquemines, and St. Bernard parishes. Multiple federal agencies support the provision of mental health and related services for children in the greater New Orleans area through various programs, including grant programs. (See app. II for information on selected federal programs that support mental health and related services for children. See app. III for information on selected services provided to children by these programs.) HHS supports the provision of mental health services for children in the greater New Orleans area through several of its agencies, including SAMHSA, HRSA, CMS, and ACF. SAMHSA, which has the primary federal responsibility for children’s mental health services, works to improve the availability of effective mental health services, substance abuse prevention and treatment services, and related services through formula grant programs—such as the Community Mental Health Services Block Grant— and discretionary grant programs—such as the National Child Traumatic Stress Initiative and the Child Mental Health Initiative. HRSA works to improve health care systems and access to health care for uninsured and medically vulnerable populations. Its Health Center Program supports health centers in the greater New Orleans area that provide primary care services, including mental health services, to adults and children. In addition, HRSA supports the provision of mental health services to children through formula and discretionary grant programs, such as the Maternal and Child Health Services Block Grant and the Bureau of Clinician Recruitment and Service’s National Health Service Corps Scholarship Program and Loan Repayment Program. CMS provides funding for health care coverage for its programs’ beneficiaries and administers certain additional grant programs related to Hurricane Katrina. CMS administers Medicaid and the State Children’s Health Insurance Program (CHIP), and the programs are jointly financed by the federal government and the states. Medicaid and CHIP represent a significant federal funding source for health services, including mental health services, for children in Louisiana. For example, in state fiscal year 2008, the Louisiana Medicaid and LaCHIP programs reimbursed almost $9.4 million to providers for over 66,000 claims for mental health services for children in the greater New Orleans area. Over 110,000 children in the greater New Orleans area were enrolled in these two programs as of August 2008. The programs cover inpatient psychiatric services, psychological and behavioral services provided by licensed psychologists, physician psychiatric services, and services of licensed clinical social workers when provided in certain settings. CMS also administers additional grant programs related to Hurricane Katrina, including the Primary Care Access and Stabilization Grant (PCASG), a program intended to assist in the restoration and expansion of outpatient primary care services, including mental health services, in the greater New Orleans area; the Professional Workforce Supply Grant, intended to address shortages in the professional health care workforce; and the Provider Stabilization Grants, a program intended to assist health care facilities that participate in Medicare to recruit and retain staff. ACF administers programs that promote the economic and social well- being of children, families, and communities. It supports counseling and treatment services, education, prevention initiatives, and ancillary services such as transportation through programs such as the Child Care and Development Fund and the Head Start program. In addition, in 2006 ACF distributed emergency supplemental Social Services Block Grant (SSBG) funding to Louisiana that in part supported mental health services. In addition to the HHS agencies, other federal agencies also support the provision of mental health and related services to children in the greater New Orleans area. Education supports mental health services for children through school violence prevention and substance abuse prevention programs, such as the Safe and Drug-Free Schools and Communities State Education Agency and Governors’ Grants. DOJ supports mental health services for children who have been victims of crime through its Crime Victim Assistance program. Some programs are the shared responsibility of multiple agencies. The Department of Homeland Security’s Federal Emergency Management Agency (FEMA) and SAMHSA are partners in administering the Crisis Counseling Assistance and Training Program (CCP), which provides crisis counseling services after events for which a presidential disaster declaration has been made. The CCP provided funding to LDHH’s Office of Mental Health, the state CCP grantee, for crisis counseling services in the greater New Orleans area after Hurricanes Katrina and Rita. FEMA also supported case management services for victims of Hurricanes Katrina and Rita through the Disaster Housing Assistance Program, which is administered by HUD. In addition to federal programs, state funding and donations also support mental health and related services to children in the greater New Orleans area. For example, a grant from the W.K. Kellogg Foundation is helping to support SBHCs in New Orleans. Louisiana must provide matching funds as a requirement of its receipt of some federal grants, so federal funding may represent only a portion of the total funding. For example, both HRSA’s Maternal and Child Health Services Block Grant and SAMHSA’s Child Mental Health Initiative require the state to match federal grant funds. Stakeholder organizations that participated in our structured interviews and responded to our DCI most frequently identified lack of mental health providers and sustainability of funding as barriers to providing mental health services to children in the greater New Orleans area. These