    [Senate Hearing 108-682]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 108-682

          MENTAL HEALTH IN CHILDREN AND YOUTH: ISSUES THROUGHOUT THE
                             DEVELOPMENTAL PROCESS

    =======================================================================

                                    HEARING

                                   BEFORE THE

                      SUBCOMMITTEE ON SUBSTANCE ABUSE AND
                             MENTAL HEALTH SERVICES

                                     OF THE

                        COMMITTEE ON HEALTH, EDUCATION,
                              LABOR, AND PENSIONS
                              UNITED STATES SENATE

                          ONE HUNDRED EIGHTH CONGRESS

                                 SECOND SESSION

                                       ON

       EXAMINING MENTAL HEALTH IN CHILDREN AND YOUTH, FOCUSING ON ISSUES
    THROUGHOUT THE DEVELOPMENTAL PROCESS, AND S. 1704, TO AMEND THE PUBLIC
    HEALTH SERVICE ACT TO ESTABLISH A STATE FAMILY SUPPORT GRANT PROGRAM TO
      END THE PRACTICE OF PARENTS GIVING LEGAL CUSTODY OF THEIR SERIOUSLY
      EMOTIONALLY DISTURBED CHILDREN TO STATE AGENCIES FOR THE PURPOSE OF
              OBTAINING MENTAL HEALTH SERVICES FOR THOSE CHILDREN

                                   __________

                                 APRIL 28, 2004

                                   __________

     Printed for the use of the Committee on Health, Education, Labor, and
                                    Pensions

                     U.S. GOVERNMENT PRINTING OFFICE

    93-524                  WASHINGTON : 2004
    _________________________________________________________________
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              COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                      JUDD GREGG, New Hampshire, Chairman

    BILL FRIST, Tennessee                EDWARD M. KENNEDY, Massachusetts
    MICHAEL B. ENZI, Wyoming             CHRISTOPHER J. DODD, Connecticut
    LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
    CHRISTOPHER S. BOND, Missouri        BARBARA A. MIKULSKI, Maryland
    MIKE DeWINE, Ohio                    JAMES M. JEFFORDS (I), Vermont
    PAT ROBERTS, Kansas                  JEFF BINGAMAN, New Mexico
    JEFF SESSIONS, Alabama               PATTY MURRAY, Washington
    JOHN ENSIGN, Nevada                  JACK REED, Rhode Island
    LINDSEY O. GRAHAM, South Carolina    JOHN EDWARDS, North Carolina
    JOHN W. WARNER, Virginia             HILLARY RODHAM CLINTON, New York

                      Sharon R. Soderstrom, Staff Director

          J. Michael Myers, Minority Staff Director and Chief Counsel

                                     ______

           Subcommittee on Substance Abuse and Mental Health Services

                          MIKE DeWINE, Ohio, Chairman

    MICHAEL B. ENZI, Wyoming             EDWARD M. KENNEDY, Massachusetts
    JEFF SESSIONS, Alabama               JEFF BINGAMAN, New Mexico
    JOHN ENSIGN, Nevada                  JACK REED, Rhode Island

                        Karla Carpenter, Staff Director

                      David Nexon, Minority Staff Director

                                      (ii)

                                C O N T E N T S

                                   __________

                                   STATEMENTS

                           WEDNESDAY, APRIL 28, 2004

                                                                       Page
    DeWine, Hon. Mike, a U.S. Senator from the State of Ohio, opening
      statement......................................................     1
    Reed, Hon. Jack, a U.S. Senator from the State of Rhode Island,
      opening statement..............................................     2
    Dodd, Hon. Christopher J., a U.S. Senator from the State of
      Connecticut, opening statement.................................     4
    Kennedy, Hon. Edward M., a U.S. Senator from the State of
      Massachusetts, prepared statement..............................     7
    Collins, Hon. Susan M., a U.S. Senator from the State of Maine,
      prepared statement.............................................     8
    Osofsky, Joy D., Professor of Pediatrics, Psychiatry, and Public
      Health, Louisiana State University Health Sciences Center, and
      President, Board of Directors, Zero to Three; Marleen Wong,
      Director, Crisis Counseling and Intervention Services, Los
      Angeles Unified School District, Los Angeles, CA, and Director,
      School Crisis and Intervention Unit, National Center for Child
      Traumatic Stress, UCLA and Duke University; Louise A. Douce,
      Director, Counseling and Consultation Services, the Ohio State
      University; Maryann Davis, Assistant Professor, Center for
      Mental Health Services Research, Department of Psychiatry,
      University of Massachusetts Medical School, Worcester, MA;
      Linda Champion, Child Advocate, National Alliance for the
      Mentally Ill, and Vice President, Alabama Family Ties,
      Montgomery, AL, and Barbara Altenburger, Family Advocate,
      Parents Involved Network, Mental Health Association of
      Southeastern Pennsylvania, Philadelphia, PA....................    12
        Prepared statements of:
            Joy D. Osofsky...........................................    14
            Marleen Wong, LCSW.......................................    23
            Louise A. Douce, Ph.D....................................    34
            Maryann Davis, Ph.D......................................    38
    Sessions, Hon. Jeff, a U.S. Senator from the State of Alabama,
      opening statement..............................................    44
    Altenburger, Barbara, prepared statement.........................    51

                              ADDITIONAL MATERIAL

    Statements, articles, publications, letters, etc.:
        Response to questions of Senator Reed from Joy Osofsky.......    20
        Response to questions of Senator Bingaman from Marleen Wong..    28
        Response to questions of Senator Bingaman from Maryann Davis.    40
        Response to questions of Senator Reed from Maryann Davis.....    42
        Response to questions of Senator Bingaman from Linda M.
          Champion...................................................    46
        The Keeping Families Together Act (S.1704)...................    66
        American Academy of Child and Adolescent Psychiatry..........    67
        Michael Faenza, National Mental Health Association...........    72
        Susan Mikolic, Parent and Advocate...........................    74
        The National Child Traumatic Stress Network (NCTSN)..........    82

                                     (iii)

          MENTAL HEALTH IN CHILDREN AND YOUTH: ISSUES THROUGHOUT THE
                             DEVELOPMENTAL PROCESS

                                  ----------

                           WEDNESDAY, APRIL 28, 2004

                                           U.S. Senate,
    Subcommittee on Substance Abuse and Mental Health Services,
           Committee on Health, Education, Labor, and Pensions,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 10:05 a.m., in
    room SD-430, Dirksen Senate Office Building, Hon. Mike DeWine
    (chairman of the subcommittee) presiding.
        Present: Senators DeWine, Sessions, and Reed.

                      Opening Statement of Senator DeWine

        Senator DeWine. Good morning. Let me thank all of you for
    being here today, and let me also welcome Senator Reed, with
    whom I have worked on so many issues in the past concerning
    children.
        Today, we are meeting to talk about mental health issues
    concerning children and youth throughout their developmental
    process. The simple fact is that children and youth with
    emotional and behavioral needs face tremendous challenges in
    receiving care in our Nation today. Mental health care is
    dispersed across many systems for children, including schools,
    the juvenile justice system, the child welfare system, the
    substance abuse treatment system, through their primary care
    providers, and within their own families.
        I have seen in my own home State of Ohio serious failures
    in the child mental health system. Just a few weeks ago, a
    series of disturbing stories ran in the Cincinnati Enquirer
    regarding the children's mental health system in Ohio. These
    articles focused on children who are mistreated at treatment
    centers, are in families unable to afford necessary care, and
    children whose parents give them up to child protection
    services in order to receive treatment. The many shortcomings
    of the current system resulted in mental health needs of
    children not being met and actual harm being done to children
    who were in the care of those paid to protect and help them.
        Now, obviously, passing Senator Pete Domenici's mental
    health parity legislation--officially called the Senator Paul
    Wellstone Mental Health Equitable Treatment Act--would be the
    best solution for many of the children in these articles, as
    well as many children facing similar problems in other States.
    We know that these children are many in number.
        Each year, approximately 5 to 9 percent of children suffer
    from serious mental illness or serious emotional disturbances.
    However, fewer than one in five of these children will receive
    needed treatment.
        Early childhood is a critical time period to prevent the
    onset of emotional and behavioral impairments. If these
    children do not receive appropriate treatment or if their
    illness is too severe, these children are more likely to
    continue on paths which lead to expulsion from school and
    child-care facilities for disruptive behavior, separation from
    their family, visits to juvenile justice facilities, and
    dropping out of high school.
        Some of the issues concerning children and youth in the
    mental health system were discussed at a hearing that we held
    to examine the Final Report of the President's New Freedom
    Commission on Mental Health. The report found that
    fragmentation of the mental health system and gaps in care for
    children were serious problems.
        The report also stated that the multiple programs created
    to finance and support children and youth with mental illness
    help foster an approach that is complex, fragmented, and
    inconsistent in its coverage, which makes the entire process
    very difficult for parents or caretakers.
        Mental health is absolutely fundamental to a person's
    overall physical health and well-being and is critical to
    leading a productive and balanced life. Our children and young
    people deserve access to services that are appropriately and
    effectively provided. That is why I have worked with Senator
    Dodd and Senator Smith from Oregon to introduce the Youth
    Suicide Early Intervention and Prevention Expansion Act--a bill
    that would provide funding for the creation and expansion of
    statewide youth suicide early intervention and prevention
    strategies. Tragically, suicide is the third leading cause of
    death of children and youth ages 10 to 24.
        I have also been working with my friend, Senator Reed, on a
    bill we have introduced called the Campus Care and Counseling
    Act that would provide needed funds to mental and behavioral
    health centers on our Nation's college and university campuses.
    We know that rates of university-age students seeking care
    while away at school are rising, and counseling centers are
    struggling to keep up with these rising numbers.
        I look forward to discussing all these issues today and
    hearing the testimony from our witnesses. I believe that this
    testimony will serve to educate us on issues concerning the
    children and youth mental health system, and I am confident
    that these recommendations will serve as a real starting point
    for change and improvement.
        Let me now turn to Senator Reed for his comments.

                       Opening Statement of Senator Reed

        Senator Reed. Thank you very much, Mr. Chairman. Thank you
    for calling today's hearing and also for your devoted and
    consistent attempts to help children of the United States in so
    many ways through the health care system. Thank you, Mr.
    Chairman.
        As we all know, today we are facing a crisis in the mental
    health care system throughout the United States, particularly
    when it comes to the needs of our children and young adults. I
    would like to express my appreciation to the witnesses who are
    here today. Each of today's panelists offer a unique
    perspective on the critically important issue of children's
    mental health. Thank you all very much.
        The recent rash of suicides on college campuses throughout
    this country has illustrated the dire consequences of failing
    to address the mental health needs of our young people. Just
    last week, the Washington Post reported the fifth suicide at
    the George Washington University since December 2003.
        A recent study of counseling center directors found that 81
    percent were concerned about increasing numbers of students
    with severe psychological problems, 67 percent reported a need
    for more psychiatric services, and 63 percent reported problems
    with the growing demand for services without an appropriate
    increase in resources.
        I would like to share with you a sampling of the type of
    cases seen by just one counselor at the University of Rhode
    Island: one student with depression and a recent suicide
    attempt, one student with schizophrenia, two students with
    self-cutting behaviors, three with drug and alcohol problems,
    one victim of rape, two students with eating disorders, two
    with difficulty adjusting to college life, and one with panic
    attacks. And that is not even the entire caseload of this one
    counselor.
        Along with Senator DeWine, we introduced the Campus Care
    and Counseling Act to increase access and enhance mental and
    behavioral health services for our college students. This bill
    authorizes grants to colleges and universities for a range of
    activities, including prevention, screening, early
    intervention, assessment, education, treatment, and ongoing
    case management of mental and behavioral health problems.
        College mental health is just one piece, though, in the
    complicated puzzle of children's mental health. For young
    children in particular, access to care is a critical problem.
    In Rhode Island, as in most communities in this country, we are
    suffering from a severe shortage of child psychiatrists. The
    lack of competent providers, combined with limited outpatient
    mental health services, few substance abuse treatment programs,
    and virtually nonexistent residential treatment facilities, has
    left families literally with no place to turn.
        With few options at hand to access treatment, some parents
    are even forced to give up custody of their children just to
    qualify for public mental health programs.
        According to Dr. Greg Fritz, chairman of child psychiatry
    at Brown University School of Medicine, emergency room visits
    have tripled in the past 3 years. Outpatient clinics have
    waiting lists of 2 months or more. Patients being discharged
    from the hospital wind up being readmitted 6 weeks later
    because they decompensate before their number comes up on the
    waiting list for outpatient treatment.
        We as a nation have failed children with mental illnesses
    on many levels. They are often not diagnosed in a timely
    fashion, they are treated by providers with minimal mental
    health training, they are forced to bounce around between
    various systems of care--if they are able to access mental
    health services at all. Then when they finally figure out how
    the system works and provided that they do not end up as one of
    the many incarcerated mentally ill, they age out of the
    adolescent system and have to start all over in their
    transition into the adult mental health system, a system with
    even less to offer them.
        Last, I would note and echo the comments of the chairman
    that tomorrow marks the 2-year anniversary of President Bush's
    call on Congress to pass mental health parity legislation. I am
    disappointed that, despite having broad support, Congress has
    refused to act upon legislation that would aid millions of
    Americans in obtaining needed mental health treatment and
    renounce the current system that allows private mental health
    insurance plans to discriminate with impunity when it comes to
    mental health coverage.
        I extend to my colleagues the hope that this hearing will
    provide the impetus for us to take action on the Paul Wellstone
    mental health parity act. It would be a fitting tribute to
    literally a giant--well, not literally because we are the same
    size, but a giant in the U.S. Senate.
        [Laughter.]
        Mr. Chairman, I also have a statement from Senator Dodd. As
    you know, he is deeply interested in children's mental health,
    particularly with youth suicide and the use of antidepressant
    medication in children. He unfortunately is unable to attend
    today's hearing but asked that his statement be included in the
    record.
        Senator DeWine. It will be made a part of the record.
        [The prepared statement of Senator Dodd follows:]

                           Statement of Senator Dodd

        Good Morning. I would like to begin by thanking Chairman
    DeWine and Senator Reed, two of the Senate's strongest
    advocates for children's mental health reform, for holding this
    important hearing today. While I am not a member of this
    Subcommittee, both Chairman DeWine and Senator Reed are aware
    that the issue before this Subcommittee today is one that holds
    great meaning to me. Unfortunately, while other Senate business
    prevents me from attending today's hearing, I appreciate the
    Chairman making my statement part of the hearing record.
        I would also like to thank all of the witnesses who are
    testifying today and all of those in attendance. It is very
    encouraging for me to see that, collectively, you represent
    many different specialty areas within the issue of children's
    mental health--from initiatives designed to meet the needs of
    infants to those designed to meet the needs of young adults,
    from services and awareness campaigns designed to improve the
    mental health of our children in primary and secondary schools
    to those designed to improve the mental health of our young
    people in college. I commend all of your hard work, and I
    applaud your professional and personal commitment to this
    issue. If we are to start making a meaningful difference today,
    then we need the continued dedication and support of each and
    every one of you.
        I am heartened to see all of you here this morning; yet, in
    a way, I am also disheartened. The fact that the United States
    Senate needs to hear testimony from professionals and advocates
    who come from across the children's mental health spectrum
    clearly reflects the alarming fact that the problems we face as
    a society in this issue also come from across the spectrum.
        Ensuring that all of our children and young adults have
    access to comprehensive mental health care that adequately and
    fully addresses their individualized needs is one of the most
    acute crises facing our society today. We all know the alarming
    facts. According to most inter-agency studies done by the
    Department of Health and Human Services, approximately 20
    percent of children in our country suffer from a diagnosable
    mental, emotional, or behavioral disorder, while up to 10
    percent suffer from a serious disturbance or multiple
    disorders. Yet, well over half of these children are unable to
    access the appropriate community-based care they require.
    Children and their families across this country, regardless of
    their age, race, ethnicity, socioeconomic status, or location,
    all too often find themselves facing a seriously fragmented
    mental health delivery system--a system that all too often
    fails to assess and diagnose disorders and their possible
    causes accurately, cannot offer complete comprehensive
    community-based care in the child's natural setting, employs
    medical and health professionals who are well intentioned but
    improperly trained, and cannot provide adequate financial and
    emotional support, information, and hope. Clearly, these
    widespread problems, compounded by the relative paucity of
    research on the risk factors and causes of children mental
    health disorders, speak to the urgent need for greater Federal
    involvement in this area.
        In my capacity as a Senator from Connecticut, I have
    recently addressed two areas within the issue of children's
    mental health: youth suicide prevention and the use of
    antidepressant medications in children and young adults.
        We all know that youth suicide is a grave crisis in the
    United States. According to the Centers for Disease Control and
    Prevention (CDC), more than 3,000 young people take their lives
    each year, making suicide the third overall cause of death
    between the ages of 10 and 24. We also know that youth suicide
    is intricately linked to mental health--specifically to
    disorders like depression and substance abuse. More than 90
    percent of young people who attempt suicide are found to suffer
    from a mental, emotional, and behavioral disturbance.
        I am pleased that we have already taken several positive
    steps toward better understanding the tragedy of youth suicide
    and its emotional and behavioral risk factors--both on the
    Federal and local levels. Today, hundreds of community-based
    programs and statewide collaborative strategies across the
    country offer a variety of early intervention and prevention
    services to thousands of children and young adults--services
    that include comprehensive screening, assessment, and
    individualized counseling. However, we still face significant
    challenges in this area. As we all know too well, a large
    number of States and localities are finding themselves with
    unprecedented budget deficits--making the establishment of new
    services and the retention of existing services increasingly
    more difficult.
        I have introduced bipartisan legislation with Chairman
    DeWine along with Senators Gordon Smith and Harry Reid. This
    legislation, the Youth Suicide Early Intervention and
    Prevention Expansion Act of 2004, seeks to support further the
    good work being done on the community level, the State level,
    and the Federal level with regards to youth suicide. Through
    the establishment of a new grant initiative, this legislation
    supports the further development and expansion of statewide
    youth suicide early intervention and prevention strategies and
    the community-based services they seek to coordinate. It also
    encourages greater Federal support in the planning,
    implementation, and evaluation of these strategies and services
    and creates a new inter-agency collaboration that promises to
    focus on research, policy development, and the dissemination of
    data specifically pertaining to youth suicide. Along with
    Chairman DeWine, I am fully committed in working to pass the
    legislation this year.
        Although today's hearing is not focused on prescription
    drug treatment for depression in adolescents and children, I
    would like to touch on the issue briefly. Last Friday, the
    Washington Post reported on the results of a study published in
    the Lancet, a British medical journal, showing an increase in
    the risk of suicidal behavior among children taking four
    popular antidepressants. The study also showed no measurable
    benefit to children. This disturbing report added to the
    growing questions surrounding the use of antidepressants, and
    specifically the class of drugs known as selective serotonin
    reuptake inhibitors (SSRIs), in children.
        SSRIs are prescribed to millions of American children each
    year, and that number continues to increase. Families and
    physicians caring for children suffering from depression are
    desperate for answers about the appropriate use of
    antidepressants. While many experts insist that antidepressants
    can be a critical component of care, parents cannot help but
    take reports of ineffectiveness and increased risk seriously.
        It is imperative that questions surrounding SSRIs are
    answered as quickly as possible. If these drugs do indeed pose
    a risk to children, physicians and the public must be made
    aware of that risk immediately. On the other hand, it is
    equally important to discover the truth in the case that SSRIs
    do not pose a threat to children's well-being, so that doctors
    can continue to prescribe these life-saving medicines without
    fear. In the current environment of uncertainty, there is a
    legitimate concern that children who now benefit, or who may
    benefit, from SSRIs will be inappropriately denied access to
    these drugs.
        Yesterday, I sent a letter to Acting FDA Commissioner
    Lester Crawford urging the agency to bring some clarity to this
    issue as soon as possible. This letter was a follow-up to a
    letter that I sent on March 1 to then-Commissioner Mark
    McClellan, along with nine of my Senate colleagues. In that
    earlier letter, we asked the FDA to consider invoking its
    authority to require additional testing of SSRIs to determine
    once and for all whether or not these drugs benefit our
    children. With the recent report in the Lancet, our request has
    taken on even greater urgency.
        I have asked Acting Commissioner Crawford to share with me
    the FDA's plans to address this issue. I have also offered to
    help in whatever way I can, so that families can be confident
    that their children are receiving the best possible care. We
    must get to the bottom of this issue as soon as possible.
        Lastly, Mr. Chairman, no discussion of mental health would
    be complete without mentioning the critical absence of parity
    between our mental and physical healthcare systems. Two years
    ago this week President Bush endorsed the notion that there is
    need for equity between these two disparate systems. Sadly,
    however, legislation ensuring parity, originally championed by
    our dear friend Senator Paul Wellstone, has yet still failed to
    pass, despite the co-sponsorship of close to 70 members of the
    Senate, including both the Chair and Ranking Member of this
    Subcommittee. Mental health parity is critically essential not
    only if we are to address the mental healthcare needs of our
    children but also the needs of all Americans.
        We have a societal obligation to break through the stigma
    that is still unfortunately attached to children's mental
    health--a stigma that still keeps these issues largely off our
    television airwaves and the front pages of our newspapers. We
    have an obligation to reach out to our young people--to help
    them understand that whatever difficulties or illnesses they
    might be experiencing are only temporary and treatable in a
    comfortable setting. And, most important, we have an obligation
    to instill in our young people a sense of value, self-worth,
    and resilience. Therefore, I am fully committed to working with
    each of you--doctors, psychiatrists, psychologists, counselors,
    nurses, teachers, advocates, and affected families--so that we
    can better understand the causes of mental health disorders and
    develop effective mental health initiatives and services that
    reach every child and young adult in this country--
    compassionate initiatives that give them encouragement, hope,
    and above all, life.
        Senator Reed. I thank the chairman again for holding
    today's hearing, and I look forward to working with him on
    these critical issues and listening to these outstanding
    witnesses.
        Thank you, Mr. Chairman.
        Senator DeWine. Senator Reed, thank you very much.
        At this time I would like to submit a prepared statement
    from Senators Kennedy and Collins to be included in the record.
        [The prepared statement of Senator Kennedy follows:]

                Prepared Statement of Senator Edward M. Kennedy

        Thank you, Senator DeWine, for convening this important
    hearing and for your strong commitment to the well-being of the
    nation's children.
        As the report of the President's New Freedom Commission
    stated, our mental health care system is in crisis. The quality
    of care isn't good enough, access, isn't broad enough, and the
    whole system isn't consumer-oriented enough.
        No group in our population bears a greater burden of this
    failure than the young. One in five children and adolescents
    have mental health disorders, but three-quarters of them never
    receive the care they need. The large racial disparities in
    access to care and quality of care are serious problems as
    well.
        The results of this failure are higher school drop-out
    rates, more frequent family conflicts, higher rates of drug
    abuse and violence and higher rates of anxiety disorders,
    depression, and even suicide.
        It is clear that we can do much more to prevent, treat, and
    cure mental illness in children. The panelists here today
    demonstrate that it is a problem we must meet at all stages of
    development.
        The recommendations of the New Freedom Commission offer us
    a unique opportunity to act effectively. One of the key
    recommendations is to improve mental health care services in
    schools.
        Schools have become the de facto providers of mental health
    care for children. In fact, 80 percent of the children who
    receive mental health care services receive them in schools.
    But the care in schools is plagued by the same factors that
    plague other systems of care--not enough funds, not enough
    personnel, poor quality of care, little involvement of parents,
    and few prevention efforts.
        In addition, the lack of research and dissemination of
    evidence-based practices has meant few advances in intervention
    and treatment.
        Complex and costly care has led to families doing the
    unthinkable--giving up custody of their child to the child
    welfare system or juvenile justice system in order to obtain
    services, even though such systems are ill-prepared to meet
    their needs. A lack of parity in financing for mental health
    care for children has contributed greatly to this disturbing
    defect.
        It's clear we can't afford to wait any longer to make
    urgently needed improvements, and I look forward to working
    with Senator DeWine, Senator Reed and other Members of the
    Subcommittee on the recommendations made by today's panelists.
        [The prepared statement of Senator Collins follows:]

