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.