oversight

Child Welfare and Juvenile Justice: Federal Agencies Could Play a Stronger Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental Health Services

Published by the Government Accountability Office on 2003-04-21.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

United States General Accounting Office
Washington, DC 20548



          August 11, 2003

          ERRATA

          CHILD WELFARE AND JUVENILE JUSTICE: Federal Agencies Could Play a Stronger
          Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental
          Health Services (GAO-03-397, April 21, 2003)

          Page 3, paragraph 1, third sentence should read:

          “Child welfare directors in 6 other states and the District of Columbia advised us that
          their states do not allow parents to place children voluntarily with child welfare
                                            6
          agencies to access such services. ”

          Page 3, footnote 6 should read:

          “The 6 states are Florida, Hawaii, Missouri, Montana, New Hampshire, and Texas,
          based on information received in response to our survey concerning placements in
          fiscal year 2001. However, New Hampshire indicated that the state introduced
          voluntary services in state fiscal year 2002 and that it anticipates that some parents
          will seek placement for their children.”

          Page 14, footnote 14 should read:

          “Nineteen states provided estimates. Eleven states could not provide the data
          requested, 6 states and the District of Columbia said the practice was either not legal
          in their states or that the state generally did not allow parents to place their children
          solely to receive mental health services, and 10 states could not provide the data
          requested but indicated that voluntary placement happens. Four states did not
          respond to the survey.

          Page 15, Table 2, the following states should have only the following table notes:

          “Georgia                   b”
          “Kansas                    b”
          “Montana                   c”

          Page 16, Table 2, table note ‘c’ should read:
           c
          “ The practice of voluntary placement or relinquishment is either not legal in the state
          or the state generally does not allow parents to place their children solely to receive
          mental health services.”
             United States General Accounting Office

GAO          Report to Congressional Requesters




April 2003
             CHILD WELFARE
             AND JUVENILE
             JUSTICE
             Federal Agencies
             Could Play a Stronger
             Role in Helping States
             Reduce the Number of
             Children Placed Solely
             to Obtain Mental
             Health Services




GAO-03-397
                                               April 2003


                                               CHILD WELFARE AND JUVENILE
                                               JUSTICE

Highlights of GAO-03-397, a report to          Federal Agencies Could Play a Stronger
Congressional Requesters
                                               Role in Helping States Reduce the
                                               Number of Children Placed Solely to
                                               Obtain Mental Health Services

Recent news articles in over                   Child welfare directors in 19 states and juvenile justice officials in
30 states describe the difficulty              30 counties estimated that in fiscal year 2001 parents placed over
many parents have in accessing                 12,700 children into the child welfare or juvenile justice systems so that
mental health services for their               these children could receive mental health services. Nationwide, this number
children, and some parents choose              is likely higher because many state child welfare directors did not provide
to place their children in the child
welfare or juvenile justice systems
                                               data and we had limited coverage of county juvenile justice officials.
in order to obtain the services they           Although no agency tracks these children or maintains data on their
need. GAO was asked to determine:              characteristics, officials said most are male, adolescent, often have multiple
(1) the number and characteristics             problems, and many exhibit behaviors that threaten the safety of themselves
of children voluntarily placed in the          and others.
child welfare and juvenile justice
systems to receive mental health               Neither the child welfare nor the juvenile justice system was designed to
services, (2) the factors that                 serve children who have not been abused or neglected, or who have not
influence such placements, and                 committed a delinquent act. According to officials in the 6 states we visited,
(3) promising state and local                  limitations of both public and private health insurance, inadequate supplies
practices that may reduce the need             of mental health services, limited availability of services through mental
for child welfare and juvenile
justice placements.
                                               health agencies and schools, and difficulties meeting eligibility rules for
                                               services influence such placements. Despite guidance issued by the various
                                               federal agencies with responsibilities for serving children with mental
                                               illness, misunderstandings among state and local officials regarding the roles
                                               of the various agencies that provide such services pose additional challenges
The Departments of Health and                  to parents seeking such services for their children.
Human Services (HHS) and Justice
(DOJ) should consider the                      Officials in the states we visited identified practices that they believe may
feasibility of tracking children               reduce the need for some child welfare or juvenile justice placements.
placed by their parents in the child           These included finding new ways to reduce the cost of or to fund mental
welfare and juvenile justice                   health services, improving access to mental health services, and expanding
systems to obtain mental health
                                               the array of available services. Few of these practices have been rigorously
services. HHS, DOJ, and the
Department of Education                        evaluated.
(Education) should develop an
interagency working group to                   Factors Influencing Placement
identify the causes of the
misunderstandings at the state and
local levels and create an action
plan to address those causes.
These agencies should also
continue to encourage states to
evaluate the programs that the
states fund or initiate and
determine the most effective means
of disseminating the results of
these and other available studies.
www.gao.gov/cgi-bin/getrpt?GAO-03-397.

To view the full report, including the scope
and methodology, click on the link above.
For more information, contact Cornelia Ashby
at (202) 512-8403 or ashbyc@gao.gov.
Contents


Letter                                                                                         1
               Results in Brief                                                                4
               Background                                                                      7
               While No Formal Tracking Occurs, Available Estimates Indicate
                 That Many Children Were Placed with the State—Primarily
                 Adolescent Males—to Access Mental Health Services                           14
               Multiple Factors Influence Decisions to Place Children                        20
               States Have Developed a Range of Practices That May Reduce the
                 Need for Some Mental Health-Related Child Welfare and
                 Juvenile Justice Placements                                                 31
               Conclusions                                                                   38
               Recommendations                                                               39
               Agency Comments                                                               39

Appendix I     Scope and Methodology                                                         44



Appendix II    State Statutes Containing Language Allowing
               Voluntary Placement to Obtain Mental Health
               Services                                                                      46



Appendix III   Comments from the Department of Education                                     47



Appendix IV    Comments from the Department of Health and Human
               Services                                         51



Appendix V     Comments from the Department of Justice                                       56



Appendix VI    GAO Contacts and Acknowledgments                                              59
               GAO Contacts                                                                  59
               Acknowledgments                                                               59




               Page i                GAO-03-397 Children Placed to Obtain Mental Health Services
Related GAO Products                                                                                   60



Tables
                       Table 1: Characteristics of Key Agencies with Responsibilities for
                                Children with a Mental Illness                                           8
                       Table 2: States’ Estimated Number of Children Placed in the Child
                                Welfare System to Obtain Mental Health Services in Fiscal
                                Year 2001                                                              15
                       Table 3: Estimated Number of Children Placed in the Juvenile
                                Justice System in 33 Counties to Obtain Mental Health
                                Services in Fiscal Year 2001                                           17
                       Table 4: Key Features of Health Insurance Parity Laws in 6 States               22
                       Table 5: Key Medicaid and SCHIP Programs for Children with
                                Mental Illness in 6 States                                             23
                       Table 6: Survey Numbers and Response Rates                                      44
                       Table 7: Statutes in 11 States Allowing Parents to Place Children in
                                Child Welfare Systems in Order to Obtain Mental Health
                                Services While Retaining Custody of the Child                          46




                       Page ii                 GAO-03-397 Children Placed to Obtain Mental Health Services
Abbreviations

ACF               Administration for Children and Families
AFCARS            Adoption and Foster Care Analysis and Reporting System
CMS               Centers for Medicare & Medicaid Services
DOJ               Department of Justice
EPSDT             Early Periodic Screening, Diagnostic and Treatment
ERISA             Employee Retirement Income Security Act
HCBS              Home and Community-Based Services
HHS               Health and Human Services
IDEA              Individuals with Disabilities Education Act
IEP               Individualized Education Program
JADE              Juvenile Alternative Defense Effort
MHPA              Mental Health Parity Act
OSERS             Office of Special Education and Rehabilitative Services
OJJDP             Office of Juvenile Justice and Delinquency Prevention
SAMHSA            Substance Abuse and Mental Health Services
                  Administration
SCHIP             State Children’s Health Insurance Program
SED               serious emotional disturbances
SSI               Supplemental Security Income
TANF              Temporary Assistance for Needy Families
TBS               Therapeutic Behavioral Services
TEFRA             Tax Equity and Fiscal Responsibility Act




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Page iii                    GAO-03-397 Children Placed to Obtain Mental Health Services
United States General Accounting Office
Washington, DC 20548




                                   April 21, 2003

                                   The Honorable Susan M. Collins
                                   United States Senate

                                   The Honorable Pete Stark
                                   The Honorable Patrick Kennedy
                                   House of Representatives

                                   Recent news articles in over 30 states and prominent mental health
                                   advocacy organizations have reported on the difficulty many parents have
                                   accessing mental health services for their children with severe mental
                                   illness.1 In some cases, parents must choose to keep their children at home
                                   without receiving the mental health and supportive services that they need
                                   or to remove them from their home and seek alternative living
                                   arrangements by inappropriately placing them in the child welfare or
                                   juvenile justice system to obtain mental health services—two systems not
                                   designed to care for children solely because of their mental health needs.2
                                   Although the people and conditions described in the reports varied, all
                                   documented that many children with severe mental illness needed services



                                   1
                                    Federal agencies and states have varying definitions for children with serious emotional
                                   disturbances (SED). For example, the Department of Health and Human Services’ (HHS)
                                   Substance Abuse and Mental Health Services Administration (SAMHSA) defines SED as a
                                   diagnosable mental disorder found in persons from birth to 18 years of age that is so severe
                                   and long lasting that it seriously interferes with functioning in family, school, community,
                                   or other major life activities. Because of these differences, we use the term “children with
                                   severe mental illness” throughout this report.
                                   2
                                    Child welfare systems are designed to protect children who have been abused or neglected
                                   by, for example, placing children in foster care or providing family preservation services;
                                   and juvenile justice systems are designed to rehabilitate children who have committed
                                   criminal or delinquent acts and to prevent such acts from occurring. Consequently, the
                                   goals of these systems and the background and training of their staff reflect these
                                   purposes. In addition, parents cannot voluntarily place their children in the juvenile justice
                                   system—children are detained in this system as a result of their delinquent acts or status
                                   offenses—that is, according to the Department of Justice (DOJ), behaviors that are law
                                   violations only if committed by juveniles. However, parents sometimes request that police
                                   arrest their children for delinquent behaviors or status offenses that are related to or stem
                                   from their mental illness when they cannot obtain services through other means. In this
                                   report, we use the term “placed” to refer both to children who have been voluntarily placed
                                   in the child welfare system and children who enter the juvenile justice system to receive
                                   mental health services. Because information was not available, we were not able to report
                                   on whether parents relinquished custody of their children to obtain the services.



                                   Page 1                       GAO-03-397 Children Placed to Obtain Mental Health Services
such as psychiatric and family support services that are not readily
accessible in their communities. Various federal laws require that state
and local agencies provide services to disabled children, including
children with a mental illness, in the least restrictive setting appropriate to
their needs; that is, children have a right to receive services in their
communities unless their needs can only be met by the state in residential
or institutional placements.

Several federal agencies have various responsibilities for children with
mental health needs. For example, HHS’s SAMHSA provides funds and
guidance to help states and localities address the needs of children with
mental illness. HHS’s Centers for Medicare & Medicaid Services (CMS)
administers both the Medicaid Program and the State Children’s Health
Insurance Program (SCHIP). These programs provide funds to states for
public health insurance programs, which can cover mental health services,
for the approximately 26.5 million enrolled children who are members of
low-income families and certain children with disabilities. Similarly, the
Department of Education’s (Education) Office of Special Education and
Rehabilitative Services (OSERS) provides funding and technical assistance
to help states provide needed services, including mental health services, to
disabled children with special education needs. Title IV-E of the Social
Security Act provides reimbursement for foster care maintenance
payments to states, which is available when child welfare agencies place
eligible children in approved out-of-home settings, including some
                                  ,
residential treatment facilities.3 4 In many cases, these costs are high;
residential treatment facilities can cost over $250,000 a year for one child.
Federal law does not require parents to relinquish their parental rights to
place their children with child welfare agencies. However, after children
have been in care for a specific period of time, the law requires the court
to review the child’s status and determine the best interest of the child—
which, in some cases, may include termination of parental rights.



3
 In commenting on a draft of this report, HHS said that federal reimbursement is only
available for children placed by a juvenile justice agency when that agency has an
agreement with a child welfare agency under Title IV-E. HHS also said that many facilities
that treat children with serious mental health issues are not considered within the scope of
foster care and the Title IV-E program. Some states have developed procedures for using
Title IV-E funding for the residential placement of children with mental health needs by
arranging for courts to make similar findings in these cases as are required for the
placement of children removed for safety reasons in situations of abuse and neglect.
4
  A residential treatment facility is an inpatient facility, other than a hospital, that provides
psychiatric services to individuals under age 21.




Page 2                        GAO-03-397 Children Placed to Obtain Mental Health Services
State laws addressing the ability of parents to place their children in child
welfare systems vary across states. Nationwide, laws in 11 states allow
parents to place children in child welfare systems on a voluntary basis in
order to access mental health services for as long as necessary without
relinquishing custody of the child to the state.5 Child welfare directors in
6 other states and the District of Columbia advised us that their states do
not allow parents to place child voluntarily in child welfare agencies to
access such services.6 Laws in the remaining states are generally silent
regarding voluntary placements for mental health. (See app. II for a
description of state placement statutes.)

You asked us to determine: (1) the numbers and characteristics of children
voluntarily placed in the child welfare and juvenile justice systems in order
to receive mental health services, (2) the factors that influence such
placements, and (3) promising state and local practices that may reduce
the need for some child welfare and juvenile justice placements.