                 Prepared Statement of Senator Susan M. Collins

        I want to commend the Subcommittee Chairman for holding
    this hearing to examine mental health issues in children and
    youth throughout the developmental process. Unfortunately, I am
    chairing a Governmental Affairs Committee hearing this morning,
    so I am unable to deliver my testimony in person, but I
    appreciate the Chairman's kind offer to make certain that it is
    included as a part of the hearing record.
        Serious mental illness afflicts millions of our nation's
    children and adolescents. It is estimated that as many as 20
    percent of American children under the age of 17 suffer from a
    mental, emotional or behavioral illness. What I find most
    disturbing, however, is the fact that two-thirds of all young
    people who need mental health treatment are not getting it.
        Behind each of these statistics is a family that is
    struggling to do the best it can to help a son or daughter with
    serious mental health needs to be just like every kid--to
    develop friendships, to do well in school, and to get along
    with their siblings and other family members. These children
    are almost always involved with more than one social service
    agency, including the mental health, special education, child
    welfare and juvenile justice systems. Yet no one agency, at
    either the State or the Federal level, is clearly responsible
    or accountable for helping these children and their families.
        My interest in this issue was triggered by a compelling
    series of stories by Barbara Walsh in the Portland Press Herald
    which detailed the obstacles that many Maine families have
    faced in getting desperately needed mental health services for
    their children.
        Too many families in Maine and elsewhere have been forced
    to make wrenching decisions when they have been advised that
    the only way to get the care that their children so desperately
    need is to relinquish custody and place them in either the
    child welfare or juvenile justice system.
        Yet neither system is intended to serve children with
    serious mental illness. Child welfare systems are designed to
    protect children who have been abused or neglected. Juvenile
    justice systems are designed to rehabilitate children who have
    committed criminal or delinquent acts. While neither of these
    systems is equipped to care for a child with a serious mental
    illness, in far too many cases, there is nowhere else for the
    family to turn.
        Last year, I commissioned a GAO report with Representatives
    Pete Stark and Patrick Kennedy that found that, in 2001,
    parents placed more than 12,700 children into the child welfare
    or juvenile justice systems so that these children could
    receive mental health services.
        Moreover, I believe that this is just the tip of the
    iceberg, since 32 States--including the five States with the
    largest populations of children--did not provide the GAO with
    any data.
        There have been other studies indicating that the custody
    relinquishment problem is even more pervasive. A 1999 survey by
    the National Alliance for the Mentally Ill found that 23
    percent--or one in four parents surveyed--had been told by
    public officials that they needed to relinquish custody of
    their children to get care, and that one in five of these
    families had done so.
        While some States have passed laws to limit or prohibit
    custody relinquishment, simply banning the practice is not a
    solution, since it can leave mentally ill children and their
    families without services and care. Custody relinquishment is
    merely a symptom of the much larger problem, which is the lack
    of available, affordable, and appropriate mental health
    services and support systems for children with serious mental
    health needs and their families.
        I chaired a series of hearings in the Governmental Affairs
    Committee last summer to examine this issue further. We heard
    compelling testimony from mothers who told us that they were
    advised that the only way to get the intensive care and
    services that their children needed was to relinquish custody
    and place them in the child welfare system. This is a wrenching
    decision that no family should be forced to make. No parent
    should have to give up custody of his or her child just to get
    the services that the child needs.
        The mothers also described the barriers they faced in
    getting care for their children. They told us about the
    limitations in both public and private insurance coverage. They
    also talked about the lack of coordination and communication
    among the various agencies and programs that serve children
    with mental health needs. One parent, desperate for help for
    her twin boys, searched for 2 years until she finally located a
    program--which she characterized as ``the best kept secret in
    Illinois''--that was able to help.
        Parents should not be bounced from agency to agency,
    knocking on every door they come to, in the hope that they will
    happen upon someone who has an answer. It simply should not be
    such a struggle for parents to get services and treatment for
    their children.
        The Keeping Families Together Act, which I have introduced
    with a bipartisan group of my colleagues, would help to reduce
    the barriers to care for children with serious mental health
    needs and would assist States in eliminating the practice of
    parents relinquishing custody of their children solely for the
    purpose of securing mental health services.
        The legislation authorizes $55 million for competitive
    grants to States to create an infrastructure to support and
    sustain statewide systems of care to serve children who are in
    custody or at risk of entering custody of the State for the
    purpose of receiving mental health services. States already
    dedicate significant dollars to serve children in State
    custody. These Family Support Grants would help states serve
    children more effectively and efficiently, while keeping them
    at home with their families.
        The legislation would also remove a current statutory
    barrier that prevents more States from using the Medicaid home
    and community-based services waiver to serve children with
    serious mental health needs. This waiver provides a promising
    way for States to address the underlying lack of mental health
    services for children that often leads to custody
    relinquishment. While a number of States have requested these
    waivers to serve children with developmental disabilities, very
    few have done so for children with serious mental health
    conditions. Our legislation would provide parity to children
    with mental illness by making it easier for States to offer
    them home- and community-based services under this waiver as an
    alternative to institutional care.
        The Keeping Families Together Act takes a critical step
    forward to meeting the needs of children with mental or
    emotional disorders and their families. Attached to my
    testimony is a more detailed summary of the Keeping Families
    Together Act, and I urge all of the Members of the Subcommittee
    to work with me so that we can get this legislation passed and
    signed into law before the end of the year.
        Again, Mr. Chairman, thank you for allowing me to submit my
    testimony, and I look forward to working with you to ensure
    that appropriate and affordable mental health services and
    support systems are available for all children and young people
    with mental health needs and their families.
        Let me introduce the panel. I will introduce all the
    members of the panel. We will keep your statements to 5
    minutes. We are going to be fairly tight on that because that
    will give us an opportunity to ask some questions and hear your
    comments.
        On our panel this morning, I would first like to introduce
    Dr. Joy Osofsky. She is currently professor of Pediatrics,
    Psychiatry, and Public Health at Louisiana State University
    Health Sciences Center in New Orleans and is the head of the
    Division of Pediatric Mental Health. She serves as director of
    the Violence Intervention Program for Children and Families and
    the Harris Center for Infant Mental Health. The doctor has
    published and edited numerous articles on the effects of
    violence in young children, and in June of this year, she will
    publish an edited book titled ``Young Children and Trauma.''
    She is president of Zero to Three: National Center for Infants,
    Toddlers, and Families, and in 2002, she was awarded the
    Nicholas Hobbs Award for contributions to public policy by
    Division 37 of the American Psychological Association.
        Next, let me introduce Marleen Li Chen Wong. She is the
    director of Mental Health, District Crisis Intervention Teams,
    and Suicide Intervention Programs for the Los Angeles Unified
    School District, the second largest school district in the
    United States. She has administrative responsibility for four
    outpatient child clinics, a staff of 186 clinical social
    workers and clinical psychologists, child psychiatrists, and
    community workers; and 350 district crisis team members. She is
    also responsible for administering the mental health
    consultation program in over 100 children's day care centers in
    Los Angeles Unified School District schools. She is currently
    serving as director of the School Crisis and Disaster Recovery
    Program at the National Center for Child Traumatic Stress at
    UCLA and Duke University.
        Next, let me introduce Dr. Louise Douse. She is the
    director of the Counseling and Consultation Service at the Ohio
    State University, which serves the full range of counseling and
    mental health needs of the Ohio State University student body.
    She is a specialist in college student mental health and has
    been counseling college students for the past 25 years. She is
    the immediate past president of the Society of Counseling
    Psychology, Division 17 of the American Psychological
    Association, and in the year 2003, the Association of
    University and College Counseling Center Directors presented
    her with the Lifetime Achievement Award.
        Next, I would like to introduce Dr. Davis. Dr. Davis is
    currently an assistant professor in the Department of
    Psychiatry at the University of Massachusetts and a faculty
    member of the Center for Mental Health Services Research. Her
    current efforts focus on the mental health needs of children
    transitioning into adulthood. Dr. Davis has designed and
    implemented a transition support project, Project Nexus, to
    assist children with mental health needs during this difficult
    transitional period. Dr. Davis also serves as a consultant to
    the Center for Mental Health Services of the Substance Abuse
    and Mental Health Services Administration on their evaluation
    program of the Partnership for Youth Transition grant program.
        Let me also introduce Linda Champion. Since 2002, Mrs.
    Champion has served as a data analyst for the Alabama
    Department of Mental Health and Mental Retardation. She is the
    vice president of Alabama Family Ties, an advocacy group which
    advocates for children and adolescents with mental illness.
    Mrs. Champion is also the Children's Issues Advisor to the
    National Alliance for the Mentally Ill in Alabama and serves on
    numerous planning committees working with the State of Alabama
    Department of Mental Health and Mental Retardation.
        Finally, let me introduce Barbara Altenburger. As the
    parent of an adolescent with serious emotional and behavioral
    disorders, she has had to navigate the children's mental health
    system herself and, therefore, can offer great insight to us.
    We commend her commitment to helping us all better understand
    this important and complex issue. She serves as a family
    advocate at Parents Involved Network of Philadelphia, a program
    of the Mental Health Association of Southeastern Pennsylvania.
    In addition to her work with the Parents Involved Network, she
    has shared her experiences at local workshops and conferences
    and is a long-time advocate for improved mental health and
    related services for children, adolescents, and their families.
        We thank all of you very much for joining us, and we
    appreciate it. We look forward to all of your testimony. We
    will start on my right with Dr. Osofsky. Doctor, thank you very
    much.

        STATEMENTS OF JOY D. OSOFSKY, PROFESSOR OF PEDIATRICS,
       PSYCHIATRY, AND PUBLIC HEALTH, LOUISIANA STATE UNIVERSITY
    HEALTH SCIENCES CENTER, AND PRESIDENT, BOARD OF DIRECTORS, ZERO
        TO THREE; MARLEEN WONG, DIRECTOR, CRISIS COUNSELING AND
    INTERVENTION SERVICES, LOS ANGELES UNIFIED SCHOOL DISTRICT, LOS
    ANGELES, CA, AND DIRECTOR, SCHOOL CRISIS AND INTERVENTION UNIT,
       NATIONAL CENTER FOR CHILD TRAUMATIC STRESS, UCLA AND DUKE
         UNIVERSITY; LOUISE A. DOUCE, DIRECTOR, COUNSELING AND
       CONSULTATION SERVICES, THE OHIO STATE UNIVERSITY; MARYANN
     DAVIS, ASSISTANT PROFESSOR, CENTER FOR MENTAL HEALTH SERVICES
    RESEARCH, DEPARTMENT OF PSYCHIATRY, UNIVERSITY OF MASSACHUSETTS
    MEDICAL SCHOOL, WORCESTER, MA; LINDA CHAMPION, CHILD ADVOCATE,
      NATIONAL ALLIANCE FOR THE MENTALLY ILL, AND VICE PRESIDENT,
     ALABAMA FAMILY TIES, MONTGOMERY, AL; AND BARBARA ALTENBURGER,
       FAMILY ADVOCATE, PARENTS INVOLVED NETWORK, MENTAL HEALTH
       ASSOCIATION OF SOUTHEASTERN PENNSYLVANIA, PHILADELPHIA, PA

        Ms. Osofsky. Mr. Chairman and Members of the Committee, I
    am delighted to have the opportunity to appear before you today
    on behalf of Zero to Three. As you introduced me, I am Joy
    Osofsky, a professor of pediatrics, psychiatry, and public
    health at Louisiana State University Health Sciences Center,
    and president of the board of directors of Zero to Three. Zero
    to Three is a national, nonprofit organization that has worked
    to advance the healthy development of America's babies and
    toddlers for over 25 years. I would like to start by thanking
    the committee for their interest in addressing the mental
    health needs of infants, toddlers, and families, and I would
    particularly like to thank you, Mr. Chairman, for your
    leadership in helping to address the mental health needs of our
    most vulnerable infants and toddlers, those involved in the
    child welfare system through your support of the Court Teams
    for Change Project, an effort that I will describe in a few
    minutes.
        Despite what we know from science and research, discussions
    on children's mental health have consistently excluded babies
    and toddlers, focusing instead on school-age children and
    adolescents. Although they cannot talk to us about what they
    are feeling like older children can, sometimes referred to as
    ``silent victims,'' babies and toddlers have many ways of
    communicating, and we have many ways to assess their social and
    emotional needs.
        Unfortunately, some infants and toddlers experience mental
    health problems. Their early social and emotional development
    is vulnerable to such factors as repeated exposure to violence,
    persistent fear and stress, abuse and neglect, severe chronic
    maternal depression, or biological factors such as prematurity
    and low birthweight and conditions associated with substance
    abuse.
        Babies do not exist in isolation. The parent's mental
    health can also affect the young child. Conditions such as
    maternal depression and anxiety disorders can disrupt
    parenting. For example, infants of mothers who have chronic,
    untreated depression often withdrawn, ultimately affecting
    their language skills, as well as their physical and cognitive
    development.
        The message I want to convey today, however, is not a
    pessimistic one. When we do identify these children and their
    parents, we know how to provide effective infant mental health
    interventions for the baby and for the significant adults in
    the baby's life. These interventions can prevent or ameliorate
    the effects of negative early experiences. What we are missing
    is the widespread awareness of the problem, the systems to
    identify children who are affected, and readily accessible
    services to meet their needs.
        So why should we care about infant mental health? First,
    learning to regulate emotions and developing secure attachments
    form the very foundation of a child's ability to learn, and
    infants cannot wait. The early years are a period of extremely
    rapid brain growth, wiring and pruning of neuronal connections.
    The pathways that are laid down in these early years are the
    ones that will guide the child's reactions and emotions for the
    rest of her life.
        Second, science supports our concern. The National Academy
    of Sciences report ``From Neurons to Neighborhoods'' concluded
    that the elements of early childhood programs that enhance
    social and emotional aspects of development are just as
    important as those supporting cognitive and linguistic
    competence. The goal of ensuring that all children are ready
    for school has become a national priority. Young children who
    do not achieve early social and emotional milestones perform
    poorly in the early school years and are at higher risk for
    school problems and juvenile delinquency later in life.
        Infants and toddlers in foster care represent a group of
    children that are extremely vulnerable. Juvenile and family
    court judges are uniquely positioned to improve the well-being
    of infants and toddlers in the child welfare system to ensure
    that they are receiving the resources and supports they need to
    address their social and emotional needs.
        I have been involved in developing an approach to working
    with these young children in Miami-Dade Juvenile Court. Three
    years of data show substantial gains in improving social and
    emotional development of infants, toddlers, and their families.
    Of the families selected to receive the intervention, 58
    percent of the children improved in their developmental
    functioning, 100 percent of the infants were reunified with
    their families, and substantiated reports of abuse and neglect
    were reduced from 97 percent to zero.
        The Federal Government is in a unique position to support
    the documented and growing needs of mental health services for
    infants, toddlers, and families. While some child-related
    services such as early Head Start and Part C early intervention
    address infant mental health, only a small number of children
    meet the eligibility requirements of these programs. Zero to
    Three recommends that the mental health needs of infants,
    toddlers, and families be recognized and addressed in bills
    currently up for reauthorization, including Head Start,
    Individuals with Disabilities Education Act, Child Care
    Development Fund, and Substance Abuse and Mental Health
    Services Administration.
        These recommendations are supported by findings in
    President Bush's New Freedom Commission on Mental Health, as
    well as the National Research Council Institute of Medicine
    report ``From Neurons to Neighborhoods: The Science of Early
    Childhood Development.''
        Our recommendations are as follows:
        One, strengthen infant and early childhood mental health
    services and integrate such services into all child-related
    services and systems.
        Two, assure earlier identification and intervention of
    mental health problems and disorders in infants, toddlers, and
    their parents.
        Three, develop system capacity through professional
    development/training of service providers.
        Four, assure comprehensive mental health services for
    infants and toddlers in foster care.
        Five, provide infant/toddler child-care programs with
    access to mental health consultation and support.
        Six, support and advance evidence-based practices in infant
    and early childhood mental health through the establishment of
    a national infant mental health resource center.
        In conclusion, Mr. Chairman, existing Federal, State, and
    community programs for young children should be used as
    foundations to expand and improve infant mental health
    services. Although research is clear in demonstrating the
    importance of healthy social and emotional development at the
    earliest stages of life in assuring school readiness and
    developing healthy relationships later in life, we have not
    translated this knowledge into what we do for babies and
    toddlers. If we truly desire children to be ready to learn,
    much less to grow up as healthy adults, we need to make a
    concerted effort to address the critical mental health needs of
    our youngest children and families.
        Thank you very much.
        Senator DeWine. Doctor, thank you.
        [The prepared statement of Ms. Osofsky follows:]
                      Prepared Statement of Joy D. Osofsky
        Mr. Chairman and Members of the Committee, I am delighted to have
    the opportunity to appear before you today on behalf of ZERO TO THREE.
    I am Joy Osofsky, a psychologist and Professor of Pediatrics,
    Psychiatry, & Public Health at Louisiana State University Health
    Sciences Center and President of the Board of Directors of ZERO TO
    THREE. ZERO TO THREE is a national non-profit organization that has
    worked to advance the healthy development of America's babies and
    toddlers for over 25 years. I would like to start by thanking the
    committee for their interest in addressing the mental health needs of
    infants, toddlers, and their families. I would also like to
    particularly thank Senator DeWine for his leadership in helping to
    address the mental health needs of our most vulnerable infants and
    toddlers, those involved in the child welfare system through his
    support of the Court Teams for Change Project, an effort that I will
    describe in just a few minutes.
                         what is infant mental health?
        Despite what we know from science and research, discussions on
    children's mental health have consistently excluded babies and
    toddlers, focusing instead on school-age children and adolescents.
    Although they cannot talk to us about what they are feeling like older
    children can, babies and toddlers have many ways of communicating, and
    we have many ways to assess their social and emotional needs.
        Most babies experience healthy social and emotional development.
    They smile and coo, cry and recover, and become social beings. Babies
    and toddlers with typical mental health have the capacity to
    experience, regulate and express emotions; form close and secure
    interpersonal relationships; and explore the environment and learn. The
    healthy mental development of babies and toddlers is dependent upon
    their ability to manage their feelings, develop trust with others, and
    learn about the world in which they live.
        This all happens as infants and toddlers work to make sense of
    their environment. It is then that they first find their efforts
    encouraged--or not; first attempt to concentrate and find that
    possible--or not; first conclude that the world seems organized and
    reasonably predictable--or not; first learn that others are basically
    supportive--or not. It is in the first years of life that the
    foundations for empathy, trust, curiosity, and competence are laid
    down.
        Attachment is one of the most critical developmental tasks of
    infancy. We know from the science of early childhood development that
    early relationships and attachments to a primary caregiver are the most
    consistent and enduring influence on social and emotional development
    for young children.\1\ Infants and toddlers who are able to develop
    secure attachments are observed to be more mature and positive in their
    interactions with adults and peers than children who lack secure
    attachments.\2\ They may also have a better self-concept, more advanced
    memory processes, and a better understanding of emotions.\3\ Those who
    do not have an opportunity to form a secure attachment with a trusted
    adult (for example, infants and toddlers who experience multiple foster
    homes) suffer grave consequences. Their development can deteriorate,
    resulting in delays in cognition and learning, relationship
    dysfunction, difficulty expressing emotions, and future mental health
    disorders.
    ---------------------------------------------------------------------------
        \1\ Shonkoff, J., & Phillips, D. (Eds.). (2000). From neurons to
    neighborhoods: The science of early childhood development. Washington,
    DC: National Academy Press.
        \2\ Ibid.
        \3\ Ibid.
    ---------------------------------------------------------------------------
        Unfortunately, some infants and toddlers experience mental health
    problems. The early social and emotional development of babies and
    toddlers is vulnerable to such factors as repeated exposure to
    violence, persistent fear and stress, abuse and neglect, severe chronic
    maternal depression, biological factors such as prematurity and low
    birth weight, and conditions associated with prenatal substance abuse.
    Without intervention, these risk factors can result in mental health
    disorders. In babies and toddlers, the effects of these factors may
    look like excessive and inconsolable crying; a heightened sensitivity
    to touch and cuddling; excessive biting, kicking and hitting; inability
    to focus on activities, flat affect (no expression, no emotions) and
    depression. Infant mental health intervention for the baby, and for the
    significant adults in the baby's life, can prevent or ameliorate the
    effects of negative early experiences.
        Unlike adults, babies and toddlers have fairly limited ways of
    responding to stress and trauma. They may respond through inconsolable
    crying, withdrawal from daily activities, sleeplessness or lack of
    appetite due to depression, anxiety, and traumatic stress reactions,
    poor weight gain, or aggressive behavior in older toddlers. If the
    underlying causes of the stress are not addressed, they can develop
    into serious mental health disorders, including depression, attachment
    disorders, and traumatic stress disorders. Infants can experience
    withdrawal and depression as early as 4 months of age.\4\
    Unfortunately, despite the severe consequences, these disorders are not
    being identified. Neither parents nor most providers know enough about
    how to identify the early warning signs to make effective referrals.
    ---------------------------------------------------------------------------
        \4\ Luby, J. (2000). Depression. In C. Zeanah (Ed). Handbook of
    Infant Mental Health (pp. 296-382).
    ---------------------------------------------------------------------------
        Babies do not exist in isolation. The parent's mental health can
    also affect the young child. Conditions such as maternal depression and
    anxiety disorders can disrupt parenting. For example, infants of
    mothers who have severe chronic, untreated depression often withdraw,
    ultimately affecting their language skills, as well as physical and
    cognitive development. Older children of depressed mothers show poor
    self-control, aggression, poor peer relationships, and difficulty in
    school. \5\
    ---------------------------------------------------------------------------
        \5\ Embry, L. and Dawson, G. (2002). Disruptions in parenting
    behavior related to maternal depression: Influences on children's
    behavioral and psychobiological development. In J. Borkowski, S.,
    Ramey, C. & Bristol-Powers, M. (Eds). Parenting and the young child's
    world. (pp. 203-214) Mahwah, NJ: Erlbaum.
    ---------------------------------------------------------------------------
        Ultimately, for the very young child, mental health disorders will
    have a significant effect on later school performance and life
    successes. In fact, more and more young children are being expelled
    from child care and preschool for behavior problems, and supports are
    not available for these children, their parents, or their caregivers.
    Without early identification, assessment and effective intervention
    these problems will escalate.
        Given the importance of social and emotional development in the
    first 3 years of life, the scarcity of data on the mental health of
    babies and toddlers is disappointing, but not surprising, considering
    the lack of attention to social and emotional development in infants
    and toddlers. Although no data are available for children under age 3,
    it is estimated that between 2 percent and 8 percent of all children
    under the age of 18 are reported to have a mental/emotional problem or
    functional limitation.\6\,\7\ If these same estimates are
    applied to the birth to 3-age population, between 228,000 to 913,000
    infants and toddlers are at risk of mental health disorders.
    ---------------------------------------------------------------------------
        \6\ Colpe, L. (2000). Estimates of mental and emotional problems,
    functional impairments, and associated disability outcomes for the U.S.
    child population in households. Retrieved April 24, 2003, from
    www.mentalhealth.org/publications.
        \7\ Halfon, N. & Newacheck, P. (1999). Prevalence and impact of
    parent-reported disabling mental conditions among U.S. children.
    Journal of the American Academy of Child and Adolescent Psychiatry,
    38(5), 600-609.
    ---------------------------------------------------------------------------
                 why should we care about infant mental health?
        Learning to regulate emotions and developing secure attachments are
    not simple, pleasant milestones in a baby's development that take a
    backseat to the growth of cognitive skills as a child prepares to enter
    school. Rather, they are the very foundation of the child's ability to
    learn. A child who has not developed consistent, positive relationships
    with adults, cannot regulate his own emotions, cannot consider the
    emotions of his peers, does not trust adults, has difficulty in being
    motivated to learn, or cannot calm himself to tune into teaching will
    not benefit from early educational experiences.
        There are many good reasons to care about early social and
    emotional development. First, infants can't wait. The early years are a
    period of extremely rapid brain growth, wiring and pruning of neuronal
    connections. The pathways that are laid down in these early years are
    the ones that will guide the child's reactions and emotions for the
    rest of her life. Second, science supports our concern. The National
    Academy of Sciences report From Neurons to Neighborhoods \8\ concluded
    that the elements of early childhood programs that enhance social and
    emotional aspects of development are just as important as the component
    that support cognitive and linguistic competence.
    ---------------------------------------------------------------------------
        \8\ Shonkoff, J. & Phillips, D. (Eds.) (2000). From neurons to
    neighborhoods: The science of early childhood development. Washington,
    DC: National Academy Press.
    ---------------------------------------------------------------------------
        The goal of ensuring that all children are ``ready for school'' has
    become a national priority. As a result, programs that support
    children's school readiness are becoming more and more important to
    policy-makers, parents, and the general public. It is becoming very
    clear that efforts to improve school success cannot begin at preschool,
    nor focus exclusively on academics. In fact, studies suggest that
    emotional, social, and behavioral competence is a strong predictor of
    academic performance in elementary school. Young children who do not
    achieve early social and emotional milestones perform poorly in the
    early school years, and are at higher risk for school problems and
    juvenile delinquency later in life.\9\
    ---------------------------------------------------------------------------
        \9\ Raver, C. (2002). Emotions matter: Making the case for the role
    of young children's emotional development for early school readiness.
    Social Policy Report of the Society for Research in Child Development,
    16(1) 3-23.
    ---------------------------------------------------------------------------
        Finally, we should all care about early social and emotional
    development because barriers exist for families and providers, and our
    inaction is making the problem of accessing infant mental health
    services worse. Barriers include the scarcity of infant mental health
    providers and supervisors; the lack of awareness by the general public,
    policy-makers, parents, teachers, health care providers and others
    about the importance of early social and emotional development; limited
    funding for infant mental health services; lack of capacity to provide
    mental health services to parents along with their children; reluctance
    by families to use mental health services; and the overall lack of
    application of scientific knowledge to practice.
                            federal recommendations
        The Federal Government is in a unique position to support the
    documented and growing needs of mental health services for infants,
    toddlers, and families. While some child related services, such as
    Early Head Start and Part C Early Intervention address infant mental
    health, only a small number of children meet the eligibility
    requirements of these programs. ZERO TO THREE recommends that the
    mental health needs of infants, toddlers, and families be recognized
    and addressed in bills currently up for reauthorization including Head
    Start, Individuals with Disabilities Education Act (IDEA), Child Care
    Development Fund (CCDF), and Substance Abuse and Mental Health Services
    Administration (SAMHSA). These recommendations are supported by
    findings in President Bush's New Freedom Commission on Mental Health
    (2003) as well as in the National Research Council Institute of
    Medicine report From Neurons to Neighborhoods: The Science of Early
    Childhood Development (2000). \10\,\11\ Our recommendations
    are as follows:
    ---------------------------------------------------------------------------
        \10\ New Freedom Commission on Mental Health (2003). Achieving the
    promise: Transforming mental health care in America. Executive Summary.
    DHHS Publication No. SMA-03-3831. Rockville, MD: U.S. Department of
    Health and Human Services.
        \11\ Shonkoff, J. & Phillips, D. (Eds.) (2000). From neurons to
    neighborhoods: The science of early childhood development. Washington,
    DC: National Academy Press.
    ---------------------------------------------------------------------------
        1. Strengthen infant and early childhood mental health services and
    integrate such services into all child-related services and systems.
        Infant mental health services are scarce. Where they do exist, they
    are fragmented and disconnected from the settings and services most
    frequently used by young children and families. Infant and early
    childhood mental health services across the continuum of promotion,
    prevention, and treatment must be created, expanded, and improved.
    Services must be comprehensive: they should promote healthy social and
    emotional development for all young children, provide prevention
    services for families of young children experiencing or at risk of
    experiencing situations that jeopardize healthy social and emotional
    development, and provide individualized treatment services for children
    who have mental health disorders.
        Illinois has utilized this comprehensive approach in addressing
    infant mental health. Evaluation of an integrated mental health
    approach in Illinois documented the effectiveness of including Social
    Emotional Specialists in Part C Early Intervention programs. These
    specialists provide training, technical assistance, as well as mental
    health consultation to the managers, coordinators, and providers of the
    Part C program. Evaluation findings revealed positive improvements in
    practice that are helping programs to address all components of Part C,
    easier access to mental health services, and earlier identification of
    mental health disorders.
        Social and emotional development is not an isolated issue. It
    spills over into all areas of early childhood development. Infant
    mental health services must be integrated into all services that touch
    the lives of infants, toddlers, and their families. These may include
    child care, Early Head Start, pediatric and family health care, public
    health, community mental health, child welfare/social services, home-
    visiting, and Part C Early Intervention.
        2. Assure earlier identification and intervention of mental health
    problems and disorders in infants, toddlers and their parents.
        Early identification of risk factors is critical in preventing and
    treating mental health disorders in young children. All professionals
    who have contact with infants and toddlers, and families should be
    aware of early risk factors, how to screen and where to refer for
    assessment and intervention. Developmentally appropriate screening and
    assessment tools for infants, toddlers, and parents are critical for
    the early identification of, planning and delivery of effective
    interventions. Screening and assessment of parental mental health,
    stress and support systems are equally important in enabling providers
    to document the needs of parents. The well-child visit is an important
    opportunity for early identification of developmental, emotional, and
    behavioral problems. Physicians, time-pressured to provide both medical
    care and anticipatory guidance, would be best supported if they had
    ready access to screening tools, (including those that could be
    completed by parents), practical information about referral
    information, and financing strategies.
        To encourage developmental and behavioral screening and assessment
    for all infants and toddlers, barriers to reimbursement must be
    eliminated. Strategies to improve financing include encouraging the use
    of appropriate diagnostic procedures and billing codes; expansion of
    billing options in Medicaid to allow for treatment of parents and
    infants together; maximizing use of Early and Periodic Screening,
    Diagnosis, and Treatment Program (EPSDT) and State Children's Health
    Insurance Program (SCHIP), and recognizing infant, toddler, and parent
    mental health concerns as legitimate treatment issues.
        3. Develop system capacity through professional development/
    training of service providers.
        Neurons to Neighborhoods informs us that, ``Given the substantial
    short- and long-term risks that accompany early mental health
    impairments, the incapacity of early childhood programs to address
    these concerns and the severe shortage of early childhood professionals
    with mental health expertise are urgent problems.'' \12\ If we hope to
    make a positive difference in the lives of children who are already
    affected by mental health disorders, violence, and trauma and promote
    healthy social and emotional development we must invest in building a
    strong infant mental health workforce.
    ---------------------------------------------------------------------------
        \12\ Shonkoff, J. & Phillips, D. (Eds.) (2000). National Research
    Council and Institute of Medicine. From neurons to neighborhoods: The
    science of early childhood development. Washington, DC: National
    Academy Press.
    ---------------------------------------------------------------------------
        The quality of a service system depends on the individuals that
    deliver the services. ``Substantial new investments should be made to
    address the nation's seriously inadequate capacity for addressing young
    children's mental health needs. Expanded opportunities for professional
    training, as recently called for by the Surgeon General, and incentives
    for individuals with pertinent expertise to work in settings with young
    children are first steps toward more effective screening, early
    detection, treatment, and ultimate prevention of serious childhood
    mental health problems.'' \13\
    ---------------------------------------------------------------------------
        \13\ Ibid.
    ---------------------------------------------------------------------------
        Greater investments must be made in infant mental health. Both the
    community at large as well as parents and the early care and education
    providers need to be aware of the importance of early social and
    emotional development. In addition, there should be increased support
    for training, continuing education, recruitment, and retention of
    professionals with special training in infant and early childhood
    mental health services.
        There are no national data to document shortages in infant mental
    health personnel. Anecdotally, based on calls and requests that ZERO TO
    THREE receives from States and communities, the need for specialized
    training as well as general awareness of social and emotional
    development is overwhelming. In a recent survey of unmet needs in the
    Illinois early care and education system, 62 percent of programs
    reported inadequate mental health resources. Investing in mental health
    training yields promising outcomes. In 24 Early Head Start programs
    that participated in the ``Pathways to Preventions'' training model,
    three critical objectives were achieved: staff knowledge and skills
    were extended into programs beyond Early Head Start, program supports
    were strengthened, availability of mental health providers were
    increased, and staff retention improved.
        4. Assure comprehensive mental health services for infants and
    toddlers in foster care.
        Infants and toddlers in foster care represent a group of children
    that are extremely vulnerable. Most have been seriously maltreated;
    they exhibit behavior problems such as failure to thrive, tantrums,
    self-endangering, aggression, and inability to be consoled. Nearly 80
    percent are prenatally exposed to substance abuse, 40 percent are born
    prematurely and/or low birth weight, and all of them experience
    repeated and often traumatic separation from caregivers, placing them
    at risk for future mental health disorders. Infants are the fastest
    growing and single largest cohort in foster care. Babies placed in
    foster care before 4 months of age remain in foster care longer than
    other children.\14\ Over 39,000 infants enter foster care each year.
    Infants and toddlers who have suffered physical or sexual abuse,
    neglect, and separation from their parents will also suffer emotional
    and developmental consequences unless they, and their parents, foster
    parents and other primary caregivers, are provided with supportive
    mental health interventions.
    ---------------------------------------------------------------------------
        \14\ Wulczyn, F., Harden, B. and Hislop, K. (2002). The placement
    of infants in foster care. Infant Mental Health Journal, 23(5), 454-
    475.
    ---------------------------------------------------------------------------
        Juvenile and Family Court Judges are responsible for the well-being
    of the children in their courts and can be powerful agents of change.
    They are uniquely positioned to improve the well-being of infants and
    toddlers in the child welfare system and to ensure that they are
    receiving the resources and supports they need to address social and
    emotional needs. In fact, judges have an opportunity, perhaps the last
    one for these most vulnerable infants and toddlers, to focus on healing
    in the process of adjudicating the case. \15\
    ---------------------------------------------------------------------------
        \15\ Osofsky, J.D. & Lederman, C.S. (in press). Healing the child
    in juvenile court. In J.D. Osofsky (Ed). Young Children and Trauma:
    Intervention and Treatment. New York: Guilford, 2004.
    ---------------------------------------------------------------------------
        I have been involved in developing an approach to working with
    these young children in the Miami-Dade Juvenile Court. Three years of
    data show substantial gains in improving social and emotional
    development of infants, toddlers, and their families. In this court,
    all infants, toddlers and their mothers receive screening and
    assessment services. Babies are screened for developmental delays and
    referred for services. A parent-infant psychotherapy intervention is
    available to a select number of mothers. An Early Head Start program
    connected to the court is the first designed specifically to meet the
    needs of maltreated children. Children showed significant improvements
    in enthusiasm, persistence, positive affect and a reduction of
    depression, anger, withdrawal and irritability.\16\ Of the families
    selected to receive the intervention: 58 percent of children improved
    in their developmental functioning; \17\ 100 percent of infants were
    reunified with their families; \18\ and reports of abuse/neglect were
    reduced from 97 percent to 0.\19\
    ---------------------------------------------------------------------------
        \16\ Lederman, C. (2003). Mental health trends in 2003: Miami's
    infant and young children's mental health program: A place where the
    healing begins. The National Center for State Courts.
        \17\ Adams, S., Osofsky, J., Hammer, J., & Graham, M. (2003).
    Program Evaluation Florida Infant & Young Child Mental Health Pilot
    Project, Year 3, Final Report, Tallahassee, FL: Florida State
    University Center for Prevention & Early Intervention Policy.
        \18\ Lederman, C. (2003). Mental health trends in 2003: Miami's
    infant and young children's mental health program: A place where the
    healing begins. The National Center for State Courts.
        \19\ Ibid.
    ---------------------------------------------------------------------------
        5. Provide infant/toddler child care programs with access to mental
    health consultation and support.
        Increasingly, young children are being expelled from child care and
    preschool for behavior problems, including biting, tantrums, hitting,
    throwing objects, or inconsolable crying.\20\,\21\ A survey
    of child care providers in New Hampshire found that 53 percent of
    respondents had expelled at least one child, age birth through six.
    Young children with behavior problems are difficult to teach, and if
    disliked by teachers and peers because of behavior, quickly lose
    motivation for learning, withdraw from peers, or face social
    rejection.\22\
    ---------------------------------------------------------------------------
        \20\ Wheatley, E. (2001). Child care expulsion survey. Bow, NH: New
    Hampshire Association for Infant Mental Health.
        \21\ Cutler, A. & Gilkerson, L. (2002). Unmet needs project: A
    research, coalition building and policy initiative on the unmet needs
    of infants, toddlers and families. Chicago, IL: University of Illinois
    at Chicago and Erikson Institute.
        \22\ McEvoy, A. & Welker, R. (2000). Antisocial behavior, academic
    failure and school climate: A critical review. Journal of Emotional and
    Behavioral Disorders, 8(3), 130-140.
    ---------------------------------------------------------------------------
        An estimated 7 million babies and toddlers (nearly 65 percent of
    all children under age 3) spend time in non-parental care each day.
    \23\ Good child care can be an excellent early learning environment
    where healthy social and emotional development can be promoted for all
    children. With mental health consultation and training, staff can
    support and promote social and emotional development, prevent
    behavioral problems, and identify early warning signs of mental health
    disorders.
    ---------------------------------------------------------------------------
        \23\ Oser, C. & Cohen, J. (2002). America's Babies: The ZERO TO
    THREE Policy Center Data Book. Washington, DC: Zero to Three Press.
    ---------------------------------------------------------------------------
        A Kentucky study demonstrated success of mental health consultation
    in child care. Of the approximately 400 children served through June
    2003, 88 were identified as being at-risk for such discharge. Of these,
    only 8 lost their placement due to behavior problems, while 80 had been
    successfully maintained in these programs.
        6. Support and advance evidence-based practices in infant and early
    childhood mental health through the establishment of a national infant
    mental health resource center.
        Parents and professionals are hungry for information about social
    emotional development. There is new research available and some
    promising models for addressing infant mental health, but providers are
    largely unaware of this information. One way to improve the mental
    health outcomes for young children is by creating a national resource
    center for infant mental health. Such a center would:
         Provide information, technical assistance, training and
    other resources about social-emotional development in infants and
    toddlers with disabilities to early intervention personnel and parents.
         Identify and disseminate infant mental health models.
         Translate current research about effective infant mental
    health intervention and treatment approaches for parents and early
    intervention professionals.
         Develop materials screening and assessment tools, how to
    integrate mental health goals into Part C Individualized Family Service
    Plans, and infusing relationship-based approaches into Part C practice.
         Coordinate with other mental health initiatives such as
    those through the Early Head Start National Resource Center to assure a
    systematic approach across birth to three programs.
        Many States are in the process of developing strategic plans for
    early childhood mental health services, developing financing
    strategies, etc. This is an opportune time to identify and disseminate
    promising evidence-based practices, and translate what is known from
    the science of early childhood education into what we do for infants,
    toddlers and families.
        In conclusion, Mr. Chairman, existing Federal, State, and community
    programs for young children should be used as foundations to expand and
    improve infant mental health services. Although research is clear in
    demonstrating the importance of healthy social and emotional
    development at the earliest stages in life in assuring school readiness
    and developing healthy relationships later in life, we have not
    translated this knowledge into what we do for babies and toddlers. If
    we truly desire children to be ready to learn, much less to grow up to
    be healthy adults, we need to make a concerted effort to address the
    critical mental health needs of our youngest children and their
    families.
             Response to Questions of Senator Reed From Joy Osofsky
        Question 1. Is there evidence of improved outcomes, better
    compliance, and cost savings through providing combined services? For
    example, properly treating an alcoholic's bipolar illness to avoid
    relapsing on alcohol.
        Answer 1. Unfortunately, many juvenile facilities have inadequate
    mental health services and limited programs to help change behaviors
    and provide rehabilitation for incarcerated juveniles. Incidences of
    recidivism are high. Most show antisocial behaviors entering the prison
    and many more show antisocial traits and mental health symptoms while
    in prison related to the harsh treatment and experiences while they are
    in the facility. Most juvenile facilities are understaffed with mental
    health professionals and do not have good individual and group services
    to meet the mental health needs of the youth. To address this issue, it
    can be helpful for correctional facilities to link with universities,
    medical schools, community programs, and other settings that may be
    able to provide services and help to develop more positive programs for
    the youth.