organizations most frequently identified a lack of transportation, competing family priorities, and concern regarding stigma as barriers to families’ obtaining mental health services for children. A lack of mental health providers in the greater New Orleans area was the most frequently identified barrier to providing services to children among the stakeholder organizations that participated in our structured interviews. (See table 1.) Fifteen of the 18 organizations identified a lack of mental health providers—including challenges recruiting and retaining child psychiatrists, psychologists, and nurses—as a barrier. Several organizations specifically described challenges in recruiting and retaining staff with particular training, such as in evidence-based practices or treatment of children and adolescents. One organization said that while a nationwide shortage of trained mental health providers contributed to recruitment difficulties before Hurricane Katrina, the hurricane exacerbated the situation because many providers left the greater New Orleans area. In their responses to the DCI, 14 of the 15 organizations reported that recruitment was more challenging now than before Hurricane Katrina, and 12 of the 15 reported that retention was more challenging now than before Hurricane Katrina. Other developments underscore the lack of mental health providers as a barrier. For example, HRSA designated the parishes in the greater New Orleans area as health professional shortage areas (HPSA) for mental health in late 2005 and early 2006; before Hurricane Katrina, none of the parishes had this designation for mental health. HRSA’s ARF data also indicate that the greater New Orleans area has experienced more of a decrease in mental health providers than some other parts of the country. For example, the ARF data documented a 21 percent decrease in the number of psychiatrists in the greater New Orleans area from 2004 to 2006, during which time there was a 1 percent decrease in Wayne County, Michigan (which includes Detroit and which had pre-Katrina poverty and demographic characteristics similar to those of the greater New Orleans area) and a 3 percent increase in counties nationwide. Furthermore, LDHH data showed a 25 percent decrease in the number of mental health providers in the greater New Orleans area—including psychiatrists and licensed clinical social workers—who participated in Medicaid and LaCHIP from state fiscal year 2004 to state fiscal year 2008. Sustainability of funding—including difficulty securing reliable funding sources and limitations on reimbursement for services—was the second most frequently identified barrier to providing services for children. Thirteen of the 18 organizations identified sustainability of funding as a barrier. One organization stated that there was a need to secure sustainable funding from public and private sources because individuals and organizations that had provided funding before Hurricane Katrina were no longer donating because they were leaving the greater New Orleans area. Two organizations said that the ability to obtain reimbursement for mental health services provided outside of traditional clinic settings, such as in schools, would allow some of these services to be sustained over the long term. Organizations that participated in the structured interviews identified several additional barriers to providing services for children. Availability of referral services—including the limited availability of space at inpatient psychiatric hospitals and other types of treatment facilities—was identified as a barrier by five organizations. One organization noted that in order to place children in residential treatment for mental illness, it had to compete for beds in Shreveport—located 5 hours outside the greater New Orleans area—or potentially send children out of state. In either case, regular family involvement in treatment, which experts say is important for treatment success, would be limited. Three organizations identified a lack of coordination between mental health providers or other providers serving children as a barrier. A 2006 review of the mental health system in Louisiana found that children with mental health problems could receive services through multiple systems—such as primary health care, schools, and social services—and that the lack of coordination and communication among these systems could result in providers not providing services to children who need them or providing duplicated services. Finally, two organizations identified availability of physical space in which to house programs as a barrier. One organization said that more than 3 years after Hurricane Katrina, providers still had difficulty locating physical space. A lack of transportation in the greater New Orleans area was the most frequently identified barrier to obtaining mental health services for children among the stakeholder organizations that participated in our structured interviews. (See table 2.) Twelve of the 18 organizations identified a lack of transportation as a barrier. For example, 1 organization told us that it was difficult for children and families to travel to clinics to obtain services because the bus system was not running at full capacity and high gas prices in 2008 made travel by car more expensive. Another organization mentioned that more families had cars before Hurricane Katrina, but many of these vehicles were destroyed in the flooding. Furthermore, in their DCI responses, 10 of the 12 organizations reported that transportation was more challenging now than before Hurricane Katrina. Competing family priorities—including dealing with housing problems, unemployment, and financial concerns—was tied as the second most frequently identified barrier to obtaining services for children. Competing family priorities was identified as a