To address your questions, we surveyed state child welfare directors in all
states and the District of Columbia and juvenile justice officials in
33 counties in the 17 states with the largest populations of children under
age 18. We surveyed juvenile justice officials at the county level, rather
than at the state level, because of the decentralized nature of the juvenile
justice system. In addition, we researched state laws and regulations
regarding voluntary placement and relinquishment of parental rights, and
interviewed officials of child-serving agencies,7 caseworkers, and parents
in 6 states (Arkansas, California, Kansas, Maryland, Minnesota, and New
Jersey) and judges in 5 states. We chose these states because they
represented diversity in geographical location, legal requirements
concerning children’s placement, use of Medicaid waivers and optional




5
  The 11 states are: Alaska, Colorado, Connecticut, Iowa, Maine, Minnesota, North Dakota,
Oregon, Rhode Island, Wisconsin, and Vermont.
6
 The 6 states are Florida, Hawaii, Missouri, Montana, New Hampshire, and Texas, based on
information received in response to our survey concerning placements in fiscal year 2001.
However, New Hampshire indicated that the state introduced voluntary services in state
fiscal year 2002 and that it anticipates that some parents will seek placement for their
children.
7
 Child-serving agencies include mental health, Medicaid and SCHIP, juvenile justice,
education, and child welfare.




Page 3                      GAO-03-397 Children Placed to Obtain Mental Health Services
                   services,8 and the role of state and county agencies in administering child
                   welfare and juvenile justice programs. Also, we observed programs that
                   state officials identified as model programs in those 6 states and
                   interviewed key federal officials and national experts. A more detailed
                   discussion of our scope and methodology appears in appendix I. We
                   conducted our work between March 2002 and February 2003 in
                   accordance with generally accepted government auditing standards.


                   State child welfare officials in 19 states and county juvenile justice
Results in Brief   officials in 30 counties who responded to our surveys estimated that in
                   fiscal year 2001 parents in their jurisdictions placed over 12,700 children—
                   mostly adolescent males—into the child welfare or juvenile justice
                   systems so that these children could receive mental health services.
                   However, this estimate understates the prevalence of these children for
                   two reasons. First, 32 state officials, including officials of 5 states with the
                   largest populations of children, did not provide us with data. However,
                   officials in 11 of those states indicated that although they could not
                   provide an estimate, such placements occurred in their state. Also, we
                   surveyed juvenile justice officials in only 33 counties, 30 of which
                   responded with an estimate. Moreover, no formal or comprehensive
                   federal or state tracking of such placements occurs. According to the
                   officials we interviewed, many of these children exhibited behavior that
                   threatened their safety and the safety of others. In addition, these officials
                   said children who were placed came from families of all financial levels
                   and that the seriousness of the child’s illness strained the family’s ability to
                   function. For example, some parents found they were not able to meet the
                   needs of other children in the family or fulfill job-related responsibilities.




                   8
                    Medicaid is a federal-state health financing program for certain low-income individuals
                   established by Title XIX of the Social Security Act; under Medicaid, states must meet
                   minimum federal rules of coverage in order to receive federal matching dollars. People
                   eligible for Medicaid can generally be divided into three categories: (1) the mandatory
                   categorically needy, (2) the optional categorically needy, and (3) the medically needy.
                   States have several methods by which they can customize their Medicaid program to meet
                   the needs of these enrollees. States can choose to cover certain optional services, such as
                   prescription drugs, or certain optional populations; for example, several states have
                   expanded eligibility for Medicaid to certain groups of children who would not otherwise
                   qualify for the program because their families’ incomes are too high. A limited number of
                   states can also request that HHS waive certain statutory requirements for a specified period
                   of time.




                   Page 4                      GAO-03-397 Children Placed to Obtain Mental Health Services
A variety of factors influenced whether parents placed their children in the
child welfare and juvenile justice systems to receive mental health services
for them. Some parents we spoke to in all 6 states reported these factors
often created delays or prevented them from obtaining the mental health
services that their children needed. According to child welfare, child
mental health, and juvenile justice officials, a number of parents placed
children in the child welfare and juvenile justice systems because their
health insurance had limitations, such as restrictions on mental health
services. These same officials said some mental health services, such as
child psychiatric and residential services, were in short supply. In all the
states we visited, some parents who could not afford or access needed
mental health services said they sought help from mental health agencies
and schools but reported these agencies had limited resources. Parents
seeking placements for children in residential treatment facilities faced
further challenges. Mental health and education officials in the 6 states we
visited did not support residential placement for children except in
extraordinary situations because federal law requires that mental health
officials provide services for children in the least restrictive setting as
possible and requires education officials to educate children with
disabilities with children who are not disabled to the maximum extent
possible. These officials believed providing services in a community-based
program is a better option for children and families than providing
services in residential treatment facilities. In addition, some parents in all
6 states said gaps in services occurred because child-serving agencies have
different eligibility requirements for programs and this made it difficult for
them to access the child mental health and family support services they
needed from various agencies. For example, children who were eligible for
psychological services under Medicaid could lose these services if their
families’ income increases beyond eligibility thresholds. Finally, state and
local officials’ views of the roles of their own agency and other agencies,
such as mental health, child welfare, education, and juvenile justice,
showed that they misunderstood those roles and, therefore, could not
effectively give parents complete and accurate information about available
services their agency and other agencies could provide. Federal officials,
experts, and service providers agreed that agencies must work together to
meet the needs of children. Although federal officials work together on
various advisory and information-sharing committees, co-sponsor
programs designed to help children with a mental illness, and disseminate
much guidance regarding their policies and programs, some state and local
officials with responsibilities for children with a mental illness did not
understand the program requirements and capacities of their agencies and
other child-serving agencies.



Page 5                  GAO-03-397 Children Placed to Obtain Mental Health Services
Officials in all 6 states that we visited identified a range of practices in
their states that they believe may help reduce the need for some child
welfare and juvenile justice placements. Overall, these practices are
consistent with those suggested by federal agencies and child mental
health experts, and most parents we spoke with who had children in these
programs found these practices helpful. However, the effectiveness of the
practices is generally unknown because many were new and few were
rigorously evaluated. In addition, many of these practices served a small
number of children or only served children in specific locations. To fund
mental health services, some state and county officials developed
practices that increased the use of less expensive services and providers
and distributed mental health costs among several agencies so no single
agency paid the entire cost of a child’s care. For example, a program in
Minnesota used experienced, masters-level staff to supervise less
experienced, bachelor-level staff instead of using the more costly master’s
level workers as the primary service provider. States and counties
identified several practices that may improve access to mental health
services, such as providing a variety of services for children in a
convenient public facility and creating a single entity with responsibility
for meeting children’s mental health needs. For example, a service
provider in Kansas operated a facility that housed a variety of county child
welfare, juvenile justice, and education service providers as well as county
child mental health providers. States and counties also identified several
practices that may improve the treatment of children with a mental illness,
such as expanding the array of available mental health services for
children and addressing the needs of the family to help the family maintain
children with a mental illness at home. For example, in one city in Kansas,
caseworkers from one mental health center worked with families of
children with severe mental illness to identify community supports and
services, such as mentors and after-school programs, which support the
entire family.

To determine the extent to which children may be placed inappropriately
in the child welfare and juvenile justice systems in order to obtain mental
health services, we are recommending that the Secretary of HHS and the
Attorney General investigate the feasibility of tracking these children to
identify the extent and outcomes of these placements. To help reduce
misunderstandings at the state and local level, we also recommend that
the Secretaries of HHS and Education and the Attorney General develop
an interagency working group to identify the causes of these
misunderstandings and create an action plan to address those causes. We
further recommend that these agencies continue to encourage states to
evaluate the child mental health programs that the states fund or initiate


Page 6                 GAO-03-397 Children Placed to Obtain Mental Health Services
             and that the Secretaries of HHS and Education and the Attorney General
             determine the most effective means of disseminating the results of these
             and other available studies to state and local entities. In commenting on a
             draft of this report, Education, HHS, and DOJ generally agreed with our
             findings but did not fully concur with the recommendations. Education
             said that it did not understand how tracking the children discussed in this
             report will increase the likelihood of progressive practices to provide
             children’s mental health services and noted that no recommendations
             were made for increased grant spending to duplicate or disseminate the
             positive features of such practices. HHS said that asking the agencies to
             track this population of children in foster care does not address the larger
             point of the lack of mental health resources for families and communities
             and does not address the problems of the children or their parents. DOJ
             agreed that tracking should occur, but only in the short term, and said that
             HHS should take the lead in this activity. All three agencies said they
             would participate in any interagency working group that might be
             established based on our recommendation and DOJ suggested an existing
             group as the forum. HHS, however, said that such a group would do little
             to address the lack of resources. Education also said we should be more
             specific on the role of the interagency working group and added that such
             a group would not have the power to address congressional lawmaking.


             As defined by the President’s New Freedom Commission on Mental
Background   Health, the mental health system in the United States collectively refers to
             the full array of private and public programs for individuals with mental
             illness that deliver or pay for treatment and services. The federal
             government plays a major role in funding mental health services through
             public insurance—Medicaid and SCHIP—and grants to states and local
             agencies, and state and local governments play a major role in delivering
             services. Most families depend on private and public insurance to pay for
             mental health services because such services are expensive; although, as
             we discussed in a previous report, children may face certain limitations
             depending on their type of coverage and where they lived.9

             At the federal level, several federal agencies—including HHS’s SAMHSA,
             CMS, and the Administration for Children and Families (ACF); DOJ’s



             9
             U.S. General Accounting Office, Mental Health Services: Effectiveness of Insurance
             Coverage and Federal Programs for Children Who Have Experienced Trauma Largely
             Unknown, GAO-02-813 (Washington, D.C.: Aug. 22, 2002).




             Page 7                    GAO-03-397 Children Placed to Obtain Mental Health Services
                                            Office of Juvenile Justice and Delinquency Prevention (OJJDP); and
                                            Education’s OSERS—have a role in addressing the mental health needs of
                                            children. However, all have individual mandates, target different but often
                                            overlapping populations, and share responsibilities to varying degrees with
                                            state and county agencies. (See table 1.)

Table 1: Characteristics of Key Agencies with Responsibilities for Children with a Mental Illness

 Department and      Key activities related to                                    Authorizing           Population targeted and
 agency              children’s mental health                                     Statute               definition of mental illness
 HHS (CMS)           Administers the Medicaid and SCHIP programs that             Title XIX of the      Certain low-income individuals
                     provide health insurance coverage, including some            Social Security       and certain disabled individuals.
                     coverage for severe mental illness.                          Act
                     Awards research grants.                                                            Uses a clinical classification of
                     Provides technical assistance to state agencies.                                   diseases to identify children
                                                                                                        with a mental illness.
 HHS (ACF)           Oversees the Adoption and Safe Families Act of 1997          Title IV, Part E of   Children and families.
                     (ASFA) that improves the safety of children and              the Social
                     promotes adoption and permanent homes for children           Security Act          Uses a clinical classification to
                     who need them and supports families.                                               identify children with a mental
                     Administers Title IV-B of the Social Security Act that       ASFA                  illness and accepts
                     provides funds to states for services that protect the                             classifications used by
                     welfare of children. For example, these services                                   individual states in identifying
                     address problems that may result in the abuse and                                  children with mental health
                     neglect of children. The funds may also be used to                                 needs.
                     provide services to families of children with a mental
                     illness.
                     Administers the Title IV-E Foster Care Funds Program
                     that provides funds to states to partially cover the costs
                     of room and board for eligible children from low-income
                     families who are placed in approved out-of-home living
                     arrangements.
                     Maintains the Adoption and Foster Care Analysis and
                     Reporting System (AFCARS), to which states report
                     demographic data on children in foster care, including
                     diagnoses of mental illness.
                     Awards development, training, research, and
                     demonstration grants.
                     Disseminates research.
                     Provides technical assistance.




                                            Page 8                       GAO-03-397 Children Placed to Obtain Mental Health Services
 Department and   Key activities related to                                       Authorizing            Population targeted and
 agency           children’s mental health                                        Statute                definition of mental illness
 Education        Monitors the implementation of the Individuals with             IDEA                   Promotes improvement in
 (OSERS)          Disabilities Education Act (IDEA). IDEA established the                                educational results for infants,
                  right of disabled children—including children with                                     toddlers, and children with
                  mental illness—to receive special education and                                        disabilities.
                  related services, such as mental health services,
                  designed to meet their unique needs and prepare them                                   Under IDEA, the term “child
                  for employment and independent living when such                                        with a disability” means a child,
                  services are needed for children to make adequate                                      who by reason of a physical or
                  progress in school. IDEA requires schools to evaluate                                  mental disability, needs special
                  children who are referred for special education services                               education and related services.
                  and, if services are required, develop an individualized
                  education program (IEP) that documents the type and
                  intensity of services that will be provided.
                  Funds formula and discretionary grants.
                  Provides technical assistance.
                  Disseminates research.
 HHS (SAMHSA)     Provides funds to states and local entities to help them        Public Health          Individuals with substance
                  administer, support, or establish programs that                 Service Act            abuse problems, mental illness
                  specifically target the mental health needs of children                                or at risk of substance abuse
                  and provides block grant funding that enables the                                      and mental illness.
                  states to maintain and enhance mental health services.
                  Sponsors the Systems of Care Initiative to help                                        Children served meet the
                  children and adolescents with severe mental illnesses                                  following criteria:
                  and their families receive a variety of services from                                  • age 0 to 18 and
                  schools, community mental health centers, and social                                   • have a diagnosed mental,
                  services organizations and facilitate coordination                                         behavioral, or emotional
                  among these service providers.                                                             disorder of sufficient duration
                  Awards formula and discretionary development and                                           to meet diagnostic criteria
                  demonstration grants.                                                                      that results in impairment
                  Disseminates research.                                                                     that substantially interferes
                  Provides technical assistance.                                                             with or limits the child’s
                                                                                                             functioning in family, school,
                                                                                                             or community activities.