        Question 2. Are different Federal funding streams a barrier to
    quality mental health care?
        Answer 2. Barriers when they transition out of juvenile facilities
    include: (1) Traditional case management services that are often
    inadequate to help youth with the transition; and (2) few good
    community programs to help develop skills and support them when they
    return to their home communities.
        What judges can do to help this situation:
        (1) Judges can help to develop collaborations where youth and their
    families can participate in prevention and intervention programs in
    their communities to prevent their being incarcerated.
        (2) Judges can work together with mental health professionals and
    school systems to try to develop diversionary programs for first time
    offenders who have not committed violent crimes in order to provide
    intervention and, hopefully, prevention in their communities.
        (3) Judges can play an active role in monitoring the treatment of
    juveniles in facilities by periodic review.
        (4) Judges can play a key role with youth being returned to the
    community in establishing and monitoring community programs to prevent
    recidivism.
        (5) Judges need more education about mental health issues in
    juveniles and effective programs and interventions.

        Senator DeWine. Ms. Wong?
        Ms. Wong. Good morning, Mr. Chairman and Members of the
    Subcommittee. I am Marleen Wong, and for the past 30 years, I
    have worked in School Mental Health Services, District Crisis
    Teams, and the Suicide Prevention Unit of the Los Angeles
    Unified School District. For 8 of those years, I was the
    director.
        I have been asked today to comment on the state of school
    mental health services and the priorities that our country
    might establish in response to the recommendations of the
    President's New Freedom Commission on Mental Health,
    particularly the recommendation that school-based mental health
    services be expanded and enhanced. I temper my ``Director of
    School Mental Health'' remarks with my personal experience as a
    mother of two children, a school social worker, a former school
    board member, a past member of the local teachers union, a
    current member of the local administrators union, the director
    of the school unit for the National Center for Child Traumatic
    Stress, a current member of the Institute of Medicine Board of
    Neuroscience and Behavioral Health, and a consumer of mental
    health services.
        What is the scope of the problem for our school children
    who need mental health services? The 1999 Surgeon General's
    Report on Mental Health reported that in any given year about
    20 percent of children have a mental disorder requiring the
    attention of a mental health professional. And yet a recent
    Rand study notes that only 8 percent of children who need
    mental health care actually receive services. This leaves 92
    percent of our children who need are without any services. Of
    the 8 percent who do receive services, 85 percent of the
    children receive them in school mental health programs, making
    schools the de facto primary source of mental health services
    for children K-12 in this country.
        Currently in the United States, there are about 15,000
    school districts and approximately 100,000 schools. During a
    regular school week, 70 percent of the total population of
    children kindergarten through 12th grade in public and private
    schools are in attendance.
        If we are to transform our mental health care system, we
    must establish a true system of care for all children, not just
    those with persistent and chronic mental illness. We must
    include children at every age and stage, those at risk for
    serious disorders, children caught in family or community
    crises, and disabled children. All aspects of children's lives
    are in a fluid state of development. early intervention and
    disability prevention means a shift in thinking to a ``well
    child'' mental health system, one that is adequately resourced
    for each of the components of early identification, early
    intervention, prevention, and effective treatments. One aspect
    of care should not be sacrificed for another because of funding
    disparities. One child should not be left behind because of
    another's needs.
        School mental health services must be supported with
    adequately quality assurance and accountability measures. Most
    importantly, in measuring our success, mental health
    professionals must find a way to integrate the mission of
    mental health with the mission of education. Outcomes must not
    only include a decrease of symptoms but evidence of improved
    academic functioning--support for better grades, improved
    classroom behavior, fewer absences, and increased attendance,
    less dropout. These criteria are generally not within the realm
    of traditional treatment outcome. However, they are solid
    indices of health, rehabilitation, and recovery for children.
        I would also like to speak about the Individuals with
    Disabilities Education Improvement Act, a critically important
    piece of legislation that helps to support children who are
    disabled. I would especially like to thank the committee for
    recognizing the disabling effects that trauma exposure can have
    for young children and for the inclusion of language in the
    bill that can help children who struggle in school as a result
    of trauma and the effects of traumatic events.
        Fragmentation of funding, programs, and personnel is a
    growing problem for school mental health. They suffer from
    service and funding fragmentation. I am proud to say that the
    Los Angeles Unified School District has supported mental health
    services for the past 71 years. However, in the 30 years that I
    have worked in the school district, we have had to fight to
    maintain those services during annual budget deliberations when
    categorical, special education, Title I, and general fund
    dollars wax and wane.
        Finally, I would like to share a personal story, one that
    shows how far we have come. My involvement in this work goes to
    an earlier generation. From the time that I was 6 years old, my
    grandmother told me stories about her early life in San
    Francisco. That beautiful city was part of the Wild West in the
    early 1900s. For Chinese immigrants, it was a vibrant and
    dangerous place.
        My grandmother, Ruth, was 5 years old when she was sold by
    her impoverished mother to a Chinese family emigrating to
    America. As a child, she remembered the day her mother pushed
    her toward a woman she had never seen and said, ``This woman
    will be like your mother now.'' As a young child, she crossed
    an ocean with strangers to confront violence in the new world
    of San Francisco Chinatown.
        Once she saw a group of men refuse to pay the bill for
    their dinner and many bottles of liquor. And when the owner of
    the restaurant insisted upon payment, they drew guns and
    destroyed the place. My grandmother, Ruth, hid in a corner,
    unharmed but traumatized. And in the following weeks, she
    refused to leave her home. She feared that she would be killed
    and that the violence would happen again.
        Not long after that incident, the violence did happen
    again. And the head of her new family was shot and killed as an
    innocent victim during a gang shooting. My grandmother never
    completed elementary school.
        In 1905, there was no counseling available in schools, nor
    was there any recognition of the paralyzing effects of violence
    on children. The year my grandmother died, in 1999, I began my
    association with Rand and UCLA to test our trauma intervention
    for its effectiveness with children in schools. And the results
    can be read in the Journal of the American Medical Association
    in the August 2003 issue.
        We have come a long way in our country in recognizing the
    need for such services to children, and yet we have so much
    more to do.
        The mission of schools is to educate. The mission of mental
    health services is to heal. And our responsibility is to the
    child who will benefit from both. The reality is that the
    mission of one cannot proceed without the success of the other.
        So I thank you, Mr. Chairman and Senator Reed and Mr.
    Kennedy and members of the committee, for the opportunity to be
    here, to present this information, and to express the gratitude
    of those who work in schools. Your work is vitally important to
    the creation of a children's mental health system that truly
    cares for children.
        Thank you.
        Senator DeWine. Ms. Wong, that is a very compelling story.
    Thank you very much.
        [The prepared statement of Ms. Wong follows:]
                    Prepared Statement of Marleen Wong, LCSW
        Good morning Mr. Chairman and Members of the Subcommittee. I am
    Marleen Wong, Director of Crisis Counseling and Intervention Services
    for the Los Angeles Unified School District, and Director of the School
    Crisis and Intervention Unit for the National Center for Child
    Traumatic Stress (NCCTS) at UCLA and Duke University. For the past 30
    years, I have worked in School Mental Health Services, District Crisis
    Teams and the Suicide Prevention Unit of the Los Angeles Unified School
    District. For 8 years, I was the Director of those services.
        The Los Angeles Unified School District, (LAUSD) is the second
    largest school district in the United States with a population of
    738,000 students K-12 and over 80,000 employees, over half of them
    teachers. The School Mental Health Service was established in LAUSD in
    1933 to assist special education students with social and emotional
    consequences of serious health conditions or physically handicapping
    challenges. During my tenure as Director, from 1993 to 2001, school
    mental health services grew from 25 to 200 staff members of child
    psychiatrists, clinical psychologists and social workers in outpatient
    clinics and schools.
        In 2001, I was appointed the Director of Crisis Counseling and
    Intervention Services in LAUSD. My responsibility is to train and
    oversee district level crisis teams comprised of 250 school counselors,
    nurses, social workers, school psychologists, school police, and
    attendance counselors. Crisis teams are required at every school site.
    Eleven district crisis teams support and enhance site teams during
    incidents that overwhelm the resources of a school.
        As a school social worker, I have worked with children representing
    every community of our diverse district and responded to hundreds of
    crisis events involving the injury or death of students or staff.
    Twenty years ago, at the 49th Street Elementary School, a man who lived
    in the second floor apartment across the street from the school, opened
    fire with multiple weapons as our students were dismissed for the day.
    He held the school under sniper fire for an hour and a half, killing a
    9-year-old girl and wounding several other students and staff. That
    tragedy prompted the development of the first formal policies and
    procedures in LAUSD, initiating our current system of crisis response,
    i.e., the formation of a crisis intervention team at every school and a
    district level team to support the school response.
        Two large scale disasters in Los Angeles, the Los Angeles riots and
    fires and the Northridge earthquake, required a larger crisis response
    and recovery programs. Our district worked closely with the Los Angeles
    County Department of Mental Health, receiving several FEMA Crisis
    Counseling Grants to reach out to our students and encourage their
    return to school. After the riots, human relationships had to be
    mended. After the earthquake and the hundreds of powerful aftershocks,
    parents sought out school mental health services for their children.
    Many of our children were afraid to return to school, suffering from
    traumatic stress and depression due to the complex interactions of
    fear, ruined homes, multiple residential relocations, and family
    conflict.
        In 2001, I was asked to join the National Center for Child
    Traumatic Stress (NCCTS), a national program initiated by Congress and
    funded by the Substance Abuse and Mental Health Services Administration
    (SAMHSA). The NCCTS oversees the National Child Traumatic Stress
    Network (NCTSN), a mental health network of 54 university, hospital,
    and community programs dedicated to raising the standard of care and
    improving access to services for traumatized children, their families
    and communities across the United States. My work as the Director of
    School Crisis and Intervention for the National Center, builds on my
    focused view of local needs and the problems of organizing and
    sustaining a school mental health program within a local education
    agency. It enables me to have a broader national perspective of the
    range of the needs and challenges confronted by community agencies and
    school districts who wish to establish school mental health services in
    rural, suburban and urban environments.
        I have been asked today to comment on the state of school mental
    health services and the priorities that our country might establish in
    response to the recommendations of the President's New Freedom
    Commission on Mental Health, particularly the recommendation that
    school-based mental health services be expanded and enhanced. I temper
    my ``Director of School Mental Health'' remarks with my personal
    experience as a mother of two children, a school social worker, a
    former school board member, a past member of the local teachers' union,
    a current member of the local administrators' union, a current member
    of the Institute of Medicine (IOM) Board of Neuroscience and Behavioral
    Health, and a consumer of mental health services.

    Demographic Information About Children, Schools and School Mental
                        Health Services

        What is the scope of the problem for our school children who need
    mental health services?
        The 1999 Surgeon General's Report on Mental Health reported that in
    any given year, about 20 percent of children have a mental disorder
    requiring the attention of a mental health professional. In 2002,
    SAMHSA's National Survey on Drug Use and Health reported that an
    estimated 5 to 9 percent of children and youth have a serious emotional
    disturbance in any 1 year.
        And yet, a 1995 RAND study notes that only 8 percent of children
    who need mental health care actually receive services--this leaves 92
    percent of our children who need care without any services. Of the 8
    percent who do receive services, 85 percent of the children receive
    them in school mental health programs. Community agencies,
    pediatricians, public mental health services agencies, even
    correctional facilities, have a role to play in providing care, but the
    reality is that schools have become the de facto primary source of
    mental health services for children.

