Many children across the country have been victims of, or witnesses to, violence in their homes, schools, or communities. In 1999, according to the most recent edition of a joint Justice and Education report, students aged 12 through 18 were victims of about 186,000 violent crimes at school and about 476,000 violent crimes away from school. In addition, thousands of children have been exposed to natural disasters or terrorist acts such as those that occurred on September 11, 2001, placing them at risk for mental health problems. While many children respond to these situations with resilience, others suffer acute and chronic effects. Children’s reactions to trauma may appear immediately after the traumatic event or may appear days, weeks, months, or even years later. Researchers report that children who experience traumatic events show a wide range of reactions, and their nature and intensity vary on the basis of factors such as the type and frequency of trauma, whether a child knew the offender or victim, the strength of the family support system, and a child’s sex and age. For example, children age 5 and younger typically react to traumatic events with crying, screaming, and fear of being separated from a parent, while adolescents tend to have reactions similar to adults, such as flashbacks, nightmares, and suicidal thoughts. A child’s reactions to traumatic events, including disasters, may also vary based on how well their parents cope with the situation and on whether a child or parent has a preexisting mental disorder. Some children have a special vulnerability to the impact of traumatic events. Studies indicate that the impact is likely to be greatest for a child who had previously been victimized or already had a mental health problem. Certain psychiatric diagnoses are associated with exposure to traumatic events, including acute stress disorder, PTSD, depression, and conduct disorder. Children with acute stress disorder can display multiple symptoms, including reexperiencing of the event, avoidance of situations that remind them of the traumatic event, sleep disturbances, poor concentration, and regressive behavior. The disorder is of short duration, with symptoms beginning within 4 weeks of a traumatic experience and lasting from 2 days to 4 weeks. If symptoms continue, the diagnosis may be reevaluated and changed to PTSD. PTSD is similar to acute stress disorder and shares many of the same symptoms, but lasts longer. It is diagnosed when symptoms persist more than a month, although the disorder may develop either immediately after a traumatic event or several months later. Exposure to traumatic events may also result in depression, which is generally characterized by changes in appetite, sleep disturbances, constant sadness, and irritability. Conduct disorder may also develop after experiencing a traumatic event. The disorder is identified by a persistent pattern of behavior that violates major age-appropriate societal norms, such as aggression toward people and animals or destruction of property. The prevalence of different diagnoses varies based on factors such as age and sex. For example, a preliminary report on how the September 11, 2001, attack affected New York City public school students found that children in grades 4 and 5 were more likely than children in grades 6 to 12 to experience PTSD and other disorders involving intense fear and avoidance of usual activities, while the older children were more likely to have conduct disorder or depression. Similarly, girls had higher rates of PTSD, depression, and generalized anxiety than boys, who had higher rates of conduct disorder. Depending on the nature and severity of a traumatized child’s condition, a variety of mental health treatment options and service settings may be recommended. These include outpatient individual, family, or group therapy; inpatient hospital care; and residential care. A range of service providers, including psychiatrists, psychologists, psychiatric nurses, counselors, and clinical social workers, may treat children who have experienced trauma. Optimal care of these children often requires participation by a variety of service systems, such as mental health and social services. The Surgeon General has reported that there are not enough mental health professionals trained to work with children. Moreover, trauma experts report that even professionals who are trained to work with children may not have specialized training or experience in working with children who have experienced trauma. Children whose families do not speak English can have a particularly difficult time finding providers who can assist them. Because the types of trauma that children experience vary considerably, numerous pathways can lead to the identification, referral, assessment, and treatment of traumatized children needing mental health services. These pathways include families; schools; day care; primary health care; and the law enforcement, juvenile justice, and child protective services systems. However, the professionals working in these systems may not be trained to identify children with trauma-related mental health problems. For example, a recent report by the Surgeon General noted that primary care providers often have little training on mental health services and vary in their capacity to recognize and diagnose disorders and to coordinate with mental health providers. In addition, the Institute of Medicine recently concluded that health professionals are not sufficiently educated about family violence. Further, not all teachers are aware of the connection between academic or behavioral problems and the possibility that they are related to a child’s exposure to violence. Justice has also reported that law enforcement personnel are generally not sufficiently aware of the psychological effects that witnessing violence can have on children. At the national level, few data are available on the number of children who need mental health services as a result of exposure to trauma and the number who receive services. For example, there are no nationwide data on the number of children in foster care and the juvenile justice system— populations likely to have been exposed to trauma—who need mental health care, or on the number who have received treatment. Access to health care services, including mental health services, is highly correlated to having health insurance coverage. According to March 2001 Current Population Survey data, over 67 million children nationwide have health insurance coverage. More than two-thirds of children under age 19— almost 54 million—obtain health insurance privately, either as a dependent under a parent’s or guardian’s employer-sponsored health plan or through the individual insurance market. In addition, almost 14 million children are enrolled in public programs such as Medicaid, SCHIP, or other federal insurance programs. Although most children have insurance coverage, over 9 million remain uninsured. (See table 1.) Despite widespread health insurance coverage of children, private health insurance plans historically included greater restrictions on mental health benefits than on benefits for other health services. Consequently, federal and state laws have attempted to partially equalize benefit levels. The federal Mental Health Parity Act of 1996 (MHPA) prohibits certain group health plans sponsored by employers with more than 50 employees from imposing annual or lifetime dollar limits on mental health benefits that are more restrictive than those imposed on other benefits. As of March 2000, more than half of the states had also passed laws that exceeded the federal law by requiring that certain health insurers not only have parity in dollar limits, but also in service limits and cost-sharing provisions. However, these state mental health parity provisions do not affect employers who pay their employees’ health expenses directly rather than by purchasing insurance. Federal law permits states to regulate insurance, but employers’ self-funded health plans, which covered almost half of all employees enrolled in employer-sponsored plans in 1999, are not affected by such state insurance regulations. Medicaid operates as a joint federal-state program to finance health care coverage for certain categories of low-income individuals. Within guidelines established by federal law, states have considerable flexibility in how they structure their programs, including determining eligibility levels and what benefits to cover. For example, federal law requires states to offer Medicaid coverage to children age 5 and under if their family incomes are at or below 133 percent of the federal poverty level and to children ages 6 to 18 if their family incomes are at or below the federal poverty level. To offer coverage to additional children, many states have set family income eligibility thresholds beyond these minimum federal levels. Benefits covered by state Medicaid programs are either mandatory or optional. For example, states are required to cover EPSDT services, which include comprehensive, periodic health and developmental evaluations or screenings. A state must cover any services necessary to treat physical and mental conditions detected through these screenings, regardless of whether the services are covered by the state’s Medicaid program. We have previously reported that the extent to which children actually receive EPSDT services is not fully known, largely because no reliable, national utilization data exist for these services. States also have the option to provide beneficiaries with a number of other services, such as inpatient psychiatric and psychological services. HHS’s Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Medicaid and SCHIP programs, does not have current data that comprehensively summarize the extent to which states cover mental health services; however, other available sources suggest that the majority of states provide some level of mental health coverage as an optional benefit. In 1997, the Congress enacted SCHIP to provide health care coverage to low-income children living in families whose incomes exceed the eligibility limits for Medicaid. Although SCHIP is generally targeted to families with incomes at or below 200 percent of the federal poverty level, each state may set its own income eligibility limits within certain guidelines. As a result, SCHIP maximum income eligibility levels vary considerably among states, ranging from 100 to 350 percent of the federal poverty level. States have three options in designing SCHIP: expand their Medicaid programs, develop separate child health programs that function independently of the Medicaid programs, or do a combination of both. States that implement SCHIP by expanding Medicaid must use Medicaid’s enrollment structures and benefit packages (including EPSDT services); in contrast, separate SCHIP programs may depart from Medicaid requirements for benefits and for the plans, providers, and delivery systems available. (See app. III for a state summary of SCHIP programs.) Several federal departments and agencies have responsibility for addressing the mental health needs of children who have experienced trauma. For example, HHS agencies have responsibility for improving the accessibility and delivery of mental health services, conducting research on children’s mental health issues, disseminating information on promising approaches for improving children’s mental health, and promoting the well- being of children. In addition to CMS, these agencies include ACF, the Health Resources and Services Administration (HRSA), the Indian Health Service, and SAMHSA. In addition, the National Institutes of Health, the Centers for Disease Control and Prevention, and the Agency for Health Care Research and Quality fund research on a range of topics related to child victims and trauma, including the effects of trauma on children