 DOJ (OJJDP)      Helps oversee juvenile justice programs across the              Juvenile Justice       Children who commit crimes or
                  nation and supports states and local communities in             and Delinquency        are delinquent and children at
                  their efforts to develop and implement effective and            Prevention Act         risk for delinquency.
                  coordinated prevention and intervention programs.
                  Helps improve the juvenile justice system’s ability to                                 Accepts mental illness
                  protect public safety, hold offenders accountable, and                                 classifications used by states to
                  provide mental health treatment and rehabilitative                                     identify children with mental
                  services.                                                                              health needs.
                  Funds formula and discretionary grants.
                  Provides technical assistance.
                  Disseminates research.
Source: GAO.

                                        Note: Other agencies, such as HHS’s Social Security Administration, Department of DOJ’s Division of
                                        Civil Rights, and HHS’s and Education’s Office of Civil Rights, also have responsibilities for children
                                        with disabilities, including children with a mental illness.




                                        Page 9                         GAO-03-397 Children Placed to Obtain Mental Health Services
Federal agencies with responsibilities for children with mental illness
support interagency collaboration at the federal and local level. For
example, officials at SAMHSA are collaborating with Safe and Drug Free
Schools officials at Education and OJJDP to improve mental health
services for children with emotional and behavioral disorders who are at
risk of violent behavior by developing and implementing a large grant
program that targets these children. This program awarded grants—about
$53.2 million in fiscal year 2001—to some local school districts that
formed partnerships with local mental health and law enforcement
agencies to provide comprehensive planning and services for children with
emotional and behavioral disorders. In addition, ACF, Education,
SAMHSA, and a private foundation are jointly administering a program
that assesses the collaborative processes being used to provide
multiagency services to very young children affected by mental illness and
substance abuse. At the state and county level, a similar array of agencies
provides or funds services for children with a mental illness, and state and
federal laws and policies often determine their roles and responsibilities.
In addition, federal agencies play an important role in funding research
and evaluation studies and disseminating the findings of these efforts. For
example, SAMSHA, OJJDP, and OSERS fund research and evaluation
studies that target children with mental illness and disseminate the
findings of these efforts, descriptions of promising practices, and other
information through their clearinghouses, journals, and Web sites.

Despite their differences, programs run by agencies at all levels of
government generally adhere to the principle of the “least restrictive
environment.”10 This principle assumes that children, like adults, have
liberty interests that include the right to live in a family situation. Under
this principal, the state has the burden of demonstrating that state-funded
out-of-home placements are necessary for the protection of the child or
society. In 1999, the Supreme Court established this principle as a right for
disabled children. In Olmstead v. L.C., the Court held that, under Title II of
the Americans with Disabilities Act, states may be required to serve people
with disabilities in community settings when such placements can be
reasonably accommodated.

Mental health treatment can be very expensive and most families rely
upon insurance to help cover the cost of these services. For example, one



10
 IDEA requires that, to the maximum extent possible, children with disabilities are to be
educated with children who are not disabled, based on the needs of the child.




Page 10                     GAO-03-397 Children Placed to Obtain Mental Health Services
outpatient therapy session can cost more than $100, and residential
treatment facilities, which provide 24 hours of care, 7 days a week, can
cost $250,000 a year or more. Nationwide, 88 percent of American children
are covered by private or public health insurance plans. Private plans,
such as employer-sponsored or individually purchased plans, provide
health insurance coverage to about 68 percent of American children, and
public programs, such as Medicaid and SCHIP, provide health insurance
coverage to about 19 percent.11

Most private health insurance plans offer different coverage for mental
health services than for physical health services. To ensure more
comparable coverage, the federal government passed the federal Mental
Health Parity Act (MHPA) of 1996. MHPA prohibited certain employer-
sponsored group plans from imposing annual or lifetime restrictions on
mental health benefits that are lower than those imposed on other
benefits. However, the act did not eliminate other restrictions and
limitations on mental health coverage, such as limiting the number of
treatments per year that are reimbursable. In addition, the law does not
apply to plans sponsored by employers with 50 or fewer employees, group
plans that experience an increase in plan claims costs of at least 1 percent
because of compliance, and coverage sold in the individual market.
According to the National Council of State Legislatures, as of November
2001, 46 states have passed mental heath parity bills. Most of these laws
meet or exceed the federal MHPA standard. However, the Employee
Retirement Income Security Act (ERISA) of 1974 preempts states from
directly regulating self-funded, employer-sponsored health plans; under
such circumstances, state requirements usually do not apply.

For more than 30 years, Medicaid has provided comprehensive health
coverage for children from low-income families. Although individual states
determine many coverage, eligibility, and administrative details, the
federal government has established certain requirements for state
Medicaid programs. These requirements include providing preventive
screening and necessary treatment of any detected health condition for
children. Under Medicaid, a state may apply for waivers from the federal
government, which exempt the state from certain provisions of the
Medicaid statute in order to operate a specific program, change the
benefits offered under Medicaid, or make comprehensive changes to their



11
 U.S. General Accounting Office, Health Insurance: States’ Protections and Programs
Benefit Some Unemployed Individuals, GAO-03-191 (Washington, D.C.: Oct. 25, 2002).




Page 11                    GAO-03-397 Children Placed to Obtain Mental Health Services
Medicaid or SCHIP programs. For example, states can use the Home and
Community-Based Services (HCBS) (section 1915(c) of the Social Security
Act) waiver to provide home and community-based long-term care
services to targeted groups of individuals who would otherwise require
care in a hospital, skilled nursing facility, or intermediate care facility. To
receive the HCBS waiver, states must demonstrate that the cost of the
services to be provided under the waiver is no more than the cost of
institutionalized care plus any other Medicaid services provided to
institutionalized individuals. Additional flexibility is available to states
under the “Katie Beckett” option, which enables states to use federal
Medicaid funds more flexibly to cover the costs of health care services in
the home and community rather than just in institutional settings,
regardless of the income and assets of the family.12 States choosing this
option provide Medicaid coverage for children under age 19 who meet
certain standards for disability, would be eligible for Medicaid if they were
in an institution, and are receiving medical care at home that would be
provided in an institution. Although family income and resources are not
considered in determining eligibility for services under the Katie Beckett
option, states can require families to contribute to the cost of the program.
The Rehabilitation option allows states to provide optional Medicaid
services such as psychiatric rehabilitation and other diagnostic, screening,
and preventive services. Under this option, children can obtain services in
nonmedical settings, including school-based or other day treatment and
home-based services.

States can expand public health insurance for uninsured children from
low-income families by implementing SCHIP programs. States have three
options in designing SCHIP programs. They may (1) expand Medicaid
programs to include children from low-income families with earnings too
high to qualify for Medicaid, (2) develop a separate child health insurance
program with benefits that differ from those offered under Medicaid, or
(3) provide a combination of both. Twenty-four states are implementing
SCHIP by expanding Medicaid. Fourteen states are enrolling children into
separate non-Medicaid plans. Other states use a combination of Medicaid
and non-Medicaid plans to serve children in families at different income
levels. If a state elects to implement SCHIP by expanding Medicaid, it must


12
   This waiver authority for seriously ill children was inspired by the case of a ventilator
dependent child, Katie Beckett. Katie’s mother successfully argued that the nursing
services her daughter required could be provided in her home and at a cost less than that of
providing the same care in a hospital. What resulted was the so-called “Katie Beckett
Waiver,” enacted as part of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982.




Page 12                     GAO-03-397 Children Placed to Obtain Mental Health Services
offer the same benefit package to SCHIP beneficiaries as it does to
Medicaid beneficiaries.

In addition, states operating SCHIP Medicaid-expansion or Medicaid-
combination programs must also screen children for various conditions so
that health problems can be found early and treated before they worsen.
This Medicaid requirement for Early and Periodic Screening, Diagnostic
and Treatment services (EPSDT) requires states to provide children and
adolescents under age 21 with access to comprehensive, periodic
evaluations of health, developmental and nutritional status, as well as
vision, hearing, and dental needs. States must provide all services needed
for conditions discovered through routine pediatric screenings regardless
of whether the service is covered for other beneficiaries by the state
Medicaid plan. In 2000, more than 1 million children were enrolled in
SCHIP Medicaid expansion programs and were, therefore, eligible for
EPSDT screens.

Certain disabled children, including children with a mental illness, may
qualify for monthly Supplemental Security Income (SSI) if they and their
families have little or no income and resources and they meet SSI’s
definition of disability. To meet SSI’s definition, a child must have a
physical or mental condition or conditions that can be medically proven,
and which result in marked and severe functional limitations; the
condition or conditions must last or be expected to last at least 12 months
or be expected to result in death; and the child may not work at a job that
is considered substantial work. The monthly SSI depends generally on
where the child lives and his or her parents’ assets. However, the monthly
SSI payment for children living in certain institutions throughout a month,
where private health insurance paid for their care or when Medicaid paid
more than half of the cost of their care, is currently capped at $30.13




13
  Not all severely limited children with a mental illness who meet SSI’s income
requirements are eligible for SSI payments because of SSI’s strict definition of disability.
Federal SSI payments for disabled children range from $1 to $545 and some states
supplement these payments. Although most children who receive SSI payments are eligible
for Medicaid, some are not.




Page 13                     GAO-03-397 Children Placed to Obtain Mental Health Services
                            State child welfare and county juvenile justice officials estimated that
While No Formal             parents in their jurisdictions placed over 12,700 children in fiscal year
Tracking Occurs,            2001, generally adolescent males, to child welfare and juvenile justice
                            agencies so that the children could receive mental health services.
Available Estimates         Nationwide, the number is likely higher because officials in 32 states,
Indicate That Many          including the 5 states with the largest populations of children, did not
                            provide us with estimates. Additionally, officials in 11 states that could not
Children Were Placed        provide estimates indicated that such placements occurred in their state.
with the State—             Moreover, we surveyed juvenile justice officials in only 33 counties, with
Primarily Adolescent        30 providing estimates. Only estimates were available because no federal
                            or state agency tracked children placed to obtain mental health services in
Males—to Access             a formal or comprehensive manner. Officials in the 6 states we visited
Mental Health               reported that placed children came from families of all financial levels and
                            said that the seriousness of the children’s illnesses strained families’
Services                    abilities to function. For example, some parents are not able to meet the
                            needs of children in the home and some found that they were less able to
                            meet work demands.


Some Officials Estimate     The state child welfare officials and county juvenile justice officials who
That Parents Placed Over    responded to our surveys estimated that over 12,700 children entered the
12,700 Children to Access   child welfare or juvenile justice systems in order to receive mental health
                            services in fiscal year 2001. Of these children, about 3,700 entered the
Mental Health Services      child welfare system. State child welfare officials reported estimates that
                            ranged from 0 to 1,071 children, with a median of 71. Table 2 provides
                            detailed information about the number of children placed in the child
                            welfare system.14 Approximately 9,000 children entered the juvenile justice
                            system. County juvenile justice officials reported estimates that ranged
                            from 0 to 1,750, with a median of 140. Table 3 provides details on the
                            estimated number of children placed in the juvenile justice system.




                            14
                               Nineteen states provided estimates. Eleven states could not provide the data requested, 6
                            states and the District of Columbia said the practice was either not legal in their states or
                            that the state generally did not allow parents to place their children solvely to receive
                            mental health services, and 10 states could not provide the data requested but indicated
                            that voluntary placement happens. Four states did not respond to the survey.




                            Page 14                      GAO-03-397 Children Placed to Obtain Mental Health Services
Table 2: States’ Estimated Number of Children Placed in the Child Welfare System
to Obtain Mental Health Services in Fiscal Year 2001

State                                                   Number of children placed
                                                                                   a
Alaska
Alabama                                                                         130
                                                                                   d
Arkansas
                                                                                   d
Arizona
                                                                                   b
California
                                                                                   b
Colorado
Connecticut                                                                     738
                                                                                   c
District of Columbia
Delaware                                                                           0
                                                                                   c
Florida
                                                                                   b
Georgia
                                                                                   c
Hawaii
                                                                                   d
Iowa
Idaho                                                                           123
                                                                                   a
Illinois
Indiana                                                                            0
                                                                                   b
Kansas
Kentucky                                                                         14
                                                                                   a
Louisiana
                                                                                   b
Massachusetts
Maryland                                                                         54
                                                                                   d
Maine
                                                                                   b
Michigan
Minnesota                                                                     1,071
                                                                                   c
Missouri
Mississippi                                                                      13
                                                                                   c
Montana
North Carolina                                                                  440
                                                                                   d
North Dakota
                                                                                   b
Nebraska
                                                                                   c
New Hampshire
                                                                                   b
New Jersey
                                                                                   b
New Mexico
Nevada                                                                           20
                                                                                   b
New York
                                                                                   d
Ohio
Oklahoma                                                                          3
Oregon                                                                          101
Pennsylvania                                                                     71
Rhode Island                                                                    279
                                                                                   a
South Carolina




Page 15                  GAO-03-397 Children Placed to Obtain Mental Health Services
    State                                                              Number of children placed
                                                                                                        d
    South Dakota
                                                                                                        d
    Tennessee
                                                                                                        c
    Texas
                                                                                                        d
    Utah
                                                                                                        d
    Virginia
    Vermont                                                                                            60
    Washington                                                                                        423
                                                                                                        b
    Wisconsin
    West Virginia                                                                                   135
    Wyoming                                                                                           5
    Total                                                                                         3,680
Source: GAO survey.
a
    State did not respond to our survey.
b
    State could not provide the data requested.
c
The practice of voluntary placement or relinquishment is either not legal in the state or the state
generally does not allow parents to place their children solely to receive mental health services.
d
    State could not provide the data requested, but indicated that voluntary placement happens.