barrier by 11 of the 18 organizations, and in their DCI responses, 10 of the 11 organizations reported that family stress was more challenging now than before Hurricane Katrina. One organization told us that families were focused on issues such as rebuilding their homes and reestablishing their lives and that mental health concerns were seen as a low priority. The organization added that in the greater New Orleans area the cost of living, such as for rent and food, had risen. For example, the average fair market rent in the New Orleans Metropolitan Statistical Area for a two-bedroom unit rose about 40 percent—from $676 to $949 per month—from fiscal year 2005 to fiscal year 2009, exceeding the estimated affordable monthly rent for a resident earning the average income of about $37,000 a year. Concern regarding the stigma that is associated with receiving mental health services was the other barrier to obtaining services for children that was identified second most frequently—by 11 organizations. One organization said that a perception existed that a parent, by seeking out mental health services for his or her child, was labeling that child as “crazy.” In their DCI responses, 7 of the 11 organizations reported that concern regarding stigma was as challenging now as it was before Hurricane Katrina. Several organizations, however, told us that although individuals may continue to have concern about stigma if their own child is identified as needing mental health services, they have also observed more acceptance of the idea of mental health services in general. Organizations identified several additional barriers to obtaining children’s mental health services in the greater New Orleans area. A lack of service availability—including the availability of translation services and the ability to easily obtain an appointment—was identified as a barrier by eight organizations. For example, one organization told us that one parish’s high schools had students from up to 50 different ethnic groups, including a larger number of non-English-speaking students than before Hurricane Katrina. Although the children were learning English, the teachers and administrators were challenged in trying to communicate with the parents and to preserve confidentiality when using an interpreter. In addition, five of the eight organizations reported in their DCI responses that the availability of translation and interpretation services was more challenging now than before Hurricane Katrina. Three organizations identified not knowing where to go to obtain services as a barrier. For example, one organization said that before the hurricane many people knew mental health services were available at Charity Hospital, but that following its closing fewer people were aware of alternate locations offering such services. All three organizations reported in their DCI responses that not knowing where to go for services was a more challenging barrier now than before Hurricane Katrina. Finally, the lack of health insurance was identified as a barrier by two organizations. One organization said that many parents were overwhelmed by the process of signing up their children for LaCHIP, especially because living in multiple states complicated the process. A range of federal programs address the most frequently identified barriers to providing and obtaining mental health services for children, but much of the funding for these programs is temporary. Since Hurricane Katrina, SBHCs have emerged as a key approach to addressing barriers to obtaining services, and state agencies have used federal funding to support these clinics. We found that the federal programs in our review provided funding that addresses four of the five most frequently identified barriers but that much of it was temporary and did not fully address the remaining barrier in this group, sustainability of funding. (See app. II and app. III, respectively, for additional information on the federal programs in our review and selected services supported by these programs.) Lack of mental health providers. After Hurricane Katrina, the greater New Orleans area received funding from CMS and HRSA programs to address a general lack of providers, including children’s mental health providers. For example, as of May 2008, CMS’s Professional Workforce Supply Grant, created with the intent to recruit and retain health professionals in the greater New Orleans area, was used to provide financial incentives to 82 mental health providers who agreed to either take a new position or continue in a position in the greater New Orleans area and to serve for at least 3 years. This funding will be available through September 2009. About two-thirds of the provider organizations receiving PCASG funds told us they used some of the funding to hire mental health providers; these funds will be available through September 2010. In addition, through CMS’s Provider Stabilization Grants, awarded to Louisiana to help health care facilities hire and retain providers, $52,001 was provided in June 2007 to community mental health centers in Orleans Parish that serve children. As of October 2008, HRSA’s Bureau of Clinician Recruitment and Service, which provides student loan repayment and scholarships to providers serving in designated HPSAs, was supporting 7 mental health professionals in the greater New Orleans area—4 social workers, 2 psychologists, and 1 child psychiatrist. A few federal programs support training of children’s mental health providers, which helps address a lack of providers trained in children’s mental health, which was identified as a barrier in our structured interviews. SAMHSA’s National Child Traumatic Stress Initiative awarded two grants in October 2008 to providers in the greater New Orleans area to provide training on, implement, and evaluate trauma-focused treatment for