and interventions to assist children who have experienced trauma. HHS’s Office of Public Health and Sciences coordinates programs across agencies and supports crosscutting initiatives involving children’s mental health. FEMA is charged with providing financial and technical assistance to states and federally recognized Indian tribes for crisis counseling and other services to children and adults affected by presidentially declared disasters, which can include earthquakes, fires, floods, hurricanes, and terrorism. Justice seeks to mitigate the effects of violence on children, including by paying for mental health services for children who are victims of, or witnesses to, violent crimes. Offices within Justice that focus on this population include the Office of Juvenile Justice and Delinquency Prevention, the Violence Against Women Office, and the Office for Victims of Crime (OVC), all within the Office of Justice Programs. In addition, Education, through its Office of Elementary and Secondary Education, oversees programs that can help students obtain services to ensure that mental health problems do not interfere with their ability to learn. Private health insurance plans, such as employer-sponsored or individually purchased plans, and public programs, such as Medicaid or SCHIP, provide health insurance coverage to 88 percent of children. Although most children have health insurance, the level of mental health coverage available to children varies and depends largely on the type of insurance they have. While children enrolled in private insurance plans often face limitations in their mental health coverage, such as the exclusion of certain diagnoses from coverage or limits on the number of covered visits for outpatient therapy, children in Medicaid and SCHIP programs generally have coverage for a wide range of mental health services. The typically broader coverage of Medicaid programs and SCHIP programs that are Medicaid expansions is largely due to these programs being required to cover all necessary health care for problems detected through an EPSDT screening. Despite the availability of public insurance coverage, other factors, such as low Medicaid reimbursement rates that discourage provider participation or SCHIP cost-sharing requirements that may make services unaffordable for some families, could affect children’s access to services. Although little is known nationwide about the extent to which children in public insurance programs receive mental health services, available evidence suggests that children in some states may not be receiving services they need. The extent to which private health insurance plans cover mental health services varies. Most employer-sponsored health plans cover inpatient and outpatient mental health services, as do individual insurers, although to a lesser extent. However, private insurance plans often contain coverage or other restrictions, which may limit the availability of mental health services to enrollees, including children who have been exposed to trauma. For example, private plans may impose day or visit limits on mental health treatment, exclude certain diagnoses or benefits from coverage, or not offer mental health coverage at all. Employer-sponsored group health plans, which cover over 50 million children, or 66 percent, typically include mental health benefits that children who have experienced trauma may need. However, many of these plans impose more restrictive limits, such as day or visit limits, on mental health benefits than on other benefits. For example, in a prior survey of nearly 900 employers, we found that 87 percent of employer plans complied with the dollar parity requirements of the MHPA but set other limits that were not prohibited by MHPA, such as the number of allowable outpatient visits or inpatient days for mental health treatment. In contrast, few plans imposed limits on hospital days or office visits for health conditions not related to mental health. In addition, a survey conducted by Mercer/Foster Higgins of 2,813 employers that sponsor health plans found that at least 73 percent of preferred provider organization (PPO), point of service (POS), and health maintenance organization (HMO) health plans offered by employers with more than 500 employees imposed annual limits on mental health services. These plans most commonly imposed day and visit limits on mental health services, with median limits of 30 inpatient days and 30 outpatient visits per year. (See table 2.) Although for some children these service levels are sufficient, these limits may not provide adequate coverage for some traumatized children who require long-term mental health treatment. Limitations in mental health coverage are more pronounced for the over 3 million children covered by individual insurance plans. Unless precluded by state law, mental health benefits in the individual market can be more restrictive than other benefits in such areas as annual or lifetime dollar limits on what the plan will pay and service limits, such as fewer covered hospital days or outpatient office visits. The individual market may also have higher cost-sharing, such as deductibles, copayments, or coinsurance. We found such limitations among individual health plans we reviewed. For example, one insurer imposed a lifetime limit of $10,000 on mental health benefits, while another insurer that sells individual health plans in nearly 40 states includes mental health coverage only if required by state law. Another insurer limited annual mental health coverage to $1,500 for each member. (See app. IV for a summary of differences in individual market health plan coverage for certain mental health treatments available to children in six states.) In addition, few states require insurers in the individual market to guarantee access to health insurance coverage for people with mental disorders, leaving some children unable to obtain any health insurance. We recently reported that in several states, applicants for individual health insurance who had certain conditions, such as PTSD, would likely be denied coverage by five of the seven insurers reviewed. To address these and other limitations in mental health coverage, many states have passed laws that exceed the requirements of MHPA. Among the six states we reviewed, three—California, Massachusetts, and Minnesota—mandated that health plans offer mental health benefits at the same level as other benefits. The other three states—Georgia, Illinois, and Utah—took varied approaches to requirements on mental health coverage. Laws in these states apply only to certain types of health plans or do not require health plans to include mental health coverage. However, self- funded employer group plans, which covered close to half of all private sector employees in group health plans in 1999, are beyond the purview of state regulation and thus exempt from these reforms. (See app. V for a summary of selected laws related to mental health insurance coverage in these states.) The 16 percent of children enrolled in Medicaid and SCHIP typically have coverage for a wide range of mental health benefits. However, coverage limitations and other factors, such as Medicaid reimbursement rates to providers and SCHIP cost-sharing requirements, could affect children’s access to services and available data suggest that some enrolled children are not receiving mental health services they need. With few exceptions, the Medicaid programs in the six states we reviewed provided children with coverage for a wide range of mental health services. For example, all six states provided children with coverage for diagnostic assessments, outpatient therapy, medication management, and mental health treatment in residential care facilities, and did not impose day or visit limits or cost-sharing requirements. In addition to specified mental health services, Medicaid requires states to cover all necessary health treatment services when a health problem that could affect a child’s development is detected during an EPSDT screening, regardless of whether the condition or treatment is explicitly covered by the state’s Medicaid program. A required element of an EPSDT screening is a comprehensive history, which is supposed to include an assessment of a child’s mental health needs. Although many states have developed recommended screening protocols for health care providers to complete on specified schedules, CMS defines screenings very broadly and considers any encounter with a health care provider to be a screening sufficient to identify and require the provision of needed services. One mental health service that can be important to families of children who have experienced trauma is respite care. Although respite care is not a mandatory Medicaid service, states may use flexibility available under the Medicaid statute to cover respite services, such as child care and weekend group home services, in order to provide some relief for an eligible child’s parent, guardian, or primary caregiver. By providing a temporary period of time apart for parents and their children, respite care services can decrease stress in the family and increase the likelihood that a child with a mental illness can continue to live at home and avoid placement in an institution. However, only one of the six state Medicaid programs we reviewed—Minnesota—explicitly covered respite services for some children with mental illness. Despite having mental health coverage, children enrolled in Medicaid may face constraints when they attempt to obtain covered services. For example, children may have difficulty finding providers to treat their mental health needs. Officials in the six states we reviewed said that their states had shortages of mental health providers, especially child psychiatrists, and that these shortages were particularly acute in rural areas. In addition, some providers said that low Medicaid reimbursement rates, coupled with delayed payments from states, discourage providers from participating in Medicaid. Although not specifically focused on mental health services, studies have compared Medicaid fee-for-service reimbursement rates to Medicare and have shown that Medicaid rates are significantly lower. For example, in the six states we reviewed, Medicaid reimbursed physicians for a psychiatric diagnostic interview at rates that ranged from 28 to 78 percent of the average national rate Medicare pays for the same service. The SCHIP programs in the six states we reviewed varied in their extent of mental health service coverage and the extent to which they have instituted cost-sharing requirements for covered beneficiaries. Four of the six SCHIP programs we reviewed covered generally the same extensive mental health benefits as Medicaid programs in their states. For example, SCHIP beneficiaries in Minnesota have coverage for the same unlimited mental health benefits as Medicaid beneficiaries and are not responsible for any out-of-pocket costs. Similarly, the SCHIP benefits of Illinois, Georgia, and Massachusetts generally mirror the benefits available under their state Medicaid programs, albeit with limited cost-sharing that Medicaid does not require. For example, Georgia families must pay a premium of $7.50 per month for each child over age six, with a monthly limit of $15 per family. Similarly, families in Illinois with incomes over 150 percent of the federal poverty level must pay $5 for each outpatient or inpatient mental health visit and a monthly premium of $15 for one child, $25 for two children, and $30 for three children. SCHIP children in California diagnosed with severe emotional disturbance are eligible for these services through the county mental health departments. Unlike California and Utah, whose SCHIP programs are largely modeled after private insurance plans, states that elect to expand their Medicaid programs, such as Minnesota, must offer the same comprehensive