    The Goals and Recommendations of the President's New Freedom Commission
                        on Mental Health

        I would like to discuss school mental health services within the
    context of the goals and the recommendations of the President's New
    Freedom Commission on Mental Health.
        The Commission has recommended that we:
         Place consumers and their families at the center of
    service decisions.
        Currently in the United States, there are about 15,000 School
    Districts and approximately 100,000 Schools. During a regular school
    week, 70 percent of the total population of children Kindergarten
    through 12th grade are in attendance at one of these schools. If we add
    to this large number, the parents, siblings and families of the
    students, and the families of teachers, administrators and other school
    personnel, over 50 percent of the total United States population is
    connected during the work week to a school somewhere in this country.
    Schools are natural sites of service for children and families.
        The Commission has recommended that we:
         Reduce disparities and the burden of unmet needs and lack
    of access to services among minority groups.
        and
         Develop a model that emphasizes early intervention and
    disability prevention.
        If we are to transform our mental health care system, we must
    establish a true system of care for all children, not just those with
    persistent and chronic mental illness. We must include children at
    every age and stage, those at risk for serious disorders, children
    caught in family or community crises, and disabled children. All
    aspects of children's lives are in a fluid state of development. Early
    intervention and disability prevention means a shift in thinking to a
    ``well child'' mental health system, one that is adequately resourced
    for each of the components of early identification, early intervention,
    prevention, and effective treatments. One aspect of care should not be
    sacrificed for another because of funding disparities. One child should
    not be left behind because of another's needs.
        School personnel are intimately aware of the social, psychological,
    and academic toll that mental health disorders, traumatic experiences,
    and mental illness can take on our children and adolescents. Early
    identification and intervention can make a difference at any grade.
    Children may not do well in preschool because their experience of
    domestic violence has interfered with their brain development, capacity
    to learn, and behavior. Elementary school children exposed to trauma
    and violence can lead to poor sleep and poor learning, compromising
    their acquisition of basic educational skills. A child who has done
    well in elementary school may be bullied in middle school or exposed to
    violence in the community, and go on to develop symptoms of
    posttraumatic stress that disturb academic performance, classroom
    behavior, and school attendance. A student in high school may suffer a
    traumatic loss because of the death of a close friend through a traffic
    accident, catastrophic school violence, or suicide, and become
    seriously depressed.
        Middle school and high school students often respond to experiences
    of trauma and loss by abusing alcohol or drugs or by engaging in
    reckless or high-risk sexual behaviors. They may also struggle with
    thoughts of suicide.
        Schools are the place where the loss of motivation for learning of
    such students can be noted as a symptom of depression or trauma, and
    can best be addressed through school mental health programs.
        In our crisis intervention work in the Los Angeles Unified School
    District and in many other parts of the country, we have worked with
    children in a post-crisis school setting. Often, while working with
    their trauma, we discovered children with other mental health problems
    that had never been addressed. Unfortunately, schools are limited by
    the lack of personnel to adequately provide intermediate and long term
    mental health and case management services that children need.
        Our crisis intervention work showed that most students suffer
    silently from trauma or depression, spending their school days ``hidden
    in plain sight''. Schools routinely screen for vision and for hearing,
    two conditions which we would all agree are crucial to learning. Just
    as crucial may be school screening for trauma and depression, where
    fear, disturbing thoughts, feelings and images become barriers to
    school attendance and classroom participation.
        The Commission has recommended that we:
         Establish ``evidence-based practices'' as the bedrock of
    service delivery.
        We can do this by supporting ongoing practical research that is
    embedded in schools and communities, and by providing training linked
    to scientific findings and clinical experience. This is one of the
    central goals of the National Child Traumatic Stress Network.
        The Commission has recommended that we:
         Improve quality and accountability:
        Establishing school based mental health services is not a panacea.
    Services must be supported with adequate quality assurance and
    accountability measures. An example of such requisite oversight is that
    44 percent of the students who seek help at school-based health clinics
    present with mental health disorders or problems. Of the students who
    seek help for depression, few receive evidence-based treatments. The
    average number of three to four visits suggests that few ever receive
    the full ``dose'' of recommended treatment, and follow up is rarely
    done.
        Some disorders, such as psychological trauma and depression, are
    very amenable to identification and treatment within a school setting.
    These are also the disorders that are being identified as leading
    causes of disability among the general population of children in the
    United States. Our work in LAUSD with RAND and UCLA Health Sciences
    Research Center, documented disrupted academic performance, negative
    classroom behavior and less school attendance among students
    traumatized by their exposure to community violence. In fact,
    scientific studies are showing that childhood trauma further affects
    the onset and course of many other child and adolescent health and
    mental health conditions, from attention deficit and bipolar disorder
    to substance abuse and conduct disorder.
        Most importantly, in measuring our success, mental health
    professionals must find a way to integrate the mission of mental health
    and the mission of education. From an organizational perspective,
    mental health services in schools cannot operate outside the structure
    and organization of the educational environment. In order to succeed
    within the educational environment and to gain acceptance from
    educators, the integrity of the academic day must be preserved.
    Outcomes must include not only a decrease of symptoms but also evidence
    of improved academic functioning--better grades, improved classroom
    behavior, fewer absences, and increased attendance. These criteria are
    generally not within the realm of traditional treatment outcomes.
    However, they are solid indices of health, rehabilitation, and recovery
    for children.

    IDEA

        I would also like to speak about the Individuals with Disabilities
    Education Improvement Act, a critically important piece of legislation
    that helps to support services for children who are disabled. Although
    IDEA has not yet been enacted, I would like to commend the committee
    for the progress it has made in the Senate. I want to affirm that
    school children with disabilities need the help that can be provided
    through this bill, and they need it now. I would especially like to
    thank the committee for recognizing the disabling effects that trauma
    exposure can have for young children, and for the inclusion of language
    in the bill that will help children who struggle in school as a result
    of trauma and the effects of traumatic events.
        A report on developmental disabilities and trauma was developed by
    the NCTSN, and has been submitted for the record. That report includes
    information from population studies showing that the national
    prevalence rate for developmental disabilities in the United States is
    1.8 percent. This translates into many children in our school systems
    needing the specialized education provided through IDEA. Additional
    studies have shown that individuals with developmental disabilities are
    at increased risk for abuse as compared to the general population. For
    example, 64 percent of maltreated children have a disability, such as
    behavioral disorders; speech, language, or learning disabilities; or
    mental retardation. Children with mental retardation were the most
    severely abused. When we identify a child with special needs, it is
    essential to determine the full context of the child's life and history
    so that the most appropriate services can be provided.
        It is therefore a major step forward for the Senate to recognize
    that the development of vulnerable young children can be thrown off
    course because of traumatic experiences, and that, with timely
    intervention, a child's life can be supported back onto a normal
    developmental path.

    Obstacles to Mental Health Services Access

        In establishing the New Freedom Commission on Mental Health,
    President Bush noted three key obstacles that keep people with mental
    illnesses from getting the services they need:
        1. The stigma that still surrounds these illnesses;
        2. The fragmented mental health care service system; and
        3. Existing treatment and dollar limits for mental health care.

    Lack of Parity

        In our society, and in our health care system, children with mental
    disorders face the same stigma and discrimination as adults. It is
    unfair that an illness that can affect the brain, emotions,
    intellectual development and capacity, and relationships, and can so
    tragically affect the development of a child, is treated as less than
    serious, less than real. Schools can only do so much. When children are
    referred for mental health care, even those whose families have private
    insurance often cannot get medically necessary care because of the lack
    of parity in mental health coverage. This situation is worse than
    unfair . . . it can be lethal. Efforts to enact Federal mental health
    parity legislation have been close to success many times, and even now,
    parity has the widespread support of the Senate, the House, the
    President, and over 360 national organizations. Yet, American families
    are still waiting. It is the hope of all of us who work with children
    and their families that a full and fair mental health parity bill will
    be finally enacted in this Congress.

    Overcoming Stigma Through School Mental Health Programs

        In Los Angeles, we have completed 4 years of trauma work with
    students who have been exposed to community violence. Through concerted
    effort, our program of mental health services has overcome much of the
    stigma that often surrounds such programs. Perhaps the greater
    acceptance of our mental health services is that we approach problems
    as developmental challenges and tasks, providing education, case
    management and support to parents; making consultation available to
    teachers; and providing treatment to children so that they can succeed
    in school. In the initial cohort of 20 LAUSD schools receiving special
    trauma intervention, only 3 percent to 5 percent of parents declined
    mental health services for their children.
        Our intervention was tested in randomized clinical trials and the
    results were published as an ``original contribution'' in the August
    2003 Journal of the American Medical Association. A screening of
    thousands of children in LAUSD over the past 4 years found that 90
    percent of students in some neighborhoods had been exposed to multiple
    incidents of violence, as witnesses and victims and that 27 percent of
    them had clinical levels of PTSD and 16 percent of them had clinical
    levels of depression. After 10 sessions of CBITS, the majority of
    children significantly decreased their symptoms of PTSD and Depression
    to the extent that they could no longer be diagnosed as traumatized or
    depressed. In the evaluation of an early group of students, there was a
    significant increase in grade point average as compared not only to
    students who had not yet received the intervention, but also as
    compared to students who had tested negative for either of the
    disorders.
        More importantly, after students completed the Cognitive Behavioral
    Intervention for Trauma in Schools (CBITS), over 92 percent of the
    parents understood that exposure to community violence had created
    serious psychological and academic problems in their children's lives.
    Eighty-five percent of the parents were pleased with the outcomes of
    treatment and 76 percent wanted to refer another family member or
    friend to receive services.

    Fragmentation of Funding, Programs, and Personnel

        Like public mental health systems, school mental health programs
    also suffer from service and funding fragmentation. I am proud to say
    that the Los Angeles Unified School District has supported mental
    health services for the past 71 years. However, in the 30 years that I
    have worked in LAUSD, we have had to fight to maintain those services
    during annual budget deliberations when categorical, special education,
    Title I and general fund dollars wax and wane. This year, many mental
    health professionals, such as school counselors and social workers,
    will lose their jobs because of severe budget cuts necessitated by the
    downturn in the economy.
        In 1992, I worked with our Los Angeles County Department of Mental
    Health Services to negotiate the first Medi-Cal (Medic-Aid) contract
    between a school district and a county mental health service. We are
    currently able to draw down ``rehabilitation'' reimbursements for
    services to Medi-Cal eligible students and their families.
        This funding stream, however, does not provide any financial
    support for the work we do with indigent, uninsured children and
    families. Over 73 percent of LAUSD students and their families live
    below the poverty level and receive free and reduced lunch. The budget
    crisis in California has been so severe that there is no longer public
    mental health funding available for indigent, uninsured children, the
    largest socioeconomic group of students within our school district.
        Further hampering the foundation of economic support, reimbursement
    dollars for school mental health services are often absorbed by the
    larger district budget to offset losses in other areas. Locally,
    reimbursements ``earned'' through these programs and others, such as
    designated instructional counseling mandated by the Individual
    Education Plan (IEP) for special education students, or Local Education
    Agency (LEA) Medic-Aid, are not necessarily returned to support the
    programs that provided the services.
        What is needed are multiple sources of funding earmarked for school
    mental health services that is protected within State, Federal and
    local education budgets to establish and sustain programs that serve
    children's needs.

    The NCTSN: The National Child Traumatic Stress Network and the National
                        Center for Child Traumatic Stress (NCCTS)

        In my work with the National Center for Child Traumatic Stress, and
    the 54 affiliated sites that form the larger National Child Traumatic
    Stress Network, we are enacting one of the basic principles in delivery
    of services to children--to make services available to the children
    where they are, in schools and other community settings where they live
    their lives. This is why our network is helping to bring trauma-
    informed services to children in schools, residential treatment
    centers, child welfare systems, correctional facilities, rural clinics,
    domestic violence shelters, community-based programs, refugee services,
    and many more. Our goal is to raise the standard of care for
    traumatized children by developing and delivering evidence-based
    treatment and services in a timely and effective way.
        In my role as Director of the School Crisis and Intervention Unit
    of the National Child Traumatic Stress Network, I can attest to the
    increasing acceptance of school-based mental health services by
    families and school communities. These services are critical to meeting
    our nation's mission of promoting academic excellence, good citizenship
    and the well-being of our children.
        Children and adolescents in our schools feel comfortable asking for
    these services, courageously commit to the hard work involved in
    treatment, and even refer their friends. Parents and guardians have
    told us that they are very pleased that the services are being offered.
    Teachers have seen the results in their classrooms, and have
    enthusiastically expressed their support. Integrating mental health
    services in schools can be successful with sufficient support.

    Historical Roots: The Story of Ruth

        My involvement in this work goes back many generations. From the
    time I was 6 years old, my grandmother told me stories about her early
    life in San Francisco. That beautiful city was part of the Wild West in
    the early 1900's. For Chinese immigrants it was a vibrant and dangerous
    place. The residents of Chinatown were vulnerable to violence from
    Chinese gangs who victimized businesses, from Tong warfare (kinship and
    clan organizations fighting for economic, social and political
    dominance), and from white Americans who viewed the Chinese as less
    than human.
        The process of immigration from Macao, the island of my
    grandmother's birth, to San Francisco was no less dangerous. Pirates
    and thieves preyed on children and adults who boarded boats to escape
    the effects of the Boxer Rebellion in South China. They fled to find
    their way to ``Gold Mountain'', the name given to California and the
    promises it held for a better life.
        My grandmother, Ruth, was 5 years old when she was sold by her
    impoverished mother to a wealthy Chinese family emigrating to America.
    As a child, she remembered the day her mother pushed her toward a woman
    she had never seen before and said, ``This woman will be like your
    mother now.'' As a young child, she crossed an ocean with strangers to
    confront violence in the new world of San Francisco Chinatown.
        Once she saw a group of men refuse to pay the bill for their dinner
    and many bottles of liquor. When the owner of the Chinese restaurant
    insisted upon payment, they drew guns and shot bullets into the walls,
    ceiling and floors, smashing the furniture and laughing as they left.
    Ruth hid in a corner, unharmed but traumatized. In the following weeks,
    she refused to leave her home. She feared that she would be killed and
    that the violence would happen again.
        Not long after that incident, the violence did happen again. The
    head of her new family was shot and killed as an innocent bystander
    during a gang shooting. My grandmother never completed elementary
    school.
        In 1905, there was no counseling available in schools, nor was
    there recognition of the paralyzing effects of violence on children.
    The year my grandmother died, in 1999, I began my association with RAND
    and UCLA Research to test our intervention for its effectiveness in
    schools.
        The scars of violence can last a lifetime, but with early
    identification and early intervention in schools, the distress,
    anxiety, depression and trauma can be lifted and healed and children
    can be helped to resume productive and successful social, emotional and
    academic lives.
        We have come a long way in our country in recognizing the need for
    such services to children, and yet we do have so much more to do. The
    children are waiting.

    In Closing

        The mission of schools is to educate. The mission of mental health
    services is to heal. Our responsibility is to the child who will
    benefit from both. The reality is that the mission of one cannot
    proceed without the success of the other.
        I thank you, Mr. Chairman, Mr. Kennedy, and Members of the
    Subcommittee, for the opportunity to be here, to present this
    information to the subcommittee, and to express the gratitude of those
    of who work in the schools. Your work is vitally important to the
    creation of a children's mental health system that truly cares for
    children.
          Response to Questions of Senator Bingaman From Marleen Wong
        Question 1. Every year, an estimated 9 percent to 13 percent of
    children and adolescents in the United States experience a clinically
    significant mental disorder that warrants treatment. Yet, according to
    the Surgeon General's Report on Mental Health, two-thirds of these
    vulnerable young people do not receive any mental health treatment at
    all. What can we do to improve access to treatment?
        Answer 1. In establishing the New Freedom Commission on Mental
    Health, President Bush noted three key obstacles that keep people with
    mental illnesses from getting the services they need: 1. The stigma
    that still surrounds these illnesses; 2. The fragmented mental health
    care service system; and 3. Existing treatment and dollar limits for
    mental health care.
        If we are to transform our mental health care system, we must
    establish a true system of care for all children, not just those with
    persistent and chronic mental illness. We must include children at
    every age and stage, those at risk for serious disorders, children
    caught in family or community crises, and disabled children. All
    aspects of children's lives are in a fluid state of development. Early
    intervention and disability prevention means a shift in thinking to a
    ``well child'' mental health system, one that is adequately resourced
    for each of the components of early identification, early intervention,
    prevention, and effective treatments. One aspect of care should not be
    sacrificed for another because of funding disparities. One child should
    not be left behind because of another's needs.
        Lack of access to treatment is the result of many failures in the
    health care system. One way that access to mental health treatment
    would be improved is through the funding of preventive programs and
    early intervention mental health services in schools. The Early
    Periodic Screening, Diagnosis and Treatment (EPSDT) programs were meant
    to serve this purpose but have never been instituted or sufficiently
    funded to operate effectively in schools. Unlike community mental
    health clinics, hospitals or doctor's offices, schools are natural
    settings for children and parents. School mental health programs have
    demonstrated that children and families accept such services with less
    stigma and are more likely to complete the course of treatment.
        Community agencies, pediatricians, public mental health services
    agencies, even correctional facilities, have a role to play in
    providing care, but the reality is that schools have become the de
    facto primary source of mental health services for children. A 1995
    RAND study noted that only 8 percent of children who need mental health
    care actually received services--this leaves 92 percent of our children
    who need care without any services. Of the 8 percent who did receive
    services, 85 percent of the children received them in school mental
    health programs.
        In our crisis intervention work in the Los Angeles Unified School
    District and in many other parts of the country, we have worked with
    children in a post-crisis school setting. Often, while working with
    their trauma, we discovered children with other mental health problems
    that had never been addressed. Unfortunately, schools are limited by
    the lack of personnel to adequately provide intermediate and long term
    mental health and case management services that children need.
        To improve access, we need to address the barriers to treatment on
    several fronts. One approach is greater detection through improved
    education of professionals who work with children such as teachers,
    pediatricians, DCFS workers, and probation counselors, a principle
    supported in proposed S. 1223. Community leaders, including school
    superintendents, principals, union officials and faith leaders must
    also be included in an educational campaign to ensure that their
    decisions about children's programs are informed by scientific
    knowledge. Developing cultural competency in addition to high quality,
    and effective services, also noted in S. 1223, are crucial to this
    goal. National education and media campaigns about children's mental
    health should address this problem in multiple communities. One of the
    issues pertinent to access and disparity are the racial and ethnic
    differences among groups which include stereotypes that prevent
    appropriate treatment from being provided, language and cultural
    barriers, and lack of resources in disadvantaged communities. The work
    of Drs. Sheryl Kataoka and Ken Wells, UCLA Health Services Research
    Center, has elucidated these issues in details.
        Making mental health screening in schools routine for easily
    treatable problems, such as traumatic stress and depression will
    identify unmet needs and improve access to care. Our crisis
    intervention work showed that most students suffer silently from trauma
    or depression, spending their school days ``hidden in plain sight''.
    Schools routinely screen for vision and for hearing, two conditions
    which we would all agree are crucial to learning. Just as crucial may
    be school screening for trauma and depression, where fear, disturbing
    thoughts, feelings and images become barriers to school attendance and
    classroom participation. Schools are the place where the loss of
    motivation for learning of such students can be noted as a symptom of
    depression or trauma, and can best be addressed through school mental
    health programs.
        In our society, and in our health care system, children with mental
    disorders face the same stigma and discrimination as adults. It is
    unfair that an illness that can affect the brain, emotions,
    intellectual development and capacity, and relationships, and can so
    tragically affect the development of a child, is treated as less than
    serious, less than real. Schools can only do so much. When children are
    referred for mental health care, even those whose families have private
    insurance often cannot get medically necessary care because of the lack
    of parity in mental health coverage. This situation is worse than
    unfair . . . it can be lethal. Efforts to enact Federal mental health
    parity legislation have been close to success many times, and even now,
    parity has the widespread support of the Senate, the House, the
    President, and over 360 national organizations. Yet, American families
    are still waiting. It is the hope of all of us who work with children
    and their families that a full and fair mental health parity bill will
    be finally enacted in this Congress.

        Question 2. Evidence-based treatments are now available for the
    full range of child and adolescent mental disorders. Yet these
    effective treatments fail to reach a majority of those who can benefit
    from them. How can we close the gap between research and real-world
    practice to ensure that evidence-based treatments are available in
    community service settings?
        Answer 2. Closing the gap between research and practice begins in
    graduate training programs. S. 1223 supports the concept that teaching
    evidence based treatments begins in graduate programs of psychiatry,
    psychology, school psychology, psychiatric nursing, social work, school
    social work, marriage and family therapy, school counseling, and
    professional counseling. Support for continuing education through loan
    repayments, scholarships, and grants that increase the number of mental
    health providers expert in child and adolescent mental disorders will
    facilitate the infusion of sufficient numbers of providers in all child
    settings and enhance the quality of evidence-based services for
    children.
        In my work with the National Center for Child Traumatic Stress, and
    the 54 affiliated sites that form the larger National Child Traumatic
    Stress Network, we are enacting one of the basic principles in delivery
    of services to children--to make services available to the children
    where they are, in schools and other community settings where they live
    their lives. This is why our network is helping to bring trauma-
    informed services to children in schools, residential treatment
    centers, child welfare systems, correctional facilities, rural clinics,
    domestic violence shelters, community-based programs, refugee services,
    and many more. Our goal is to raise the standard of care for
    traumatized children by developing and delivering evidence-based
    treatment and services in a timely and effective way. And we are doing
    this by directly linking the researchers and the providers in ongoing
    collaborations to improve care based on research and clinical practice.
        The New Freedom Commission stated that ``evidence-based practices''
    are the bedrock of service delivery and that we improve quality and
    accountability. We can support this effort by supporting ongoing
    practical research that is embedded in schools and communities, and by
    providing training linked to scientific findings and clinical
    experience. This is one of the central goals of the National Child
    Traumatic Stress Network.
        Establishing school based mental health services is not a panacea.
    Services must be supported with adequate quality assurance and
    accountability measures. An example of such requisite oversight is that
    44 percent of the students who seek help at school-based health clinics
    present with mental health disorders or problems. Of the students who
    seek help for depression, few receive evidence-based treatments. The
    average number of 3 to 4 visits suggests that few ever receive the full
    ``dose'' of recommended treatment, and follow up is rarely done.
        Some disorders, such as psychological trauma and depression, are
    very amenable to identification and treatment within a school setting.
    These are also the disorders that are being identified as leading
    causes of disability among the general population of children in the
    United States. Our work in LAUSD with RAND and UCLA Health Sciences
    Research Center, documented disrupted academic performance, negative
    classroom behavior and less school attendance among students
    traumatized by their exposure to community violence. In fact,
    scientific studies are showing that childhood trauma further affects
    the onset and course of many other child and adolescent health and
    mental health conditions, from attention deficit and bipolar disorder
    to substance abuse and conduct disorder.
        Most importantly, in measuring our success, mental health
    professionals must find a way to integrate the mission of mental health
    and the mission of education. From an organizational perspective,
    mental health services in schools cannot operate outside the structure
    and organization of the educational environment. In order to succeed
    within the educational environment and to gain acceptance from
    educators, the integrity of the academic day must be preserved.
    Outcomes must include not only a decrease of symptoms but also evidence
    of improved academic functioning--better grades, improved classroom
    behavior, fewer absences, and increased attendance. These criteria are
    generally not within the realm of traditional treatment outcomes.
    However, they are solid indices of health, rehabilitation, and recovery
    for children.

        Question 3. Children with serious emotional disturbance often have
    multiple problems and require services from several systems, including
    the mental health, educational, child welfare, and juvenile justice
    systems. How can we enhance the coordination and collaboration of
    various child-serving systems?
        Answer 3. What is needed are multiple sources of funding earmarked
    for mental health services that are protected within State, Federal and
    local education budgets to establish and sustain programs that serve
    children's needs. Coordination and collaboration of various child
    servicing systems can be enhanced by placing those services at one
    location within an area or geographic region. In addition, a multi-
    disciplinary collaborative team approach to serving each child would
    enhance and promote ``wrap-around'' services, tailoring the services to
    the changing needs of the child.
        Many public mental health systems suffer from service and funding
    fragmentation. I am proud to say that the Los Angeles Unified School
    District has supported mental health services for the past 71 years.
    However, in the 30 years that I have worked in LAUSD, we have had to
    fight to maintain those services during annual budget deliberations
    when categorical, special education, Title I and general fund dollars
    wax and wane. This year, many mental health professionals, such as
    school counselors and social workers, will lose their jobs because of
    severe budget cuts necessitated by the downturn in the economy.
        In 1992, I worked with our Los Angeles County Department of Mental
    Health Services to negotiate the first Medi-Cal (Medic-Aid) contract
    between a school district and a county mental health service. We are
    currently able to draw down ``rehabilitation'' reimbursements for
    services to Medi-Cal eligible students and their families.
        This funding stream, however, does not provide any financial
    support for the work we do with indigent, uninsured children and
    families. Over 73 percent of LAUSD students and their families live
    below the poverty level and receive free and reduced lunch. The budget
    crisis in California has been so severe that there is no longer public
    mental health funding available for indigent, uninsured children, the
    largest socioeconomic group of students within our school district.
        Further hampering the foundation of economic support, reimbursement
    dollars for school mental health services are often absorbed by the
    larger district budget to offset losses in other areas. Locally,
    reimbursements ``earned'' through these programs and others, such as
    designated instructional counseling mandated by the Individual
    Education Plan (IEP) for special education students, or Local Education
    Agency (LEA) Medic-Aid, are not necessarily returned to support the
    programs that provided the services.
        In my work with the National Center for Child Traumatic Stress, and
    the 54 affiliated sites that form the larger National Child Traumatic
    Stress Network, we are enacting one of the basic principles in delivery
    of services to children--to make services available to the children
    where they are, in schools and other community settings where they live
    their lives. This is why our network is helping to bring trauma-
    informed services to children in schools, residential treatment
    centers, child welfare systems, correctional facilities, rural clinics,
    domestic violence shelters, community-based programs, refugee services,
    and many more. Our goal is to raise the standard of care for
    traumatized children by developing and delivering evidence-based
    treatment and services in a timely and effective way.
        I would also like to speak about the Individuals with Disabilities
    Education Improvement Act, a critically important piece of legislation
    that helps to support services for children who are disabled. I would
    especially like to thank the committee for recognizing the disabling
    effects that trauma exposure can have for young children, and for the
    inclusion of language in the bill that will help children who struggle
    in school as a result of trauma and the effects of traumatic events.
        A report on developmental disabilities and trauma was developed by
    the NCTSN, and has been submitted for the record. That report includes
    information from population studies showing that the national
    prevalence rate for developmental disabilities in the U.S. is 1.8
    percent. This translates into many children in our school systems
    needing the specialized education provided through IDEA. Additional
    studies have shown that individuals with developmental disabilities are
    at increased risk for abuse as compared to the general population. For
    example, 64 percent of maltreated children have a disability, such as
    behavioral disorders; speech, language, or learning disabilities; or
    mental retardation. Children with mental retardation were the most
    severely abused. When we identify a child with special needs, it is
    essential to determine the full context of the child's life and history
    so that the most appropriate services can be provided.
        It is therefore a major step forward for the Senate to recognize
    that the development of vulnerable young children can be thrown off
    course because of traumatic experiences, and that, with timely
    intervention, a child's life can be supported back onto a normal
    developmental path.

        Question 4. The New Freedom Commission on Mental Health and the
    Surgeon General's report both identified a national shortage of mental
    health professionals trained to treat mental illness in children and
    adolescents. I have introduced S. 1223, The Child Health Care Crisis
    Relief Act, which creates incentives to help train, recruit, and retain
    child mental health professionals through loan repayments,
    scholarships, and grants. Do you feel passage of this legislation would
    be helpful in reducing the shortage of qualified professionals?
        Answer 4. The passage of S. 1223 would significantly reduce the
    shortage of qualified professionals in several ways. First, it provides
    graduate students and working professionals with much needed financial
    support to further their studies with competitive grants. The proposed
    bill also addresses all the major issues and recommendations of the
    President's New Freedom Commission Report, especially the need to:
        Reduce disparities and the burden of unmet needs and lack of access
    to services among minority groups.
        Establish ``evidence-based practices'' as the bedrock of service
    delivery.
        Improve quality and accountability.
        Through my work with the National Center for Child Traumatic
    Stress, and the 54 affiliated sites that form the larger National Child
    Traumatic Stress Network, I am very aware of the difficulties of
    insufficient numbers of trained health care providers who are expert in
    child mental health or child trauma. In our network, we are directly
    linking providers with training programs so that we can enact one of
    the basic principles in delivery of services to children--to make
    services available to the children where they are, in schools and other
    community settings where they live their lives. This is why our network
    is helping to bring trauma-informed services to children in schools,
    residential treatment centers, child welfare systems, correctional
    facilities, rural clinics, domestic violence shelters, community-based
    programs, refugee services, and many more. Our goal is to raise the
    standard of care for traumatized children by developing and delivering
    evidence-based treatment and services in a timely and effective way.
    But without sufficient numbers of providers, and without a decent and
    fair health care reimbursement system, even the best training programs
    may not lead to successful integration of more providers throughout the
    system of child health care. This is why school-based mental health
    programs, IDEA improvements, and mental health parity legislation must
    be pursued at the same time that we enhance training programs for child
    health care providers.