children. For example, providers in the greater New Orleans area were trained on various trauma-related interventions, which included evidence- based practices that are delivered in schools. In addition, the Children’s Health Fund Community Support and Resiliency Program, whose funding from SAMHSA expires in September 2009, provides comprehensive training and technical assistance on the assessment and treatment of trauma in children for medical, mental health, education, and child care professionals in the greater New Orleans area. Lack of transportation. Although none of the federal programs included in our review are designed solely to provide transportation for children obtaining mental health services, officials we interviewed told us that funding from several federal programs has been used in that way. For example, Louisiana designated $150,000 in the fiscal year 2009 Community Mental Health Services Block Grant state plan for transportation for children in the greater New Orleans area, and funding from ACF’s 2006 SSBG supplemental grant and SAMHSA’s Child Mental Health Initiative has also been used to supply transportation to mental health appointments for children. Louisiana Medicaid officials told us that the Louisiana Medicaid program provides reimbursement for nonemergency, previously authorized transportation for enrolled children for any Medicaid-covered service and for medical emergencies, including transportation to inpatient mental health facilities. Louisiana Medicaid also provides reimbursement to family or friends who provide medically necessary transportation for Medicaid enrollees and provides reimbursement for home- or community- based treatment, which can reduce the need for transportation to provider offices. SAMHSA’s National Child Traumatic Stress Initiative has two grantees in the greater New Orleans area that provide trauma-focused mental health services to children in schools, which can also reduce the need for transportation to provider offices. For example, an official from one grantee told us they have provided mental health services to children who live in the more rural sections of the greater New Orleans area, for whom travel time to services could be a significant barrier to obtaining care. Competing family priorities. Federal programs provide funding that is used to alleviate conditions that create competing family priorities— including dealing with housing problems, unemployment, and financial concerns—to help families more easily obtain children’s mental health services. Federal programs address competing priorities, in part, by providing case management, information, and referral services, which can help families identify and obtain services such as health care, housing assistance, and employment assistance. For example, the 2006 SSBG supplemental funding supported over 25,000 case management services to children in Louisiana from July 2006 through September 2008. In addition, officials from a local organization that received funding from ACF’s Head Start told us that the program had provided families with information and referrals for mental health services. HUD’s and FEMA’s Disaster Housing Assistance Program provided case management services, which included social services such as job training and referrals for mental health services, in addition to rental assistance to certain families displaced by Hurricanes Katrina and Rita. The program ended on March 1, 2009, but program clients in Louisiana will continue to receive services through a transitional program through August 31, 2009. Federal programs also address competing family priorities by providing direct financial assistance, which may help alleviate family stress and make it easier for families to devote resources and effort to obtaining mental health services for their children. For example, the Metropolitan Human Services District uses federal funding from the Community Mental Health Services Block Grant to give financial assistance for utilities, rent, and school uniforms to families of children who have certain mental health disorders, or to provide family stabilization services to help keep these children in their homes. In addition, the Louisiana state program that uses the SAMHSA Child Mental Health Initiative grant provides time- limited funding for tutoring, school uniforms, and other expenses when they are a part of an individualized service plan for children with diagnosed mental health disorders. Concern regarding stigma. An official from one of the National Child Traumatic Stress Initiative grantees in the greater New Orleans area told us that because school systems they have worked with have integrated the delivery of mental health services into the schools, the stigma associated with mental health services has decreased. In addition, some federal programs support the provision of education services, which the President’s New Freedom Commission on Mental health reported can reduce stigma associated with mental health services. For example, in 2008 FEMA’s and SAMHSA’s CCP program provided information about counseling services through a media campaign that included billboards, television commercials, and print and radio advertisements. SAMHSA’s State/Tribal Youth Suicide Prevention Grants provided suicide prevention and education services through a 2007 media campaign that included busboards, radio public service announcements, and print advertisements throughout the greater New Orleans area. Sustainability of funding. Although most of the federal programs we identified were not established as a direct result of Hurricane Katrina, the programs that are hurricane-related have been an important source of support for mental health services for children in the greater New Orleans area. However, much of this funding is temporary. For example, three hurricane-related