benefit package, including EPSDT services, to SCHIP beneficiaries as they do to Medicaid beneficiaries. Officials in three other states we reviewed—Georgia, Illinois, and Massachusetts—told us they also make EPSDT services available to SCHIP enrollees, although these services are not required. may not provide sufficient coverage to some traumatized children who require long-term mental health treatment. In addition to inpatient day and outpatient visit limits, children in California and Utah are also subject to cost-sharing requirements through SCHIP that may make mental health services unaffordable for some families. For example, depending upon the level of their income, families in California must pay $5 for each outpatient visit and must also pay a monthly premium of $4 to $9 for each child enrolled in the program, with a monthly limit of $27 per family. Although Utah’s SCHIP program does not charge monthly premiums, it requires families with incomes from 100 to 150 percent of the federal poverty level to pay a $5 copayment for each outpatient visit, and families with incomes from 151 to 200 percent of the federal poverty level to pay for half of the total cost of the outpatient service. Little is known about the extent to which traumatized children with public insurance utilize mental health services, largely because no reliable, national utilization data exist for mental health services covered by Medicaid or SCHIP. While states are required by law to submit annual reports on the utilization of EPSDT services, CMS’s efforts to assemble reliable information about EPSDT participation in each state have been unsuccessful, despite 1999 revisions to the annual report that sought to clarify and simplify reporting requirements. State-reported data are often untimely or inaccurate, particularly in states where children receive services through managed care plans that are prospectively paid on a capitated basis, meaning the plans receive a flat payment per member, regardless of the cost of treating the patient. Moreover, states are not required to report mental health services provided under the EPSDT program. Limitations in other CMS data reporting requirements also make it difficult for the agency to determine the extent to which children are receiving mental health services. For example, periodic reports on health care utilization and expenditures that CMS requires states to submit do not collect consistent data on mental health services covered by Medicaid and SCHIP. Although national data regarding publicly insured children’s use of mental health services are not available, numerous lawsuits alleging shortcomings in the provision of EPSDT services, coupled with individual state utilization data that were available from most of the states we reviewed, indicate that children enrolled in Medicaid or SCHIP may not be obtaining needed services. According to the National Health Law Program, a national public interest law firm, as of September 1, 2001, 49 court opinions had been rendered on challenges alleging a state’s failure to properly implement EPSDT or to provide access to necessary services. In several of these cases, courts have found that a state violated EPSDT requirements by not providing all necessary mental health services to children. For example, in response to a class action lawsuit alleging that children were not being provided with access to mental health services, the court approved a consent decree by the parties under which West Virginia agreed to ensure that all EPSDT screens and subsequent treatments include behavioral and mental health services. In addition, statewide utilization data collected by four of the six states we reviewed—California, Illinois, Minnesota, and Utah—indicated that a small percentage of children enrolled in the state’s Medicaid and SCHIP programs, ranging from 0.7 percent of children in Illinois to 6 percent of children in Minnesota, used mental health services. Utilization data collected by Massachusetts, however, indicated that close to 16 percent of the children enrolled in its Medicaid and SCHIP managed care program were using available mental health services. Based on their experience and their reviews of research, officials in California and Utah told us they would expect the proportion of children needing mental health services to be higher. State officials and providers told us that various factors, such as the difficulty associated with identifying children with mental illness, lack of parental awareness of mental illness, and the stigma associated with mental illnesses, could contribute to lower than expected utilization of services. A child’s type of health insurance and state of residence generally determine the extent of mental health coverage available. To demonstrate the variation between public and private insurance programs in the availability and cost of mental health services for children, as well as variation among states, the following example outlines the covered benefits and annual benefit limitations of various types of insurance available to a hypothetical 5 year-old child who has experienced trauma and resides in either California or Illinois. Depending on the recommended treatment, which may include individual, group, or family therapy; inpatient hospitalization; or care in a residential facility, the services available and their cost to the child’s family could vary considerably. (See fig. 2.) For example, if enrolled in Medicaid, the child in California would have coverage for all these services at no cost; if enrolled in SCHIP, the child may not have coverage for residential care or transportation and could face limits on the number of inpatient days and outpatient visits allowed. In addition, the family of the SCHIP-enrolled child would be responsible for a $5 copayment for each outpatient visit. This child would experience similar differences among types of coverage in Illinois. Under Illinois’ Medicaid and SCHIP programs, the child would have coverage for all these services without limitations. However, the family of the child enrolled in SCHIP would also have to pay a copayment for each outpatient visit, and depending on the family’s income, could be responsible for a monthly premium as well. In comparison, a child in Illinois who relied on coverage from the individual insurer specified would not have coverage for residential care and would be limited to 10 inpatient days and 20 outpatient visits each year. $15/visit and 20% of charges premium) premium) Maximum 20 visits with family therapy equal to 2 visits = service covered with limitations; = service not covered; and N/A = information was not available. The Medicaid programs in both states cover mental health services provided to enrollees in residential care facilities but not the cost of room and board. Some health plans in California do not choose to impose these limits on services. In addition, children in California who are diagnosed with SED have coverage for all the services included in figure 2, without limitations, through county mental health departments. Also, day and visit limits do not apply to SCHIP children diagnosed with SMI. Maximum of $27 premium per family per month. Maximum family copayment of $250 per year.. However, copayments are not required for services provided to SED children in county mental health centers. These data represent conditions and in-network costs for a sample of PPO plans of employers with 500 or more employees; these plans had a median family deductible of $600. The data represent the most common day and visit limitations and other costs, and the average employee premium portion for family coverage. Data are from a PPO that is one of the most popular health plans sold in the individual insurance market in California and has a $1,000 deductible per person (maximum of $2,000 per family). Children who are diagnosed with a SED or one of nine SMI are eligible for unlimited benefits and pay 25 percent of service fees. This applies only to a child in a family whose income exceeds 150 percent of the federal poverty level. For two children, the premium is $25; for three, the premium is $30. Maximum copayment per year per family is $100. This example represents conditions for a sample of HMO plans of employers with 500 or more employees. The data represent the most common day and visit limitations, and the average employee premium portion for family coverage and outpatient copayment costs. Data are from an HMO that is one of the most popular plans sold in the individual health insurance market in Illinois. A health plan official told us that this service is available to members who meet the plan’s medical necessity criteria. Beyond insurance, a range of federal programs–-including over 50 grant programs we identified–-can help children who have experienced trauma obtain needed mental health services. (See app. VI for descriptions of selected federal grant programs.) Some federal programs pay for crisis counseling, such as the crisis counseling program for victims of disasters, which is administered by FEMA in collaboration with SAMHSA. Justice’s VOCA Crime Victim Compensation grants and Crime Victim Assistance grants to states help pay for mental health treatment needed by crime victims. However, factors such as state eligibility requirements and mental health service caps, as well as families’ lack of knowledge about the programs, may limit some child victims’ ability to benefit from these programs. Several federal grant programs encourage coordination among mental health and other service systems—such as social services, health care, and justice—so that children who have experienced trauma and their families can more easily gain access to the full range of services they need. One such program is SAMHSA’s National Child Traumatic Stress Initiative, a recent effort specifically designed to take a coordinated approach to improving mental health care for children who have experienced various kinds of trauma. Some federal programs have a broader focus, such as general mental health, or are targeted to specific populations, such as children in foster care, but grantees can elect to use program funds to provide mental health and other needed services to children who have experienced trauma and their families. Little is known about the extent to which these broader programs assist these children. Moreover, little is known about the effectiveness of federal programs that help children who have experienced trauma to obtain mental health services. For example, FEMA and SAMHSA have not evaluated the effectiveness of the disaster crisis counseling program. Federal agencies provide financial and technical assistance to states and localities to meet crisis-related mental health needs of children and adults who are victims of natural disasters and mass violence. FEMA collaborates with SAMHSA’s Center for Mental Health Services to provide financial and technical assistance to states and federally recognized Indian tribes that request aid for crisis counseling and other services for children and adults affected by presidentially declared disasters. FEMA funds the program, and SAMHSA, through an interagency agreement, provides technical assistance, program guidance, and oversight. The Crisis Counseling Assistance and Training grant funds are generally available for up to 12 months after a disaster declaration. FEMA reported that in fiscal year 2001, it had obligated about $16.2 million in crisis counseling funds. In addition to crisis counseling, program funds are used for such activities as training paraprofessionals to provide crisis counseling, distributing information to increase public awareness about the effect disasters can have on children, and helping identify and refer children who may need longer term mental health treatment. For example, New York and Virginia were declared disaster areas after the