        Senator DeWine. Dr. Douce, thank you.
        Ms. Douce. Good morning, Chairman DeWine and Senator Reed.
    Thank you very much for inviting me here today. As a member of
    the American Psychological Association and as director of the
    Counseling and Consultation Services at the Ohio State
    University, I oversee the provision of a broad range of mental
    and behavioral health services to nearly 50,000 students a
    year. I appreciate this opportunity to speak with you today
    about the growing mental and behavioral health needs of college
    students as you consider the College Care and Counseling Act.
        Let me start with an example. Consider a senior in the
    business school who is struggling with a broken relationship.
    He cannot sleep, he cannot concentrate, he does not go to
    class, and he finds himself sitting outside his ex-girlfriend's
    apartment at night waiting to see whom she is dating. He
    imagines beating that man to a pulp. He is a first-generation
    college student. He works 25 to 30 hours a week in addition to
    going to school, and he is qualified for significant financial
    aid to put himself through college. If he cannot address his
    emotions and his behavior, he is at risk of not graduating and,
    frankly, at risk for stalking. It is hard for him to seek help,
    but seeing his whole future disintegrating has convinced him to
    try counseling.
        In my written testimony, I offer an example of a young
    woman with a severe eating disorder and a young man that is at
    high risk for suicide.
        Situations like those I have just shared are common to
    college and university campuses throughout our country. During
    the period from 1975 to 1995, college and university counseling
    centers saw a dramatic increase in both the numbers and the
    severity of the mental health concerns.
        In fact, many of the students that colleges and
    universities want to retain leave school for personal rather
    than academic difficulties. A number of studies have shown a
    positive relationship between counseling services and actually
    staying in school and graduating. It is a lose-lose situation
    when a student who has taken out loans, received Federal grant
    aid, does not complete his or her degree. The loans do not go
    away. The student is not better off. And neither is our
    government investment in them.
        Now, let me just speak to some of the most serious issues.
    The most serious issue to me is suicide. Suicide is the second
    leading cause of death among college students. A 2000 survey by
    the American College Health Association found that within the
    previous year 22 percent felt they were so depressed that they
    could barely function, 9 percent had seriously considered
    suicide, and 1.5 percent had made attempts. In our own center,
    last year, 273 students admitted to suicidal ideation at
    intake, 11 had plans and means. None of those students died,
    yet tragically three other OSU students did end their lives by
    suicide.
        Suicide is preventable with knowledgeable and skilled
    intervention. Depression and anxiety are often at the root, and
    these are curable diseases. increased awareness, early
    detection, effective referral, and skilled intervention are the
    keys, and I would like to commend you, Mr. Chairman, for your
    leadership on the issue of suicide prevention.
        A second major issue is alcohol and substance abuse.
    Approximately 1,400 college students between the ages of 18 and
    24 die each year from alcohol-related injuries; 500,000
    students are injured while under the influence of alcohol;
    600,000 students are assaulted by another student who has been
    drinking; and 70,000 students are victims of alcohol-related
    sexual assault and date rape. These numbers are astounding.
        We know that facing the consequences of addictive behavior
    is one of the first steps to change. College and university
    counseling centers can play a major role in participating in
    wellness and prevention programs, counseling students in
    trouble, providing court-mandated therapy for students in the
    legal system for alcohol-related behavior. Our services assist
    students in facing their consequences, examining their choices,
    and learning to choose more appropriate alternatives.
        I would like to take my last few minutes to acknowledge the
    leadership of Senators Reed and DeWine in meeting the mental
    and behavioral health needs of college students with their
    introduction of the College Care and Counseling Act. Along with
    the support and involvement of Senators Smith and Clinton, you
    have introduced significant legislation that can really make a
    difference in the lives and successes of our Nation's students
    enrolled in postsecondary education.
        Funds would be made available for use for activities such
    as prevention, screening, early intervention, assessment,
    treatment, management, and education of mental and behavioral
    health needs of students on campus.
        This year, the Federal Government expects to spend $70
    billion in student financial assistance. This investment often
    makes the difference in a student's decision to pursue their
    dream of a college education. While undoubtedly significant, it
    is an investment that may not always yield the results we
    anticipate.
        Mental and behavioral health concerns and how they are
    addressed can make this difference. I sincerely believe it is
    one of the best returns on investment you can make. I hope that
    as the Senate Health, Education, Labor, and Pensions Committee
    moves forward with its reauthorization of the Higher Education
    Act that this legislation will be a priority for inclusion in
    the final bill. It is too important not to.
        Finally, I would again like to thank you, Senator DeWine,
    for having me testify in this important hearing today and for
    cosponsoring this bill.
        I will be glad to respond to any questions.
        Senator DeWine. Thank you very much.
        [The prepared statement of Ms. Douce follows:]
                  Prepared Statement of Louise A. Douce, Ph.D.
        Good morning Chairman DeWine and Members of the Subcommittee. Thank
    you for inviting me here today. As an active member of the American
    Psychological Association and as Director of Counseling and
    Consultation Services at the Ohio State University, I oversee the
    provision of a broad range of mental and behavioral health services to
    nearly 50,000 students each year. I appreciate this opportunity to
    speak with you today about the growing mental and behavioral health
    needs of college students as you consider the College Care and
    Counseling Act (S. 2215).
        Let me outline why these mental and behavioral health services on
    college campuses are so important:
         Maximize student success
         Increase rates of retention and graduation
         Provide crisis management and services
         Provide mental health consultation to faculty and staff
         Develop prevention strategies and contribute to a wellness
    culture
         Advance multicultural competency in a global community
         Ensure appropriate continuum of care
        I would like to begin by sharing some real life stories of college
    students that have sought help at our counseling center at Ohio State.
        Consider a senior in the business school who is struggling with a
    broken relationship. He can't sleep, he can't concentrate and he finds
    himself sitting outside his ex-girlfriend's apartment at night waiting
    to see whom she is dating. He imagines beating that man to a pulp. He
    is a first generation college student, works 25 hours a week and has
    qualified for significant financial aid to put himself through college.
    If he cannot address his emotions and his behavior, he is at risk of
    not graduating and, frankly, at risk for stalking. It is hard for him
    to seek help, but seeing his whole future disintegrating has convinced
    him to try counseling.
        Now consider a young woman who is a freshman in the Honors program.
    She is very bright, has very high SAT scores and feels pressure from
    everyone's expectations for her success. She has also had an eating
    disorder since junior high school. She worries constantly, is obsessed
    with her weight and limits food. Since starting school her anxiety has
    been very problematic, she rarely eats and her weight has gone below
    100 pounds. She realizes she needs help and seeks counseling.
        Finally consider a graduate student who is struggling with
    depression. He cannot get to sleep at night until 3 or 4 a.m. and then
    oversleeps his 9 a.m. class. He has trouble getting out of bed some
    days, does not enjoy anything he used to, pushes friends away, knows he
    is failing and blames himself. About the only way he can think to
    escape his despair is suicide. His mother, who lives 1,500 miles away,
    convinces him to find the counseling center.

    Increased Need

        Situations like those I have just shared are common on college and
    university campuses throughout our country. During the period from 1975
    and 1995 colleges and university counseling centers saw a dramatic
    increase in both the numbers and severity of mental health concerns. A
    national survey of counseling center directors confirmed that this
    trend of increased demand continued throughout the 1990s.
        More specifically, a research consortium of 36 counseling centers
    found increases in anxiety, fear and worries and dysfunctional behavior
    including eating disorders, alcohol and substance abuse and anger/
    hostility. They also reported increases in the impact of violence,
    family dynamics, depression and bipolar disorder.
        This study outlines the major issues in college student mental
    health:
         Depression, anxiety and anger (also referred to as
    Affective Disorders)
         Eating Disorders and body image distortion
         Traumatic Stress Reactions following exposure to
                 Violence in community and war (returning veterans
                & internationals)
                 Date rape, harassment and stalking
                 Family discord, dysfunction and abuse
                 Natural disasters around the world
         Alcohol and substance abuse
         Future, career and crisis of hope
        In the years ahead, I would expect to see the trend of an
    increasing number of students seeking mental and behavioral health
    services to continue--if not grow at a more significant pace. Current
    research suggests that more students are entering college with prior
    treatment histories of severe mental illness now controlled with
    medication, a great thing. However, they may have more difficulty with
    adjustment to change and are at increased risk of relapse or
    reoccurrence without appropriate mental health support. In addition,
    the Institute for Higher Education Policy recently reported that
    between 2000 and 2015, the college-age population will increase by 16
    percent or 2.6 million students, 80 percent of whom will be ethnic
    minorities, and nearly half Hispanic. The report noted that students
    from ethnic minority communities historically suffer most from
    financial, academic, and cultural barriers. This may be especially
    salient for first generation college students. Providing culturally
    competent therapy and prevention programming is a vital element in
    graduating a fully diverse class. A better-educated population is in
    turn necessary for the United States to remain competitive in a global
    economy. We, as a Nation are counting on them to be successful.

    Students Who Receive Mental and Behavioral Health Services Have Higher
                        Retention Rates

        In fact, many of the students that colleges and universities want
    to retain leave school for personal rather than academic difficulties.
    Recent research has demonstrated that students who receive counseling
    for their mental and behavioral health needs reported increases in
    ``personal well being, academic success and retention.'' Further, a
    number of studies have discovered a positive relationship between
    counseling services and retention rates. It's a lose-lose situation
    when a student, who has taken out loans and received Federal grant aid,
    doesn't complete his or her degree. The loans don't go away. The
    student is not better off--and neither is our government investment in
    them. On the other hand, both the student and the government win when a
    student who received financial assistance from the Federal Government
    graduates and goes on to future success. That student is better off--
    and so is our Nation. Sometimes all that it takes to turn a potentially
    tragic situation into a success story is an interest and commitment to
    a student's mental health needs.

    Suicide Prevention

        Let me speak to one of the most serious issues in this population,
    suicide. Suicide is the second leading cause of death among college
    students. A 2000 survey by the American College Health Association
    found that within the last year 33 percent of college students reported
    feeling hopeless, 22 percent said they felt so depressed they could
    barely function, 9 percent seriously considered suicide; and, 1.5
    percent had actually attempted suicide. Last year in our center, 273
    students admitted to suicidal ideation at intake, 11 had plans and
    means. None of those students died yet, sadly, three other OSU students
    did end their lives by suicide.
        The Ohio State University participated in a decade long study of
    suicide at Big 10 Universities in the 1980's. The researcher, Dr. Mort
    Silverman, visited with coroners and traced all student deaths to
    verify all deaths by suicide and determine patterns. The overall number
    of such deaths was less than the rate for the general population aged
    15 to 24. Dr. Silverman attributed this to the relatively greater
    access to mental health care through the Big 10 university counseling
    centers. What were especially helpful from this study were patterns
    specific to each university. At Ohio State we had a significant number
    of deaths by cyanide and a higher rate among international graduate
    students than the other schools. We immediately addressed access to
    cyanide in chemistry labs and developed greater prevention efforts with
    the international population including orientation workshops on family
    stress, dating ``American style'' and stress management. Since then we
    have had no cyanide deaths and reduced our suicide rate by 40 percent
    from 4.5 persons to 2.7 persons over the last 5 years. That is 2.7 too
    many, but lower than one would predict for 50,000 students. Suicide is
    often preventable with knowledgeable and skilled intervention.
    Depression and anxiety are often at the root and those are curable
    diseases. Increased awareness, early detection, effective referral and
    skilled intervention are the keys. I would like to commend you Mr.
    Chairman for your leadership on this issue of suicide prevention.

    Alcohol and Substance Abuse

        Approximately 1,400 college students between the ages of 18 and 24
    die each year from alcohol-related unintentional injuries, including
    motor vehicle crashes. Five hundred thousand students are injured while
    under the influence of alcohol and 600,000 students are assaulted by
    another student who has been drinking. Seventy thousand students are
    victims of alcohol-related sexual assault or date rape. These numbers
    are astounding. The related damage in drunk driving, vandalism,
    property damage and police involvement is incredible. In 2001,
    approximately two in five (44.5 percent) college students reported high
    risk or binge drinking. Our own data at Ohio State University indicates
    that this rate continued to climb in 2002 to 52.8 percent (from 44.2
    percent in 2000). We also saw a 10 percent increase for women, students
    of color, students of legal drinking age and seniors. We did see a
    decline in use by first year students, which we attribute to a
    multifaceted education campaign. We have known for years that college
    students engage in high risk drinking. We also know that many of these
    students stop this behavior sometime during their college career. Many
    do not. We also know that facing consequences of addictive behavior is
    one of the first steps to change. College and university counseling
    centers can play a major role in participating in wellness and
    prevention programs, counseling students in trouble and providing court
    mandated therapy for students in the legal system for alcohol related
    behavior. Our services assist students in facing their consequences,
    examining their choices and learning to choose more appropriate
    alternatives.

    Counseling and Mental Health Service Reductions

        As you probably know, college tuition continues to rise
    dramatically. State subsidies for higher education continue to be cut
    across the Nation and college administrators are caught in the squeeze.
    They look to cut costs internally wherever possible and mental health
    services have been severely impacted. In the last 10 years colleges and
    universities have had to set session limits (39 percent 1992; 44
    percent in 2002), impose fees (7.4 percent in 1992, 15 percent in 2000)
    and reduce staff. At a time when the mental and behavioral health care
    needs of students are increasing, the means to meet those needs are
    being reduced. Employing usage fees affects students on financial aid
    disproportionately. These students have fewer resources to start with
    and may be at higher risk for leaving school because of personal
    problems--problems that could be resolved with appropriate and
    accessible care.

    Campus Care Act

        I would like to take my last few minutes to acknowledge the
    leadership of Senators Reed and DeWine in meeting the mental and
    behavioral health needs of college students with their introduction of
    the College Care and Counseling Act--S. 2215. Along with the support
    and involvement of Senators Smith and Clinton, you have introduced
    significant legislation that can really make a difference in the lives
    and successes of our Nation's students enrolled in postsecondary study.
    This bill will help thousands of students get the help they need, when
    they need it and better insure the return in our Nation's investment in
    them.
        S. 2215 authorizes $10 million in competitive grant funds to
    college counseling centers, mental health clinics, and psychology
    service centers within institutions of higher education to create or
    expand the mental and behavioral health services to students. Funds
    made available can be used for activities such as prevention,
    screening, early intervention, assessment, treatment, management and
    education of the mental and behavioral health needs of students on
    campus. Resources may also be used to better educate families about the
    psychological health of their children. These are critical areas
    identified by counseling centers on campus that need attention. Over
    the past 5 years, counseling center directors reported substantial
    increases in the percentage of students they see with severe
    psychological problems, sexual assault concerns, alcohol problems,
    illicit drug use, and eating disorders with little to no increase in
    resources to support their work.

    Why Support College and University Counseling and Mental Health
                        Services? Why the Federal Government?