Page 16                           GAO-03-397 Children Placed to Obtain Mental Health Services
Table 3: Estimated Number of Children Placed in the Juvenile Justice System in
33 Counties to Obtain Mental Health Services in Fiscal Year 2001

                                                                             Number of
    State                        County                                 children placed
    Arizona                      Maricopa                                            60
    Arizona                      Pima                                             1,750
                                                                                       a
    California                   Los Angeles
    California                   San Diego                                          200
    Colorado                     El Paso                                             40
    Colorado                     Jefferson                                          100
    Florida                      Broward                                              0
    Florida                      Miami-Dade                                         999
    Georgia                      Fulton                                             172
    Georgia                      Gwinnett                                           100
    Illinois                     Cook                                                 0
    Illinois                     DuPage                                              35
    Indiana                      Lake                                               600
    Indiana                      Marion                                             100
    Louisiana                    Jefferson Parish                                    50
    Michigan                     Oakland                                            160
    Michigan                     Wayne                                              400
                                                                                       a
    New Jersey                   Bergen
    New Jersey                   Middlesex                                          999
    New York                     Brooklyn                                            74
    New York                     Queens                                              49
                                                                                       a
    Ohio                         Cuyahoga
    Ohio                         Franklin                                           363
    Pennsylvania                 Montgomery                                          20
    Pennsylvania                 Philadelphia                                       500
    Texas                        Dallas                                             200
    Texas                        Harris                                             200
    Virginia                     Fairfax                                            350
    Virginia                     Prince William                                     840
    Washington                   King                                               575
    Washington                   Pierce                                               0
    Wisconsin                    Dane                                               120
    Wisconsin                    Milwaukee                                            0
    Total                                                                         9,056
Source: GAO survey.
a
County was unable to estimate the number of children.


Nationwide, the number of children placed is likely to be higher. Eleven
states reported that they could not provide us with an estimate even
though they were aware that such placements occurred. Moreover,



Page 17                      GAO-03-397 Children Placed to Obtain Mental Health Services
                        officials in 9 additional states that responded to our survey did not provide
                        an estimate and did not mention whether or not parents turned to the child
                        welfare system to access mental health services. However, child welfare
                        workers we interviewed in 2 of these 9 states—California and New
                        Jersey—confirmed that these placements did in fact occur. Although some
                        of the state child welfare officials that we visited in California said
                        children do not enter that system to obtain mental health services, county
                        child welfare workers said that they knew of such placements and
                        explained how the cases were coded in their system. Four states did not
                        respond to the survey.15 Information on the prevalence of children present
                        in the juvenile justice system is also limited in this report since we
                        surveyed only 33 counties. In 3 of those counties, juvenile justice officials
                        reported that while they were not able to provide estimates, they knew
                        that children were entering the system to obtain mental health services
                        because they were not able to access such services in other ways.

                        Federal and state systems that track children in the juvenile justice and
                        child welfare systems do not track in a formal or comprehensive way
                        children placed to receive mental health services. For example, ACF’s
                        AFCARS, which contains data reported by states about children in foster
                        care or adopted out of foster care, does not have a data element that
                        identifies this population. Similarly, every 2 years OJJDP conducts the
                        Census of Juveniles in Residential Placement, which gathers information
                        on children in juvenile residential facilities and their characteristics but no
                        database variable exists to isolate children whose parents sought the help
                        of the juvenile justice system to meet children’s mental health needs from
                        other children in the juvenile justice system who may also have mental
                        health problems. OSERS maintains extensive data about children who
                        receive special education services, but data are aggregated at the state
                        level and do not include information about who has custody of the child.


Officials Said Placed   According to our survey of state child welfare directors, placed children
Children Were Mostly    are more likely to be boys than girls and are more likely to be adolescent.
Adolescent Males with   Child welfare directors in 19 states reported that, in fiscal year 2001,
                        65 percent of placed children were male and 67 percent were between the
Severe Mental Health    ages of 13 and 18. While juvenile justice officials could not provide
Problems                information about the gender and ages of children placed in their system,




                        15
                             These 4 states were Alaska, Illinois, Louisiana, and South Carolina.




                        Page 18                         GAO-03-397 Children Placed to Obtain Mental Health Services
most children in the juvenile justice population are male and range in age
from 13 to 18.16

The officials from state and county child-serving agencies and parents we
interviewed in the 6 states that we visited said that children who were
placed had severe mental illnesses, sometimes in combination with other
disorders, and their parents believed they required intense treatment that
could not be provided in their homes. Many of these children were violent
and had tried to hurt themselves, their parents, or their siblings and often
prevented their parents from meeting the needs of the other children in
the family. For example, in Kansas, one parent reported that her three
other children refused to remain in the home with her son who has bipolar
disorder,17 is very aggressive, and has molested other children in the past.
In Maryland, officials from both state and county child-serving agencies
told us about a teenage boy who was mentally ill, developmentally
disabled, autistic, and hospitalized. Because the boy was both violent and
sexually aggressive, the county told his mother that if she brought him
home from a stay in the hospital, they would remove her other children
from the house. Caring for children who are seriously mentally ill can also
prevent parents from obtaining full-time work or cause disruptions in their
work lives. For example, an Arkansas parent now raising her grandchild
does not work because of the time necessary to care for her mentally ill
granddaughter. State and county officials from child-serving agencies in
5 of the 6 states that we visited told us that finding placements for children
who were mentally ill and who also had other developmental disabilities
was particularly difficult. One such child in Maryland was rejected by
facilities that serve the developmentally disabled because he was mentally
ill and rejected by facilities that serve the mentally ill because he was
developmentally disabled. Moreover, parents and officials in 4 of the
6 states that we visited also told us of youth who were not only mentally
ill, but who also abused illegal drugs and alcohol as a way to self-medicate
their mental illnesses.

Children who are placed or are at risk of placement come from families
that span a variety of economic levels. Officials from state and county



16
 In commenting on a draft of this report, DOJ said that, in the absence of formal tracking
and official data, describing with any certainty the characteristics of youth placed
voluntarily by their parents in the juvenile justice system is impossible.
17
 Bipolar disorder is characterized by the occurrence of one or more major depressive
episodes accompanied by at least one manic episode over a brief time interval.




Page 19                     GAO-03-397 Children Placed to Obtain Mental Health Services
                             child-serving agencies in all 6 states that we visited reported that families
                             of all economic levels have placed children or are at risk of doing so.
                             Officials in child-serving agencies in all of the 6 states that we visited said
                             children from middle class families are more likely to be placed because
                             they are not eligible for Medicaid and their families do not have the funds
                             to pay for treatments not covered by insurance.


                             Multiple factors influence parents’ decisions to place their children in the
Multiple Factors             child welfare and juvenile justice systems so that they can obtain mental
Influence Decisions to       health services for them. Private health insurance plans often have gaps
                             and limitations in the mental health coverage they provide—for example,
Place Children               some may not cover certain mental illnesses and others may limit the
                             amount and type of services that are covered—and not all children
                             covered by Medicaid received needed services. Even when parents could
                             afford mental health services, some could not access services—such as
                             child psychiatric services—at times when they needed those services
                             because of an inadequate supply of such services. In other instances, some
                             mental health agencies and schools have limited resources to provide
                             mental health services and are required to serve children in the least
                             restrictive environment possible or to educate eligible disabled children
                             with children who are not disabled to the maximum extent possible,
                             respectively—which can limit the alternatives available to parents whose
                             children need residential placements. In other instances, parents
                             sometimes have difficulty obtaining all needed services for their children
                             in their communities because eligibility requirements for services provided
                             by various agencies differ. Furthermore, some officials and service
                             providers have misunderstood the role of their own and other agencies
                             and, therefore, gave parents inaccurate or incomplete information about
                             available services for families. These misunderstandings created gaps in
                             services for some children.


Limitations in Private and   Almost all state child welfare directors and county juvenile justice officials
Public Insurance Often       who responded to our surveys reported that private health insurance
Restrict Access to Mental    limitations were increasing the number of child welfare and juvenile
                             justice placements to obtain mental health services, and well over half
Health Care, and Some        reported Medicaid rules also increased such placements. For example,
Services are Limited         according to parents and state and local officials in all 6 states that we
                             visited, many private insurance plans and separate SCHIP plans offered




                             Page 20                 GAO-03-397 Children Placed to Obtain Mental Health Services
limited coverage for traditional or clinical treatments, such as
psychotherapy or psychiatric consultations,18 and did not cover residential
treatment placements. In addition, state officials in 3 of the 6 states we
visited said that Medicaid rules in some states that require the
preauthorization of services could result in delays and denials of
community-based services.

The legislatures in the 6 states that we visited passed health insurance
parity laws to increase the coverage that was available for mental health
services by requiring insurance companies to provide mental health
coverage that was comparable to what they offered for physical health
care. Although these laws met or exceeded the standard established by the
federal MHPA, they did not require private plans to cover intensive, long
term, and nontraditional services such as respite care and wrap-around
services,19 although mental health officials and service providers in the
states that we visited said these services were often necessary to help
families maintain their severely children with a mental illness in their
homes. Furthermore, federal law20 preempts states from directly regulating
self-funded, employer-sponsored health insurance plans and in doing so
exempted many families from the enhanced benefits and protections
found in state parity laws. Table 4 shows the key features of these laws.




18
 These services are generally provided by licensed or certified psychiatrists, psychologists,
or master’s level social workers.
19
  Respite care refers to the supervision of mentally ill or other disabled children by a
trained caretaker for brief periods of time in order to provide parents relief from the strain
of caring for a child with serious mental illness. Wrap-around services encompass a variety
of community supports, including counseling, mentoring, tutoring, and economic services
that are designed to meet the individual needs of children and their families.
20
     See ERISA, 29 U.S.C. sections 1001-1461.




Page 21                        GAO-03-397 Children Placed to Obtain Mental Health Services
Table 4: Key Features of Health Insurance Parity Laws in 6 States

                                                                                                                         Meets       Exceeds
 State                  Major provisions                                                                                 FMPHA       FMHPA
 Arkansas               • Does not apply to state employees and companies with less than 50 workers.                                    ✓
                        • Exempts any group health plan whose costs increase 1 percent or more due to the act’s
                          application.
                        • Does not apply to health insurance plans if the act’s application to these plans will result
                          in an increase in the cost of the health plan of at least 1.5 percent.

 California             •   Applies generally to all employers, regardless of size.                                                      ✓
                        •   Applies to all health plans that provide benefits.
                        •   Coverage is limited to 20 outpatient visits and 30 days of inpatient care for mental
                            illnesses that do not meet the state’s SED criteria.
                        •   Covers severely emotionally disturbed children with certain categories of mental illness.
 Kansas                 •   Applies to health insurance plans that provide mental health benefits.                                       ✓
                        •   Plans must provide coverage for psychotherapeutic drugs used for the treatment of
                            mental health under conditions no less favorable than for other drugs.
                        •   Coverage is limited to 45 outpatient visits and 45 days of inpatient care.
 Maryland               •   Applies to all health insurance policies that provide coverage on an expense-incurred                        ✓
                            basis.
                        •   Includes drug and alcohol disorders.
                        •   Co-payments and deductibles must be equal to those for other conditions.
                        •   Outpatient coverage schedule provides for 80 percent coverage for the first five visits in
                            a 12-month period, 65 percent for the 6–30th visits, and 50 percent for the 31st and
                            subsequent visits.
 Minnesota              •   Applies to all health plans that provide mental health benefits.                                             ✓
                        •   Applies to all health plans that provide benefits except self-insured health insurance
                            plans.
                        •   Plans with 100 subscribers or more can limit mental health coverage to 80 percent of the
                            customary charge for the first 10 hours of treatment over a 12-month period and
                            75 percent for additional treatment over the same 12-month period.
 New Jersey             •   Every individual health insurance policy must provide coverage for biologically based                        ✓
                            mental illness.
                        •   Covers biologically based mental illness under the same terms as other sicknesses.
Source: GAO analysis.

                                                      In the 6 states that we visited, state and local mental health officials agreed
                                                      that Medicaid had far fewer restrictions and limitations than private health
                                                      insurance plans. In addition, mental health officials in Arkansas,
                                                      California, and Maryland told us that differences between private
                                                      insurance and Medicaid programs had created two distinct systems of
                                                      child mental health services. Under these systems, children covered by
                                                      Medicaid had greater coverage for mental health services than children
                                                      covered by private insurance.

                                                      All 6 of the states that we visited covered optional Medicaid and SCHIP
                                                      services by expanding their programs for children with mental illness who
                                                      were ineligible for Medicaid on the basis of their families’ income. These
                                                      included the HCBS waivers, Katie Beckett option, Rehabilitation option,




                                                      Page 22                      GAO-03-397 Children Placed to Obtain Mental Health Services
                                               and SCHIP programs. See table 5 for Medicaid and SCHIP programs used
                                               in the states that we visited.

Table 5: Key Medicaid and SCHIP Programs for Children with Mental Illness in 6 States

                            Waivers        Types of optional services                             Types of SCHIP programs
                                                                                                                   Combination
                        Home and                                                                  Separate         (Medicaid
                        Community-                                               Medicaid         (non-Medicaid) expansion and
                                      a
 State                  Based Services    Katie Beckett    Rehabilitation        expansion        program          separate) program
 Arkansas                                       X               X                     X
 California                    X                                X                                                                    X
 Kansas                        X                                X                                          X
 Maryland                      X                   X            X                                                                    X
 Minnesota                     X                   X            X                       X
 New Jersey                                                     X                                                                    X
Source: GAO analysis.
                                               a
                                                Of the 4 of the 6 states that we visited that had a HCBS waiver, only Kansas had a waiver
                                               specifically for children with serious emotional disturbances.


