Almost 4 years after Hurricane Katrina, the children living in the greater New Orleans area may be at particular risk for needing mental health services, but certain barriers may impede the delivery of such care. Since Hurricane Katrina, there has been increasing emphasis on providing community-based, rather than hospital-based, mental health services for low-income and uninsured children in the greater New Orleans area. Multiple federal agencies support the provision of mental health and related services for these children through various programs. Children in the greater New Orleans area may be at particular risk for needing mental health services. Researchers at LSU Health Sciences Center have conducted semiannual mental health screenings in selected schools in the greater New Orleans area since Hurricane Katrina. One of the lead LSU Health Sciences Center researchers told us that they had screened about 12,000 area children as of January 2008; of the children screened in January 2008, 30 percent met the threshold for a possible mental health referral. Although this was a decrease from the 49 percent level during the 2005-06 school year screening, the rate of decline was slower than experts had expected. The LSU Health Sciences Center lead researcher we spoke with interpreted this slower-than-expected decline as indicating that the mental health needs of children in the greater New Orleans area continue to be significant. The effects of a traumatic event can persist for years. For example, a 2006 study on the use of counseling services by people affected by the 2001 World Trade Center attack found that some people first sought counseling services more than 2 years after the event. Research has shown that children who grow up in poverty as well as those who are exposed to violence during or after a catastrophic disaster are at risk for the development of mental health disorders. In 2007 the poverty rate for each of the four parishes in the greater New Orleans area was higher than the national average, and in Orleans and St. Bernard parishes, the rate was at least twice the national average. People who have experienced or witnessed certain incidents, including serious physical injury, during or after a catastrophic disaster can face an array of psychological consequences. The LSU Health Sciences Center lead researcher we spoke with told us that January 2008 data showed that 16 to 21 percent of children screened had a family member who had been injured in Hurricane Katrina, and 13 to 18 percent of children screened had a family member who had been killed in the hurricane. The President’s 2003 New Freedom Commission on Mental Health determined that many barriers can impede delivery of services for people with mental illness. The commission specifically identified stigma, cost, not knowing where or how to obtain services, unavailable services, workforce shortages, and a fragmented mental health delivery system as barriers. The stigma surrounding mental illness—negative attitudes and beliefs about mental illness that can deter people from seeking treatment—was described as a pervasive barrier preventing Americans from understanding the importance of mental health. The commission also noted that there was a national shortage of mental health providers and a lack of providers trained in evidence-based practices. The commission recommended early intervention, education, and screening in low-stigma settings—such as primary care and school settings—as ways to prevent mental health problems in children from worsening. Before Hurricane Katrina, health care services for low-income and uninsured children and families in the greater New Orleans area were primarily hospital-based. These individuals had access to mental health services through Charity and University hospitals, which were a major source of psychiatric care for the area. About half of the patients served by these hospitals were uninsured, and about one-third were covered by Medicaid. Since Hurricane Katrina and the subsequent reduction in hospital capacity, according to state and local officials, there has been an increasing emphasis on providing community-based mental health services, including through school-based health centers (SBHC) and other programs that provide mental health services in schools. In general, SBHCs are located in schools or on school grounds and provide a comprehensive range of primary care services to children. Louisiana’s SBHCs provide mental health services in addition to other primary care services. The LDHH Office of Public Health operates the Adolescent School Health Initiative, which facilitates the establishment of SBHCs in Louisiana, establishes standards for SBHCs, and monitors their quality of care. Each SBHC is administered by a sponsor organization, such as a hospital or school, and is required to have a mental health provider on staff. A parent or guardian must sign a written consent form for a student to receive services at an SBHC. Some children can gain access to mental health services through the regional human services districts, to which LDHH’s Office of Mental Health, Office for Addictive Disorders, and Office for Citizens with Developmental Disabilities give funding to provide services in certain areas of the state. The regional human services districts operate and manage community-based programs and services, including mental health services. In the greater New Orleans area, the Jefferson Parish Human Services Authority serves Jefferson Parish, and the Metropolitan Human Services District serves