        This year, the Federal Government expects to spend nearly $70
    billion in student financial assistance. This investment often makes
    the fundamental difference in a student's decision to pursue the dream
    of a college education. It is the most significant contribution the
    Federal Government makes to our Nation's postsecondary students. And
    while undoubtedly significant, it is an investment that may not always
    yield the results we anticipate--for a variety of reasons, but often
    due to undiscovered, unaddressed or unmet needs related to mental and
    behavioral health problems.
        Mental and behavioral health concerns and how they are addressed--
    can make the difference between a student that finishes in 4 years
    versus 7; a student that graduates and one who drops out; and a student
    who takes his or her own life and one that goes on to live a healthy
    life. The Campus Care and Counseling Act calls for a small contribution
    of resources but it offers a sound, targeted, intervention, based on
    research, that can yield big contributions in areas including academic
    success, retention, graduation rates and life and death.
        I sincerely believe it is one of the best returns on investment you
    can make. I hope that as the Senate Health, Education, Labor, and
    Pensions Committee moves forward with its reauthorization of the Higher
    Education Act that this legislation will be a priority for inclusion in
    the final bill. It is too important not to. Finally, I would again like
    to thank you, Senator DeWine for having me testify at this important
    hearing today and for cosponsoring S. 2215.
        I will be glad to respond to any questions.
        Senator DeWine. Dr. Davis?
        Ms. Davis. Mr. Chairman and members of the subcommittee, I
    am grateful for this opportunity to talk with you today about a
    developmental stage that is ignored and a group of young people
    that we cannot afford to lose. I study the transition into
    adulthood of youth with the most serious mental health
    conditions and the public systems with which they are involved.
    I hope my testimony, which is based on my and my colleagues'
    research, convinces you that we need to change our service
    systems to help these young people become contributing members
    of society rather than what our service systems do now, which
    is to abandon them and their families in the middle of this
    critical developmental stage.
        The transition period covers ages 14 to 25. Of those who
    are 14 to 25, 2 to 3.5 million of them have the most serious
    mental health conditions. The typical transition to adulthood
    that most of us experience is based on the steady accumulation
    of cognitive, emotional, and social maturity and increased
    skills and knowledge so that by age 25 society reasonably
    expects us to have finished school, to be working, and to move
    out of the family home.
        For adolescents with serious mental health conditions,
    particularly those in public systems like special education,
    child welfare, or child mental health, their odds of becoming
    successful young adults are bleak. Disability and circumstance
    slow their steady accumulation of maturity skills and
    knowledge. By young adulthood, about 30 percent have
    experienced homelessness. The rate of school dropout,
    unemployment, drug or alcohol problems, and pregnancy covers
    around 50 percent. And by age 25, up to 65 percent have been
    arrested. In essence, they are failing in every domain of adult
    functioning.
        But the real failure is our inadequate service systems.
    While their need for services does not go away, our service
    systems do, right in the middle of this critical developmental
    stage.
        This mid-transition service loss is caused by unintentional
    barriers that are produced by the separateness of our child and
    adult funding streams, entitlements, and service systems. Not
    only do individuals lose services, but the services that do
    exist rarely address the particular needs of youth with serious
    mental health conditions.
        Let me illustrate some of these barriers through real life
    stories. Matt, who had been involved with special education,
    child welfare, and the State child mental health system since
    age 5, could not access the State's adult mental health system
    when he turned 19. Matt lived in a State, like many other
    States, in which child and adult mental health systems restrict
    access to their services to those who have one of a list of
    qualifying psychiatric diagnoses. In 62 percent of States, the
    list of diagnoses for adult services is more restrictive than
    they are for child services. Matt did not have one of those
    qualifying adult diagnoses, and he was denied any further
    access to the State's mental health system.
        Hannah, who developed a major depressive disorder when she
    was 16, had been on an adolescent psychiatric hospital unit for
    6 months when she turned 18. With little notice, she was
    transferred to the adult unit. There she was the only patient
    under age 30. The sudden shift of unit that broke off her
    relations with those on the adolescent unit and put her with
    older adults that she found frightening led to despair and
    suicide attempts. When she eventually left the hospital, like
    most young adults in the adult mental health system, she found
    few programs that had any younger adults in them and no
    recognition of her transition support needs.
        We have learned that the causes of this service inadequacy
    and the mid-transition service loss are complex. For example,
    State mental health systems are greatly dependent on Medicaid
    funding. Child eligibility for Medicaid is different from adult
    eligibility. And as a result, each day some young people with
    serious mental health conditions lose the payer of their needed
    services because of the passage of a birthday that marks entry
    into adulthood.
        While the solution to these problems is complex, the goal
    is clear. Give these young people a chance for successful
    adulthood by providing supportive services throughout the
    transition age, until adult functioning has been attained. No
    States have come close to this goal, although most are making
    efforts.
        To achieve this goal, we need to motivate our systems to be
    creative in solving the system problems, to embrace this
    developmental stage, and to embrace these young people. We also
    need to develop more knowledge to guide these efforts.
        I thank you for providing a forum from which greater
    progress may evolve. I would especially like to thank you,
    Chairman DeWine, and Representative Stark for your focused
    effort in the transition issue.
        Senator DeWine. Doctor, thank you very much.
        [The prepared statement of Ms. Davis follows:]
                   Prepared Statement of Maryann Davis, Ph.D.
        Mr. Chairman and Members of the Subcommittee, I am Maryann Davis,
    Ph.D., a psychologist on the faculty of the Center for Mental Health
    Services Research, in the Department of Psychiatry at the University of
    Massachusetts Medical School. Over the past 10 years I have conducted
    research on the developmental needs of youth with serious mental health
    conditions during the transition to adulthood and the public systems
    with which these young people are involved. I am very grateful for the
    opportunity to talk with you today about a developmental stage that is
    ignored, in a group of young people we can't afford to lose. I hope my
    testimony convinces you that we need to change our service systems to
    help these young people become contributing members of our society,
    rather than what our systems do now, which is to abandon them, and
    their families, in the middle of this developmental stage.
        The transition period covers ages 14 through 25. At any given time,
    there are 2-3.5 million individuals in the transition age who have the
    most serious mental health conditions. The typical transition to
    adulthood that most adolescents experience involves the steady
    accumulation of cognitive, emotional, and social maturity, that under
    most conditions, results in increased skills and knowledge so that by
    age 25 we reasonably expect young people to finish school, be working,
    move out of the family home, develop adult friendships and loving
    relationships, and begin to contribute to our society. For adolescents
    with serious mental health conditions involved with public systems,
    like special education, child welfare, or child mental health services,
    their odds of becoming successful young adults is bleak. During
    adolescence their psychosocial development is delayed in every area. By
    young adulthood about 30 percent have experienced homelessness, almost
    half have a developed drug or alcohol abuse or dependence, half have
    dropped out of high school, about half are unemployed, up to half of
    these young women have become pregnant, and, by age 25, up to 65
    percent have been arrested. In essence, as a group, they largely fail
    in every domain of adult functioning.
        But the real failure is our inadequate support system. While their
    psychiatric disability does not go away, our support system for them
    does. In the midst of this important developmental stage there is an
    abrupt loss of services that has no correlation with an improvement in
    their state of mental health. Rather it is the result of myriad system
    barriers erected by the separateness of our child and adult services,
    agencies, funding streams, and entitlements. Adolescent services that
    address the particular transition needs of those with serious mental
    health conditions are too rare. Few of these adolescents gain access to
    the adult mental health system, which contains vocational, supported
    education, housing, and substance abuse services in addition to mental
    health treatment. However, the few who are given access to adult
    services encounter find that adult systems typically have no
    developmental framework in their policy or practice. There is little
    recognition that a 22-year-old needs different types of services than a
    40-year-old. Thus the adult system, that frequently denies them any
    entry, also typically offers few services that are appropriate or
    appealing to this young adult population. Currently, there is no State
    that has been able to overcome these system problems.
        I'd like to relate one young person's story to demonstrate this
    point. Matt became involved with special education, child welfare, and
    the child mental health system since age 5. By age 17 he had a social
    worker from each of these systems who were responsible for finding
    services for him. He had a single mother and younger siblings. His
    residential treatment ended at age 17. He was sullen, depressed, and
    had angry outbursts. He was on numerous psychotropic medications. He
    yearned for acceptance, but put up a gruff unfriendly exterior to ward
    off the expected rejection.
        His special education program couldn't find a school program for
    him for months. Things got worse at home. He joined a gang, fathered a
    son, and turned 18 in the ensuing months. Like so many youth with
    serious mental health conditions he dropped out of school. His
    transition plan, mandated by the Individuals with Disabilities
    Education Act became moot upon his dropping out. The school made an
    application for him to access adult mental health services which could
    start serving him when he turned 19. But, in his State, like many
    States, the child and adult mental health system restricts their
    services to those who have one of a narrow list of qualifying
    psychiatric diagnoses. In 62 percent of States the list of diagnoses is
    more narrow in the adult than child mental health system. Matt didn't
    have one of the adult diagnoses, and was denied any further access to
    the State's mental health system after age 19.
        Upon his 18th birthday his child welfare case was closed. The John
    Chaffee Foster Care Independent Living Act allows many youths to
    continue voluntarily in child welfare services after age 18, receive
    independent living supports, and extends their Medicaid coverage to the
    age of 21. But, like many young people in his position Matt was not
    interested in any further involvement with this Agency.
        By age 19 he was a legal adult, with little guidance, who had lost
    all his child services. He didn't know how to apply for disability. He
    was uninsured. He had no diploma. No steady source of reliable income.
    And no hope. He was soon hospitalized for a suicide attempt, and was
    never able to provide financially or emotionally for his son.
        Matt's situation is unfortunately common among the young people
    with serious mental health conditions in our public systems. While
    special education and child welfare systems have developed many
    programs and approaches to aide the transition to adulthood, those
    approaches are targeted at nor well suited for youth with serious
    mental health conditions. Transition supports in the State child mental
    health system are sparsely distributed across the country, and adult
    mental health system has not begun to address the needs of the younger
    adult population. We miss a critical window of development. We have an
    opportunity to help these youths become productive adults in our
    society, to work, have homes, have friends, and start families. But we
    squander that opportunity, to the detriment of us all.
        The solution to these system problems is complex, but the goal is
    clear. We need to provide appropriate transition supports continuously
    into adulthood until the services are no longer needed. If we are to
    achieve this goal we need to encourage innovation and creative
    solutions to the current system barriers. We need to create the
    motivation to change these systems and we need to develop more
    knowledge to guide us as we solve this complex problem.
        There are solutions to be had at every level. At the Federal level,
    changes such as extending eligibility for Medicaid coverage for youth
    with disabilities to age 25, would facilitate the provision of
    continuous services throughout the transition stage. State mental
    health authorities can work to make their eligibility criteria the same
    for adult and child services. At the local level, young people can be
    invited into the change process, to help guide the changes so that they
    are appealing to them. We also need more research to develop and
    demonstrate treatments or services that are effective with this age
    group. Achieving our goal will prevent crime, homelessness, lost
    productivity, and lost members of society.
        Thank you, Mr. Chairman and Members of the Subcommittee, for
    providing a forum from which greater progress may evolve. I would
    especially like to thank Senator DeWine and Representative Stark for
    their focused interest in the transition issues.
          Response to Questions of Senator Bingaman From Maryann Davis
        Question 1. Every year, an estimated 9 percent to 13 percent of
    children and adolescents in the United States experience a clinically
    significant mental disorder that warrants treatment. Yet, according to
    the Surgeon General's Report on Mental Health, two-thirds of these
    vulnerable young people do not receive any mental health treatment at
    all. What can we do to improve access to treatment?
        Question 2. Evidence-based treatments are now available for the
    full range of child and adolescent mental disorders. Yet these
    effective treatments fail to reach a majority of those who can benefit
    from them. How can we close the gap between research and real-world
    practice to ensure that evidence-based treatments are available in
    community service settings?
        Question 3. Children with serious emotional disturbance often have
    multiple problems and require services from several systems, including
    the mental health, educational, child welfare, and juvenile justice
    systems. How can we enhance the coordination and collaboration of
    various child-serving systems?
        Question 4. The New Freedom Commission on Mental Health and the
    Surgeon General's report both identified a national shortage of mental
    health professionals trained to treat mental illness in children and
    adolescents. I have introduced S. 1223, The Child Health Care Crisis
    Relief Act, which creates incentives to help train, recruit, and retain
    child mental health professionals through loan repayments,
    scholarships, and grants. Do you feel passage of this legislation would
    be helpful in reducing the shortage of qualified professionals?
        The first three questions are covered very thoroughly in the New
    Freedom report for children and adolescents. What is not covered very
    well in that report are the specific needs of youth during the
    transition into adulthood. I will focus my answers on that age group.
        (1) INCREASING ACCESS. Your question is particularly important for
    youth with mental health conditions during the transition to adulthood.
    All studies converge on the fact that there is a critical loss of
    services between ages 16-23. Thus, that figure of 67 percent not
    receiving needed services increases dramatically during these ages. I
    will address some of the factors that contribute to the loss of
    services and to not accessing service in the first place.
        (A) Stigma. Teens and younger adults want to fit in with their
    peers, they do not want to be labeled as mentally ill. In this age
    group it is the young people themselves who need to be encouraged to
    identify their mental health need and to access services that can help
    them. The social stigma of mental illness is the worst of any
    disability group. Thus, more young people can be identified and treated
    if access is destigmatized. Reducing the stigma of screening or
    treatment can be achieved in various ways. The first principal is to go
    to where they are; the internet, schools, the mall, public transit,
    etc. For example, USE THE INTERNET. Having an internet screening device
    with some link to services is an anonymous way that any teen or young
    adult, who is struggling in their functioning can get some sense of
    whether they have a mental health condition that could benefit from
    treatment. The second principal is to imbed the screening and treatment
    into issues that youth care about. For example, youth might not want to
    take a mental health screening test, but they may be very interested in
    finding out why they're struggling to work, finish school, earn money,
    or move out on their own. Imbedding screening for mental health, and
    other conditions, into tools that they can readily access to help them
    figure out how to do these things better is a friendly way to help them
    find out that not only do they have a mental health condition, but that
    its getting in the way of things that they want to achieve, and there's
    help to be had. The third principle is ensure that the development of
    screening and treatment mechanisms is guided by young person input
    (young people with mental health conditions). They are the only ones
    who can really indicate what approaches will attract or repel young
    people. Making these kinds of innovative approaches work, and making
    them ethical could be the focus of Federal programs, like SAMHSA, NIMH,
    OSERS, NIDRR, NIDAA. Encouraging these agencies to work collaboratively
    increases the likelihood that the issues that young people care most
    about will help overcome the issue of stigma.
        (B) Disappearing Payors. Many young people who have mental health
    conditions, and are receiving treatment for them, lose access to
    treatment upon the passage of an ``adult'' birthday. Essentially the
    payor of their ``child'' treatments no longer covers them at this age,
    and the payors of ``adult'' treatments will not fund them. This occurs
    across numerous payors. Each suggestion below focuses on the kind of
    action that would increase access to mental health services because of
    the continued presence of a payor for those services. Parents'
    insurance can cover a young adult child as long as they remain in
    school. However, for young people with serious mental health
    conditions, this offers little help because fewer than half finish high
    school and only a small fraction go on to post secondary school.
    Encouraging insurance companies to allow parents of youth with
    disabilities to maintain their coverage until age 25, regardless of
    school status, would help maintain the continuity of services. It might
    also be a motivator for screening--since they would have to document
    disability. Medicaid eligibility is much broader for children than for
    adults. The changes take place somewhere between age 18 and 21.
    Extending eligibility for Medicaid automatically for anyone with a
    disability up to age 25 would go a very long way toward providing
    access to needed services. Changing the definition of disability, as
    used for Medicaid or social security, so that those between the ages of
    18 and 25 could qualify as disabled under EITHER the child or adult
    definition of mental health disability would also ensure that those who
    were considered disabled as a 17.99 year old, would still be considered
    disabled throughout the period of transition. Extend the eligibility
    for independent living supports provided through the John Chaffee
    Foster Care Independent Living program to the age of 25 for those with
    disabilities. Provide an extra pot of money in the Federal mental
    health block grants administered through SAMHSA for States to access to
    increase the numbers of youth who receive State mental health care
    during ages 16-25.
        (C) Embrace the developmental stage of emerging adulthood. In
    ``normative'' or ``typical'' development there is a new stage of
    development that has been recognized and described; emerging adulthood,
    which starts around age 18 and ends around age 25. There is all kinds
    of legislation around entitlements and programs that defines childhood
    as ending at 18, or 21. For youth with disabilities, their development
    is delayed, and society's expectation that they function as adults at
    18 or 21 is misplaced. Supports for youth with disabilities need to
    uniformly be extended to at least age 25. If ``typical'' development
    means full adult functioning at 25, then, really, supports,
    entitlements, programs, etc., should be extended to age 28 for youth
    with disabilities. This is a guiding principal that should be applied
    to many legislative efforts that affect the population of adolescents
    and young adults with mental health conditions.
        (2) Evidence-based practices do not exist for youth in transition.
    Like so many other realms, we have focused our evidence-based
    approaches on either child/adolescent or adult populations. The
    efficacy Multi-Systemic Treatment that is so impressive for reducing
    delinquency is unknown for youth aged 18-25. The efficacy of the
    Assertive Community Treatment Program is unknown for 14-21 year olds.
    The first step for youth in transition to adulthood is to develop
    evidence-based practices; perhaps emphasizing the need to test and
    perhaps modify existing models for this age group. NIMH should be
    encouraged to offer funding in this area. The various other
    recommendations from the New Freedom report for extending the evidence
    base to real world setting holds for this age group as well.
        (3) Youth in transition have needs that extend from the child to
    the adult system. Thus, not only do the various child-serving agencies
    need to be involved, but the various adult-serving agencies as well;
    adult mental health, housing, vocational rehabilitation, substance
    abuse services, supported education, corrections, etc. The
    recommendations in the New Freedom Commission Report for reducing
    fragmentation are excellent. I would encourage one particular aspect
    for youth in transition; the embracing of outcomes across domains of
    functioning to guide funding. Many of the ``costs'' of not treating
    youth during the transition to adulthood aren't mental health costs but
    they are broader societal costs; homelessness, unemployment, crime,
    substance use, youthful pregnancy. We need to bring together the
    Federal, State and local agencies that are involved in these domains of
    functioning so that their accountability cannot be shifted off to the
    other. If we use young adult outcomes as our guides we will definitely
    improve services for this age group, and improve our society.
        (4). Child Health Care Crisis Relief Act. Looks good to me, except
    that it does not include professionals specializing in young adults,
    I'd VERY MUCH like to see that age group included. Again, if we can
    conceptualize the developmental process leading to adulthood as
    including the ``emerging adult'' stage rather than ending at that stage
    we will be more closely aligned with the real development of these
    individuals, and with the supports that they need to be launched into a
    successful adulthood.
            Response to Questions of Senator Reed From Maryann Davis
        A significant number of mentally ill patients also suffer from
    substance abuse problems, known as ``co-morbid conditions''. As you
    well know, there are different funding sources for each. Likewise,
    these individuals access services in a variety of settings, such as
    residential facilities and the juvenile justice system. Many of you
    spoke to the fragmentation of mental health care and the difficulty of
    accessing services.
        Question 1. Is there evidence of improved outcomes, better
    compliance, and cost-savings through providing combined services? For
    example, properly treating an alcoholic's bipolar illness to avoid
    relapsing on alcohol.
        Answer 1. The simple answer is yes.
        Comorbid mental health conditions and substance abuse. Let me say
    that I am not an expert on the dual diagnosis/comorbidity literature.
    So I have examined the literature to provide an answer to you for this
    specific population. Two current critical analyses of the existing
    research on the subject indicate that, there are still many holes in
    our knowledge, the most common finding is that treatment of both
    disorders (combined services) is more successful in terms of improved
    functioning, symptomatology, or drug/alcohol use, than either alone.
    For those with comorbid mental illness and substance abuse disorders,
    there is evidence of improved outcomes when both conditions are
    treated.
        This said, both reviews were quite clear that the evidence at this
    point is thin. There have not been many or many well-designed studies
    to draw from, and the specifics of the question are vast. Just as
    specific disorders of mental illness differ, so do the specific
    disorders of substance abuse, and we don't have a complete picture
    about combined treatments for all of the different combinations. One
    specific study even found that subjects with social anxiety disorder
    and alcohol dependence who were treated for both conditions
    simultaneously actually fared worse in their subsequent alcohol use,
    than those who were treated only for their social anxiety disorder.
    However even this finding argues for the coordination of substance
    abuse and mental health treatment; if for some conditions it is
    advantageous to hold off on treatment of one condition that needs to be
    coordinated. Thus, all evidence points to the need for well-coordinated
    services.
        Overall, the specifics of good, evidence-based treatments for
    individuals with dual diagnoses are just beginning to emerge. Even less
    is known about combined treatments for adolescents, for youth in
    transition to adulthood, or for different cultural groups. I saw no
    literature on cost savings or specific findings on combined services
    improving treatment compliance. Cost improvements are implied by some
    of the findings that combined services reduce emergency room/detox
    visits, but cost analyses have not been conducted. These questions have
    simply not been addressed through research. Many more studies are
    needed.
        My own research indicates that for transition-aged youth with dual
    mental health/substance abuse conditions, the combined condition is
    exponentially worse in terms of high school dropout, not living with
    family, and trouble with the law. Again, the little bit of evidence
    from the research literature is supportive of coordinating treatment
    for both conditions. One study found that youths with SED, whose
    substance use disorder went undiagnosed by clinicians during
    adolescence, fared much worse than either youth with identified dual
    conditions, or youth with mental health conditions alone. One
    interpretation of the findings is that those who were identified as
    comorbid received some treatment for both conditions, while those whose
    substance use disorders were unrecognized deteriorated from lack of
    treatment for the substance use disorder. Similarly, a study of
    adolescents with ADHD (Attention Deficit/Hyperactivity Disorder) found
    that adult substance use disorders were much higher in adolescents who
    had not received pharmacological treatment for their ADHD. Taken
    together these studies suggest that either untreated substance use or
    mental health conditions can both lead to increased substance abuse in
    young adulthood.
        Combined services in other areas of multiple needs. There is no
    direct evidence about better outcomes, engagement, or cost
    effectiveness of combined services in the transitioning population. The
    circumstantial evidence is strong.
        (1) They clearly are involved across multiple systems; mental
    health, education, child welfare, juvenile justice, substance abuse,
    homeless-runaway youth, etc.
        (2) Their functional impairments span different agencies'
    expertises; jobs/career, education, housing, adequate parenting.
        (3) Their ``conditions'' are often multiple, mental health combined
    with substance abuse, learning disabilities, developmental
    disabilities, and chronic health conditions are common, and treatment
    for these other conditions are most commonly offered through non-mental
    health agencies.
        (4) Services that address multiple needs have been shown to be
    associated with better outcomes in various domains of functioning,
    which can be translated into cost savings.
        The general literature on well-coordinated services across
    different service domains is supportive of the notion that coordination
    alone is insufficient. That is, coordinating average care may not be
    any more effective than not coordinating it, though families are more
    satisfied when even insufficient care is coordinated. What is really
    needed is the coordination of high quality care. Several clinical
    trials are now showing things like combined pharmacotherapy with highly
    specified cognitive behavioral therapy is more effective than either
    alone. Although these particular services wouldn't necessarily come
    through different funding streams, it does highlight that combined and
    high quality services are more effective than ill-informed
    uncoordinated services.

        Question 2. In your experience, are different Federal funding
    streams a barrier to quality mental health care?
        Answer 2. Yes.
        Quality mental health care, particularly during the transition
    stage, depends on being able to fluidly address functional needs as
    they arise. A young person is not going to focus on their mental health
    treatment needs if they are imminently homeless, if they can't get a
    job and they need to support themselves, or if their lives are
    miserable at school. Similarly, not attending to their mental health
    care will interfere with their abilities to address these problems.
        Funding streams are service-based, not people-based. They help
    foster the silos of agencies at the State level. Those silos are not
    well coordinated at the individual or State level. As a result of that,
    families and youth experience gaps and redundancies in services and
    treatments, and providers are frustrated with an inability to access
    needed services. More subtly, the silos foster silo-think. That is
    those working with these young people tend to think about only the
    services that their systems offer in addressing their needs, and know
    less, have less access to, and less often consider services offered
    through other systems.
        My research has also shown that one of the barriers to accessing
    transition support services for adolescents in State mental health
    systems was that other agencies held the purse strings for many of the
    needed services, and were not motivated to address the unique needs of
    the youth in their systems that had mental health conditions. For
    example, many administrators described that there were foster care
    independent living dollars (Chaffee funds) that were available to youth
    in foster care. However, those funds were invested preferentially in
    youth who were succeeding (i.e. expected to complete high school), or
    were used for generic independent living supports that didn't address
    the needs of youth with mental health conditions.
        Administrators also described that the differing eligibilities for
    different Federal programs, such as Medicaid, EPSDT, etc., added to the
    complexity of how long they could provide services to youth. Some youth
    were eligible for Federal programs until they were 18, while others
    were eligible until age 21, so the child system ``covered'' to age 21,
    but only if an individual had health care coverage to that age.
        Finally, an analysis of ``transition support'' programs for youth
    with serious mental health conditions revealed that service providers
    attempting to serve this population must currently expend tremendous
    effort cobbling together fragments of funding that are generally time-
    limited, service-limited, age-limited, disability-limited, or income-
    limited. In a study of 18 providers serving the transitioning
    population, researchers found that these 18 providers used 40 different
    fund sources, most of which were not shared by more than 2-3 providers.
    The most common category of funding was private (i.e. private
    foundations), rather than public sources. Without a stable,
    comprehensive funding base, the system of care for youth in transition
    will develop at a snail's pace.
        Similar issues of silos exist within children's services. An
    excellent publication analyzing the impact of separate Federal funding
    streams in children's systems is Help or Hindrance?: The Federal
    Government and Interagency Systems of Care for Children with Serious
    Mental Disorders.
        Fragmentation of services and conflicting program rules have long
    impeded children's and families' access to needed care. This issue
    brief examines the Federal Government's role from the perspective of
    State officials responsible for children's mental health programming.
    (February 2003), which can be found at http://store.bazelon.org/
    children.html.

        Senator DeWine. Senator Sessions has joined us. Jeff, do
    you have any opening comments?

                     Opening Statement of Senator Sessions

        Senator Sessions. I am delighted to have Linda Champion
    here. She is a champion for the mentally ill and has been a
    friend of mine for a number of years, has always been
    exceedingly helpful in helping me understand these issues, and
    is a leader in Alabama in it.
        I thank you for inviting her to testify. Good to see her
    husband, Graham, back there. They are really fine Alabama
    citizens and leaders in particular on this issue.
        Senator DeWine. Very good.
        Mrs. Champion, with that introduction, you are next.
        Mrs. Champion. Thank you so much, Chairman DeWine, Senator
    Sessions, Senator Reed, and Members of the Committee. Thank you
    so much for holding this critically important hearing today. I
    am truly honored to be part of this panel and to speak on
    children's mental health issues.
        I am Linda Champion of Montgomery, AL. Since 2000, I have
    been a member of NAMI Alabama working as a child advocate. I am
    also vice president of Alabama Family Ties, an advocacy group
    that collaborates with NAMI Alabama to provide support and
    education to parents of children and adolescents with mental
    illness. I am first and foremost the mother of a 17-year-old
    son who has been struggling with mental illness since the age
    of 7. It is from the perspective of both a mother and a child
    advocate that I am honored to come before you today and provide
    this testimony on the current state of the children's mental
    health system.
        NAMI is the Nation's largest grassroots advocacy
    organization, with 220,000 members representing children and
    adults with mental illness and their families.
        So often I have listened to families pour out their
    heartfelt stories of failed attempts to access mental health
    services for their child in a system that is fragmented, overly
    bureaucratic, and not at all family-friendly. The system fails
    to offer support, adequate information, and resources to
    parents and caregivers of children with mental illness. The
    opening statement of Surgeon General Satcher's Report on
    Children's Mental Health really says it all: ``the burden of
    suffering experienced by children with mental health needs and
    their families has created a health crisis in this country.''
    For families of children with mental illness, this is, quite
    frankly, an understatement. Our family's experience is right in
    line with the finding of the President's New Freedom Commission
    that our Nation's mental health system is in shambles, with no
    defined or coherent system at all. At various times, we are
    accused of being ambivalent and uncaring. It is also suggested
    to us that the sins of the father are visited on sons, a direct
    reference that Lee, who is my adopted son, was being punished
    for the sins of his father. Parents and caregivers of children
    with mental illness in my State and communities across this
    country are forced to navigate a fragmented, overly
    bureaucratic, and family-unfriendly system.
        You have my family's personal story in the written
    testimony submitted for the record. I would like to highlight
    some of our struggles in attempting to access mental health
    services for Lee. I will do so in referencing numbers: three,
    the number of acute-care placements Lee has had in his short
    life thus far; five represents the number of residential
    treatment facilities Lee has lived in before he was finally
    stabilized so that he could function in a less restrictive
    environment; six is the number of different psychiatrists he
    has seen in his short life because of changes in residential
    treatment places; seven represents the number of changes that
    have occurred in medication combinations; 10,000-plus is the
    number of miles each year that we have traveled to visit Lee
    and stay involved in his treatment in the various residential
    treatment facilities he has been placed in; two is the number
    of custody changes that have occurred in Lee's life with our
    family. We gained custody through adoption, lost custody to
    obtain mental health treatment, and fought for custody of Lee,
    and he is now with us.
        But one represents the life of a child who has missed out
    on far too many normal childhood things--scouting, dating,
    going to proms, the normal things that parents usually
    experience with their children.
        As a parent who has lived through a difficult struggle in
    attempting to secure appropriate mental health services for
    Lee, I have the following suggestions of immediate actions that
    should be taken to help eliminate the burden that families are
    forced to endure and to improve services for children with
    mental health illnesses:
        End the discriminatory cap on private insurance coverage
    for mental health services. Our family was forced to give up
    custody because we quickly exhausted our lifetime private
    health benefits to provide the treatment for Lee. Please
    support the mental health parity legislation, S. 486.
        End the practice of forcing families to give up custody of
    their child to access mental health services. There is no
    greater injustice than forcing a parent to choose between
    maintaining custody of their child or seeking services for him.
    No parent should ever face this choice, yet it happens every
    day in this country, and families like ours are forced to give
    up custody and live with the consequences. Please support the
    Keeping Families Together Act to help end this practice, S.
    1704.
        Encourage States to develop effective interagency
    collaboration and partnerships between all child-serving
    agencies and with families. We were forced to act as case
    manager for Lee over and over again to work with the multiple
    agencies that failed to communicate.
        Train and educate all child-serving professionals about the
    early warning signs of mental illnesses in children. All child-
    serving professionals, especially school professionals and
    those working in child welfare and juvenile justice, should be
    trained to recognize the early warning signs of mental health-
    related concerns in children and know what to do when they
    exist.
        Build an effective children's mental health treatment
    system. Alabama and every other State must invest in building
    an effective children's mental health treatment system that
    provide a full array of services for children and families.
        Parents need to be provided with appropriate information
    about their child's diagnosis and treatment. We were often left
    in the dark about Lee's diagnosis and treatment options that
    were available to us. Much of what we learned we had to learn
    on our own.
        The good news is that the scientific community has made
    great strides in understanding childhood mental illnesses and
    treatment works for many children, if you can get it. Of
    course, we deeply regret that it took so long to access
    services for Lee and what we have missed along the way.
        Mr. Chairman, my dream is that the U.S. Senate and the
    House of Representatives will realize the precious treasure we
    have in our Nation's children. We can only help them reach
    their full potential if we can ensure that children who suffer
    from mental illnesses receive appropriate treatment and
    services. The health care needs of our children should be a
    national priority just like it is for juvenile diabetes,
    obesity, cancer, and other childhood illnesses.
        You and your colleagues are in a unique position to truly
    impact the quality of the lives of our children. We ask that
    you do so by doing the right thing today for our children and
    their families.
        I want to thank you for the opportunity to present one
    parent's story. I hope and trust that in some small way I have
    raised questions in your mind about what we can do to help our
    children.
        Thank you so much. I will be glad to answer any questions.
        Senator DeWine. Mrs. Champion, thank you very much.
        Response to Questions of Senator Bingaman From Linda M. Champion
        Question 1. Every year, an estimated 9 percent to 13 percent of
    children and adolescents in the United States experience a clinically
    significant mental disorder that warrants treatment. Yet, according to
    the Surgeon General's Report on Mental Health, two-thirds of these
    vulnerable young people do not receive any mental health treatment at
    all. What can we do to improve access to treatment?
        Answer 1. Improve Access to Treatment--Early Identification and
    Intervention
        The majority of children and adolescents suffering from a mental
    illness largely go undiagnosed due to a number of reasons: parents are
    uninformed of normal childhood development, schools label their erratic
    behavior as delinquent thus forcing them into a juvenile justice system
    that we already know from private and governmental studies are ill
    equipped to handle mental illness within their systems, and the
    appalling gaps in our child and adolescent mental health system force
    families to seek treatment far from their communities or none at all,
    and the lack of coordination within child serving agencies who serve
    some of these children in different capacities or not at all. Our child
    serving systems must be given opportunities and challenges to work
    together in identifying and treating children and adolescents with
    mental illnesses. From a parent's perspective, child-serving agencies
    do not work together and will point to their sister agencies for
    treatment services--forcing parents to become case managers for their
    child's treatment. My recommendations would be as follows:
        Train and educate all children-serving professionals about the
    early warning signs of mental illnesses in children. All child-serving
    professionals: day care providers, teachers, pediatricians, child
    welfare, juvenile justice professionals must be trained to recognize
    the early warning signs of mental health concerns.
        Build an effective children's mental health system. Federal, State
    Government, and commercial insurers should be encouraged to realign
    funding policies related to children's mental health needs and develop
    a comprehensive array of services to meet their needs. Alabama and
    every other State must invest in building an effective children's
    mental health treatment system that provides the full array of services
    for children and families. This includes home and community-based
    services, school-based services, respite services and more. We learned
    first hand about the critical shortage of qualified children's mental
    health providers and the lack of appropriate services. Our nation needs
    to address the critical shortage of children's mental health
    professionals and the lack of appropriate services, especially in rural
    communities.

        Question 2. Evidence-based treatments are now available for the
    full range of child and adolescent mental disorders. Yet these
    effective treatments fail to reach a majority of those who can benefit
    from them. How can we close the gap between research and real-world
    practice to ensure that evidence-based treatments are available in
    community service settings?
        Answer 2. Close the gap between research and real-world practice to
    ensure that evidence-based treatments are available in community
    service settings.
        We know there is a large, reliable, and evidence-based body of
    knowledge in the research community to know what works for our
    children, yet there is a definite delay in the transference of this
    knowledge to the very people who would benefit from it. From my
    perspective, professionals often do not have sufficient knowledge to
    make both accurate diagnosis and effective pharmacological
    interventions. Parents must then do the research themselves and
    advocate for their children. Not all parents are able to do this and
    our children languish in ineffective mental health systems. A
    collaborative public/private oversight organization comprised of both
    Federal representatives and private professionals from the child and
    adolescent psychiatric community should be established to review;
    approve and certify; publicize, their findings; and lastly educate all
    mental health care professionals on these findings. Federal grant
    programs should follow their recommendations. Accurate information on
    evidence-based practices must be disseminated to States, training
    initiatives on these practices should be established, and policy
    changes in Federal funding to States willing to effect change should be
    made. And lastly, families should be involved in the process to ensure
    fidelity to the process.

        Question 3. Children with serious emotional disturbance often have
    multiple problems and require services from several systems, including
    the mental health, educational, child welfare, and juvenile justice
    systems. How can we enhance the coordination and collaboration of
    various child-serving systems?
        Answer 3. Enhance the coordination and collaboration of various
    child-serving agencies.
        Encourage States to develop effective interagency collaborations
    and partnerships between all child-serving agencies and with families.
    Encourage all Federal child serving agencies to establish performance
    based indicators for collaboration programs--reward those States that
    are willing to work together by blending and braiding Federal and State
    dollars. Provide Federal seed money to States so that data systems can
    be created to provide both monitoring of collaborative programs, but
    accountability for agencies back to their respective Federal grantor.
    On the flip side, penalize those States that are not willing to set up
    true collaborative efforts.

