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A historical perspective on national child mental health policy
A historical perspective on national child mental health policy.

 

by Ira S. Lourie , Mario Hernandez

 

 

This country has never had a formalized child mental health policy, if one uses the definition of child mental health policy as the existence of governmental commitment to ensure the availability of appropriate mental health services to children (birth-21 years) and their families. Over the past century, the field of children's mental health has borrowed policy from child welfare, juvenile justice, special education, and adult mental health, but attempts to form a comprehensive policy have been inadequate in scope and follow-through. The latest attempts at the creation of such a policy through the managed behavioral healthcare revolution and the federal government's Child and Adolescent Service System Program and Child Mental Health Services Initiative have been no more successful than past efforts in creating meaningful policy. Until a comprehensive policy is forged, children's mental health services will remain informal, incomplete, and piecemeal, making it difficult for children with mental health problems and their families to receive appropriate services.

 

HAVING A NATIONAL CHILD MENTAL health policy infers a government commitment to ensure the availability of appropriate mental health services for children and their families. The United States has never had such a formalized child mental health policy. Instead, the delivery of child mental health services has been driven by a series of inferred policies that grew out of a number of programs, often short-lived, outside of the mental health field. These inferred policies were products of child welfare, special education, juvenile justice, and adult mental health policies. This article traces the history of efforts to create a national child mental health policy and concludes with recent trends affecting mental health services for children.

 

EARLY CHILD MENTAL HEALTH POLICY DIRECTIONS

 

Court Clinics

 

Almost 100 years ago, the child mental health field emerged as the result of a change in approach toward the care of "wayward" youth (Jones, 1999). The earliest child mental health efforts concerned the fate of youth who had been abandoned by families in trouble and who had run afoul of the law. Rather than approach these youth in a punitive manner, juvenile justice pushed for the development of court clinics to help judges adopt a corrective approach. The court clinics provided the first child mental health services. Over time, this corrective approach has become de facto policy, but many of the clinics themselves have disappeared. This movement toward a more humane treatment of youth formed the basis of current child welfare and juvenile justice policies. Unfortunately, a formal policy to ensure the provision of comprehensive mental health services to troubled youth never developed. It is interesting that although the earliest child mental health policy direction never led to the emergence of an actual policy, it did lead to advances in child welfare and juvenile justice policies, which were based on mental health theory and practice (Jones, 1999).

 

Affordability and Accessibility

 

During the middle decades of the 20th century, the child mental health field turned to the development of services for children who lived with their families and did not need public agency intervention. By the 1950s, the concept of child guidance (the early name for child mental health) was generally accepted. No policy was developed that ensured that these services would be available and affordable to all young persons, however. Child guidance centers provided some services to the needy for free or on a sliding-scale basis, but access to these services relied on the charity of the individual clinic.

 

Children's Bureau

 

The initial link between child guidance and formal government policy was the creation of the federal Children's Bureau in the 1930s (Jones, 1999). This new governmental unit emerged very early in the development of child guidance and represented the federal government's commitment to child development. The Children's Bureau advocated for the development of the child mental health field and educated the public about the mental health needs of children. Although the creation of the Children's Bureau was important, no formal policies related to child mental health services followed.

 

SECOND GENERATION OF POLICY DIRECTIONS

 

Community Mental Health Movement

 

The 1960s brought several changes in the mental health field, with an impact on the availability of mental health services. In 1963, Congress passed the Mental Retardation Facilities and Community Mental Health Center Construction Act, which established a policy of encouraging and enabling the development of community mental health services throughout the country. The primary impetus for the act was the growing deinstitutionalization of adults with chronic mental health problems. The purpose of community mental health centers was to provide services within communities rather than within hospitals. These services were not aimed specifically at children, and when the program was initiated, there was little-to-no recognition that children with mental health needs required specially designed services (Ad Hoc Committee on Child Mental Health, 1971). Like child guidance before it, the community mental health center movement was accepted as a positive development, but it did not lead to a mandate requiring availability and affordability of mental health services.

 

Medicaid

 

Medicaid, a medical service program for the poor, also began in the 1960s. Medicaid was a major step toward a policy that afforded universal access to medical care, and it created a mandate for mental health services for poor children. (In the last decade, through the State Child Health Improvement Program [SCHIP], this policy of entitling the poor has been expanded to include a broader population of children.) Although SCHIP represents an attempt at expanding the mental health mandate to children, the program remains voluntary and states can choose not to participate. Unfortunately, due to a shortage of funding, the families of many children who qualify for this program are not able to access services. The first legitimate national policy mandating child mental health services therefore has never completely materialized.