                                               States used different approaches to expand Medicaid coverage. For
                                               example, Medicaid officials in Kansas received permission from CMS to
                                               implement a HCBS waiver to expand coverage for community-based
                                               mental health services for a limited number of children who are
                                               chronically mentally ill. Although Medicaid officials in New Jersey
                                               financed its new child mental health system through a Medicaid
                                               Rehabilitation option, the option extends Medicaid coverage to only a
                                               limited number of children who have exhausted benefits under other
                                               insurance and who have chronic and severe mental illness. This option
                                               provides 60 days of community-based services and limited
                                               hospitalization.21 Arkansas, Maryland, and Minnesota used Medicaid’s
                                               Katie Beckett option to expand Medicaid coverage to physically or
                                               mentally disabled children who meet CMS’s requirements for institutional
                                               care. Arkansas’s program did not require parents to share program costs to
                                               receive services, but Minnesota’s program required parents to pay
                                               according to their ability as defined by a sliding scale.

                                               While states chose to use different waivers and options to expand access
                                               to mental health services, all 6 states used SCHIP programs to extend


                                               21
                                                 In commenting on a draft of this report, Kansas said that services the state provides under
                                               the Rehabilitation option are not limited to 60 days, but are based on the individual clinical
                                               and medical needs of a child.




                                               Page 23                        GAO-03-397 Children Placed to Obtain Mental Health Services
health insurance coverage to low-income families whose incomes
exceeded allowable limits under Medicaid. Kansas offered a separate child
health (non-Medicaid) expansion program. Arkansas and Minnesota
offered expanded Medicaid coverage and California, Maryland, and New
Jersey offered both and Medicaid-expansion and separate child health
programs to low-income families of different income levels. However,
mental health officials in 3 states said that their separate SCHIP programs
generally resemble many private insurance plans in terms of limits and
restrictions. For example, New Jersey’s separate SCHIP plan limits some
mental health services. California’s plan, however, entitles children who
meet the state’s definition of severely emotionally disturbed to receive the
same services from county mental health services as children covered by
Medicaid.

Although Medicaid’s EPSDT provision requires Medicaid coverage for all
medically necessary health services that are identified during routine
periodic screening as long as the treatment is reimbursable under federal
Medicaid guidelines, some state officials said many eligible children are
unable to access necessary services through Medicaid because
practitioners in the states implement EPSDT unevenly. For example, a
Medicaid official in Maryland told us that the implementation of EPSDT
varied from county to county. Medicaid officials in California said
implementation varied from practitioner to practitioner although access to
EPSDT services was increasing as a result of litigation. These officials
explained that some practitioners are reluctant to recommend services if
such services are not available, some do not have the time to question
parents about their child’s mental health, and others are not well informed
about children’s mental health issues. In a previous report, we
recommended that the Administrator of CMS work with states to develop
criteria and time frames for consistently assessing and improving EPSDT
reporting and provision of services.22 As we stated in that report,
comprehensive national data on the implementation of EPSDT are needed
to judge states’ success in implementing EPSDT requirements.

Low Medicaid reimbursement rates may restrict mental health providers’
participation in the program and thus further restrict services. In all
6 states, officials from a variety of agencies said Medicaid rates for some
services are lower than the usual and customary rates in their areas and, in



22
 U.S. General Accounting Office, Medicaid: Stronger Efforts Needed to Ensure Children’s
Access to Health Screening Services, GAO-01-749 (Washington, D.C.: July 13, 2001).




Page 24                    GAO-03-397 Children Placed to Obtain Mental Health Services
some areas, psychiatrists and psychotherapists will not accept Medicaid
patients or expand the number that they are presently seeing because of
low Medicaid reimbursements. For example, a psychologist in Minnesota
told us that Medicaid reimbursement for a psychotherapy session is about
half the customary rate, and a mental health official in New Jersey said
that Medicaid reimburses only $5 per visit for monitoring the use and
effects of psychotherapeutic medication.

Even when insurance covered the costs of mental health services, some
mental health officials and parents indicated parents often could not
access services or placements in their community because the supplies of
these services were limited. Fifteen of the 28 child welfare officials and
9 of the 23 juvenile justice officials who responded to our survey question
on the relationship between community mental health services and
voluntary placements indicated that the lack of such services increased
voluntary placements. In every site we visited, officials of state and local
child-serving agencies and parents reported inadequate supplies of mental
health service providers and specialized mental health placements. Many
of these officials said that shortages of child psychiatrists, child
psychologists, respite care workers, and behavior therapists existed on
statewide levels and were worse in rural areas. For example, state and
local mental health officials in Arkansas, California, Kansas, Maryland, and
Minnesota told us that some rural counties had very limited or no child
mental health services. Also, specialized, out-of-home mental health
placements, such as psychiatric in-patient services and residential
treatment facilities, were often not available or had long waiting lists. For
example, Arkansas officials said the state has no state-run psychiatric
hospital placements for children under age 12, and, in California, some
children have to wait about 8 months for a residential placement. Child
welfare, mental health, and juvenile justice officials in California,
Maryland, and New Jersey noted that relatively fewer residential
placements are available for girls than are available for boys and that few
placements would accept children with histories of arson and sexual
aggression. Moreover, these officials noted children placed in the child
welfare or juvenile justice systems received preference for services,
particularly when the services were court-ordered.




Page 25                GAO-03-397 Children Placed to Obtain Mental Health Services
Difficulties Accessing            In the 6 states that we visited, limited resources in mental health agencies
Services through Certain          and public schools to fund mental health services and agency officials’
Agencies, Difficulties in         attempts to minimize the use of residential services posed additional
                                  challenges for parents seeking services and placements for their children.
Meeting Service Eligibility       In addition, some children who needed multiple supports experienced
Requirements, and                 gaps in services because of differences in the eligibility requirements for
Misunderstandings among           obtaining such services. Moreover, some officials and service providers
Officials and Service             often misunderstood the responsibilities and resources of their own and
Providers Can Influence           other agencies and communicated the misunderstandings to parents,
Placements                        compounding service gaps and delays.

Difficulties Accessing Services   According to some mental health and education officials, budgetary
through Mental Health or          shortfalls in the 6 states that we visited contributed to agencies’ attempts
Education Agencies                to cut or control costs, including the cost of mental health services. Mental
                                  health agencies used a variety of strategies to control costs, such as
                                  reducing spending, requiring that services covered by Medicaid be
                                  approved before they are provided, and limiting the number of children
                                  served. In each state we visited, some parents believed the strategies
                                  affected the quality of the services their children received and created
                                  unnecessary delays in getting services. In Arkansas, private, nonprofit
                                  mental health providers that contract with the state to provide community
                                  mental health said that state officials cut their funding and, as a result,
                                  they had to reduce the length of counseling and therapy sessions and
                                  increase the length of waiting lists. In 3 of the states that we visited—
                                  Arkansas, Maryland, and New Jersey—state officials said that they
                                  contracted with private, nonprofit agencies to authorize the medical
                                  necessity of mental health services covered by Medicaid. Arkansas
                                  required preauthorization of all Medicaid-financed mental health services,
                                  including those that were legally required, such as the screening of foster
                                  children for mental health services. A variety of officials in this state and a
                                  parent reported that the preauthorization agency often denied services for
                                  children because they had not benefited from similar services in the past.
                                  For example, this parent said the preauthorization agency refused her
                                  son’s therapist’s request to hospitalize him to treat his suicidal behavior
                                  because past hospitalizations for suicide attempts had not reduced the
                                  behavior. In New Jersey, state mental health officials reduced the number
                                  of counties that had been targeted to implement the state’s new child
                                  mental health system and limited the number of children served by the
                                  system. For example, officials from a variety of county agencies reported
                                  that the new system of care limited the number of children receiving the
                                  highest level of care in their county to 180 a year, although juvenile justice
                                  officials said that at least 500 children in their system alone needed such
                                  services. Officials from child welfare, mental health, and juvenile justice


                                  Page 26                 GAO-03-397 Children Placed to Obtain Mental Health Services
agencies said eligible children who did not receive the highest level of care
were placed on waiting lists and provided less intensive services.

Other ways of controlling costs in the states that we visited included
limiting placements of children in residential treatment facilities. Mental
health officials said community-based services supported the right of
children with a mental illness to receive services in the least restrictive
setting, were more effective than residential services in helping children
and their families, and cost less, thus allowing more children to receive
services. To implement the limits and to ensure placements are necessary,
states required interagency review boards to approve such placements or
reduced the time spent in residential placements. For example, local
mental health agency officials in Maryland explained that they could not
place children in private residential facilities even if they presented a
danger to themselves and others because the state did not allow them to
pay for such placements. These officials further explained that private
residential placements had to be approved by a county interagency
coordinating committee and subsequently reviewed by a state
coordinating committee that could return requests for further
consideration. A parent in this county said the approval process took
6 months. In New Jersey, child welfare officials said a goal of the new
child mental health system is to reduce the average stay at residential
treatment facilities from 18 to 6 months, and some parents in Maryland
told us that funding limits, rather than the success of the treatment,
determine the date children will be discharged from residential treatment.

Officials from a variety of county agencies and some parents also reported
that public schools in their county—in order to control costs—were often
reluctant to provide individualized mental health services for special
education children beyond services that are routinely available. For
example, child welfare officials in three locations we visited said schools
fit children with a mental illness into preexisting programs, and school
officials in two of these locations agreed, stating that children’s IEPs could
only contain services that were available in the schools. Almost all the
parents that we interviewed said that school officials were reluctant to
evaluate their children to determine eligibility for special education
services or provide specialized services for them. For example, a parent of
a child with a mental illness in Kansas said officials in her daughter’s
school refused to evaluate the child for a year and a half. After this
evaluation, the school recommended that the child work with a learning
disability specialist for 30 minutes a week, even though the parent said this
service was insufficient and did not address her daughter’s destructive,
violent, and aggressive behavior.


Page 27                 GAO-03-397 Children Placed to Obtain Mental Health Services
                                   As a result of the difficulties encountered at both mental health agencies
                                   and schools, some parents could not access the community-based services
                                   they needed to care for their child at home nor place their child in a
                                   residential treatment facility. In 4 of the 6 states that we visited, some
                                   teachers and mental health service providers encouraged parents to refuse
                                   to bring their child home from a hospital or other supervised placement,
                                   such as a detention center, when they were informed their child was being
                                   discharged in order to obtain mental services from child welfare agencies.
                                   Although these parents realized they were abandoning their child and, as a
                                   result, could be arrested and lose custody, they believed that this was the
                                   only alternative that remained to obtain services. Some parents that we
                                   interviewed told child welfare workers they would physically abuse their
                                   child in their presence to force them to place the child in their system if
                                   they could not get help for their child any other way, and juvenile justice
                                   officials told us other parents asked the police to arrest their children.
                                   However, state officials in 2 of the states that we visited said children
                                   often remain hospitalized or in a shelter for months without appropriate
                                   services because child welfare agencies did not have the resources to
                                   provide the needed level of services or specialized placement, could not
                                   obtain resources from other agencies, or could not access appropriate
                                   services or placements that had the capacity to treat another child. In
                                   addition, although federal law does not require custody relinquishment to
                                   obtain mental health services, state child welfare officials in 2 states that
                                   we visited said that their state required parents to relinquish custody of
                                   their child to the state after the voluntary placement period ends. In
                                   1 state, these officials misconstrued federal requirements and believed that
                                   they required relinquishment and in the other state, officials said
                                   relinquishment enabled them to have more control over the child’s care.

Difficulties Meeting Eligibility   Eligibility requirements for obtaining mental health services pose several
Requirements for Mental            challenges for parents. For example, state and local Medicaid officials in
Health Services                    3 states told us that some children lose their eligibility for Medicaid-funded
                                   services because their families’ income increased beyond Medicaid’s
                                   threshold or move in and out of eligibility as their families’ income
                                   fluctuates. Also, some child welfare officials said some children receive
                                   Medicaid because they are in foster care and lose their eligibility when
                                   they return home if the family is not eligible. Alternatively, juvenile justice
                                   officials in 6 states said that children in juvenile justice correctional or
                                   detention facilities lose Medicaid eligibility and have to reapply to resume
                                   coverage when they are released from the facility.

                                   In addition, in all 6 of the school districts we visited, schools used different
                                   eligibility criteria for mental health services than mental health or other


                                   Page 28                 GAO-03-397 Children Placed to Obtain Mental Health Services
child-serving agencies in their area. For example, school officials in four
districts told us that some children with a mental illness are not eligible for
mental health services through their special education programs because
they were making adequate educational progress or because behavior
problems—rather than mental illness—prevented them from making
adequate progress. However, mental health officials who work with
children attending some of these schools reported that schools often have
a narrow definition of educational progress and do not recognize that
inappropriate behavior might be a symptom of mental illness. For
example, a parent of a child with attention deficit23 and bipolar disorders
said her son’s school refused to provide special education services for him
because his lack of educational progress was due to his failure to pay
attention and to get his work done, rather than his mental illness, and a
parent of a bipolar, schizophrenic son24 said school officials told her that
she was responsible for her son’s behavior and poor school performance.