September 11, 2001, terrorist attacks and, as of May 2002, FEMA had approved about $160.6 million in crisis counseling grants. As of March 2002, New York had reported using the FEMA funds to provide free crisis counseling to approximately 10,000 children under age 18 affected by the attacks. In addition, HHS has allocated over $28 million for crisis counseling and other mental health and substance abuse services to help areas affected by the terrorist attacks, including $6.8 million that was awarded to eight states and the District of Columbia to help support crisis mental health services and to assist mental health and substance abuse systems in these locations. HHS also awarded $10 million to 33 New York City and New Jersey community health centers to support response-related services, including the provision of grief counseling and other mental health services. The Congress also appropriated $68.1 million to Justice to further meet the crisis counseling needs of victims, their families, and crisis responders. According to Justice, as of July 2002, the department had awarded more than $40 million of this amount to California, New Jersey, New York, Massachusetts, Pennsylvania, and Virginia. According to federal officials, communities have generally found the 12-month time frame sufficient for responding to all but the most serious types of disasters, and extensions of limited duration have occasionally been approved. However, SAMHSA officials and trauma experts told us that there are concerns about whether the crisis counseling grant’s time frame is sufficient for identifying all children who may require trauma- related mental health assistance as a result of a large-scale natural disaster or act of terrorism that results in mass casualties. These experts told us, for example, that in the case of the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, the time frame was not sufficient to find, assess the mental health needs of, and provide assistance to the large number of children and adults who needed help. Although FEMA extended total grant funding to about 33 months, crisis counseling services were still needed after the funds had finally expired. As a result, Justice provided an additional $264,000 to Oklahoma’s Project Heartland to fund crisis counseling services needed by individuals with problems stemming from the bombing. Because there was a resurgence of mental health problems during the federal bombing trials, Justice also provided about $235,000 to help provide victims and other family members with needed crisis counseling services. According to a SAMHSA official, the September 11, 2001, attacks have led program officials to discuss whether changes are needed in the nature and duration of federal assistance available to address the special, longer-term mental health service needs that can arise from mass casualty disasters, especially those caused by terrorism. SAMHSA is collaborating with the National Association of State Mental Health Program Directors on the association’s review of states’ emergency response plans to identify ways that states can better plan for the mental health care needs of disaster victims. According to trauma experts and SAMHSA officials, most states have dedicated few resources to planning for mental health needs that result from such events and most have insufficient capacity to coordinate and mobilize the mental health services needed for large-scale disasters. This could result in the loss of valuable time, duplicative efforts, and missed opportunities to identify children who could benefit from mental health assistance. Another federal resource for crisis situations is Education’s School Emergency Response to Violence program, commonly known as Project SERV. Local school districts can apply for crisis response grants for generally up to 18 months to help deal with the aftermath of violent or traumatic events, such as school shootings and acts of terrorism. Education officials said school districts have used grants for children’s crisis counseling, school security, transportation to safe locations, and translation services. In addition, under the program, Education can send trauma and violence experts to a school district to help school personnel handle disaster situations. In fiscal year 2001, Project SERV obligated nearly $9.8 million to school districts responding to violence and disasters, with nearly 90 percent of the funds awarded to schools in communities affected by the September 11, 2001, terrorist attacks. The federal Crime Victims Fund is an important federal funding source for meeting the mental health needs of children who are victims of violent crimes, including mass violence and terrorism. The fund is administered by Justice’s OVC, and most of the funds available are used to support victim compensation grants and victim assistance grants to all states, the District of Columbia, Puerto Rico, and U.S. territories. Federal VOCA victim compensation grants supplement state funds to provide direct financial assistance and reimbursements to, or on behalf of, eligible crime victims or their survivors for a wide range of crime-related expenses, including those for mental health services. Federal victim assistance grants are provided to the states, which in turn award these funds to eligible public and private nonprofit organizations that work directly with crime victims to determine their needs and provide them with a range of free services, including mental health services. In fiscal year 2002, OVC allocated about $477 million to these two grant programs. States use federal victim compensation grants to supplement their efforts to compensate eligible crime victims or their survivors who file claims with state victim compensation programs for their crime-related expenses. In some instances, children who witness crimes may be eligible for compensation. State victim compensation programs provide financial assistance and reimbursement to crime victims only to the extent that other financial resources, such as health insurance, do not cover a victim’s loss. Crisis counseling, individual and group therapy, psychiatric hospital care, and prescription drugs are among the mental health services covered by states. According to OVC, state victim compensation programs reimbursed approximately $50 million in mental health expenditures to children and adults in fiscal year 2000. The percentage of annual compensation expenditures that provides reimbursement for mental health services varies widely by state. For example, in fiscal year 2001, 91 percent of California’s victim compensation funds that paid for services to children were for mental health services, while 14 percent of Illinois’s compensation funds that paid for children’s services were for mental health services. State officials told us that the availability of victim compensation funds can be particularly helpful for uninsured children or children whose insurance does not cover all needed mental health services. For example, of the claims for children’s services reimbursed by California’s compensation program in fiscal year 2001, about 58 percent were for children who were uninsured, 21 percent for children with private insurance, 10 percent for children enrolled in Medicaid, and about 11 percent for children with other financial resources. Similarly, Illinois officials told us that the state’s compensation program serves many children who have no insurance. Although crime victim compensation program guidelines require states to reimburse victims for mental health expenses, states are given discretion in setting program eligibility requirements and benefits. As a result, states have different rules for who can qualify to receive compensation benefits. In addition, states’ mental health benefits vary with respect to overall dollar limits, whether there are caps on mental health coverage within those limits and the amounts of those caps, the number of treatment sessions allowed, and the length of time that crime victims can receive mental health benefits through the victim compensation program. Furthermore, in most states when there are multiple victims of a crime, they typically must share the available overall maximum benefits. However, each family member or secondary victim is typically eligible for mental health counseling benefits up to specified caps, which generally apply to individuals and do not have to be shared. For example, the total maximum compensation in California for all victims of a crime is $70,000, with a $10,000 cap on mental health services for all direct victims, and Minnesota’s total maximum award limit is $50,000, with a $7,500 cap on mental health services. In Massachusetts and Illinois, the overall compensation ceilings are $25,000 and $27,000, respectively, with no mental health caps. New York has the most generous compensation benefit, with no overall maximum and no cap on reimbursement for victims’ mental health expenses. (See app. VII for a summary of state benefit information.) Whether state eligibility requirements and caps on mental health services are preventing some children from obtaining needed services is largely unknown. Federal and state victim compensation program officials told us that most child claimants obtain reimbursement for needed mental health services and that many do not reach their benefit limits. The state victim compensation officials, however, also told us that eligibility requirements and benefit limits may exclude some children who need assistance to pay for mental health services. OVC has not undertaken a nationwide analysis of the effect of state requirements and benefit limits on meeting the mental health needs of child crime victims. Furthermore, OVC officials told us that there are no detailed data at the national level on state compensation programs’ payment for mental health services provided to children who have experienced trauma. While OVC requires states to submit annual reports on certain activities, including overall expenditures for mental health services, it does not require information on expenditures for children’s mental health services and the types of mental health services provided to these children. Therefore, the number of children who have benefited from the mental health coverage available through state victim compensation programs is uncertain. OVC’s victim assistance grants to the states are another vehicle that can help children and their families obtain needed mental health services. In fiscal year 2000, these grants were combined with state victim assistance funds to award grants to about 4,300 public and private nonprofit organizations that in turn provided crime victims with free medical, mental health, social service, and criminal justice advocacy services. In contrast to state victim compensation programs, which require crime victims to submit detailed applications and supporting documentation, local organizations that receive grants from state victim assistance programs typically do not require as much documentation from crime victims before providing them with needed assistance. State and local officials told us that some crime victims many obtain faster help through victim assistance programs than through filing compensation claims and waiting for reimbursement for their crime-related expenses–-a process that took, on average, about 23 weeks in fiscal year 2000. State victim assistance agencies reported allocating about $542.6 million in fiscal year 2000 to provide a range of services to about 3 million crime victims. For example, nearly 1.5 million of these victims received crisis counseling and about 230,000 received individual therapy. In the four states we reviewed, children benefiting from these grants included those who had been sexually or physically abused. (See table 3.) State victim assistance programs have reported to OVC that their programs helped children