The child welfare and juvenile justice systems are becoming the de facto mental health systems for children with severe mental and emotional problems, experts warn.
About one-third of the 12,700 children were placed in the child welfare system and the other two-thirds in the juvenile justice system, according to the report.
Moreover, parents at all income levels often relinquished custody of their children to the child welfare system because they could not obtain or afford intensive mental health services in community or residential care. The child’s behavior often endangered other family members and strained the family’s ability to function.
Many more children may be ending up in these two systems than the GAO reported, because child welfare and juvenile justice systems typically don’t keep track of children placed there primarily to obtain mental health services.
The GAO researchers received responses from child welfare officials in only 19 of the 50 states surveyed and from juvenile justice officials in 30 of the 33 counties in 17 states surveyed. The GAO selected the 17 states with the largest populations of children under age 18.
It also sent investigators to six other states, where they interviewed officials of child service agencies, caseworkers, and parents.
Parents reported they had difficulty affording intensive mental health services because their health insurance plan limited mental health coverage. Residential care can exceed $250,000 annually, and outpatient weekly visits can exceed $100 per visit, according to the report.
The report also cited a shortage of psychiatric and residential services for children and federal laws requiring that children be placed in the least-restrictive settings as other barriers to care.
David Fassler, M.D., an APA trustee-at-large and past chair of the APA Committee on Children, Adolescents, and Their Families, said in an interview with Psychiatric News, "It is a tragedy and disgrace that so many families are forced to give up custody of their children to obtain necessary mental health services. The lack of parity in mental health coverage and managed care restrictions on reimbursement for chronic mental illness are major contributors to the problem. Our society would not tolerate this if these children had cancer or other severe medical illnesses."
Another problem is that many states have a patchwork of reimbursement mechanisms in response to shifting politics and federal funding streams, said Fassler. "In the real world, this produces chaos, is extremely time consuming, and creates barriers to services."
Child advocates have reported that despite recent attention to the problem, parents have relinquished child custody to obtain mental health services for more than two decades. Several patient advocacy groups have issued reports on the problem, including the National Alliance for the Mentally Ill ("Families on the Brink," 1999), Bazelon Center for Mental Health Law ("Relinquishing Custody: The Tragic Result of Failure to Meet Children’s Mental Health Needs," 2000), and National Council on Disability ("Addressing the Needs of Youth With Disabilities in the Juvenile Justice System: The Status of Evidence-Based Research," 2003).
A persistent problem has been that local child welfare and juvenile justice officials often misinterpret federal regulations about out-of-home placements and mistakenly tell parents they have to relinquish child custody to obtain mental health services.
The GAO recommended to the federal departments of Health and Human Services, Education, and Justice that they form an interagency working group to determine the causes of misinformation and correct them.
At the state level, efforts are under way to increase access to services, according to the report. For example, a Kansas county facility houses professionals from child welfare, juvenile justice, education, and child mental health systems, the report stated.
Jan McCarthy, a child welfare policy expert at Georgetown University, told Psychiatric News that New Jersey is developing a statewide system called Partnership for Children that is being implemented county by county. The partnership pools funds from the Medicaid, mental health, and child welfare systems that are then funneled through a care-management organization whose role is to ensure that families receive mental health services without having to transfer child custody, said McCarthy.
"The partnership hopes that children placed in the child welfare system because they needed mental health services will be transferred to these care-management organizations for services and eventually leave the child welfare system," said McCarthy.
Fassler, the legislative representative for the Vermont Psychiatric Association, said Vermont is rethinking how it provides health and mental health services. The Vermont House recently passed a bill (H 450) to reorganize the state’s Agency of Human Services, which provides an array of services including child welfare, juvenile justice, mental health, and substance abuse services. The goal is to provide services in a comprehensive, holistic, accessible, flexible, and coordinated manner, according to the legislation.
Vermont Gov. James Douglas (R) has promised to sign the bill once the Senate approves it, said Fassler.
"We are also working toward integrating psychiatric treatment for children and adolescents with treatment for substance abuse and physical illnesses and school-based services," said Fassler.
Reps. Pete Stark (D-Calif.) and Patrick Kennedy (D-R.I.) and Sen. Susan Collins (R-Maine) asked the GAO to investigate why parents were relinguishing their children to the child welfare and juvenile justice systems. The lawmakers "expressed outrage that families were being broken apart for lack of adequate services," according to a press release from Stark.
The legislators are drafting bills to ensure that mental health services are provided to families who need them without having to resort to relinquishing custody and other drastic measures. Kennedy’s policy advisor said that the bill will be introduced by the end of the year.
The Sen. Paul Wellstone Mental Health Equitable Treatment Act (HR 953 and S 486) and the Family Opportunity Act were reintroduced in Congress this year. Both bills are designed to ease the financial burden on families with children with mental or emotional disorders.
The parity bill would bar employers from offering mental health benefits that impose greater financial burdens or care restrictions than on other types of medical benefits (Psychiatric News, March 21).
The Family Opportunity Act included in the Leave No Child Behind Act of 2003 (HR 936) would give states the option of allowing certain families with disabled children to buy Medicaid coverage to gain access to Medicaid-financed mental health and other services (Psychiatric News, April 18).
Reps. Kennedy and Ileana Ros-Lehtinen (R-Fla.) introduced the Child Healthcare Crisis Relief Act (HR 5078) in March to provide educational incentives to encourage individuals to enter children’s mental health professions and increase the workforce needed to serve children with mental disorders (Psychiatric News, April 18).
The GAO report can be accessed on the Web at www.gao.gov by clicking on "GAO Reports" and entering the report number, GAO-03-397. Relevant federal and state legislation can be accessed on the Web at http://thomas.loc.gov by entering the bill name or number. ▪