Although a variety of officials said schools had more restrictive eligibility
requirements for mental health than other child-serving agencies, school
officials in a county in California said that their county mental health
agency used a more restrictive definition than the schools. In California,
state law required that county mental health agencies treat children
covered by Medicaid and SCHIP who were diagnosed as SED or who were
eligible for special education services.25 California also requires that
children be evaluated by county mental health agencies and fit a statutory
definition of SED. School officials said that these children get priority and
their services consumed all available county child mental health
resources. According to these officials, other children, including children
with dual diagnoses of mental illness and substance abuse, mental
retardation, or autism-related disorders and children without the required
diagnoses have to wait for county mental health services or might not
receive services at all, although some may receive services through their
school guidance counselors or social workers.



23
 Attention deficit disorder is a syndrome characterized by serious and persistent
difficulties in attention span, impulse control, and, sometimes, hyperactivity.
24
 Schizophrenia is a cluster of disorders characterized by delusions, hallucinations,
disordered thinking, and emotional unresponsiveness.
25
 The California legislature transferred the responsibility for providing mental health
services to children in special education from schools to counties in the late 1980s.




Page 29                     GAO-03-397 Children Placed to Obtain Mental Health Services
                                 Some parents bypass eligibility restrictions for special education services
                                 and procedures for receiving child welfare, mental health, and juvenile
                                 justice services by petitioning the court to provide mental health and
                                 specific education services for their child. These petitions have varying
                                 names. For example, Maryland refers to them as CINS (children in need of
                                 supervision) petitions and Arkansas refers to them as FINS (family in need
                                 of services) petitions. Three of the states that we visited—Arkansas,
                                 Maryland, and Minnesota—allowed parents to directly petition the court
                                 to order mental health services for the child. In Arkansas, a child in a
                                 court-ordered residential placement was automatically eligible for
                                 Medicaid regardless of his or her family’s income. In that state, a variety of
                                 officials told us that court-ordered placement was the most common way
                                 for parents to obtain residential mental health and education services for
                                 their child. Juvenile court officials told us that parents often come to court
                                 requesting residential treatment and lobbying judges for placement in a
                                 specific facility. Some state officials were concerned that this practice
                                 could result in inappropriate placements for some children because judges
                                 can make placement decisions with no clinical input. Mental health and
                                 juvenile justice officials told us staff from private residential facilities
                                 often evaluate children on a pro bono basis and, based on these
                                 evaluations, recommend that judges place the children in their facility.
                                 These officials said that they were concerned about the objectivity of such
                                 evaluations.

Misunderstandings of Agencies’   Program officials’ and service providers’ misunderstandings of agencies’
Responsibilities and Resources   responsibilities and resources also affect service provision.26 For example,
                                 misunderstandings about Medicaid coverage created gaps and delays in
                                 services. In 3 states, some state and county officials did not know the
                                 Katie Beckett option could expand Medicaid coverage for children with a
                                 mental illness regardless of family status. In 1 of these states, a parent told
                                 us that county Medicaid officials incorrectly told her that her son was
                                 ineligible for coverage under this option because he had a two-parent
                                 family. In 2 other states, county mental health officials erroneously told us
                                 that this option applied only to children with very severe medical
                                 conditions. In another state, a Medicaid official did not know that children
                                 enrolled in SCHIP Medicaid expansion programs were entitled to EPSDT
                                 services. Furthermore, state child welfare officials in 2 states and mental


                                 26
                                   In commenting on a draft of this report, Education said that most of the federal laws
                                 concerning this population are purposely vague, open to interpretation, and (in the case of
                                 IDEA) actively supportive of state determination of actual procedures and how they will be
                                 interpreted.




                                 Page 30                     GAO-03-397 Children Placed to Obtain Mental Health Services
                        health workers in a third did not know Medicaid’s EPSDT provision
                        includes mental health screenings, diagnosis, and treatment and thought
                        the provision covered only physical health services.

                        In all 6 states, some parents, a variety of state and local officials, mental
                        health service providers, caseworkers, and judges misunderstood the role
                        and responsibilities of schools in implementing IDEA. For example, some
                        parents we interviewed in 5 of these states said that their children waited
                        over a year to receive special education services because they and the
                        mental health professionals they worked with did not understand the
                        procedures IDEA required schools to follow. For example, some parents
                        were told that referrals for special education had to be in writing. Also,
                        some parents and professionals misunderstood that IDEA gives all eligible
                        children, including children with a mental illness, the right to a free
                        appropriate education and parents did not know that they could appeal a
                        school’s decision about providing special education services. For example,
                        a parent in Kansas agreed to home-school her 10 year old, sexually
                        aggressive, child with a mental illness because the school would not put
                        the child in a setting that would ensure the safety of his classmates.
                        Despite her long-term involvement with a community mental health
                        agency, this parent believed home schooling was her child’s only option.


                        Although few strategies were developed specifically to prevent mental
States Have             health-related child welfare and juvenile justice placements, state and
Developed a Range of    local officials identified a range of practices that they believe may prevent
                        such placements by addressing key issues that have limited access to child
Practices That May      mental health services in their state. State and local practices focused on
Reduce the Need for     three main areas: finding new ways to reduce costs or to fund services,
                        consolidating services in a single location, and expanding community
Some Mental Health-     mental health services and supporting families. Many of these practices
Related Child Welfare   were developed to reduce treatment costs and provide a better way to
and Juvenile Justice    treat children with a mental illness in their communities. Although some
                        programs were modeled on practices that had been evaluated in other
Placements              settings, the effectiveness of the practices is unknown because many of
                        them were implemented on a small scale in one location or with a small
                        target group or were too new to be rigorously evaluated.




                        Page 31                GAO-03-397 Children Placed to Obtain Mental Health Services
Finding New Ways to       According to officials in the 6 states that we visited, one way to reduce the
Reduce Costs or to Fund   cost of services is to better match children’s needs to the appropriate level
Services May Help         of service. One goal of some of the programs we reviewed was to ensure
                          that children with lower-level needs were appropriately served with lower-
Agencies Pay for Mental   level and less expensive services, reserving the more expensive services
Health Treatment          for children with more severe mental illnesses. Under New Jersey’s
                          Systems of Care Initiative, the state contracted with a private, nonprofit
                          organization for a variety of services, such as mental health screenings and
                          assessments to determine the level of care needed, authorization of
                          service, insurance determination, billing, and care coordination across all
                          agencies involved with the children. When the Initiative is fully
                          implemented statewide, the contractor in each county will use
                          standardized tools to assess children’s mental health and uniform
                          protocols to determine appropriate levels of care—children requiring
                          lower levels of care will be referred to community-based providers, while
                          children requiring a higher level of care will be approved to receive
                          services from local Care Management Organizations specifically created to
                          serve them. Presently, the System of Care Initiative has been implemented
                          in 5 of the state’s 21 counties.

                          As another cost-saving method, some programs substituted expensive
                          traditional mental health providers with nontraditional and less expensive
                          providers. Many state and local officials we interviewed in 5 of the states
                          we visited told us that the historic way to treat children with a mental
                          illness included psychiatrists and residential placements. However,
                          officials in New Jersey, Kansas, and Minnesota said their states had
                          switched their focus to using less expensive providers such as using
                          nurses to distribute medicines instead of psychiatrists or nontraditional
                          bachelor-level workers for case management instead of masters-level
                          social workers. For example, Uniting Networks for Youth—a private,
                          county-based provider in Minnesota—used two commercially available,
                          highly structured programs that allowed them to substitute lower-
                          credentialed bachelor-level staff under the supervision of a masters-level
                          clinician as the primary service provider instead of using higher-level
                          clinicians. County officials told us this structured program has many
                          safeguards, including the collection of extensive data from providers,
                          teachers, and families that allow masters-level clinicians to review the
                          appropriateness and effectiveness of provided mental health services.

                          State officials in 5 states also recommended increasing the use of
                          volunteer and charitable organizations to reduce the cost of services
                          because these organizations can provide inexpensive or free supportive
                          services to children with a mental illness and their families. While these


                          Page 32                GAO-03-397 Children Placed to Obtain Mental Health Services
services were not therapeutic, officials said that they helped families cope
with problems associated with mental illness and kept some mental health
problems from escalating. For example, the Four County Mental Health
Center in Kansas used volunteers from churches, community agencies,
and charities, such as the Salvation Army, to provide services such as
mentoring and tutoring for children with a mental illness. A county in New
Jersey increased its reliance on Big Brother-Big Sister volunteers and the
local YMCA to provide after school supervision and mentoring for children
with severe mental illness.

In addition to reducing the cost of services, state officials in all 6 states
identified the blending of funds from multiple sources as another way to
pay for services, thus working around agencies’ limitations on the types of
mental health services and placement settings each can fund. For example,
in a county in Maryland, a local Coordinating Council blends funds from
multiple agencies to provide community-based services to children with a
mental illness involved with the judicial, child welfare, and mental health
systems and with district special education programs. The Council, headed
by a judge, leveraged funding by inviting key decision makers—those that
could commit resources—from a variety of child-serving agencies and
organizations, including the local departments of social services and
juvenile justice, the public defenders office, prosecutors, attorneys, and
Catholic Charities, to serve on the Council. The Juvenile Alternative
Defense Effort (JADE), a county juvenile justice diversion program in
California, combines funds from a federal Juvenile Accountability
Incentive Block Grant and the state Temporary Assistance for Needy
Families Program (TANF)27 to provide the range of mental health services
necessary to prevent a juvenile justice placement for mentally ill youths. In
Kansas, the Family Service and Guidance Center blends funds from federal
Medicaid and Department of Transportation programs, designated funds
from the state’s Master Tobacco Settlement and Attorney General’s Office,
funds from county juvenile justice and social services agencies, county
general funds, the United Way, and several local philanthropic clubs to
provide a wide range of mental health and supportive services for children
who are seriously mentally ill in its county.




27
  TANF, created by the Personal Responsibility and Work Opportunity Reconciliation Act
of 1996, provides assistance and work opportunities to needy families by granting states
federal funds and flexibility to develop and implement their own welfare programs.




Page 33                    GAO-03-397 Children Placed to Obtain Mental Health Services
                         In addition to blending funds to pay for services, state officials in 4 of the
                         6 states that we visited identified the use of flexible funds, with few
                         restrictions, to pay for nontraditional services that are not generally
                         allowable under state guidelines. For example, Arkansas’s Together We
                         Can Program used flexible funds from a federal Social Services Block
                         Grant, state general revenue, and the Title IV-B program to provide a wide
                         range of nontraditional supportive services and items to children with a
                         mental illness and their families. Using these funds, the program provided
                         services and items such as in-home counseling, community activities,
                         respite care, mentoring, tutoring, clothing, and furniture that helped the
                         family care for the child at home and supported the child in his
                         community.


Bringing Mental Health   To improve access to mental health services and bring clarity to a
Services into a Single   confusing mental health system, 3 of the states that we visited developed a
Location May Improve     facility to be a single point of entry into the mental health system.
                         Typically, several agencies are represented at the facility and children are
Access                   assessed with a common instrument and eligible for the same services
                         regardless of what agency had primary responsibility. Kansas’s Shawnee
                         County Child and Family Resource Center is a one-stop facility and,
                         according to state mental health officials, a model for the rest of the state.
                         The center houses workers from 11 social services agencies, including
                         mental health, child welfare, juvenile justice, and education. All children
                         with mental health needs, regardless of which agency first encountered
                         the child, are referred to the center. Case managers at the Center assess
                         the child’s psychological, educational, and functional needs, determine
                         appropriate services and placements, make referrals, provide some direct
                         counseling services, and determine how to pay for services. The facility
                         includes four bedrooms for children who need to be removed from their
                         homes for short periods of time and a secure juvenile justice intake suite
                         that is staffed 24 hours a day. County officials from a variety of agencies
                         told us that the center ended service fragmentation and prevented
                         duplication of services for children with a mental illness and their families
                         by implementing one intake procedure for all county social services. For
                         example, case managers work with police to prevent the placement of
                         children with mental illness in correctional facilities. If a mental illness is
                         identified during the intake assessment, the intake workers immediately
                         link the child with a mental health worker. Working collaboratively with
                         juvenile justice, school, and other appropriate officials, the case manager




                         Page 34                 GAO-03-397 Children Placed to Obtain Mental Health Services
develops a diversion28 plan all can agree to that is aimed at preventing the
need for juvenile justice or child welfare custody, or residential or other
out-of-home placements with the goal of keeping the child at home with
the child’s own family.

State officials in all 6 of the states that we visited also identified co-
locating services in public facilities such as schools and community
centers as another way to improve access. In California, Los Angeles
county officials told us that integrating mental health services into the
school system has been a very effective way of reaching poor families
without transportation and working families, and helps to ensure regular
participation in mental health services. In Harford County, Maryland, for
example, mental health services are collocated at an elementary school
specifically to improve access to care for students with mental illness.
Using county health and mental health funds, the school developed an in-
house mental health clinic that provides mental health services through a
bachelor-level social worker, a nurse practitioner, and consultative
services from a physician and a psychiatrist. In addition, the school has a
variety of internal support staff available to children with a mental illness,
including a guidance counselor, a behavior specialist, a home visitor who
supports families and assesses the home situation, and a pupil personnel
worker who visits homes and helps with transportation issues. The school
has several programs available to children with a mental illness, including
the Classroom Support Program, an intensive, in-school program for
children with a mental illness staffed with a full-time school psychologist
for individual counseling; the Teen 2000 program, a mentoring program for
teens that uses paid school staff, high school students, and volunteer
community members to provide a combination of homework support,
play, and social skills development; the School Outreach Advocacy
Program, a program that provides counseling, tutoring, recreation, social
skills groups, home visits, referrals and some psychiatric rehabilitation
services; Project Prepare, a program to identify mentally ill elementary
school children and increase their access to services; and two
collaborative programs with contracted mental health providers that
provide community support and prevention services and intensive case
management services.