who have experienced trauma and their families in varied ways. For example, California, Illinois, and Massachusetts officials reported paying for individual and group therapy in cases where children either did not have insurance or their insurance provided reimbursement for fewer sessions than were needed. In addition, California and Massachusetts officials reported that victim assistance funds had helped provide comprehensive services to children and other family members, including case management, counseling services in their native languages, translation assistance, and help in filing claims for victim compensation. Although many children who are crime victims obtain mental health and other services through state victim compensation programs, federal, state, and local officials told us that many victims do not file compensation claims and that program limitations can constrain access to services. It is difficult to determine the exact number of victimized children who need trauma-related mental health services and who also need the financial assistance available through state victim compensation programs to obtain such services. Many crime victims may not need to file a claim for state victim compensation because they have not incurred any crime-related expenses or they have other resources, such as insurance, to help them pay for needed services. Nonetheless, California and Illinois victim compensation officials said that based on their analyses of claimant rolls and crime victim statistics in their states, they believe that many potentially eligible victims who could benefit from the assistance their programs offer had not applied for compensation. For example, an Illinois Crime Victim Compensation office analysis comparing 2000 county-level crime statistics with compensation claims received in 2001 showed that while there were 30,630 violent crimes reported in Chicago, the state victim compensation office received only 2,796 claims from victims in that city. A 2001 Justice-funded report on state victim compensation and victim assistance programs indicated that several program-related factors might impede victims’ access to services supported by such programs. These factors included (1) lack of knowledge about the programs’ existence, (2) lack of information on how to obtain available benefits, and (3) state eligibility requirements that might make it difficult for some victims to qualify for benefits. For example, most states stipulate that to qualify for compensation, a victim must file a report with law enforcement authorities shortly after a crime occurs, generally within 72 hours, and must cooperate with these authorities. However, victims of some crimes, such as sexual assault or domestic violence, may not report the crimes immediately and may be apprehensive about cooperating with authorities due to fear of retaliation by the offender. Other program barriers identified by state program managers surveyed for the report included (1) limited outreach and education, especially to racially and ethnically diverse populations and to rural communities, (2) lengthy and complex compensation award determination and payment processes, and (3) insufficient coordination between state victim compensation and victim assistance programs and with other agencies that work with these victims to eliminate gaps in assistance or duplicative services. Efforts to address some of these problems are under way in the states we contacted. For example, the Los Angeles County District Attorney’s office placed victim advocates in county courts to inform victims of their right to benefit from the victim compensation and assistance programs and to help children and their families obtain needed services, including mental health care. In addition, California, Illinois, and Minnesota officials told us that they are now more flexible with their time frames for filing crime reports with police and will accept other official reports, such as those from child protective agencies and forensic sexual assault examinations. OVC published a report in 1998 that included a recommendation that state crime victim compensation programs reexamine their mental health benefits to ensure that they are adequate. Coordination among mental health, child welfare, education, law enforcement, and juvenile justice systems can help ensure that children who have experienced trauma and their families obtain comprehensive, timely, and appropriate services. Several federal agencies have funded grant programs to promote collaborations within and across these systems—some of which have not traditionally worked together, such as police and mental health professionals. For example, although research has documented the frequent co-occurrence of domestic violence and child abuse, government officials and family violence experts report that the child welfare and domestic violence advocacy systems often fail to work together to devise safe, coordinated, and effective responses to family violence, due in part to differing missions, priorities, and perspectives. In some instances, child welfare officials want to remove a child from a home where domestic violence has allegedly occurred, while advocates for the nonoffending parent argue that taking the child out of the home would penalize that parent. Justice awards grants to help support more than 350 Children’s Advocacy Centers, which assist children who come into contact with the court system as a result of being abused. The centers aim to bring together a multidisciplinary team and promote coordination among various service systems to ensure that a child’s multiple needs are met, including access to mental health services for the child and other family members. Typically consisting of law enforcement representatives, child protection workers, prosecutors, victim advocates, and mental health professionals, the teams work to ensure that the child does not have to recount the traumatizing event in multiple interviews, which could result in additional trauma. To help communities minimize the adverse impact of family and community violence on young children, Justice initiated the Safe Start Demonstration Project in 1999. The grant program, which will last about 5 years, is designed to improve access to, and the quality of, services for young children who are at high risk of exposure to violence or who have already been exposed to violence. The program’s goal is to help communities strengthen partnerships among key service systems such as Head Start, health care, mental health care, domestic violence shelters and advocacy organizations, child welfare, and law enforcement. In fiscal year 2000, the agency awarded grants to nine communities, with each receiving $250,000 for a first-year planning phase. In addition, grantees will receive up to $670,000 annually for implementation activities. Another way federal agencies are trying to encourage service systems to work together is the Collaborations to Address Domestic Violence and Child Maltreatment Project, which is jointly funded and administered by eight agencies and offices within HHS and Justice. The one-time demonstration grant, commonly called the Greenbook Project, funds initiatives in six communities that are each receiving $350,000 annually for 3 years, starting in fiscal year 2000. The project’s goal is to help communities develop partnerships among three key stakeholders—the child welfare system, domestic violence groups, and juvenile and family courts—to improve the delivery of services to victims of domestic violence and their children. For example, a grantee in Colorado has used program funds to hire a domestic violence advocate to work in the child welfare system to improve screening for domestic violence and assess the risk to children. The grantee has also used these funds to enhance an existing program that houses police and child protective personnel at one location, allowing them to jointly respond to domestic violence calls so they can deal with the needs of all family members, including children who have witnessed the violence. Education, HHS, and Justice created the Safe Schools/Healthy Students demonstration project in 1999 to help schools and communities draw on three traditionally disparate service systems—education, mental health care, and justice—to promote the healthy development of children and address the consequences of school violence. The program, which through fiscal year 2001 had made awards totaling about $439 million, requires local education agencies to establish formal partnerships with mental health providers and local law enforcement professionals. One of the project’s six core elements is the enhancement of school- and community-based mental health preventive and treatment services. In fiscal year 2001, the agencies awarded about $177 million to 97 urban, suburban, rural, and tribal community grantees. SAMHSA’s National Child Traumatic Stress Initiative is a recent initiative specifically designed to take a coordinated approach to improving mental health care for children who have experienced various kinds of trauma. Launched in October 2001, the 3-year effort is designed primarily to (1) improve the quality, effectiveness, and availability of therapeutic services for all children and adolescents who experience traumatic events, (2) develop a national network of centers, programs, and stakeholders dedicated to improving the identification, assessment, and treatment of children, and (3) reduce the frequency and severity of negative consequences of traumatic events through greater public and professional understanding of childhood trauma and greater acceptance for child trauma intervention services. SAMHSA has taken a tiered approach in structuring the $30 million initiative by establishing three grantee categories: a National Center for Child Traumatic Stress to coordinate the overall initiative; 10 Intervention Development and Evaluation Centers, which plan to develop scientifically-based improvements in treatment and service delivery; and 25 Community Treatment and Services Centers, which focus on treating victims of various types of trauma. The initiative emphasizes partnerships and coordination among grantees at each level and across levels. It also encourages grantees to collaborate with professionals in various community service systems—including child protection, justice, education, and health care—that interact with children who have experienced trauma and their families. Because this initiative is in its early stages, information on the effectiveness of its efforts is not available. Other federal grant programs not specifically targeted to assisting children who have experienced trauma may also help fund mental health and other services needed by these children and their families. These federal grants focus on broader issues, such as general mental health or maternal and child health services or services for specific populations, such as children in foster care, homeless youth, or migrant farmworkers. (See app. VI for descriptions of selected federal grant programs.) Grantees can, if they choose, use these funds to provide a range of services beneficial to children who have been traumatized. For example, funds from the Indian Health Service’s Urban Indian Health Program, which provides health services to child and adult American Indians living in urban areas, can be used to screen, refer, and treat children who need mental health services due to trauma. ACF’s Transitional Living for Homeless Youth program, which operates transitional living projects and promotes self-sufficiency for homeless youth, requires grantees to offer mental health services, either directly or by referral. SAMHSA’s Comprehensive Community Health Services for Children and Their Families program, commonly known as the System-of-Care program, provides supportive services to children and adolescents with SED