grant programs—CMS’s PCASG and Professional Workforce Supply Grant and ACF’s 2006 SSBG supplemental funding— will no longer be available to grantees after 2010. Although the PCASG was created with the expectation that providing short-term financial relief would significantly increase the likelihood of the PCASG fund recipients’ sustainability, and PCASG recipients were required to prepare sustainability strategies as part of their application, it is too early to know whether these organizations will achieve sustainability. Since Hurricane Katrina, the number of SBHCs in the greater New Orleans area has increased. At the start of the 2005-06 school year, there were seven SBHCs providing mental health and other primary care services to children in the greater New Orleans area. Most of these SBHCs were closed as a result of damage from Hurricanes Katrina and Rita, and the ones that remained open had also sustained damage. During the 2007-08 school year, there were nine SBHCs in the greater New Orleans area, and state officials told us in February 2009 that at least four more SBHCs were in the planning stages for this area. Louisiana’s SBHCs receive their funding from several sources. The LDHH Office of Public Health, which oversees SBHCs in the state, provides some state funding. There is no federal program whose specific purpose is to support SBHCs, but LDHH and local providers have used funding from various federal sources to support SBHCs. For example, a state official told us that the Office of Public Health has used a small portion of LDHH’s annual Maternal and Child Health Services Block Grant from HRSA to support SBHCs. Some organizations that support SBHCs in the greater New Orleans area have also received temporary funding, such as from the PCASG and the hurricane-related SSBG supplemental funding. In addition, the Jefferson Parish Human Services Authority, which provides mental health services at SBHCs, has received funding allocated by LDHH’s Office of Mental Health from SAMHSA’s Community Mental Health Services Block Grant. Furthermore, providers at some SBHCs told us they could receive Medicaid reimbursement for some mental health services, including those related to psychiatric care. State officials told us that although CMS permitted the reimbursement of social work services provided at SBHCs, the Louisiana Medicaid program had not provided reimbursement for social work services because of state funding constraints. Some SBHCs may also obtain funding from nonprofit organizations. For example, grant funding from the W.K. Kellogg Foundation was significant in the rebuilding and expansion of SBHCs after Hurricane Katrina. Because Louisiana requires SBHCs to have mental health staff on-site, SBHCs can be an access point for children who need mental health services in the greater New Orleans area. Furthermore, some SBHCs in the area have a psychiatrist on staff on a part-time basis. During the 2007-08 school year, the need for mental health services was the primary reason for almost one-quarter of students’ visits to SBHCs in the greater New Orleans area. In addition, SBHC health care providers told us that students who visited the SBHCs for other reasons may have also received mental health services. SBHCs in the greater New Orleans area have emerged as a key approach to addressing the top three barriers to obtaining services identified in our structured interviews—a lack of transportation, competing family priorities, and concern regarding stigma. SBHCs are generally located in schools or on school grounds, which reduces students’ need for transportation to obtain care. The SBHCs in Jefferson Parish serve students on multiple school campuses, and students in schools not colocated with an SBHC can be transported when necessary. SBHC services may be provided at low or no cost to the patient, which lessens the financial burden on the family. The location of SBHCs in schools or on school grounds also reduces the need for a parent to take time off from work to accompany a child to appointments. In addition, colocation of mental health and other primary care services may reduce concern regarding stigma because the type of service the child is receiving at the SBHC is generally not apparent to an observer. One SBHC provider told us that offering mental health services in the same location as other primary care services “demystifies” mental health services and eliminates the perception that they are separate from primary care services. Officials at SBHCs told us they were working to obtain additional funding to help achieve long-term sustainability of the clinics. Officials from the Metropolitan Human Services District told us that it would not be possible for every school to have an SBHC, but that they were working on an initiative with other local organizations and school districts to develop a “hub” system to deliver health care services, including mental health services, to children in the greater New Orleans area. Under the planned pilot program, individual SBHCs or other community clinics would become hub clinics that would serve 10 feeder schools, 6 of which would be served by 2 mental health providers funded by the Metropolitan Human Services District, and 4 of which would be served by mental health providers funded by other organizations. Children needing services beyond those provided by their school mental health provider or nurse could be referred to the hub clinic. Officials planned to begin hiring school nurses and mental health providers for the feeder schools by July 2009. We provided a draft of this report to HHS and Education for their review. HHS provided comments on two key issues. HHS’s comments are reprinted in appendix IV and discussed below. In addition, both HHS and Education provided technical comments. We incorporated HHS and Education