28
 Diversion programs attempt to prevent or reduce the time children spend in inappropriate
placements.




Page 35                    GAO-03-397 Children Placed to Obtain Mental Health Services
Expanding Community          Officials from child-serving agencies in all 6 states we visited identified the
Mental Health Services and   expansion of the number and range of community-based services to
Supporting Families May      provide an entire continuum of care as a way to improve treatment for
                             children with a mental illness. Some programs we reviewed developed a
Improve Treatment for        complete range of community-based mental health services for children,
Children with a Mental       including early intervention, diversion, transitional services, and crisis
Illness                      intervention. In addition, some programs supported families of children
                             with a mental illness and encouraged parent involvement in their
                             children’s care. State and county officials we spoke with in all 6 states
                             stressed the importance of early identification of children at risk of mental
                             illness and the provision of therapeutic services when they were young in
                             hopes of preventing the need for extensive, and costly, residential services
                             later on. Examples of these programs follow.

                             Early Intervention: Working with local hospitals, workers from the
                             Family Service and Guidance Center in Shawnee County, Kansas, screen
                             newborns in local hospitals. If babies appear at-risk, social workers
                             conduct home visits and refer families to health care professionals or
                             others for support. The Center also developed a therapeutic preschool
                             practice directed at 3-5 year old children, with or without a mental illness
                             diagnosis, who were likely to need special education services when they
                             entered kindergarten. The program serves 32-36 children and provides a
                             half-day of services.

                             Diversion: Los Angeles’ JADE was designed to prevent or reduce the time
                             of expensive juvenile justice placements for youths with mental illness, by
                             arranging assessments, providing referrals to mental health providers and
                             advocating for these youth to ensure they receive the treatment they need.
                             Upon referral to JADE, a psychiatric social worker performs an extensive
                             psychosocial evaluation, including a developmental history, family history,
                             and educational history that include failures and successes, gang-related
                             behaviors, delinquency behaviors, and a mental health status exam. Based
                             on the evaluation, the social worker makes placement and service
                             recommendations to the juvenile court judge who makes the final
                             decisions. JADE officials said that the evaluations and recommendations
                             give the judges the information they need to consider alternatives to
                             incarceration.

                             Transitional Services: State and county juvenile justice and mental
                             health officials in the 6 states we visited stressed the importance of
                             including transitional services in a continuum of care. These services are
                             typically provided to a child leaving a residential setting and returning to
                             his or her home or community. For example, Minnesota’s Red Wing facility


                             Page 36                 GAO-03-397 Children Placed to Obtain Mental Health Services
is a secure juvenile justice facility that provides in-house mental health
services and places a strong focus on transitional services so youth can
successfully reenter their own community. Red Wing officials told us that
transition planning and reintegration efforts are very important in
preventing recidivism and they take several steps to ensure a successful
transition. The program is designed in levels that reward good behavior by
allowing youth to move to lower levels of supervision. For instance, at
level 4, youth begin to transition back to the community by making
periodic visits, called furloughs, to their homes. Officials see furloughs as
an opportunity for youth to try out the new positive behaviors that they
have learned. At level 5, youth move to a transitional living unit at Red
Wing that focuses on applying new skills to activities in their homes and
communities. After youth leave Red Wing, a county juvenile justice worker
monitors them for 90 days.

Out of frustration with the difficulties it had finding appropriate services
for mentally ill youth who were aging out of child mental health programs,
The Sycamores, a residential mental health facility in Los Angeles County,
California, created community-based transitional homes for older teens
who were leaving their facility and were unable to return to their own
homes. Its Emancipated Youth Program provides an apartment for every
two residents, a youth advocate worker to provide support, and case
managers to coordinate services. For this program, the Sycamores uses
reasonably priced private apartments in the community, instead of a group
home that would house several mentally ill youths in the same building.
When the youths become able to live independently, the Sycamores turns
the leases over to them. They also started a business card company at one
community center to provide vocational training for adolescents aging out
of their program.

Crisis Intervention: Programs we reviewed in 4 states had a mobile
crisis unit. These units consist of teams of staff that visit homes to stabilize
crisis situations. Funding, staffing, and authority of these teams vary.
Some of the crisis teams can provide direct mental health services; others
conduct assessments and make emergency petitions to psychiatric
hospitals on behalf of the family. One of the difficulties noted by program
officials is determining how to pay for crisis services since these services
may not be covered by insurance and families may not have the ability to
pay. In Harford County, Maryland, the mobile crisis team is not a fee-for-
service provider but is funded by a grant. The team—a psychiatrist, a
psychologist, and a licensed social worker—provide direct mental health
services and are authorized to do an emergency petition to get a child with
a mental illness admitted to a hospital psychiatric unit.


Page 37                 GAO-03-397 Children Placed to Obtain Mental Health Services
              A second way some states improve treatment for children with a mental
              illness is to provide services to support families and encourage parental
              involvement in their child’s care. State and local officials in all 6 states
              pointed out that involving parents was a fundamental change in
              philosophy. Previously, services were provided solely to the children and
              parents were not included in the decisions about their child’s care. Now,
              the focus is on providing the services parents need to maintain the child in
              the home and helping parents make informed decisions about their child’s
              care. For example, The Sycamores works extensively with parents of
              children who are seriously mentally ill at the facility and requires their
              participation. To help parents successfully prepare for and keep their child
              with a mental illness at home, The Sycamores provides a variety of
              supportive services—anything the family needs to make a child’s return
              home successful—including household items like refrigerators, washers,
              dryers, stoves, and car seats, and services such as transportation to and
              from the facility. In addition, as part of its transitional Home-Based
              Program, The Sycamores trains parents to use Therapeutic Behavioral
              Services (TBS), one-on-one, in-home services provided whenever needed
              24 hours a day, 7 days a week. TBS workers model good parenting skills so
              parents will be prepared for their child’s return home, such as modeling
              for the parents how to get their child with a mental illness who may have
              violent outbursts ready for the school bus in the morning without incident.
              The Four County Mental Health Center in Kansas’s provides free parenting
              classes designed to teach effective parenting skills for children with
              mental illness and a parent support coordinator who can provide support
              and information on mental health services for children. The Center also
              works with Kansas’s Keys for Networking, a statewide parent advocacy
              organization that educates parents about their child’s right to services and
              advocates on their behalf to obtain needed services.


              Some parents are placing their children, mostly adolescent boys with
Conclusions   severe mental illness, in the child welfare and juvenile justice systems to
              access mental health services. Although these children may not have been
              abused or neglected, or may not have committed a criminal or delinquent
              act, parents are turning to these agencies because they see no alternatives
              for obtaining comprehensive services for them. Because federal, state, and
              local agencies do not systematically track these children, the extent and
              outcomes of these placements are not fully known.

              Experts, agency officials, and service providers agree that agencies must
              work together to meet the needs of children who are severely mentally ill
              because these children have complex problems and are likely to need


              Page 38                GAO-03-397 Children Placed to Obtain Mental Health Services
                  services from multiple community agencies, such as mental health and
                  education, if they are to remain in their communities or if they are to
                  successfully transition from a residential facility back to their community.
                  However, in some cases, state and local officials’ misunderstandings of
                  each agency’s service requirements, responsibilities, and resources
                  prevent the provision of interagency services that have the potential to
                  address the needs of these children and their families. Opportunities exist
                  for HHS, DOJ, and Education to determine the causes for these
                  misunderstandings at the state and local level and to identify ways to
                  reduce them.

                  Although states and counties are implementing practices that may reduce
                  the need for parents to place their children with child welfare or juvenile
                  justice agencies, many of the programs are new, small, and only serve
                  children in specific localities. Furthermore, their effectiveness in achieving
                  their multiple goals—such as reducing the cost of mental health services,
                  supporting families, and helping children overcome their mental
                  illnesses—has not yet been fully evaluated. Given that states and localities
                  are developing new approaches to meeting the needs of children with
                  mental illness, it is important that the federal government continue its role
                  in supporting evaluations of these programs and disseminating the results.


                  To determine the extent to which children may be placed inappropriately
Recommendations   in the child welfare and juvenile justice systems in order to obtain mental
                  health services, we recommend that the Secretary of HHS and the
                  Attorney General investigate the feasibility of tracking these children to
                  identify the extent and outcomes of these placements. To help reduce
                  misunderstandings at the state and local level, we also recommend that
                  the Secretaries of HHS and Education and the Attorney General develop
                  an interagency working group (including representatives from CMS,
                  SAMHSA, and ACF) to identify the causes of these misunderstandings and
                  create an action plan to address those causes. We further recommend that
                  these agencies continue to encourage states to evaluate the child mental
                  health programs that they fund or initiate and that the Secretaries of HHS
                  and Education and the Attorney General determine the most effective
                  means of disseminating the results of these and other available studies to
                  state and local entities.


                  We provided a draft of this report to Education, HHS, and DOJ to obtain
Agency Comments   their comments. Each agency provided comments, which are reproduced



                  Page 39                 GAO-03-397 Children Placed to Obtain Mental Health Services
in appendixes III, IV, and V. These agencies also provided technical
clarifications, which we incorporated when appropriate.

Education generally agreed with the findings of our report, but asked that
we change some terminology to be consistent with terminology used in
IDEA. We changed this terminology to reflect IDEA when needed. HHS
also generally agreed with the findings and said that the report is
comprehensive, interesting, and provides an informative overview of the
concerns with which child welfare agencies and juvenile justice systems
are confronted when children and youth do not receive adequate mental
health services within the community. However, HHS also said that the
report is relatively critical of state and local agencies for “inappropriately”
using child welfare and juvenile justice placements to get services to
children who need them and cannot access them through other channels.
HHS further stated that a broader look at the status of children’s mental
health services in general would be useful because the problems leading
parents to place their children in child welfare and juvenile justice systems
to obtain mental health services are part of the bigger problem of
children’s mental health services in general, such as limited or non-
existent services, a lack of access, and a lack of quality providers.
Although a broad assessment of the availability and effectiveness of
children’s mental health services was beyond the scope of this report, we
have conducted studies relevant to these problems and reference to them
can be found in the related products list at the end of this report. The
purpose of this report was to shed light on the number of children placed
in the two systems solely to receive mental health services and the factors
that lead to those placements. In doing so, this report does not criticize
state and local child welfare and juvenile justice agencies that place these
children, but instead identifies the circumstances under which these
agencies play a role in meeting mental health needs, as well as the roles
that other agencies should play. DOJ also generally agreed with our
findings but was concerned that the estimates of children placed provided
by child welfare and juvenile justice officials would be taken as solid and
conclusive and be used for policy changes without further study being
undertaken. We explicitly acknowledged the limitations of these estimates
in the report and we recommended that the Secretary of HHS and the
Attorney General investigate the feasibility of obtaining more precise
numbers by tracking these children. Doing so will allow the agencies to
determine the extent of the problem.

 In commenting on the recommendations, Education said that it was not
clear to them how collecting more data and tracking outcomes will
increase the likelihood of progressive practices to provide children’s


Page 40                 GAO-03-397 Children Placed to Obtain Mental Health Services
mental health services. HHS said that asking the agencies to track this
population of children in foster care does not address the larger point of
the lack of mental health resources for families and communities and does
not address the problems of the children or their parents. HHS also said
we failed to identify to what end these data would be used and that a
request for appropriate funding for states and federal agencies involved in
tracking should accompany the recommendation for tracking. DOJ agreed
that tracking should take place, but only in the short term, and that HHS
should take the lead in such an effort. As we stated in our
recommendation, we believe HHS and DOJ should determine the
feasibility of tracking children to identify the extent and outcomes of the
mental health placements discussed in the report. Knowledge of the extent
of this practice is a necessary first step to determine what corrective
actions might be taken and might be useful in identifying which
progressive practices will most benefit these children. In addition, without
this basic information, the agencies may unknowingly limit the action
steps that they develop to alleviate state and local officials
misunderstandings and thus fail to maximize access to and the use of
existing resources. While the report recognizes that some mental health
resources may be limited, it also describes the misunderstandings that
exist among state and local officials regarding each agency’s service
requirements, responsibilities, and resources. If such misunderstandings
could be corrected, more children could possibly be served by the
agencies better designed to meet their mental health needs. Since HHS and
DOJ already track various characteristics of all children placed in the child
welfare and juvenile justice systems, these agencies should determine the
feasibility of adding data elements regarding placement solely to receive
mental health services and determine appropriate time frames for
collecting these data.

HHS also said that our estimate of the number of children placed was
presented without context, and asked how the number compares with
various groups—such as the total number of children placed in the two
systems and the number of children who remain outside the system but
are in need of the same kinds of services. We could not, however, make
these comparisons because no agency was tracking these children and we
necessarily relied on the estimates provided, which we believe to be an
underestimate for the reasons stated in this report.

All three agencies said they would participate in any interagency working
group that might be established based on our recommendation and DOJ
recommended using the existing Coordinating Council on Juvenile Justice
and Delinquency Prevention. We believe several organizational entities


Page 41                GAO-03-397 Children Placed to Obtain Mental Health Services
may be appropriate and that the member agencies forming this group
should determine the entity that is best suited. HHS, however, said that an
interagency working group would do little to address the lack of
resources. We believe that identifying the causes of the
misunderstandings that are occurring is a first step toward addressing the
lack of resources. Such a group, by promoting a more consistent
understanding of the roles and resources of state and local agencies, may
improve access to services and result in more effective utilization of
existing resources. Education commented that we should be more
specific on the role of the working group in addressing major differences
in terminology and definitions across various legislation, enormous
differences in local interpretation of federal definitions, and in local
practices for establishing eligibility. Education added that such a group
would not have the power to address congressional lawmaking and noted
that no recommendations were made for increased grant spending to
duplicate or disseminate the positive features of such practices. We
believe that our recommendation is broad enough to encompass the list of
issues Education mentions. We also believe that our recommendation
does not preclude the group from recommending legislative changes as
part of its action plan. Regarding Education’s comment on information
dissemination, we added a recommendation to that effect.