and their families. Many of the children served through this program have been exposed to violence in their homes and many have been referred by social service and law enforcement agencies. In fiscal year 2001, 45 communities received System-of-Care grants to fund a range of services, including case management, intensive home-based treatment services, family counseling, and respite care. State officials and service providers told us that some of the broader federal grants improved their ability to meet the needs of traumatized children and their families because the grants can fund services that are not always eligible for insurance reimbursement, such as case management and ancillary services for parents, including child care and transportation. Some of these broader federal grants also support screening and identification of children with trauma-related mental health problems. For example, ACF’s Head Start program, which promotes school readiness for low-income children, requires grantees to ensure that each child receives mental health screening within 45 days of entering the program. The grantees are required to consult with mental health or child development professionals, teachers, and family members in devising appropriate responses to address identified problems. In 1990, HRSA and CMS cosponsored the initiation of the Bright Futures project to help primary care health professionals promote the physical and mental well-being of children, recognize problems, and intervene early. Recently, HRSA funded the development of mental health practice guidelines outlining risk factors and potential interventions related to domestic and community violence. In addition, HRSA and the National Highway Traffic Safety Administration administer the Emergency Medical Services for Children program, which provides funds to ensure that children’s services are well integrated into the emergency medical system. Among its initiatives, the program provides training grants to improve the ability of emergency medical services workers and emergency department physicians and nurses to identify the mental health needs of children in emergency situations. Because they are not specifically designed to assist the mental health needs of children who have experienced trauma, these grants’ data reporting requirements often do not produce information on the extent to which children have been screened for trauma-related problems and the number of children who have obtained mental health services as a result of trauma. In addition, program officials were generally unable to provide specific information on the portion of program funds used to serve these children. Despite the many federal efforts that contribute to varying degrees to helping children who have experienced trauma and their families obtain mental health and other needed services, little is known about their effectiveness. Few programs have undertaken formal evaluations to assess program progress and results and to guide decisions to improve service to targeted beneficiaries. For example, FEMA and SAMHSA have not conducted an evaluation of the effectiveness of FEMA’s crisis counseling program. SAMHSA officials told us that there were no immediate plans to conduct such an evaluation. In 1995, FEMA’s Office of Inspector General recommended that the agency, in consultation with experts in disaster mental health and mental health outcomes research, evaluate the effectiveness and efficiency of the crisis counseling program. In its response to the recommendation, FEMA indicated that FEMA and SAMHSA monitored grantee activities through grantee reports and joint site visits. However, these activities do not constitute an evaluation of the crisis counseling program. For example, the site visits generally involve monitoring the grantee’s program to ensure that it is carrying out reported activities and providing technical assistance. SAMHSA recently developed guidance for grantees outlining recommended program evaluation strategies. An agency official told us that grantees are encouraged to conduct evaluations of their individual programs, but are not required to adhere to the guidance in managing their programs. According to HHS, the Department of Veterans Affairs’ National Center for Post-Traumatic Stress Disorder will conduct case studies of past and current crisis counseling program grantees’ programs and will make recommendations on programwide evaluation activities. The scope and nature of these efforts have not been fully determined. Education also has not evaluated Project SERV, which provides crisis response grants to schools, and ACF has not evaluated the Transitional Living for Homeless Youth program, which requires grantees to offer mental health services to homeless youth. Justice has funded a multiyear evaluation of the Crime Victim Compensation and Victim Assistance programs. The study was designed to, among other things, evaluate how the victim compensation and assistance programs serve crime victims and how variations in program administration and operations affect the effectiveness and efficiency of services to victims. The initial report, issued in March 2001, primarily consisted of a survey of state program managers’ views on program operations and needed improvements. The final report, which is scheduled for issuance in fall 2002, will be based on case studies of six states’ compensation and assistance programs, including a survey of compensation claimants and a survey of assistance clients in those states. The results of the survey of compensation claimants will partly reflect the experience of child victims and of victims who used mental health services. Because the survey of assistance clients had less participation by adults who could comment on a child’s experience, the study may provide less information about child victims’ experience with the assistance program. The case studies also involved discussions with state administrators and service providers that received victim assistance funds on the programs’ ability to help child victims obtain mental health services. Some federal grants include formal evaluation components, but have yet to establish their evaluation framework, including detailed outcome measures. For example, the Greenbook and Safe Start grants, which support coordination efforts, included a year-long planning process to develop their evaluation frameworks. However, as of May 2002, when these grants had been under way for almost 2 years, neither had finalized its evaluation process, including development of core performance measures. SAMHSA’s National Child Traumatic Stress Initiative also plans to undertake an evaluation of the overall initiative and individual grantee projects. As of May 2002, SAMHSA and the grantees had begun to discuss the evaluation framework but had not finalized it. In addition, other grants have established their evaluation frameworks and performance measures, but their evaluations have yet to yield results. For example, the Safe Schools/Healthy Students program is collecting data, with an interim report planned for fiscal year 2002 and a final report in fiscal year 2004. Many children who have experienced trauma are resilient and may suffer few ill effects. Others, however, require mental health services to help them cope and minimize long-term psychological, emotional, or developmental difficulties. While most children have health insurance that covers mental health services to varying degrees, coverage limitations are common and may constrain children’s ability to obtain care. Numerous federal grant programs could expand the number of children whose mental health services may be reimbursed or help increase the available services in a community, but some children who need services may not benefit from such programs. For example, some grants are awarded to a relatively small number of communities and expire after a defined period, and evidence suggests that families of some children who are eligible to benefit from Justice’s victim compensation and assistance programs may not be aware of the programs. The effectiveness of federal programs that could help children who have experienced trauma remains largely unknown. Some programs with planned evaluations, such as the Greenbook Project, have lagged in establishing their evaluation frameworks. SAMHSA’s recent National Child Traumatic Stress Initiative, which focuses specifically on the mental health needs of these children, intends to evaluate the results of grantee projects and the overall program. This effort could develop information on ways to effectively provide mental health services to traumatized children, but because the initiative is new, it is too early to gauge its success. Justice’s current evaluation of its Crime Victim Compensation and Crime Victim Assistance programs should provide some information on the experience of child victims in using the victim compensation program to obtain needed mental health services, but may provide less information on children’s ability to obtain mental health services through the victim assistance program. FEMA and SAMHSA have not evaluated the effectiveness of the long-standing disaster crisis counseling program and have no immediate plans to conduct a programwide evaluation. Without evaluations of the effectiveness of federal programs that have a clear goal of helping children who experienced trauma to obtain mental health services, federal managers and policymakers lack information that would help them assess which federal efforts are successful; determine which programs could be improved, expanded, or replicated; and effectively allocate resources to identify and meet additional service needs. We recommend that, to provide federal policymakers and program managers with additional information on federal grant programs serving children who have experienced disaster-related trauma, the Director of FEMA work with the Administrator of SAMHSA to evaluate the effectiveness of the Crisis Counseling Assistance and Training Program, including its assistance to children who need mental health services as the result of a disaster. We provided a draft of this report to four federal departments and agencies for their review. FEMA, HHS, and Education submitted written comments that are provided in appendixes VIII through X, respectively. HHS and Education also provided technical comments, as did Justice. We have modified the report, as appropriate, in response to written general and technical comments. In general, HHS stated that the report will be a useful tool for policymakers and brings important attention to the needs of children exposed to traumatic events. HHS and FEMA both agreed with our description of the Crisis Counseling Assistance and Training Program and with our conclusions on the importance of evaluating the program’s effectiveness. HHS stated that it strongly agreed that evaluation activities are critical for this program and other child trauma programs to ensure program effectiveness and the appropriate use of resources. Both agencies said they have begun, or plan to take steps, to engage in additional evaluation activities, and HHS commented that it plans to continue ongoing evaluation efforts to assure that services are appropriate, efficient, and responsive to the needs of disaster victims. At their request, we modified the report to reflect additional information the agencies provided on current evaluation activities. However, neither the FEMA and HHS activities that we described nor those that they cited in their comments constitute the programwide evaluation of the program’s effectiveness that we are recommending. Furthermore, FEMA did not indicate in its response whether it intends to implement our recommendation to coordinate with SAMHSA to conduct such an evaluation, which is needed to help federal policymakers and program managers assess whether the Crisis