comments as appropriate. In its comments, HHS stated that our draft report focused too heavily on SBHCs, to the exclusion of other models of care. HHS noted that the school systems in the greater New Orleans area have been very receptive to the direct provision of mental health services in schools, because of the psychological difficulties experienced by school children due to distress related to Hurricane Katrina. HHS supplied additional information on SAMHSA’s National Child Traumatic Stress Initiative’s two grantees in the greater New Orleans area, which provide mental health services in schools. We highlighted SBHCs in our draft report because they have emerged as a key approach to serving children in the greater New Orleans area, due in part to the state’s use of federal funds to support this model of care. Our discussion of SBHCs in the greater New Orleans area is not intended to imply that they are the only model for providing school-based mental health services to children, and we have added additional information to our report on the National Child Traumatic Stress Initiative grantees. HHS also commented that many SBHCs do not provide mental health services, and that those that do provide them may not have staff who can provide more intensive services. However, as our draft indicated, all SBHCs in Louisiana are required to have a mental health provider on staff and therefore can be a valuable resource for children seeking mental health services. We have also added information to the report indicating that some SBHCs in the greater New Orleans area have a psychiatrist on staff on a part-time basis. HHS commented that our draft report minimized housing problems faced by children and families in the greater New Orleans area in our discussion of barriers to obtaining mental health services; HHS also stated that the lack of stable housing in the area is one of the greatest barriers to children’s mental health recovery. We disagree that the draft report minimized the role of housing problems. Our findings were based on barriers identified by stakeholders, who described what they believed to be the greatest barriers to families obtaining mental health services for children. The draft report included information related to housing problems in greater New Orleans in our discussion of competing family priorities, which tied as the second most frequently identified barrier to obtaining mental health services for children. However, we added information to the report to emphasize that housing problems may affect children’s mental health. In its comments, HHS also provided additional information on SAMHSA’s Child Mental Health Initiative, which we have incorporated as appropriate. We also expanded our description of FEMA’s and SAMHSA’s CCP in our appendix on federal programs in response to HHS’s comments. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the Secretary of Health and Human Services, the Secretary of Education, and appropriate congressional committees. The report also will be available at no charge on GAO’s Web site at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or bascettac@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff members who made major contributions to this report are listed in appendix V. We have estimated that about 187,000 children through age 17 were living in the greater New Orleans area during 2008. To arrive at this estimate, we calculated the total enrollment for all public and private schools in the greater New Orleans area by adding the number of public school students as of fall 2008 (89,178) to the number of private school students reported for the 2008-09 school year (41,188). About 130,366 children were enrolled in public and private schools in the greater New Orleans area for the 2008- 09 school year, which was 70 percent of pre-Katrina enrollment (186,530 in the 2004-05 school year). However, school enrollment data underestimate the total child population, as they do not include all children younger than school age. Therefore, we generated our estimate by adding the total enrollment data to birth data for 2004 through 2008. (See fig. 1.) Table 3 is a list of the federal programs in our review that have been used to support the provision of mental health or related services to children in the greater New Orleans area. The list includes 9 formula grant programs that support the provision of mental health services through noncompetitive awards to the state based on a predetermined formula, and 13 discretionary grant programs that support services that address at least one of the identified barriers to providing and obtaining mental health services for children. It was not possible for us to calculate a total amount of federal funding allocated or spent to support mental health services to children in the greater New Orleans area or the total number of children served through federal programs because of a lack of comparable data among federal and state agencies and individual programs. Figure 2 is a list of selected services supported by the federal programs in our review for children in the greater New Orleans area. In addition to the contact named above, Helene F. Toiv, Assistant Director; Elan Martin; Roseanne Price; Julie L. Thomas; Laurie F. Thurber; Jennifer Whitworth; Malissa G. Winograd; and Suzanne Worth made key contributions to this report. Hurricane Katrina: Federal Grants Have Helped Health Care Organizations Provide Primary Care, but Challenges Remain. GAO-09-588. Washington, D.C.: July 13, 2009. Disaster Assistance: Greater Coordination and an Evaluation of Programs’ Outcomes Could Improve Disaster Case Management. GAO-09-561. Washington, D.C.: July 8, 2009. Disaster Assistance: Federal Efforts to Assist Group Site Residents with Employment, Services for Families with Children, and