        Question 4. The New Freedom Commission on Mental Health and the
    Surgeon General's report both identified a national shortage of mental
    health professionals trained to treat mental illness in children and
    adolescents. I have introduced S. 1223, The Child Health Care Crisis
    Relief Act, which creates incentives to help train, recruit, and retain
    child mental health professionals through loan repayments,
    scholarships, and grants. Do you feel passage of this legislation would
    be helpful in reducing the shortage of qualified professionals?
        Answer 4. Passage of S. 1223, The Child Health Care Crisis Relief
    Act.
        Absolutely, as we know the bill creates incentives to help recruit
    and retain child mental health professionals providing direct clinical
    care, and to improve, expand, or help create programs to train child
    mental health professionals. The passage of this legislative would
    create a richer infrastructure of child and adolescent professionals.
    The lack of qualified mental health providers is part of the reason for
    the unacceptably high number of youth with mental illnesses that fail
    to receive treatment and why families are often told that they must
    wait on long waiting lists for services for a seriously ill child.
        The Surgeon General put it best in stating that there is a
    ``dearth'' of child psychiatrists, appropriately trained clinical child
    psychologists, and social workers in this country. Here are the facts:
        The Federal Government has designated 3,543 urban, suburban, and
    rural localities as Mental Health Professional Shortage Areas due to
    their severe lack of psychiatrists, psychologists, social workers and
    other professionals to serve children with mental illnesses;
        According to the U.S. Bureau of Health Professions, the demand for
    the services of child and adolescent psychiatrists is projected to
    increase by 100 percent by 2020, while the number of these
    professionals is expected to increase by only 30 percent resulting in a
    severe shortage of child and adolescent psychiatrists;
        According to the American Academy of Child & Adolescent Psychiatry,
    there are currently approximately 6,300 child and adolescent
    psychiatrists in this country with a need at 32,000;
        The National Center for Education Statistics within the U.S.
    Department of Education reports that the national average student-to-
    school counselor ratio in U.S. schools is 513:1, more than double the
    recommended ratio of 250:1.
        The consequences of untreated mental illnesses in children are
    devastating. These youth are at higher risk for school failure and drop
    out, alcohol and drug use, suicide (the 3rd leading cause of death for
    10-24 year old young people), and engaging in high risk and unlawful
    activity.
        In Alabama, our families know on a very personal basis the effect
    of mental health professionals. Many times, parents will see three or
    four different therapists and/or psychiatrists per year in visiting
    mental health clinics, or need to travel great distances to seek
    services for their children.

        Senator DeWine. Ms. Altenburger?
        Ms. Altenburger. Mr. Chairman, Members of the Subcommittee,
    my name is Barbara Altenburger, and I am from Philadelphia, PA.
    I am the mother of Bruce Altenburger, who is a 15-year-old. I
    would like to thank you for the opportunity to speak about a
    serious problem I and many other parents across the country
    have encountered in trying to access services for our children
    through the public mental health system. We struggle to become
    our child's advocate--often learning how to make the system
    respond through a trial-and-error process. We become
    overwhelmed, frustrated, confused, and emotionally drained by
    the process. Many parents give up.
        It is important for you to know that the range of needed
    mental health services is frequently unavailable, that there is
    very little coordination among the systems that are mandated to
    serve our children, and that there is usually no plan to
    determine which public agency should be responsible for serving
    a particular child. This evasion of responsibility results in
    long delays in providing children with desperately needed
    mental health and related services. Consequently, our children
    are unserved, underserved, and inadequately served.
        The mental health needs and problems of children are
    diverse in nature and intensity. Some children have disorders
    that respond to intervention, diagnosis, treatment, and
    services. Others with more complex disorders and needs often
    find that their tragic plights are made more extreme by
    inadequate mental health services. Although every parent's
    story is unique, let me outline generally what my experience
    has been and how it is relevant to the experience of many other
    parents and children with severe emotional disturbances.
        My story and that of my son Bruce is a story of the
    difficulty of diagnosing mental disorders in children and
    adolescents. It is about the difficulty of finding qualified
    specialists to care for a very troubled child, and the even
    greater difficulty of getting access to needed care because of
    health insurance barriers. It is about the pressures put on
    parents to give up custody of their children to get needed
    mental health services. Finally, for children who are eligible
    for publicly funded care, it is about what some call the
    ``public mental health system.'' Parents across the country can
    tell you that there is no system. But it is worse than that. It
    is a maze.
        My child and many other children have gotten services
    through a variety of different, uncoordinated programs. The
    school system has provided certain services. Behavioral issues
    have led to contact with the juvenile justice system and its
    services. We have gotten services through other publicly funded
    programs. But there has never been any coordination between
    these agencies and no true system of care providing needed
    wraparound services.
        As a result, parents must become their child's best
    advocate and case manager. I have no reason to think that
    mental health services in Philadelphia are markedly better or
    worse than those elsewhere. My experience is that rather than
    enlisting parents in their child's recovery, too many programs
    lack respect for parents. In the children's recovery too many
    programs lack--I am sorry. Parents are seldom given a role in
    planning or even decisionmaking concerning their child's care.
    My experience is that while public programs are intended to
    help our children, they too often fail them. Yet the philosophy
    too often is that the ``child failed the program'' rather than
    vice versa.
        What is it like to have a child with bipolar disorder and
    learning disabilities? What is it like to be a mother perceived
    as incompetent? What is it like to be the parent of a child
    who, from an early age, always seemed to require more? A child
    who was noticed, but often for negative reasons. A child whose
    school, from nursery school on, continually suggested
    conferences. A child whose years in elementary schools were
    marked by frequent contact with principals, teachers,
    counselors. A child who seemed to be almost but never quite
    okay.
        At different times my house has been a battleground. My son
    has been severely depressed, angry, out of control, hysterical,
    and manic. At times he would be full of remorse--[Pause.]--
    excuse me--and experience great bewilderment over his
    behaviors. I felt helpless and pained by his apparent distress.
        My family had urged me to have my son evaluated by a child
    psychiatrist. It took over 90 days for our first appointment
    paid for by my personal insurance. As a result of the
    evaluation, my son was diagnosed as having severe emotional
    problems and possible bipolar. From that time on, Bruce has
    been seen by a variety of psychiatrists, and every one tried a
    different approach, different medication, and gave a different
    diagnosis. And during this period, Bruce was evaluated by the
    school psychologist because of a variety of behaviors,
    including running out of school, crying in the classroom,
    walking in the hallway while class was in session, and yelling
    that he wanted to go home. It was at this time that I could no
    longer afford private insurance because of the high out-of-
    pocket costs it required me to bear. I then turned to the
    county mental health system.
        My first experience at a community mental health center was
    devastating as I was told that I was the cause of my son's
    problems--the cause of my son's problems and that I needed
    treatment, that he was perfectly okay. I was stunned that a
    professional could make this statement after meeting with me,
    not my son, for approximately 40 minutes and when the
    psychiatrist wanted to give me a prescription for Bruce which
    would calm him down and enable me to handle him. I went to
    another community mental health center and was put on a long
    waiting list.
        And the process continues across our country of long
    waiting lists, inexperienced mental health workers, and a
    dramatic lack of public health system psychiatrists, and of
    parents being told that their child has failed the program.
        What I thought would make a difference never made enough of
    a difference. My child does not stay on an even keel for longer
    than a month or two.
        My child has attended many different special education
    programs for children with severe emotional disturbance
    provided by the school system. Through our public mental health
    system, he has been placed in residential treatment facilities
    for long-term treatment and has been hospitalized. During his
    hospital stays, he has been drugged to the point where he
    became incoherent. He has been labeled as ``severely
    emotionally disturbed'' as well as ``conduct disordered'' and
    ``bipolar.'' I have been told that his future is bleak, and at
    other times that he could have a productive life. I have been
    criticized for being overly involved and for doing too much, as
    well as reproached for being underly involved and not trying
    hard enough. I have been blamed for the ``failures'' at our
    home, school, and community by some and praised for good
    parenting by others. I have been treated with respect, and
    ignored.
        Parents across the country feel that they are their best
    resource for their children. They are the only consistent
    factor in their child's treatment and can provide information
    and insight that can come from no other source. They steel
    themselves against the subtle and not so subtle accusations of
    blame and failure. Parents go from agency to agency, all
    professing to help troubled children. We read books written by
    ``experts.'' We receive counseling and attend seminars. We try
    to find a ``cure'' for our children's outbursts, inability to
    learn and socialize like apparent ``normal'' children, and a
    few of us do manage to find help from the mental health system.
    But for the unlucky majority, the feeling of hopelessness
    increases as they see little improvement despite their efforts
    to work cooperatively with professionals that work with their
    children. Many see a future full of heartache and little hope.
        I have not given up on my son and continue to fight for his
    well-being and for the provision of needed services to help him
    overcome his problems. But I demand that our public mental
    health programs not give up on him either. There is much that
    must be done to improve public mental health service delivery.
    I agree that it must be transformed. But the one key element of
    that change, I believe, must be a change in the relationship
    between these programs and the parents of these children.
        Regardless of whether a child is living at home or away
    from home, family members must be viewed as a primary resource
    for their children and must have a voice and a vote as an equal
    partner in the planning and decisionmaking concerning their
    child.
        Mr. Chairman and Members of the Committee, children are not
    little adults. They must be treated by professionals that have
    been trained to work with children and adolescents. Parents in
    every State urge you to make children's mental health a real
    priority and to develop and fund effective Federal programs
    that serve our children's mental health needs. We know that
    there are pockets of expertise, but that is not on a scale that
    bears any relationship to the magnitude of the problems we
    encounter every day. Designing these needed programs may not be
    simple, but they must include a few elements. They must have
    child-centered services that are family-focused, community-
    based, multisystem, culturally competent, and least
    restrictive. Such services must be available across the
    country, not just as pilots in a handful of communities. And
    given that our children represent the Nation's future, we must
    approach this with the seriousness, energy, and scope of the
    Manhattan Project.
        Thank you.
        [The prepared statement of Ms. Altenburger follows:]
                   Prepared Statement of Barbara Altenburger
        Mr. Chairman and Members of the Subcommittee: My name is Barbara
    Altenburger and I am the parent of Bruce Altenburger who is 15 years
    old. Thank you for the opportunity to speak to you about the serious
    problems I and other parents like me across the country have
    encountered in trying to access services for our children through the
    Public Mental Health System. We struggle to become our child's
    advocate--often learning how to make the system respond by a trial-and-
    error process. We become overwhelmed, frustrated, confused, and
    emotionally drained by the process. Many parents give up!
        It is important for you to know that the range of needed mental
    health services is frequently unavailable; that there is very little
    coordination among the systems that are mandated to serve our children
    and there is usually no plan to determine which public agency should be
    responsible for serving a particular child. This evasion of
    responsibility results in long delays in providing children with
    desperately needed mental health and related services. Consequently,
    our children are unserved, underserved or served inappropriately.
        The mental health needs and problems of children are diverse in
    nature and intensity. Some children have disorders that respond to
    intervention, diagnosis, treatment, and services. Others, with more
    complex disorders and needs, often find their tragic plight exacerbated
    by an inadequate public mental health system. Although every parent's
    story is unique, let me outline generally what my experience has been,
    and how it is relevant to the experience of many other parents and
    children with serious emotional disorders.
        My story and that of my son Bruce is a story of the difficulty of
    diagnosing mental disorders in children and adolescents. It is about
    the difficulty of finding qualified specialists to care for a very
    troubled child, and the even greater difficulty of getting access to
    needed care because of health insurance barriers. It is about the
    pressures on parents to give up custody of their children to get needed
    mental health services, finally, for children who are eligible for
    publicly funded care it is about what some call the ``public mental
    health system.'' Parents across the country can tell you there is no
    ``system.'' But it is worse than that. It is a maze. My child, and many
    other children, has gotten services through a variety of different,
    uncoordinated programs. The school system has provided certain
    services. Behavioral issues have led to contact with the juvenile
    justice system and its services. We have also gotten services through
    other publicly funded programs. But there has never been any
    coordination between these different agencies and no true system of
    care providing needed wraparound services. As a result, parents must
    become their child's most effective advocate and their case manager. I
    have no reason to think that mental health services in Philadelphia are
    markedly better or worse than they are elsewhere. But my experience is
    that rather than enlisting parents in the children's recovery, too many
    programs lack respect for parents. Parents are seldom given a role in
    planning or even decision-making concerning their children's care. My
    experience is that while public programs are intended to help our
    children, they too often fail them. Yet the philosophy too often is
    that the ``child failed the program'' rather than vice-versa.
        What is it like to have a child with a Bipolar Disorder and
    learning disabilities? What is it like to be perceived as the
    incompetent mother? What is it like to be the parent of a child, who
    from an early age, always seemed to require more? A child who was
    noticed, but often for negative reasons. A child whose school, from
    nursery school on, continually suggested conferences. A child whose
    years in elementary schooled were marked by frequent contact with
    principals, teachers, and counselors. A child who seemed to be almost,
    but never quite, okay.
        At different times my house has been a battleground. My son has
    been severely depressed, angry, out of control, hysterical, and manic.
    At other times he would be full of remorse and expressed great
    bewilderment at his behavior. I felt helpless and pained by his
    apparent distress.
        My family urged me to have my son evaluated by a child
    psychiatrist. It took over 90 days for our first appointment paid for
    by my personal insurance. As a result of the evaluation he was
    diagnosed as having serious emotional problems and possible Bipolar
    Disorder. From that time on Bruce was seen by various psychiatrists and
    each one tried a different approach, different medication and gave a
    different diagnosis. And during this period Bruce was evaluated by the
    school district psychologist because of his various behaviors including
    running out of the school, crying in the classroom, walking the
    hallways while classes were in session and yelling that he wanted to go
    home. It was at this time that I could no longer afford private
    insurance because of the high out-of-pocket cost it required me to bear
    and I then turned to the county mental health system.
        My first experience at a community mental health center was
    devastating as I was told that I was the cause of my son's problems and
    that I needed to be in treatment and that he was perfectly okay! I was
    stunned that a professional could make this statement after meeting
    with me, not my son, for approximately 40 minutes. I was astonished
    when the psychiatrist wanted to give me a prescription for Bruce which
    would calm him down and enable me to then ``handle him''. I went to
    another community mental health center and was put on a long waiting
    list.
        And the process continues across our country, of long waiting
    lists, inexperienced mental health workers, a tremendous lack of public
    mental health system child psychiatrists, and of parents being told
    that their child failed the program.
        What I thought would make the difference never made enough of a
    difference; my child does not stay on an even keel for more than a
    month or two at a time.
        My child has attended many different special education programs for
    children with serious emotional disturbance provided by our school
    system. Through our public mental health system he has also been placed
    in residential treatment facilities for long-term treatment and been
    hospitalized. During his hospital stays he has been so drugged, that he
    became incoherent. He has been labeled ``severely emotionally
    disturbed'' as well as ``conduct disordered'' and ``Bipolar.'' I have
    been told his future is bleak and, at other times, that he can have a
    productive life. I have been criticized for being over-involved and
    doing too much, as well as reproached for being under-involved and not
    trying hard enough. I have been blamed for the ``failures'' at home,
    school, and community by some, and praised for good parenting by
    others. I have been treated with respect, as well as patronized and
    ignored.
        Parents across the country feel they are the best resource for
    their children. They are the only constant factor in their children's
    treatment and can provide information, insight, and continuity that can
    come from no other source. They steel themselves against the subtle and
    not-so-subtle accusations of blame and failure. Parents go from agency
    to agency, all professing to help troubled children. We read books
    written by ``experts.'' We receive counseling and attend seminars. We
    try to find a ``cure'' for our child's outbursts, inability to learn
    and socialize like other apparent ``normal'' children and a few of us
    do manage to find help from the mental health system. For the unlucky
    majority, the feeling of hopelessness increases as they see little
    improvement despite all their efforts to work collaboratively with the
    professionals that work with their children. Many see a future full of
    heartache and little hope!
        I have not given up on my son, and continue to fight for his well-
    being and for the provision of needed services to help him overcome his
    problems. But I demand that our public mental health programs not give
    up on him either. There is much that must be done to improve public
    mental health service delivery. I agree that it must be
    ``transformed.'' But the one key element of that change, I believe,
    must be a change in the relationship between these programs and the
    parents of these children.
        Regardless of whether a child is living at home or away from home,
    family members must be viewed as a primary resource for the child and
    must have a voice and a vote as an equal partner in planning and
    decision-making concerning their child.
        Mr. Chairman and Members of the Committee--children are not little
    adults and they must be treated by professionals that have been trained
    to work with children and adolescents. Parents in every State urge you
    to make children's mental health a real priority and to develop and
    fund effective Federal programs that serve our children's mental health
    needs. We know that there are pockets of excellence, but not on a scale
    that bears any relationship to the magnitude of the problems we
    encounter every day. Designing these needed programs may not be simple,
    but they must include a few key elements. We must have child-centered
    services that are family-focused, community-based, multi-system,
    culturally competent and least restrictive/least intrusive. Such
    services must be available across the country, not just as pilots in a
    handful of communities. And given that our children represent our
    Nation's future--we must approach this with the seriousness, energy,
    and scope of the Manhattan Project. Thank you.