 

Joint Commission on the Mental Health of Children

 

Emerging during the 1960s, the child mental health movement had developed a growing advocacy base that in 1965 led to the congressionally established Joint Commission on the Mental Health of Children. In its 1970 report, Crisis in Child Mental Health, the Joint Commission laid the framework for a child advocacy approach to children's services. This approach was to be based on the child guidance principles of development, emotional needs, and family support, and it also was to reflect the special needs of children, including needs met by child welfare, corrections, education, health, and mental health agencies. A mental health services mandate never developed from the Joint Commission work, but the principles of child advocacy that were articulated have become the basis for the direction that the child mental health field has taken to date.

 

Demonstration Programs for Children's Mental Health

 

In the early 1970s, the federal Community Mental Health Center (CMHC) program funded a number of demonstrations of children's services. This effort, labeled Part F of the Mental Retardation Facilities and Community Mental Health Center Construction Act, represented a major step toward recognizing the special needs of children. However, it affected less than 12% of the funded CMHCs. Several years later, the success of these demonstrations led the government to make the supplying of children's services a requirement of all CMHCs (Lourie, Katz-Leavy, DeCarolis, & Quinlan, 1996). At the same time, the government also added, without extra funding, six additional new requirements for the centers, most of which were already experiencing fiscal problems. Another factor that limited the impact of the CMHC program on children's services was the failure of states to fully accept the CMHC mandate. When the CMHC federal grants were exhausted, the states did not provide equivalent financial support to sustain the effort. Consequently, CMHCs began to eliminate those services that could not pay for themselves. Among the most vulnerable were children's services.

 

Special Education

 

Another major influence on child mental health took place in the 1970s with the enactment of the Education for All Handicapped Children Act (1975), which became known as the Individuals with Disabilities Education Act of 1990 (IDEA) when it was reauthorized. These acts required states to provide special education and related services to children with disabilities. One of the disability conditions identified under this law was "serious emotional disturbances," or SED, thus creating a mandate for mental health services to be provided to a specific population of children. Even though IDEA represents education policy not primarily aimed at mental health issues, this law offers one of the few mandates for the provision of child mental health services. Most of these services are strictly educational in nature; however, some school districts provide direct clinical mental health services (e.g., assessment, counseling). Unfortunately, in spite of the many exemplary education-based programs created across the country to better serve the needs of children with emotional problems, the system has never become complete nor comprehensive in all jurisdictions (Knitzer, Steinberg, & Fleisch, 1990).

 

President's Commission on Mental Health

 

The next major shift in mental health policy occurred in 1978, when former first lady Rosalynn Carter's interest in mental health led to the convening of a President's Commission on Mental Health. The Commission's recommendations were implemented through the development of the National Plan for the Chronically Mentally Ill (President's Commission on Mental Health, 1978). Even though the children's section of the National Plan was relegated to the status of an appendix (Lourie et al., 1980), the President's Commission and the National Plan highlighted two underserved mental health populations: adults with chronic mental illness (today referred to as serious and persistent mental illness) and children with SED. The reason identified in the Plan for this lack of service was the failure of community mental health centers to adequately address these populations. The governmental response was rapid for adults and led to the Community Support Program (CSP), which aimed to develop state and local social/rehabilitation resources for individuals with serious and persistent mental illness. The needs of children were addressed less comprehensively, with the response consisting entirely of the small Most-In-Need program of services for children in Native American communities, funded only by the Indian Health Service and administered by the National Institute of Mental Health.

 

CURRENT ERA IN POLICY DIRECTIONS

 

Unclaimed Children

 

In 1982, the Children's Defense Fund supported a study of services for children with severe emotional problems, which was directed by Jane Knitzer. Her report, Unclaimed Children, documented the lack of services; lack of coordination among service providers; overuse of residential care for children with the most severe mental health problems; and the failure of federal, state, and local governments to respond to that crisis (Knitzer, 1982). The response to Unclaimed Children came in 1984 from the National Institute of Mental Health, which instituted a funded program to better meet the needs of this population: the Child and Adolescent Service System Program (CASSP).

 

CASSP

 

The policy direction of CASSP was the "system of care" concept, a multiagency approach to the delivery of services, which are to be community-based, child-centered, and family-focused. The system of care was operationalized in the now classic monograph, A System of Care for Children and Youth with Serious Emotional Disturbances (Stroul & Friedman, 1986). CASSP's first goal was to encourage state and local governments to create interagency systems of care for the purpose of ensuring that the needs of children with mental health challenges and their families would be met (Lourie, Katz-Leavy, et al., 1996). Initially, states developed interagency processes that brought the mental health, child welfare, juvenile justice, and special education agencies together for joint planning of how they could and would coordinate services. Ultimately, these state-level interagency processes were to be applied at the community level to create local systems of care, the mission of which was to provide individual children and their families with the most appropriate and least restrictive services.