Counseling Assistance and Training Program is effectively assisting children who have experienced disaster-related trauma. HHS said that the draft report emphasized the lack of data on the prevalence of children exposed to trauma and their mental health needs but did not discuss National Institutes of Health and National Institute of Mental Health research data, including data from nationally representative surveys. The types of research studies HHS referred to in its comments generally focus on specific communities or certain defined populations, and existing nationwide surveys have limitations such as not covering certain age ranges or addressing the full range of traumatic situations that children may experience. Appendix II of our draft report included ACF’s nationwide data on children who have been abused and neglected and the number of those who received mental health services. However, for other kinds of trauma, there are few nationwide data estimating the number of children who need mental health services due to these traumas and the number who receive services. HHS suggested that the report should more fully discuss the availability of providers trained to help children who have experienced trauma. The department said the country does not have a child mental health workforce with the capacity to meet the needs of children and that responding to PTSD in children requires even more specific training. The draft report did refer to workforce issues that could affect children’s access to needed mental health services, and we have included additional information in response to HHS’s comments. A detailed discussion of workforce issues, however, was not within the scope of this report. HHS also expressed concern that the report did not discuss the need for more research on specific mental disorders and effective treatments, the stigma often associated with mental health problems and its effect on the delivery of mental health services to children who have experienced trauma, or problems in the public mental health system. We agree that these are important issues and modified the report to acknowledge the potential role of stigma. However, a detailed discussion of these issues was also outside the scope of this report. HHS further commented that the report should contain a more thorough discussion of HRSA’s grants to help meet the mental health needs of children. Appendix VI of the draft report described several HRSA grants, including the Maternal and Child Health Block Grant. Based on the department’s comments, we modified the appendix to describe additional HRSA grants. HHS acknowledged that the report provides information on the limits insurance plans often place on mental health coverage, but said that the draft report did not address the ramifications of mental health parity. We added clarification that the federal mental health parity law does not require group health plans to offer mental health benefits, but otherwise believe the report provides ample information on the limits of federal and state mental health parity laws. Education concurred with the information discussed in the report. Like HHS, the department raised concerns about the availability of mental health providers to serve children who have experienced trauma. As arranged with your offices, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after its issue date. We are sending copies of this report to the Secretary of Health and Human Services, the Attorney General, the Secretary of Education, the Director of the Federal Emergency Management Agency, appropriate congressional committees, and others who are interested. We will also make copies available to others who are interested upon request. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov. If you or your staffs have any questions, please contact me or Kathryn G. Allen, Director, Health Care—Medicaid and Private Insurance Issues, at (202) 512-7119. An additional contact and the names of other staff members who made contributions to this report are listed in appendix XI. To do our work, we obtained program documents, pertinent studies, and data from the Department of Health and Human Services’ (HHS) Administration for Children and Families (ACF), Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administration, Indian Health Service, National Institutes of Health, Office of the Secretary, Office of the Assistant Secretary for Planning and Evaluation, and Substance Abuse and Mental Health Services Administration (SAMHSA); the Department of Justice’s Bureau of Justice Statistics, National Institute of Justice, Office of Juvenile Justice and Delinquency Prevention, Office for Victims of Crime, and Violence Against Women Office; the Federal Emergency Management Agency; the Department of Education; and the Department of Agriculture. We also interviewed officials from these agencies. We also reviewed the relevant literature and interviewed officials or obtained information from national organizations including the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Psychiatric Association, American Psychological Association, American Public Human Services Association, Child Welfare League of America, Family Violence Prevention Fund, National Association of Crime Victim Compensation Boards, National Association of Social Workers, National Association of State Mental Health Program Directors, National Coalition Against Domestic Violence, National Council of Juvenile and Family Court Judges, and Prevent Child Abuse America. To determine the extent to which private and public insurance programs cover mental health services for children, we reviewed national employer benefit surveys; reviewed the benefit design of health plans provided by 13 insurers in the individual market, state Medicaid programs, and State Children’s Health Insurance Programs (SCHIP); and interviewed representatives of private insurers and public officials in California, Georgia, Illinois, Massachusetts, Minnesota, and Utah. These states were selected on the basis of variation in the number of beneficiaries covered, in geographic location, in the extent to which the insurance market is regulated, and in the design of the SCHIP program. For information on the extent to which employers offer mental health benefits to employees, as well as the conditions under which coverage is made available, we relied on private employer benefit surveys conducted in 2001, specifically those of (1) William M. Mercer, Incorporated (formerly produced by Foster Higgins) and (2) the Health Research and Educational Trust, sponsored by the Kaiser Family Foundation. These surveys are distinguished from a number of other private ones largely because of their random samples, which allow their results to be generalized to a larger population of employers. For the mental health services covered by private individual market insurers, we interviewed state insurance regulators in each of the six states to learn about state laws related to the provision of mental health benefits and to identify the insurers in the individual market in the state. We then reviewed the benefit designs of popular health plans sold in the individual market. To obtain information about the mental health coverage of the public insurance programs in these states, we reviewed state Medicaid and SCHIP plans, which specified program characteristics, including covered benefits and limitations, and we interviewed program officials to obtain information on income eligibility and service delivery models. In several of the states, we also interviewed Mental Health Department officials, providers, and consumer advocates. To identify federal programs that help children who have experienced trauma receive mental health services, we reviewed the Catalog of Federal Domestic Assistance. After identifying programs, we interviewed and collected information from federal program officials to confirm whether these programs can support activities, such as mental health treatment, screening and referral services, educational outreach, training for medical and other professionals on the needs of children exposed to trauma, and research and evaluation of mental health services. The federal program officials also identified other programs and efforts that can address the mental health needs of children exposed to trauma and provided perspectives on barriers to these children receiving mental health services. We obtained additional information on grants that appeared to be most relevant to the population discussed in this report. The programs and efforts we discuss in this report do not represent an exhaustive list of all federally funded programs that can address the mental health needs of children exposed to trauma; they highlight a range of programs that target varied populations, services, and systems that come into contact with this population. We report that these programs can provide mental health services to this population because funds may be used for this purpose. We were not generally able to obtain information on the nature of the services provided or the level of service used by children exposed to trauma because some programs we identified do not collect information specifically on mental health services provided to children exposed to trauma. We obtained additional information on selected federally supported programs and problems children face in obtaining needed mental health services through site visits in California and Massachusetts. In these states, we interviewed officials or obtained data from state and local mental health agencies, state crime victim compensation and assistance programs, child welfare and protective service agencies, and other organizations receiving federal grants. We also contacted service providers with federal grants located in Colorado, Illinois, Minnesota, and Oregon. We selected these locations to visit or contact because they have organizations receiving federal grants focused on children and trauma, such as SAMHSA’s Child Traumatic Stress Initiative or HHS/Justice’s Greenbook Project, or recognized experts in the field of child trauma. We also obtained data on child abuse and neglect, domestic violence, and sexual assault that were collected and analyzed by HHS’s ACF and Justice’s Bureau of Justice Statistics, National Institute of Justice, and Federal Bureau of Investigation. We did not verify the accuracy of these data. We conducted our work from September 2001 through August 2002 in accordance with generally accepted government auditing standards. This appendix presents information on child maltreatment, intimate partner violence, and sexual assault. ACF data provide information on children’s entry into the child protective service system and the services that they and their families received (see tables 4 to 7); additional information was provided by ACF on a program to increase contact between children and their noncustodial parents. (See table 8.) Justice data provide information on individuals who were victims of intimate partner violence and sexual assault. (See tables 9 to 12 and fig. 3.) We did not confirm the accuracy of these data. In 1996, the Child Abuse Prevention and Treatment Act was amended to require states receiving a Child Abuse and Neglect State Grant to report to the National Child Abuse and Neglect Data System, to the extent practicable, 12 specific data items on child maltreatment, such as the number of victims of abuse and neglect and the number of children who received services. States can voluntarily report data in other categories, such as the number of children receiving mental health services. All states submitted data for 1999, the most recent year for which data are available. All states did not respond to all required items. For example, 10 states did not report information on the number of victims who received services. (See table 6.) ACF reported in Child Maltreatment 