DOJ also said that while evaluating child mental health programs is a
worthwhile goal, states should consider evaluating their entire systems of
care for children to determine (1) how many children with serious mental
illness are in need of care but unable to obtain it, (2) how state and local
child-serving agencies attempt to address the needs of these children, and
(3) how effective these systemic efforts are in actually meeting these
needs and those of their families. While we concur that such evaluations
are worthwhile, including this suggestion is beyond the scope of our
report.

We also provided a copy of our draft to state officials in the 6 states we
visited (Arkansas, California, Kansas, Maryland, Minnesota, and New
Jersey). Kansas provided technical clarifications, which we incorporated
when appropriate. Minnesota made a general comment that required no
changes in the report, and California said that it had no suggested
corrections or edits.


We are sending copies of this report to the Secretaries of HHS and
Education and the Attorney General, appropriate congressional
committees, state child welfare directors, selected juvenile justice


Page 42                GAO-03-397 Children Placed to Obtain Mental Health Services
officials, and others who are interested. We will also make copies available
to others upon request. In addition, the report will be available at no
charge on GAO’s Web site at http://www.gao.gov.

If you or your staff have any questions, or wish to discuss this material
further, please call me at (202) 512-8403 or Diana Pietrowiak at (202)
512-6239. Key contributors to this report are listed in appendix VI.




Cornelia M. Ashby
Director, Education, Workforce,
 and Income Security Issues




Page 43                GAO-03-397 Children Placed to Obtain Mental Health Services
             Appendix I: Scope and Methodology
Appendix I: Scope and Methodology


             To obtain estimates of the number and characteristics of children
             voluntarily placed in the child welfare and juvenile justice systems to
             receive mental health services, we conducted two surveys. We sent the
             first survey to state child welfare directors in the 50 states and the District
             of Columbia. We conducted the second survey by telephoning directors of
             county juvenile justice agencies in large counties in the 17 states with the
             largest populations of children under age 18. Overall, 71 percent of the
             children in juvenile justice facilities resided in these states. In most cases,
             we interviewed juvenile justice agencies in the two largest counties in
             each state. We chose to survey a sample of juvenile justice officials at the
             county level because, unlike child welfare, all states do not have a juvenile
             justice agency. Also, children who enter the juvenile justice system for
             mental health services are more difficult to identify than children who
             enter through child welfare systems because parents cannot directly place
             children in juvenile justice systems and children cannot enter juvenile
             justice solely to access mental health services. Telephone contacts with
             local juvenile justice officials allowed us to obtain information from
             individuals who were more likely than state officials to have direct
             knowledge of how children enter the juvenile justice system.

             We asked both groups to estimate1 the number of children voluntarily
             placed in their system by actions of their parents in order to obtain mental
             health services, the characteristics of the children, and factors influencing
             the rate of placements. Table 6 provides survey numbers and response
             rates for the surveys.

             Table 6: Survey Numbers and Response Rates

                                                           Number of                 Number of survey
              Survey of                            surveys conducted               responses received
              Child welfare directors                             51                               47
              Juvenile justice officials                          33                               33
             Source: GAO.


             Not all respondents to the surveys answered every survey question. For
             example, 19 respondents to the child welfare survey and 30 respondents to
             the juvenile justice survey provided estimates of number of children


             1
               Child welfare directors and juvenile justice officials used a variety of means to estimate
             the numbers of children placed. For example, some child welfare directors spoke to their
             counterparts at the local level and asked them to provide estimates. In other instances, the
             directors estimated based on the number of children receiving the highest level of mental
             health services.




             Page 44                       GAO-03-397 Children Placed to Obtain Mental Health Services
              Appendix I: Scope and Methodology




              placed. Some respondents indicated that they were unable to access
              information to generate estimates.


Site Visits   To determine the factors that influence child welfare and juvenile justice
              placements for mental health services, we included questions on these
              issues in our surveys and interviewed federal, state, and local officials and
              national child mental health experts. We interviewed officials at the
              Department of Health and Human Services (HHS), the Department of
              Justice (DOJ), and Education. We spoke with state and local officials in
              6 states—Arkansas, California, Kansas, Maryland, Minnesota, and New
              Jersey—and in one county in each of these states. The officials
              represented state and county agencies that were responsible for child
              welfare, child mental health, Medicaid, juvenile justice and education
              services. We also interviewed judges in 5 states and caseworkers and
              parents in all 6 states. Staff of community mental health centers and other
              programs serving families with children with a mental illness, such as a
              Family Support Organization and a residential treatment facility, selected
              parents of children with, or who had, severe mental illness and invited
              them to attend our interviews. We selected states that varied in
              geographical location, legal requirements concerning placement, the use
              of Medicaid options and waivers, and the authority of state and county
              agencies in administering child welfare and juvenile justice programs; and
              counties that varied in demographic characteristics.

              To identify promising practices that may reduce the need for some child
              welfare and juvenile justice placements by meeting the needs of children
              with a mental illness and their families, we asked national experts and
              state and local officials to identify such practices in the states that we
              visited. We visited 16 programs that embodied these practices.

              We conducted our work between March 2002 and February 2003 in
              accordance with generally accepted government auditing standards.




              Page 45                   GAO-03-397 Children Placed to Obtain Mental Health Services
                                                     Appendix II: State Statutes Containing
Appendix II: State Statutes Containing               Language Allowing Voluntary Placement to
                                                     Obtain Mental Health Services


Language Allowing Voluntary Placement to
Obtain Mental Health Services
Table 7: Statutes in 11 States Allowing Parents to Place Children in Child Welfare Systems in Order to Obtain Mental Health
Services While Retaining Custody of the Child

 State                  Statute citation                          Statute
 Alaska                 M.S.A. Section 260C.201 (3)               Where a parent enters into a voluntary placement agreement, the
                                                                  agreement may not preclude the parent from regaining care of the child at
                                                                  any time.
 Colorado               C.R.S.A. Section 19-3-701(1)              Where a parent voluntarily places a child out of the home for the purpose of
                                                                  obtaining treatment for an emotional disability solely because the parent is
                                                                  unable to provide care, relinquishment of legal custody is not required.
 Connecticut            C.G.S. A. Section 17a-129                 Their shall be no requirement for the Department to seek custody or
                                                                  protective supervision of a child or youth who needs or is receiving
                                                                  voluntary services unless the child or youth is otherwise alleged to be
                                                                  neglected or abused.
 Iowa                   I.C.A. Section 232.1784 and 232.182       Petitions for voluntary placements shall describe the child’s emotional
                        (5) (d)                                   disability which requires care and treatment; the reasonable efforts to
                                                                  maintain the child in the child’s home; a determination of whether services
                                                                  or support provided to the family will enable the family to continue to care
                                                                  for the child in the child’s home; and the reason the child’s parent has
                                                                  requested a foster care placement. A court may only order foster care
                                                                  placement if it makes a determination that services or support provided to
                                                                  the family will not enable the family to continue to care for the child in the
                                                                  child’s home. If the court finds that reasonable efforts have not been made
                                                                  and that services or support are available to prevent placement, the court
                                                                  may order the services or support to be provided to the child.
 Maine                  22 M.R.S.A. Section 4004-A(1) and (2)     If certain conditions are met, a parent may enter into a voluntary placement
                                                                  agreement in which the parent retains legal custody of the child.
 Minnesota              M.S.A. Section 260C.201(3)                If a court determines a child is in need of special services to treat a mental
                                                                  disability, the court may order the child’s parent or health plan company to
                                                                  provide such services. If the parent or the health plan is unable to provide
                                                                  care, the court may order that treatment be provided. If the child’s disability
                                                                  is not the result of abuse or neglect by the parent, the court shall not
                                                                  transfer legal custody of the child in order to obtain treatment solely
                                                                  because the parent is unable to provide care.
 North Dakota           N.D.C.C. 50-06-06.13                      The Department of Human Services may not require a parent to relinquish
                                                                  legal custody in order to have the child voluntarily placed.
 Oregon                 O.R.S. Section 418.312(1)and (2)          To have a child placed in a foster home, group home, or institutional child
                                                                  care setting for the sole purpose of obtaining services for the child’s
                                                                  emotional or mental disorder, a parent is not required to transfer legal
                                                                  custody. Rather, the child is placed pursuant to a voluntary placement
                                                                  agreement that specifies the rights and obligations of the parent, the child,
                                                                  and the Department of Human Services.
 Rhode Island           R.I.S.T. Section 14-1-11.1                Where a parent voluntarily places a child with an emotional disorder with
                                                                  the Department of Human services for the purpose of accessing an out-of-
                                                                  home program, relinquishment of legal custody is not required.
 Wisconsin              W.S.A. Section 48.13(4) and               Where a parent is financially unable to provide treatment for a child, the
                        938.34(6)(a) and (ar)                     parent may sign a petition giving a court exclusive jurisdiction. The court
                                                                  may then order an appropriate agency to provide treatment whether or not
                                                                  legal custody has been taken from the parent.
 Vermont                33 V.S.A. Section 4305(g)                 A child with an emotional disorder may receive services, including an out-
                                                                  of-home placement, without a parent surrendering legal custody.
Source: GAO analysis.




                                                     Page 46                    GAO-03-397 Children Placed to Obtain Mental Health Services
              Appendix III: Comments from the Department
Appendix III: Comments from the
              of Education



Department of Education




              Page 47                   GAO-03-397 Children Placed to Obtain Mental Health Services
Appendix III: Comments from the Department
of Education




Page 48                   GAO-03-397 Children Placed to Obtain Mental Health Services
Appendix III: Comments from the Department
of Education




Page 49                   GAO-03-397 Children Placed to Obtain Mental Health Services
Appendix III: Comments from the Department
of Education




Page 50                   GAO-03-397 Children Placed to Obtain Mental Health Services
             Appendix IV: Comments from the Department of Health and Human Services
Appendix IV: Comments from the
Department of Health and Human Services




             Page 51                   GAO-03-397 Children Placed to Obtain Mental Health Services
Appendix IV: Comments from the Department of Health and Human Services




Page 52                   GAO-03-397 Children Placed to Obtain Mental Health Services
Appendix IV: Comments from the Department of Health and Human Services




Page 53                   GAO-03-397 Children Placed to Obtain Mental Health Services
Appendix IV: Comments from the Department of Health and Human Services




Page 54                   GAO-03-397 Children Placed to Obtain Mental Health Services
Appendix IV: Comments from the Department of Health and Human Services




Page 55                   GAO-03-397 Children Placed to Obtain Mental Health Services
                   Appendix V: Comments from the Department of Justice
Appendix V: Comments from the Department
of Justice




         Page 56                  GAO-03-397 Children Placed to Obtain Mental Health Services
          Appendix V: Comments from the Department of Justice




Page 57                  GAO-03-397 Children Placed to Obtain Mental Health Services
          Appendix V: Comments from the Department of Justice




Page 58                  GAO-03-397 Children Placed to Obtain Mental Health Services
                            Appendix VI: GAO Contacts and Acknowledgments
Appendix VI: GAO Contacts and
Acknowledgments

                  Diana Pietrowiak (202) 512-6239
GAO Contacts      Kathleen D. White (202) 512-8512



                  In addition to those named above, Karen A. Brown, Erin Williams, and
Acknowledgments   Katherine L. Wulff made key contributions to the report. Rebecca Shea,
                  Patrick Dibattista, Alice London, Behn Miller, and Carolyn Yocom provided
                  key technical assistance.




                  Page 59                 GAO-03-397 Children Placed to Obtain Mental Health Services
             Related GAO Products
Related GAO Products


             Medicaid and SCHIP: States Use Varying Approaches to Monitor
             Children’s Access to Care. GAO-03-222. Washington, D.C.: January 14,
             2003.

             Mental Health Services: Effectiveness of Insurance Coverage and Federal
             Programs for Children Who Have Experienced Trauma Largely
             Unknown. GAO-02-813. Washington, D.C.: August 22, 2002.

             Medicaid and SCHIP: Recent HHS Approvals of Demonstration Waiver
             Projects Raise Concerns. GAO-02-817. Washington, D.C.: July 12, 2002.

             Foster Care: Recent Legislation Helps States Focus on Finding
             Permanent Homes for Children, but Longstanding Barriers Remain.
             GAO-02-585. Washington, D.C.: June 28, 2002.

             Long-term Care: Implications of Supreme Court’s Olmstead Decision
             Are Still Unfolding. GAO-01-1167T. Washington, DC: September 24, 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.

             Medicaid Managed Care: States’ Safeguards for Children With Special
             Needs Vary Significantly. GAO/HEHS-00-169. Washington, D.C.:
             September 29, 2000.

             Children with Disabilities: Medicaid Can Offer Important Benefits and
             Services. GAO/T-HEHS-00-152. Washington, D.C.: July 12, 2000.

             Mental Health Parity Act: Employer’s Mental Health Benefits Remain
             Limited Despite New Federal Standards. GAO/T-HEHS-00-113.
             Washington, D.C.: May 18, 2000.

             Mental Health Parity Act: Despite New Federal Standards, Mental Health
             Benefits Remain Limited. GAO/HEHS-00-95. Washington, D.C.: May 10,
             2000.

             Medicaid Managed Care: Challenges in Implementing Safeguards for
             Children with Special Needs. GAO/HEHS-00-37. Washington, D.C.: March
             3, 2000.


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                         Page 60    GAO-03-397 Children Placed to Obtain Mental Health Services
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