 

A second major goal of CASSP was to increase the role played by mental health agencies within the multiagency systems of care. By 1995, it was noted that all states had at least one full-time child mental health specialist at the state level (Davis, Yelton, Katz-Leavy, & Lourie, 1995). In most states, however, there was a paucity of available mental health resources and no governmental agency clearly charged with the responsibility for ensuring their availability. CASSP acted to create a specific child mental health presence in state government to increase state child mental health budgets and to develop mechanisms for passing this increased state-level focus on child mental services down to the community level.

 

Enhancing the role of the family was another major goal of CASSP (Friesen & Huff, 1996). Early in its development, CASSP recognized the destructive nature of parent blaming and moved toward its abolition (including the practice of having parents give up custody in order to receive care through child welfare). CASSP proffered the theory that a system of care required that family members must participate in defining and running it, as well as benefiting from its services. The parent movement that grew out of CASSP, embodied in the Federation of Families for Child Mental Health and the National Alliance for the Mentally Ill-Child and Adolescent Network, has had a major impact on improving the systems of care that have developed nationally and in advocating that parents need to be supported in the care of their children in need, rather than being blamed for those needs.

 

Cultural competence was the other major goal of CASSP, which recognized the need for members of culturally diverse groups to have input into how the system of care is created and how the interventions they and their children receive approach their unique cultural values. At the highest level of cultural competence, child mental health and its system-of-care practices need to celebrate cultural differences and utilize them in the interventions offered to children and families (Cross, Bazron, Dennis, & Isaacs, 1989).

 

Comprehensive Community Mental Health Services

 

CASSP was followed by a policy direction focusing on the development and support of systems of care for children with SED and their families. In 1992, Congress passed an act that created the Comprehensive Community Mental Health Services for Children and Their Families Program (ADAMHA Reorganization Act, 1992). This program was initiated to fund service development in communities that had developed a system-of-care approach. Through the federal fiscal year 1999, this grant program had supported service development in more than 45 communities and had federal funding of nearly $80 million (U.S. Department of Health and Human Services, 1999).

 

Managed Care

 

Over the last 20 years, managed care has influenced the child mental health field. It has had particular impact on mental health, under the aegis of "behavioral health." Overutilization of mental health inpatient hospital beds for children occurred in the 1980s. This was specifically evident in the private mental health sector and was a drain on health insurance dollars. This condition afforded additional fuel for a managed care revolution, and behavioral health organizations took over the funding of most private mental health services. The managed care mechanisms that led to the largest cost savings were restrictions of hospital admissions and limitations placed on length of hospital stays. Reductions occurred in outpatient care as well, but these did not have the same fiscal impact as the reduction in hospital stays. Thus, private sector managed behavioral health care became the primary strategy of cost containment through the restriction of services (Lourie, Howe, & Roebuck, 1996). When costs became the driving force behind private sector managed care, the reduction of costs became the prominent policy that drove mental health practice.

 

Managed Care and the Public Sector

 

Managed care eliminated private financial support for most long-term mental health treatments and institutional placements. Because children still needed intensive long-term interventions, parents were forced to obtain services for them from public agencies, such as child welfare, juvenile justice, special education, and where available, public mental health (usually paid for by Medicaid). This led to a major shift in cost to the public sector, as state and federal governments provided funds for these services. As the costs for these services grew, state agencies, like the private sector before them, began to see managed care as a strategy for cutting and containing costs.

 

The Health Care Reform Tracking Project, funded by the federal government and conducted collaboratively by the Research and Training Center for Children's Mental Health at the University of South Florida, the National Technical Assistance Center for Children's Mental Health at Georgetown University, and the Human Service Collaborative, has studied the growing phenomenon of public managed care (Pires et al., 1996; Stroul, Pires, & Armstrong, 1998). The project found that some state officials felt

 

that managed care technologies would allow for the funding of the full array of services dictated by system-of-care practice. Unfortunately, managed care policy has not resulted in major changes in the delivery of services in the public sector. The findings of the Health Care Reform Tracking Project suggest that managed care policy is still developing and that the full impact of this approach on the funding and delivery of mental health services to children is yet to be seen.

 

CONCLUSION

 

Unfortunately, this brings the discussion back to the initial premise of this article--that there is no policy that creates a meaningful, comprehensive mandate for mental health services for children in this country. Until this happens, child mental health policy will remain informal, incomplete, and piecemeal. The failure to formulate and implement a child mental health policy in the United States has led to the frustrating position of recognizing children's mental health needs, having the technologies to ameliorate those needs, yet being unable to find ways of ensuring that those in need receive appropriate services. As a result, parents are forced to relinquish custody of their children, often simultaneously declaring themselves unfit to parent, in order to obtain public services. In addition, children are being labeled as delinquent or educationally disabled in order to receive crucial mental health services through the juvenile justice or special education systems. The formulation of a national child mental health policy would create a mandate under which all those who are in need of services could receive those services.