1999 that the required child maltreatment data had been validated for consistency and clarity, but ACF officials told us that state definitions vary, making comparisons between states difficult. The Personal Responsibility and Opportunity Act of 1996 authorized ACF to provide $10 million to states to establish and operate access and visitation programs. The overall goal of the program is to increase children’s contact with their noncustodial parents. Individual grantees, however, often have additional goals that relate to child well-being, such as providing a safe, stress-free environment in which children and noncustodial parents can interact, when a court has said that the child is at risk for harm. Most families either self-refer to access and visitation programs or are referred by courts, child support agencies, or child welfare agencies. Eligible services include, but are not limited to, mediation, counseling, education, development of parenting plans, visitation enforcement, and development of guidelines for visitation and alternative custody arrangements. These services are provided in urban, suburban, and rural locations and are administered by state and county agencies, courts, and nonprofit organizations. As a condition of receiving these funds, states must report annually on program activities funded through the grant and on funding priorities for the next fiscal year, one of which can be counseling. (See table 8.) Data that Justice has collected on victimization include information on intimate partner violence and sexual assault. Justice’s Bureau of Justice Statistics’ National Crime Victimization Survey provided estimates on intimate partner violence over time (see figure 3), while the National Violence Against Women Survey, jointly conducted by the National Institute of Justice and HHS’s Centers for Disease Control and Prevention, provided more detailed descriptions of intimate partner violence and victim behavior. (See tables 9 and 10.) Justice’s Federal Bureau of Investigation collects data on the forcible rape of women using the Uniform Crime Reporting Program. (See table 11.) The program collects annual counts of reported criminal activity from city, county, and state law enforcement agencies; incidents not reported to law enforcement are not included in counts. In addition, the Bureau of Justice Statistics collects information on sexual assault convictions using the National Judicial Reporting Program. (See table 12.) States have flexibility in the way they design their SCHIP program. They may expand their Medicaid programs, develop a separate child health program that functions independently of the Medicaid program, or do a combination of both. Although SCHIP is generally targeted to families with incomes at or below 200 percent of the federal poverty level, each state may set its own income eligibility limits within certain guidelines. (See table 13.) The over 3 million children who are covered by an individual insurance plan may face limitations in mental health coverage, largely because federal and most state parity laws do not apply to health plans sold in this market. Unless precluded by state law, restrictions on mental health benefits in the individual market can include limitations on hospital days or outpatient office visits or higher out-of-pocket expenses. Figure 4 summarizes differences in individual market preferred provider organization (PPO) and health maintenance organization (HMO) health plan coverage for certain mental health treatments available to children in six states. Plan C Plan D Plan E = service covered with limitations; and = service not covered. Under California’s parity law, limits do not apply to children with severe mental illnesses (SMI) or those diagnosed with a serious emotional disturbance (SED). Maximum of 20 total outpatient visits per year. Patient is responsible for additional cost-sharing after the 48th individual or family therapy visit each year. For group therapy, one visit is equal to half of an individual or family therapy visit, and enrollees are responsible for the full treatment cost after the 96th group therapy visit each year. Maximum of 30 outpatient visits per year with a maximum of 100 visits per lifetime. Maximum of 15 outpatient visits per year. All mental health services are limited to a total benefit of $1,500 per member per year. One family therapy session is equal to two outpatient visits. Maximum of 30 inpatient days per year. Maximum of 45 inpatient days per year. One residential treatment day is counted as one inpatient day. Patient is responsible for additional cost-sharing after the 30th inpatient day each year. Maximum of 10 inpatient days per year. Care received in a residential treatment center (a licensed 24-hour facility that offers mental health treatment). Room and board costs are not covered. One day of residential care is equal to two inpatient days. Many states have sought to equalize mental health and other benefits beyond the requirements of the federal Mental Health Parity Act of 1996 (MHPA), which prohibited certain group health plans that are sponsored by employers with more than 50 employees and include mental health benefits from imposing annual or lifetime dollar limits on mental health benefits that are more restrictive than those imposed on other benefits. Laws in the six states we reviewed differed in the extent to which they addressed mental health coverage and limitations. Three states we reviewed—California, Massachusetts, and Minnesota— enacted laws that are more comprehensive than the federal parity law, requiring certain health plans to offer mental health benefits to certain populations with parity in service limits and cost-sharing. For example, California law requires all health plans to provide mental health coverage with the same restrictions and limits as other benefits to members with severe mental illnesses (SMI) and children with serious emotional disturbances (SED). (See table 14.) While states have primary responsibility for regulating the business of insurance, they are preempted by the Employee Retirement and Income Security Act of 1974 (ERISA) from regulating employer-sponsored health plans. Therefore, state laws that have sought to equalize mental and other benefits beyond MHPA do not apply to self-funded employer-sponsored plans, through which close to 50 percent of employees with employer-sponsored coverage obtain health insurance. Illinois’s mental health coverage laws do not apply to all health plans; further, Illinois’s laws allow health plans to limit the number of visits or days of mental health treatment for children and require parity only for serious mental illness. For example, Illinois law requires HMOs to offer mental health coverage with annual minimums of 10 inpatient days and 20 individual outpatient visits for each member. Similar requirements, however, do not exist for other types of health plans, such as PPOs. In addition, Illinois requires group health plans with more than 50 employees to provide coverage for serious mental illnesses under the same conditions as coverage for other illnesses. (See table 15.) The remaining two states—Georgia and Utah—address mental health coverage similarly. State laws in Georgia and Utah do not require health plans to include a minimum level of mental health coverage. Rather, both of these states require health plans to offer an additional plan that exclusively covers mental health services and can be purchased in addition to the standard health plan. For example, Georgia’s mandated offer requirement applies to individual, small group, and large group major medical health plans, and requires coverage for annual and lifetime dollar mental health benefits to be equal to or greater than coverage for physical illnesses. Utah’s law requires only that group health plans offer mental health coverage as an option. Table 16 is a nonexhaustive list of federal grants that may be used to help children who were exposed to trauma obtain mental health services. The list includes 15 formula grants and 38 discretionary grants from seven departments and agencies. The federal Crime Victims Fund, administered by Justice’s Office for Victims of Crime, provides annual crime victim compensation grants to the states’ crime victim compensation programs. Federal victim compensation funds can help crime victims who file claims with state victim compensation agencies obtain reimbursement for mental health expenses, as well as lost wages, loss of support, and medical, dental, and funeral expenses. Federal law requires that states provide certain benefits, including mental health counseling benefits. However, states have discretion in setting program eligibility requirements and benefit amounts. According to the National Association of Crime Victim Compensation Boards, most states’ overall maximum benefit is linked to the individual crime rather than to individual primary victims, family members, or other persons affected by the crime. When there are multiple secondary victims of an individual crime, they typically must share the available maximum benefits. However, maximum mental health counseling benefits are typically linked to individual victims, with each family member or secondary victim typically eligible for mental health counseling benefits up to specified caps, unless otherwise stated. (See table 17.) In addition to the person named above, key contributors to this report were Susan Anthony, Alice L. London, Janina Austin, Sari Bloom, Emily Gamble Gardiner, William D. Hadley, Christi Turner, and Behn Miller. Private Health Insurance: Access to Individual Market Coverage May Be Restricted for Applicants with Mental Disorders. GAO-02-339. Washington, D.C.: February 28, 2002. Bioterrorism: Public Health and Medical Preparedness. GAO-01-915. Washington, D.C.: September 28, 2001. Medicaid and SCHIP: States’ Enrollment and Payment Policies Can Affect Children’s Access to Care. GAO-01-883. Washington, D.C.: September 10, 2001. Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001. Health and Human Services: Status of Achieving Key Outcomes and Addressing Major Management Challenges. GAO-01-748. Washington, D.C.: June 15, 2001. Major Management Challenges and Program Risks: Department of Health and Human Services. GAO-01-247. Washington, D.C.: January 1, 2001. Mental Health Parity Act: Despite New Federal Standards, Mental Health Benefits Remain Limited. T-HEHS-00-113. Washington, D.C.: May 18, 2000. The General Accounting Office, the investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. 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Summary: Eighty-eight percent of children nationwide have private or public health insurance that, to varying degrees, covers mental health services, including those that may be needed to help children recover from traumatic events, such as natural disasters, school shootings, or family violence. Despite the widespread prevalence of health insurance coverage for children, depending on their type of insurance coverage and where they live, children may face certain limitations in coverage or other barriers that could affect their access to needed services. The 16 percent of children who are enrolled in Medicaid and the State Children's Health Insurance Program public insurance programs generally have coverage for a wide range of mental health benefits, and those enrolled in Medicaid are not subject to day or visit restrictions. Beyond providing insurance that can give children access to mental health services, a range of federal programs can help children who have experienced trauma obtain needed services. GAO identified over 50 programs that can be used by grantees to provide mental health and other needed services to children who have never experienced trauma, although many of these programs have a broader focus and were not designed specifically for this purpose.