Orleans, Plaquemines, and St. Bernard parishes. Multiple federal agencies support the provision of mental health and related services for children in the greater New Orleans area through various programs, including grant programs. (See app. II for information on selected federal programs that support mental health and related services for children. See app. III for information on selected services provided to children by these programs.) HHS supports the provision of mental health services for children in the greater New Orleans area through several of its agencies, including SAMHSA, HRSA, CMS, and ACF. SAMHSA, which has the primary federal responsibility for children’s mental health services, works to improve the availability of effective mental health services, substance abuse prevention and treatment services, and related services through formula grant programs—such as the Community Mental Health Services Block Grant— and discretionary grant programs—such as the National Child Traumatic Stress Initiative and the Child Mental Health Initiative. HRSA works to improve health care systems and access to health care for uninsured and medically vulnerable populations. Its Health Center Program supports health centers in the greater New Orleans area that provide primary care services, including mental health services, to adults and children. In addition, HRSA supports the provision of mental health services to children through formula and discretionary grant programs, such as the Maternal and Child Health Services Block Grant and the Bureau of Clinician Recruitment and Service’s National Health Service Corps Scholarship Program and Loan Repayment Program. CMS provides funding for health care coverage for its programs’ beneficiaries and administers certain additional grant programs related to Hurricane Katrina. CMS administers Medicaid and the State Children’s Health Insurance Program (CHIP), and the programs are jointly financed by the federal government and the states. Medicaid and CHIP represent a significant federal funding source for health services, including mental health services, for children in Louisiana. For example, in state fiscal year 2008, the Louisiana Medicaid and LaCHIP programs reimbursed almost $9.4 million to providers for over 66,000 claims for mental health services for children in the greater New Orleans area. Over 110,000 children in the greater New Orleans area were enrolled in these two programs as of August 2008. The programs cover inpatient psychiatric services, psychological and behavioral services provided by licensed psychologists, physician psychiatric services, and services of licensed clinical social workers when provided in certain settings. CMS also administers additional grant programs related to Hurricane Katrina, including the Primary Care Access and Stabilization Grant (PCASG), a program intended to assist in the restoration and expansion of outpatient primary care services, including mental health services, in the greater New Orleans area; the Professional Workforce Supply Grant, intended to address shortages in the professional health care workforce; and the Provider Stabilization Grants, a program intended to assist health care facilities that participate in Medicare to recruit and retain staff. ACF administers programs that promote the economic and social well- being of children, families, and communities. It supports counseling and treatment services, education, prevention initiatives, and ancillary services such as transportation through programs such as the Child Care and Development Fund and the Head Start program. In addition, in 2006 ACF distributed emergency supplemental Social Services Block Grant (SSBG) funding to Louisiana that in part supported mental health services. In addition to the HHS agencies, other federal agencies also support the provision of mental health and related services to children in the greater New Orleans area. Education supports mental health services for children through school violence prevention and substance abuse prevention programs, such as the Safe and Drug-Free Schools and Communities State Education Agency and Governors’ Grants. DOJ supports mental health services for children who have been victims of crime through its Crime Victim Assistance program. Some programs are the shared responsibility of multiple agencies. The Department of Homeland Security’s Federal Emergency Management Agency (FEMA) and SAMHSA are partners in administering the Crisis Counseling Assistance and Training Program (CCP), which provides crisis counseling services after events for which a presidential disaster declaration has been made. The CCP provided funding to LDHH’s Office of Mental Health, the state CCP grantee, for crisis counseling services in the greater New Orleans area after Hurricanes Katrina and Rita. FEMA also supported case management services for victims of Hurricanes Katrina and Rita through the Disaster Housing Assistance Program, which is administered by HUD. In addition to federal programs, state funding and donations also support mental health and related services to children in the greater New Orleans area. For example, a grant from the W.K. Kellogg Foundation is helping to support SBHCs in New Orleans. Louisiana must provide matching funds as a requirement of its receipt of some federal grants, so federal funding may represent only a portion of the total funding. For example, both HRSA’s Maternal and Child Health Services Block Grant and SAMHSA’s Child Mental Health Initiative require the state to match federal grant funds.