 

References

 

Ad Hoc Committee on Child Mental Health. (1971). Ad Hoc Committee on Child Mental Health: Report to the Director, National Institutes of Mental Health. Rockville, MD: National Institute of Mental Health.

 

Alcohol, Drug Abuse Mental Health Administration, Pub. L. No. 102-321,106 Stat. 438 Reorganization Act of 1992 (1992).

 

Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Child Mental Health.

 

Davis, M., Yelton, S., Katz-Leavy, J., & Lourie, I. (1995). Unclaimed children revisited. Journal of Mental Health Administration, 22, 142-166.

 

Education for All Handicapped Children Act of 1975, 20 U.S.C. [section] 1400 et seq.

 

Friesen, B. J., & Huff, B. (1996). Family perspectives on systems of care. In B. A. Stroul (Ed.), Children's mental health: Creating systems of care in a changing society (pp. 41-67). Baltimore: Brookes.

 

Individuals with Disabilities Education Act of 1990, 20 U.S.C. [section] 1400 et seq.

 

Joint Commission on the Mental Health of Children. (1970). Crisis in child mental health: Challenge for the 1970s. New York: Harper & Row.

 

Jones, K. (1999). Taming the troublesome child: American families, child guidance, and the limits of psychiatric authority. Cambridge, MA: Harvard University Press.

 

Knitzer, J. (1982). Unclaimed children. Washington, DC: Children's Defense Fund.

 

Knitzer, J., Steinberg, Z., & Fleisch, B. (1990). At the schoolhouse door. New York: Bank Street College of Education.

 

Lourie, I. S., with Fishman, M., Hersh, S., Platt, L., Schultebrandt, J., Silver, L., et al. (1980). Chronically mentally ill children and adolescents: A special report for the national plan for the chronically mentally ill. Rockville, MD: National Institute of Mental Health.

 

Lourie, I. S., Howe, S. W., & Roebuck, L. L. (1996). Systematic approaches to mental health care in the private sector for children, adolescents, and their families: Managed care organizations and service providers. Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Child Mental Health.

 

Lourie, I. S., Katz-Leavy, J., DeCarolis, G., & Quinlan, W. (1996). The role of the federal government. In B. A. Stroul (Ed.), Children's mental health: Creating systems of care in a changing society (pp. 99-114). Baltimore: Brookes.

 

Mental Retardation Facilities and Community Mental Health Center Construction Act of 1963, Pub. L. No. 88-156, [section] 2661 et seq., 77 Stat. 282.

 

Pires, S. A., Stroul, B. A., Roebuck, L. L., Friedman, R. M., McDonald, B. B., & Chambers, K. L. (1996). Health Care Reform Tracking Project: Tracking state health care reforms as they affect children and adolescents with emotional disorders and their families--The 1995 state survey. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, Department of Child and Family Studies, Research and Training Center for Children's Mental Health.

 

President's Commission on Mental Health. (1978). Report to the President from the President's Commission on Mental Health. Washington, DC: U.S. Government Printing Office.

 

Stroul, B. A., & Friedman, R. M. (1986). A system of care for children and youth with serious emotional disturbances (Rev. ed.). Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Child Mental Health.

 

Stroul, B. A., Pires, S., & Armstrong, M. I. (1998). Health Care Reform Tracking Project: Tracking state health care reforms as they affect children and adolescents with emotional disorders and their families--The 1997 impact analysis. Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, Department of Child and Family Studies, Research and Training Center for Children's Mental Health.

 

U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. Rockville, MD: Author.

 

About the Authors

 

IRA S. LOURIE, MD, is a child psychiatrist who currently is a partner in the Human Service Collaborative, an organization that provides consultation, technical assistance, and training in areas of human services policy and services system development. He is also medical director of AWARE of Anaconda, Montana, an agency for troubled children, and a psychiatric consultant for two other agencies that provide community-based and wraparound services, the Pressley Ridge Schools of Maryland and the Maryland and Virginia Intensive Family Treatment Programs of KidsPeace National Centers. MARIO HERNANDEZ, PhD, is a clinical and community psychologist. He is an associate professor and director of the Division of Training, Research, Evaluation, and Demonstration in the Department of Child and Family Studies at the University of South Florida. Address: Ira S. Lourie, 13133 Fountain Head Road, Hagerstown, MD 21742.
 
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