Transportation. GAO-09-81. Washington, D.C.: December 11, 2008. Catastrophic Disasters: Federal Efforts Help States Prepare for and Respond to Psychological Consequences, but FEMA’s Crisis Counseling Program Needs Improvements. GAO-08-22. Washington, D.C.: February 29, 2008. School Mental Health: Role of the Substance Abuse and Mental Health Services Administration and Factors Affecting Service Provision. GAO-08-19R. Washington, D.C.: October 5, 2007. Hurricane Katrina: Status of Hospital Inpatient and Emergency Departments in the Greater New Orleans Area. GAO-06-1003. Washington, D.C.: September 29, 2006. Hurricane Katrina: Status of the Health Care System in New Orleans and Difficult Decisions Related to Efforts to Rebuild It Approximately 6 Months after Hurricane Katrina. GAO-06-576R. Washington, D.C.: March 28, 2006. Hurricane Katrina: GAO’s Preliminary Observations Regarding Preparedness, Response, and Recovery. GAO-06-442T. Washington, D.C.: March 8, 2006. Mental Health Services: Effectiveness of Insurance Coverage and Federal Programs for Children Who Have Experienced Trauma Largely Unknown. GAO-02-813. Washington, D.C.: August 22, 2002.

Summary: The greater New Orleans area--Jefferson, Orleans, Plaquemines, and St. Bernard parishes--has yet to fully recover from the effects of Hurricane Katrina. As a result of the hurricane and its aftermath, many children experienced psychological trauma, which can have long-lasting effects. Experts have previously identified barriers to providing and obtaining mental health services for children. The Department of Health and Human Services (HHS) and other federal agencies have supported mental health services for children in greater New Orleans through various programs, including grant programs initiated in response to Hurricane Katrina. GAO was asked to study the federal role in addressing barriers to these services in greater New Orleans. In this report, GAO (1) identifies barriers to providing and to obtaining mental health services for children in greater New Orleans, and (2) describes how federal programs, including grant programs, address such barriers. To do this work, GAO used a structured interview and a written data collection instrument to gather views on barriers from 18 state and local stakeholder organizations selected on the basis of experts' referrals and the organizations' roles in children's mental health. To learn how federal programs address these barriers, GAO reviewed documents from and interviewed federal, state, and local officials involved in providing mental health services to children. GAO's work included a site visit to greater New Orleans. Stakeholder organizations most frequently identified a lack of mental health providers and sustainability of funding as barriers to providing mental health services to children in the greater New Orleans area; they most frequently identified a lack of transportation, competing family priorities, and concern regarding stigma as barriers to families' obtaining services for children. Fifteen of the 18 organizations identified a lack of mental health providers--including challenges recruiting and retaining child psychiatrists and psychologists--as a barrier to providing services to children. Thirteen organizations identified sustainability of funding, including difficulty securing reliable funding sources, as a barrier to providing services. A lack of transportation was most frequently identified--by 12 organizations--as a barrier to families' ability to obtain services for their children. The two second most frequently identified barriers to obtaining services were competing family priorities, such as housing problems and financial concerns, and concern regarding the stigma associated with receiving mental health services. A range of federal programs, including grant programs, address some of the most frequently identified barriers to providing and obtaining mental health services for children, but much of the funding they have supplied is temporary. Several federal programs support state and local efforts to hire or train mental health providers. For example, HHS's Professional Workforce Supply Grant has resulted in recruitment and retention incentives to mental health providers in the greater New Orleans area. Several HHS programs allow funding to be used to transport children to mental health services, including Medicaid and the 2006 Social Services Block Grant (SSBG) supplemental funding provided to Louisiana. However, much of the funding, including that from the Professional Workforce Supply Grant and the supplemental SSBG, is hurricane-related and will no longer be available after 2010. School-based health centers (SBHC) have emerged as a key approach in the area to address barriers to obtaining mental health services for children, and although there is no federal program whose specific purpose is to support SBHCs, state programs have used various federal funding sources to support them. For example, a Louisiana official told us funds from HHS's Maternal and Child Health Services Block Grant and Community Mental Health Services Block Grant support SBHCs in greater New Orleans. SBHCs address the transportation barrier because they are located on school grounds, and they help families by reducing the need for a parent to take time off from work to take a child to appointments. In addition, because SBHCs provide both mental health and other primary care services, the type of service a child receives is not apparent to an observer, which may reduce concern about stigma. In commenting on a draft of this report, HHS provided additional information on mental health services provided in schools other than through SBHCs and emphasized the effect of a lack of stable housing on children's mental health. HHS also provided technical comments. GAO incorporated HHS's comments as appropriate.