        Senator DeWine. Thank you very much.
        Senator Reed?
        Senator Reed. Thank you very much, Mr. Chairman, and thank
    you, ladies, for your eloquent and very effective testimony.
        Senator Kennedy and Senator Dodd asked me to raise some
    questions on their behalf, so if I may, Ms. Wong, in our
    schools today children are so often subject to some traumatic
    events--snipers, CNN war stories, and contaminated mail. How
    can schools best help these students when they face these
    unusual traumatic circumstances? And what resources become
    paramount when responding to these types of situations?
        Ms. Wong. In our work also with the Department of Justice
    with Cops in Schools as well as our National Center for Child
    Traumatic Stress, we found that children are exposed to
    violence at a far higher rate than in previous generations and
    if we exclude even the violence that they see on TV. The
    research would suggest, at least the little that we have, after
    the Oklahoma City bombing, show that especially younger
    children are quite traumatized by television viewing of this
    sort. But with older children, we are finding higher rates of
    exposure to community violence, to bullying in schools, to acts
    of violence in the community.
        In Los Angeles, for instance, in certain of our
    communities, especially, I think this can be generalized in
    communities where there are large urban centers, communities
    where there are high rates of crime, gang activity, drug abuse,
    etc, we found up to 90 percent of our students in these
    selected communities had high rates of violence exposure, and
    27 percent of them had posttraumatic stress disorder at
    clinical levels, 16 percent of them had depression at clinical
    levels. We suspect that among special education children as
    well that are integrated into the school district programs that
    there might be high rates of violence exposure.
        I think what we have, we are very lucky in Los Angeles to
    have a school mental health program, but I think the testimony
    you heard today is very true. I think it is quite fragmented. I
    think schools try to piece it together as best they can and
    that there needs to be a system in place where across the
    country--it does not matter whether you live in a rural or
    urban or suburban area--that any parent can access these
    programs for their children, and particularly, as we said,
    programs that respond to trauma and depression and suicide.
        I think these in particular are problems and disorders and
    challenges that can be very well addressed, addressed early,
    and really have a very good outcome, both for the mental health
    of children and success in education.
        Senator Reed. Another question, if I may, and I will
    address it to Ms. Wong and Ms. Osofsky. We screen children for
    vision. We screen children for hearing. We screen children
    routinely for many things. And there is some discussion, at
    least in the literature, about screening children for mental
    health issues. Is that something that you would advocate or
    could comment upon? Ms. Osofsky and then Ms. Wong perhaps.
        Ms. Osofsky. The issue you raise, Senator Reed, is very
    important. The answer is yes, we do need to screen for mental
    health as we screen for medical conditions, physical
    conditions, vision, hearing, those types of issues.
        One of the problems and I think one of the very important
    areas that I would urge the subcommittee to consider as we are
    putting forth these bills is prevention and early intervention
    is very important, but we cannot accomplish prevention and
    early intervention unless we do screening. And there are ways
    to do screening ranging from better education for child-care
    providers, better education for child protection, certainly
    better education for primary care providers and pediatricians
    who see children as part of their well-baby checkups, including
    mental health screening as part of ESDP, the Medicaid screening
    that occurs routinely or is supposed to occur routinely for
    children when they are referred or an evaluation.
        And I think we need to turn to experts in the mental health
    community to develop screenings that are feasible to use. It is
    not feasible during a well-baby checkup to have to spend half
    an hour in-addition to other kinds of things. But what we are
    really interested in are screenings that would alert primary
    care physicians or child-care providers or child protection or
    even parent advocates under certain circumstances, a whole
    variety of people, to what we call red flags. And when they
    recognize some of these red flags, which could be behavior that
    is out of control, aggressive behavior, which could be
    withdrawal on the part of the child, which could be other types
    of things, to then refer them for a more extensive evaluation.
    So we need a variety of levels there.
        But if these things are picked up earlier, we are able to
    do much more in the way of prevention and early intervention.
        Senator Reed. Thank you very much, Dr. Osofsky.
        Dr. Davis, you sketched out a very complex and troubling
    situation where people age out of the system. The story of the
    young woman who was transferred from a pediatric psychiatric
    setting to an adult one sounds like something out of Hollywood
    in the 1930s--horrific.
        Part of the problem is trying to coordinate the system, not
    just the health care system but the housing system, the
    substance abuse system. Any thoughts you have on how we can
    better coordinate that?
        Ms. Davis. You are right. It does all need to be
    coordinated. Quick thoughts are difficult.
        I think one of the things that we have learned in
    children's mental health systems, the system-of-care principle
    where we recognize that children have needs across many
    different agencies certainly holds through this developmental
    stage. And so one of the things that we might think about would
    be the various mechanisms that we have already used to try to
    encourage more system-of-care development where there is a
    recognition that needs go across many different domains of
    functioning and that there is expertise and resources that go
    across our various public agencies.
        And so I think to the extent that we can extend that
    philosophy and those approaches--and basically there are
    various different mechanisms. There are Federal funding
    mechanisms. There are a variety of different mechanisms that
    have developed to try to enhance a wraparound or a system-of-
    care approach that would extend through age 25, I think we
    would benefit tremendously.
        I think what we have learned in children's mental health
    would help us tremendously. There is a tremendous strength in
    thinking about individuals developmentally, about thinking
    about the critically important role of families, that when you
    get into the adult mental health system, and other adult
    systems, it does not exist. They tend to think monolithically
    about the adult and not think developmentally, and tend to even
    more so minimize family involvement. So I think that we can
    take that strength from the kid side.
        On the adult side, there is a lot of expertise that the kid
    side does not have in terms of how do you help with vocational
    rehabilitation, the more current models on recovery. Those are
    very important--housing, co-morbid substance abuse.
        Those are all issues that the adult system knows about.
    They just do not know how to apply it to this developmental
    stage. So I think that there is a lot to be done concretely.
        I think at the Federal level there are many different
    things that we can examine and I cannot give you a short answer
    as to exactly what those should be, but clearly an examination
    of the funding mechanisms, as I mentioned, in Medicaid would be
    extremely important to look at in detail about what are some of
    the mechanisms there that are barriers? What are some
    mechanisms that could actually facilitate systems to solve this
    issue?
        I will just tell you quickly, last summer I spoke with one
    member from every State who was in charge of, who was a lead
    administrator for adult mental health systems for every single
    State in the country. And one of the things that they said
    about this population is that this age group, they are just one
    of many populations that they have to worry about. In essence
    it had not received a priority enough for adult systems to turn
    around and handshake with child systems. I think that we have
    many different mechanisms for encouraging that kind of
    prioritization and that is really what needs to happen at this
    time.
        Senator Reed. Thank you.
        Mr. Chairman, I am asking questions for both Senator Dodd
    and Senator Kennedy, so I will not ask for three times the
    time, but----
        Senator DeWine. I was going to say that would give you
    about half an hour.
        [Laughter.]
        Senator Reed  [continuing]. Half an hour, that is right,
    just the warm up time.
        First, Dr. Douce, thank you for your kind words about the
    legislation that the Chairman and I are sponsoring. One of the
    aspects of getting health care is the community's support for
    the individual. However, there is a stigma attached to asking
    for help particularly for a college student asking for help,
    any kind of help. Do you find that as a problem on campus?
        Ms. Douce. Yes, I do, although I think it is lessening, and
    we in fact have a stigma reduction committee as part of our
    counseling center prevention outreach. Next week is Suicide
    Prevention Week and our Stigma Reduction Group has designed a
    number of sort of informational pieces to reduce the stigma of
    accepting help and to demonstrate that it is actually a
    strength to seek help, and it is a strength to seek help
    earlier when the problem is just beginning than to lose your
    whole term by sinking deeper and deeper into a depression of
    anxiety.
        Senator Reed. Thank you very much. Senator Dodd wanted me
    to pose this question, and I recognize that none of the
    panelists are MD's, but the recent controversy surrounding
    antidepressants, and specifically the class of drugs known as
    selective serotonin re-uptake inhibitors, SSRIs, raises real
    questions about the appropriate use of these medicines in
    children. Would anyone like to advance a view as to the use of
    these medicines from your perspective, not as physicians but as
    someone who closely looks at the children's mental health
    system throughout the country? Dr. Osofsky.
        Ms. Osofsky. I work within a medical center and I consult
    frequently with child psychiatrists, and I am not an expert in
    psychopharmacology. However, we see a great deal of use of
    medications for children of all ages. We focus a great deal on
    very young children as well, even children 3-years-old, where
    we find their primary care physicians, often pediatricians,
    will put them on sometimes even more than one medication. Many
    of us are very, very concerned about the fact that instead of
    the issues that you are addressing in terms of screening,
    recognizing the problems, evaluation, early treatment,
    intervention, actually that speaks to the whole age range.
    People are very quick to put children on medication.
        Part of it is I think the reimbursement system because some
    of the reimbursement system is for a very few number of
    sessions, sometimes even just a short consultation, and people
    are looking for quick fixes. They think that the medication
    will change the behavior, and I think it is really not only
    unfortunate, but it does need to be used in a much more
    cautious way.
        What we would urge is to be able to do the things we have
    been talking about in terms of screenings, good evaluations,
    and then sometime medication is very helpful in conjunction
    with treatment, but that better evaluations will probably lead
    to much less medication as well as better reimbursement for
    services.
        Senator Reed. Thank you very much.
        Thank you, Mr. Chairman, you have been most gracious. Thank
    you.
        Senator DeWine. Good questions. Thank you very much.
        Senator Sessions?
        Senator Sessions. Thank you, Mr. Chairman. You have been a
    leader on this issue for so many years, and I am glad I could
    be here. I am sorry I had to be at a conference on health care
    this morning that caused me to be late.
        One of the things we talked about, Dr. Osofsky, at the
    hearing on how to contain health care costs, one of the
    suggestions that I made is, with regard to prescription drugs,
    that we are prescribing drugs that not only do not work, but
    sometimes are harmful. That article that Senator Dodd referred
    to and Senator Reed, indicates that is true on occasion. Do you
    feel like there is enough certainty of efficacy of certain
    drugs, and can we do a better job as a government helping to
    establish which ones are effective and which ones are not,
    therefore helping the psychiatrists and psychologists as they
    treat young people?
        Ms. Osofsky. Training is a very important issue, and
    certainly in our medical schools and our medical centers we
    offer a great deal of training related to psychopharmacology. I
    would agree that if people were better informed about
    medications that may work under certain circumstances and how
    they might be used, that it would be helpful.
        I think that, unfortunately, medications are being
    prescribed, medications that speak to issues of mental illness
    and mental disorders, and these kinds of issues, by people who
    have had less experience with how those medications might
    relate in various ways, but I also think, again, we are very
    quick to think that we can provide some kind of medication to a
    young person, as I say, even as young--we see them as young as
    3-years-old and 4-years-old. Instead of evaluating the problem
    in the context of what is going on with them, what is going on
    with the problem, provide support to the family, a much more
    integrated approach, so that then we might choose medication
    after a period of time, and certainly it is very helpful with
    various disorders, certainly bipolar disorder, other types,
    depression, it can be very effective. But we do need to
    evaluate certainly children within the context of relationships
    and be very careful in terms of the types of treatment. And we
    do need more reimbursement for services.
        Senator Sessions. Any brief comment on that subject?
        Ms. Champion, you are indicating, as did Ms. Altenburger,
    that you did not feel like that some of the professionals or
    health care personnel respected you or understood the
    difficulties you were facing. At one point I think you
    indicated they thought you were indifferent. Why do you think
    that is? Is that a problem in the system?
        Ms. Champion. Yes, it definitely is a problem in the
    system. Parents go through this blame and shame cycle. There is
    something inherent that a parent is to be able to control a
    child, and if you cannot control a child, you are deemed a bad
    parent. So you are not only----
        Senator Sessions. Is that at school too sometimes?
        Ms. Champion  [continuing]. It is at school. I think it is
    throughout the entire community, in school settings, in social
    circles, church circles as well, and it is very difficult.
    Parents usually feel very alone, very alienated. And mental
    health professionals by and large, unless you really get in and
    establish a dialogue and a relationship with the mental health
    professional, it is very difficult to do so. You are
    essentially separated from your child, whether you are entering
    an acute care system or a residential system. Your child is
    taken into the system and you are immediately separated from
    that child, and not much interfacing with them. The systems
    usually are not very family friendly to do so.
        That also bears witness to a lack of coordination among the
    child-serving agencies. There is a lot of finger pointing going
    on, and that of course, boils down to dollars and cents. If
    child-serving agencies can learn to braid and blend Federal and
    State dollars in a different way, I think that you will find a
    much better system overall for children, and a much fuller
    array and richer array of services for children.
        Senator Sessions. You certainly had a number of situations
    in which your child was moved, and you had to make a lot of
    different changes. Is that sort of symptomatic of what you were
    saying, that the system is fragmented and not well organized?
        Ms. Champion. Yes, sir. It certainly is. Mental health
    professionals usually are not aware of a higher level of care
    that is required for your child. They may certainly be able to
    recognize that an outpatient treatment is not suiting the needs
    of their child, that maybe residential treatment is required,
    but oftentimes they cannot point you to a residential treatment
    facility that would meet the needs of your particular child.
        Senator Sessions. Thank you.
        Ms. Altenburger, I thank you for sharing similar comments
    from your background. I think my time has expired.
        Thank you, Mr. Chairman.
        Senator DeWine. Dr. Davis, I am not sure I understand fully
    the barriers you are talking about in regard to this
    transitional period of time. Can you spell that out for me so
    that we can, my staff and I, and Senator Reed and Senator
    Sessions maybe can do something about this?
        Ms. Davis. I would be happy to. I think that the most
    concrete barrier that we see is that we have separate funding
    for child and adult services, and so what typically happens is
    those systems evolve to serve each of their mandated population
    as best they can. So we have various systems just preserving
    children. You have those who are in the child welfare system,
    special education. I do not have to tell you all the various
    systems that we have.
        What surprises me the most is when you get to a system
    where there is no obvious reason why there should not be a
    continuity within the mental health system. We have children,
    adolescents, young adults, adults, older adults, all who have
    mental health needs. We have split our systems into separate
    child and adult systems, and what happens within those systems
    is that the priority populations get defined differently, so in
    the child system we have youth with serious emotional
    disturbance, and adults is typically adults with serious mental
    illness.
        While in fact those disorders do not have to look very
    different, States tend to interpret those as being very
    different definitions. So in the adult system, they will
    typically have a more narrow definition because they feel like
    the adults that they are meant to serve are those with the most
    serious and chronic conditions, and they often then do not take
    into consideration what might be child--typically conditions
    that develop in childhood that could continue into adulthood.
    They say in their list, those are not diagnoses that get you
    entry into the adult system.
        So you have a group of young people, particularly things
    that involve more behavioral kinds of components like conduct
    or disruptive behavior disorder. If a young person is
    identified as primarily suffering from that kind of diagnostic
    criteria, when they go to--somebody has to apply for them to
    get into the adult system even though they are in the State's
    child system. They then have to apply. And at that point the
    eligibility person typically says: this is not one of our
    qualifying diagnoses. You cannot enter. So that is one of the
    major things.
        We just completed a study where we looked at, just in
    policy, the differences for eligibility for child and adult
    mental health systems within a singular State mental health
    agency, and with the exception of one State, every single State
    has some difference and some meaningful difference in their
    eligibility requirements, and they require youth who have just
    been served because they are a child, to meet the new service
    eligibility for adulthood. That is a funnel. In essence there
    is a significant group of young people who do not make it
    through that funnel because of that eligibility difference.
        What we tend to see as a result of that, the people who
    work with these young people know that they are not going to
    get them into the adult mental health system. They start
    screening them out, in essence.
        There are several States that show a tremendous marked
    decrease in receiving services at age 16, and while not all of
    that can be attributed to the service system, per se, young
    people can decline services. There are a variety of reasons.
    But one of the major ones that we know forces a barrier is that
    if case managers know that they are not going to be entitled,
    they start essentially screening them out of the system at that
    point. So you end up with a very small number who actually
    applies for eligibility to the adult system. That is at the
    State level.
        When we were doing that study we looked at Medicaid
    eligibility entitlements and definitions, and what you see over
    and over is that there are conditions and situations that will
    entitle a child to access Medicaid eligibility. Those
    definitions typically end at age 18. Sometimes States have the
    flexibility to end that at 18, 19, 20 or 21. None of those goes
    beyond age 21. What happens, in essence, is that you had a
    condition that could qualify for a child but now that you are
    now adult, you are no longer eligible for and you can lose
    those Medicaid entitlements at that point or that Medicaid
    service that you needed because you are not qualified any
    longer.
        Those are some of the simple concrete things that get in
    the way of being able to provide continuous services. I think
    the thing that more broadly leads to that is that we haven't
    recognized this as a developmental stage, that we tend to as a
    society say there is some age at which you are an adult, and we
    have legally made that 18. For drinking purposes and those
    kinds of things it is 21. But we do not recognize--we do for
    ourselves and for those of us who have children who are college
    age, most of us would not boot them out the door at 18. We know
    that they continue to need services and we know that there is
    sort of a new developmental stage that is being defined within
    developmental psychology called ``emerging adulthood,'' and
    that is defined as existing up to age 25. We as a society are
    not yet making our service systems accommodate the fact that we
    are not ready at 18 or 21 typically to function as adults, and
    yet these more vulnerable young people who have even fewer
    resources to draw from and forced out without any further
    recognition.
        So I think part of it is that we have made this false
    dichotomy, you are either a child or an adult, and our systems
    follow that and our funding follows that and our entitlements
    follow that, but it is not in fact matching up at all with what
    naturally occurs with a young person's development which
    extends much more toward age 25.
        Does that help clarify?
        Senator DeWine. Sure. I think it is difficult, I think you
    would agree it is difficult to translate that into legislation.
        Ms. Davis. It is, although I think an examination of
    Medicaid and----
        Senator DeWine. I mean your point is very well taken and I
    understand what you are saying, and we have got these
    artificial barriers and they have been erected over the years,
    and the question is how do you begin to try to break that down
    and how do you begin to deal with the reality of the way people
    live their lives, and we do not do that for anybody else, but
    yet we have set this up for this group of people, and we have
    kind of set this artificial barrier, and boom, there it is.
        Ms. Davis  [continuing]. I think one of the things that I
    was impressed with when I looked at the Medicaid eligibility is
    that there are some things that will extend for children who
    have disabilities, certain entitlements from 18 to 21. That is
    the kind of mechanism that may not open up the door for
    everybody, but given that this is a partly vulnerable group who
    has a disability, that kind of thing is possible.
        Senator DeWine. Thank you very much.
        Ms. Davis. You are welcome.
        Senator DeWine. Dr. Douce, let me ask you about--you have
    detailed, particularly in your written statement, what you have
    done at Ohio State. What is your feeling as far as the universe
    of colleges and universities across the country in how well
    they are doing, how well we are doing as a society in regard to
    providing mental health services to students today? How are we
    doing today versus in 1990, 1980, 1970? I mean what have been
    the trend lines here, particularly when we look at the suicide
    problem? Let us just focus on that.
        Ms. Douce. I think services are uneven I think across all
    colleges and universities. Some have extensive, comprehensive
    services available. Some have very limited services available.
    Some have no services available. I think the issue of suicide
    continues to be an issue, and I think the issue of anxiety and
    drivenness feeds that suicidality, that it is actually a
    combination of depression and anxiety that causes someone to
    choose to end their lives, to end the despair.
        The fact that it is uneven, the fact that college
    administrators struggle with the rising costs of college and
    trying to cut costs in any ways they can, some cut mental
    health services out all together. Some provide very limited
    mental health services.
        Senator DeWine. If you do not know the answer to this, just
    tell me, but is there a difference between campuses that are
    residential campuses and campuses that are less residential or
    more commuter campuses?
        Ms. Douce. Absolutely. The reality is when you have
    students on campus and you have a high residential population,
    you have them 24 hours. So you have suicide attempts in the
    dorms. You have drug overdoses. You have assaults. You have
    things that you have to deal with. Those campuses tend to also
    put mental health services in play because they need them for
    the residential students.
        For campuses that are primarily commuter, sometimes those
    campuses, especially if they are regional campuses or draw from
    a variety of different counties, those students are really at
    risk to get the services they need because the local county may
    not choose to serve them if they are not a resident of that
    county. So the commuter services, the regional campuses, the
    campuses that actually are trying to attract more rural
    students, more first generation students, have some of the
    greatest need and some of the fewest services.
        The Act, what I think is important about this Act is it
    applies grants. There will be competitive grants. There will be
    a strong evaluative component to those grants, so that services
    that are needed in unmet areas can be responded to.
        Senator DeWine. You use the term ``availability of
    services.'' It is one thing to be available. It is another
    thing to be accessed. How do you deal with that?
        Ms. Douce. I think there is a real important need to have
    prevention and outreach services to really try to establish a
    wellness culture on your campus. If we are out there doing
    programs at different clubs, in classrooms, in residence halls,
    in a number of places, you present yourself as someone for whom
    you might go seek help. That is how you fight stigma reduction.
        Availability is also about waiting lists and----
        Senator DeWine. About what? I am sorry.
        Ms. Douce [continuing]. Waiting lists, and the reality on
    college campuses, when you talk about a trend from 1975 to
    1995, many, many, many more students are seeking services, and
    most university counseling centers have a hard time meeting
    those services at the time they need to be met. If you spend
    several weeks getting up the courage to go seek counseling, you
    finally go, you get an urgent important or an intake
    appointment, and then you wait another 3 or 4 weeks to get
    service, you have lost your term. That is a problem.
        Senator DeWine. Can you comment at all about the culture on
    a campus? Is there any relationship between, if you know, if
    you have read any studies on this or if there have been any
    studies on this, about the pressure on campus, the academic
    pressure or any other kind of social pressure connected with
    the suicide rate?
        Ms. Douce. I am trying to think of studies in my head.
    Certainly the biggest increase that we have seen in the last 10
    years is anxiety-related disorders, full-blown panic attacks,
    obsessive-compulsive disorders, anxiety disorders in general.
    That anxiety is related to the stress that many people feel
    about needing to be at a certain place, needing to achieve in a
    certain way, where we in our attempt to maximize student
    success, have created a younger generation that is quite
    driven, and driven with a sense of fear of not meeting certain
    expectations, and that fear drives self-destructive behavior,
    suicidal behavior, alcohol abuse behavior, cutting. We are
    seeing more cutting in college students than we ever have.
        Senator DeWine. Seeing more what?
        Ms. Douce. Cutting, which is a self-injurious behavior,
    where you actually cut yourself in a ritualistic way. Twenty
    years ago when I started, if I saw a student who was cutting, I
    could assume that they had had childhood sexual abuse. Today
    that is not the case. It is actually a shared behavior, a very
    self-destructive shared behavior, to relieve the anxiety and
    stress that builds up. That does then relate to suicide. It
    does then relate to serious mental health issues.
        I would like to say that we have covered a whole gamut, and
    more of the students in your system are coming to my system.
    That is an advantage. One of the real advantages of medication
    is we have many, many more people who are able to go to college
    with serious mental disorders than they ever have before. We
    have many, many more people with a variety of disabilities
    going to college than we ever have before. They struggle with
    transition. They struggle with adjustment. They are at higher
    risk and need higher services, but it is to this Nation's
    advantage to have our country continue to be able to compete
    globally, that we graduate a much greater range of students,
    more diverse students, more culturally sensitive.
        Senator DeWine. Sure. I wonder if you could talk in more
    detail about the alcohol and drug abuse focused services that
    you provide. In particular, I am interested in students with
    these co-occurring disorders. I wonder if you find a large
    number of students with clinically diagnosed mental health and
    substance abuse disorders.
        Ms. Douce. Yes, the dual diagnosis is a major issue. In my
    center we have expertise, a full range of expertise, but
    specific expertise in substance and alcohol abuse. We work with
    the Students Wellness Committee to try to do both alcohol
    education and substance abuse education. We have groups that
    focus on success, not excess, which is really not an
    abstinence-based program but a responsibility-based program. We
    accept court mandated DUIs. Part of my dream is actually to
    develop a college student DUI program, because I think when
    college students are sent to the community DUIs, they look at a
    number of people that are older, have more serious addictions
    and distance themselves. Yet, I think that first legal or
    judicial infraction is an absolute educational opportunity to
    require people to look at their own behavior.
        Senator DeWine. Dr. Osofsky, you talked about the need to
    have professionals better trained to identify people who have
    these problems. I wonder if you could talk, for example, about
    pediatricians. Are they getting the professional training today
    in medical schools?
        Ms. Osofsky. Actually, that is one of the groups that we
    need to address very clearly related to training. The focus in
    pediatric training has been, or primary care training as well,
    primarily physical health. They may focus on vision and hearing
    and those types of things, but much more on taking care of
    those types of issues than mental health issues, and, yes, I
    would agree with you very strongly that we need to address, in
    medical school education as well as additional training for
    pediatricians, ways to identify, the red flags to identify
    mental health issues and refer for additional consultation.
        One of the programs that I am involved with, Harris Center
    for Mental Health, where we provide training to mental health
    professionals, we also are actually just starting a program
    where we are going to be consulting with pediatricians and
    pediatric clinics as well to offer mental health consultation,
    but also education and training for pediatricians.
        So many things are missed at that point that that issue is
    very important because often either at a well-baby check, or
    even an emergency room check, that is the only time we are
    going to see some of these people with the kinds of problems
    that we are talking about, and I think that the issues that are
    being raised on the college level with older children are also
    very relevant for the younger children, the issue of
    availability of services, access to services, the stigma around
    services, and I think if we broadened our education related to
    mental health issues for primary care physicians and
    pediatricians, perhaps some of that stigma could be reduced and
    be part of a regular care that they generally achieve.
        Senator DeWine. Senator Sessions.
        Senator Sessions. I do not know whether NIH is investing
    enough in that. To me, some more research in general might be
    helpful in how to diagnose and how to treat these illnesses but
    that is another issue I suppose.
        Dr. Davis, you really raise an interesting point about
    children growing into adulthood. I visited a group home in
    Huntsville, AL. It was basically built by HUD. We provide
    housing for people who have difficulties anyway, and so they
    pooled that money with some other money from other agencies,
    and had a very nice group home for people with mental illness,
    and it helped them, many of whom were working independently. Do
    you think that would be something that might work for a number
    of these children? And what percentage do you think could
    benefit from something like that?
        Ms. Davis. If I understand specifically what that
    represents, this is certainly a group of young people who need
    support around housing as they age out of the children's
    system. Many of them are leaving foster care and foster care
    settings, so they do not have----
        Senator Sessions. A home to live in.
        Ms. Davis. Any homes to go to, yes. So there is a large
    number. I cannot put a precise number, but there are various
    States that have looked at the child welfare population and
    estimated up to 60 and sometimes higher proportions, have a
    serious emotional disturbance, depending on where those studies
    have occurred. So there is a good number of young people who
    have those kinds of conditions exiting foster care with a
    disability. That would clearly be helpful.
        I think that there are many things that are available
    within adult systems for adults with mental illness. I think
    the crux of the difficulty for this age is twofold. You have a
    group that is aging out of the children's system with a
    category that we consider serious emotional disturbance, that
    there is a group of them that will not meet the eligibility for
    adults with serious mental illness because we define that
    slightly differently. So because of that sort of arbitrary
    distinction, some of them will not get into that housing
    because somebody will say, oh, you do not have a mental health
    disability because you do not meet the criteria any longer.
        For those who do meet that criteria, they may have
    developed their mental illness as a young adult, or they may
    have had it since they were younger. The difficulty that we
    have is that a lot of those programs that are currently funded
    that adults can access are largely holding adults that are 30-
    to 50-years-old, and so when we create a group situation in
    particular, it is not very feasible to just make any old adult
    program open to our younger adult population. First of all,
    they will not accept it, they will not stay. For many of them
    if they do stay it can be quite traumatizing for them. For many
    of them essentially they just walk away. So it is a complicated
    issue. It certainly is helpful. I certainly would not want to
    say no, it would not be helpful, but I think we have to look at
    some of these other barriers that are contributing to that not
    being as helpful as it should be.
        Senator Sessions. Thank you very much.
        Ms.  Champion, I know you and I talked one time about the
    school and IDEA Individuals with Disabilities Education Act.
    Most schools are supposed to be able to provide appropriate
    care for children with any disability, and they heroically try
    really. But if you made a decision that there was a private
    center that your child would be particularly benefited by going
    to instead of going to school, and you decided you were
    prepared to fund that yourself, would you get any reimbursement
    from the system at all for that today, even though it would
    relieve a financial burden on the school system if you had sent
    the child to the school?
        Ms. Champion. I would probably need to work very
    aggressively with the school system in accessing services
    through an IEP, and quite frankly, would more than likely
    involve some litigation on the part of trying to do that. I
    think some come full circle in thinking that schools have been
    given quite a bad rap in trying to provide services for
    children that they consider seriously emotionally disturbed,
    and I think more often that advocacy groups and family networks
    need to reach out to school systems and provide a better
    relationship with them, to go in and actually assist them in
    providing a safe environment within the school system or an
    alternate environment that is going to the school system
    instead of parents going in and being very contentious in
    trying to access services for their children.
        I would say that in our State, I think that is beginning to
    happen. Certainly with the school officials that we have had an
    opportunity to talk with recently, they know that they cannot
    handle this age, this population on their own and that it is
    not going away. By just putting them into alternative schools
    or boot camps, they are still coming back into the system with
    the same issues, and they need to look at alternative ways in
    approaching it.
        NAMI has a very wonderful program called Parents and
    Teachers as Allies that certainly needs to be looked at in
    every school system, but I think that particularly in our State
    we are going to try to reach across that bridge to school
    officials and work more effectively with them, and quite
    frankly, it is going to take a culture change.
        Senator Sessions. I know you have been a leader in that,
    and I thank you for it and the advice you have given me on it.
        I think making it easier, Mr. Chairman, that a person could
    use just a small amount of the money the school system would
    have used for care for this child, plus their own. They may
    have an opportunity to make a decision that could provide
    really special care for a child, and it is pretty inflexible as
    it is today. I think we can do better on that.
        Thank you very much, and thank you for your leadership.
        Senator DeWine. Thank you, Senator Sessions.
        This has been a great panel. Thank you very much. We
    appreciate all of you being here, sharing your experiences with
    us. We intend to move forward. This subcommittee has two bills
    that we have introduced. Senator Reed and I have introduced
    one. Senator Dodd and I have introduced another bill. We hope
    to move forward on this legislation. We also have taken from
    you some very specific, several specific recommendations which
    we would hope in the future to be able to move forward on. So
    this has been a very productive meeting. Thank you very much.
        [Additional material follows.]

                              ADDITIONAL MATERIAL

                  The Keeping Families Together Act (S. 1704)
        Each year, thousands of parents are forced to relinquish their
    custody rights to the State in order to obtain mental health care for
    their seriously ill children. Services to treat severe mental disorders
    in children can be extremely expensive and private insurance tends to
    run out after a few months, leaving even middle class parents unable to
    afford the cost. Yet affected children often remain ineligible for
    Medicaid because their parents' income and assets keep them from
    qualifying for assistance. With no other way to get their treatment for
    their children, parents are forced to choose between custody or care.
    The GAO reported in April that, in 2001, parents in 19 States placed
    12,700 children in State welfare or juvenile justice agencies in order
    to obtain mental health services for them. Moreover, that estimate is
    considered low, because 31 States did not respond to the survey.
        The Keeping Families Together Act seeks to keep these children with
    their families and includes three main components:
                        family support grants to states
        Authorizes $55 million in competitive grants to States that would
    be payable over 6 years to create an infrastructure to support and
    sustain statewide systems of care to serve children who are in custody
    or at risk of entering custody of the State for the purpose of
    receiving mental health services. These grants are intended to help
    States serve these children more effectively and efficiently, while
    keeping them at home with their families.
        The Family Support Grants could be used to:
         Foster inter agency cooperation and cross-system financing
    among the various State agencies with responsibilities for serving
    children with mental health needs. This will help to eliminate
    fragmentation of services and will increase the capacity of agencies to
    share public resources. States already dedicate significant dollars to
    serving children in State custody, and this will enable them to use
    those resources more effectively, while still allowing children to
    remain with their families;
         Provide a comprehensive array of community-based mental
    health and family support services for eligible children and their
    families that will be sustainable after the grant has expired;
         Facilitate the design of a State plan through a
    collaborative process involving State child-serving agencies, parents,
    providers, and other stakeholders;
         Provide outreach and public education programs to increase
    awareness about the services that are available to eligible children
    and their families;
         Carry out administrative functions related to the programs
    and activities carried out under the grant, including the development
    and maintenance of data systems.
        Requires States to provide matching funds over the 6-year period of
    the program, ultimately equaling not less than $2 for each $1 of
    Federal funds provided under the grant. States would also be required
    to report annually, beginning with the second fiscal year in which a
    State receives funding under a grant, on the progress and success of
    the programs and activities carried out by the State under the grant.
    Not later than 3 years after the date of enactment, and after the full
    6 years of the grant, a report to Congress is required evaluating the
    success of States in using the grants to eliminate the problem of
    custody relinquishment.
                         Federal Interagency Task Force
        Requires the Administrator of the Substance Abuse and Mental Health
    Services Administration, acting in conjunction with the Director of the
    Office of Juvenile Justice and Delinquency Prevention, the
    Administrator of the Administration for Children and Families, the
    Administrator of the Centers for Medicare&Medicaid Services, and the
    Assistant Secretary of Education for Special Education, to establish a
    Federal interagency task force to examine mental health issues in the
    child welfare and juvenile justice systems and the role of their
    agencies in promoting access by children and youth to needed mental
    health services. The task force would also be charged with monitoring
    the family support grants, making recommendations to Congress on how to
    improve mental health services, and fostering interagency cooperation
    and removing interagency barriers that contribute to the problem of
    custody relinquishment.
     allows states to use the medicaid home- and community-based waiver to
        treat children with mental illness in less restrictive settings
        Modernizes a critical Medicaid State waiver program by making
    children and adolescents in residential treatment facilities, like
    those in hospitals, eligible for home- or community-based services
    under Medicaid, providing that the cost is no higher than that of
    institutional care.
       Prepared Statment of the American Academy of Child and Adolescent
                                   Psychiatry

    Introduction

        The American Academy of Child and Adolescent Psychiatry (AACAP) is
    a medical membership association established by child and adolescent
    psychiatrists in 1953. Now over 6,900 members strong, the AACAP is the
    leading national medical association dedicated to treating and
    improving the quality of life for the estimated 7-12 million American
    youth under 18 years of age who are affected by emotional, behavioral,
    developmental and mental disorders. AACAP supports research, continuing
    medical education and access to quality care. Child and adolescent
    psychiatrists are the only medical specialty fully trained in the
    treatment of mental illness in children and adolescence.
        The AACAP thanks Substance and Mental Health Services Subcommittee
    chairman, Sen. Mike DeWine (R-OH) for holding this important hearing,
    and we applaud his continued commitment to increasing access to
    treatment for children and adolescents with mental illnesses.
        The Surgeon General's 2000 report on children's mental health
    estimated that 20 percent of American children and adolescents have a
    diagnosable mental or emotional illness. Of this number, fewer than one
    in five receive treatment. Barriers to treatment include a lack of
    affordability, lack of availability of specialists, including child and
    adolescent psychiatrists, and stigma. Anxiety disorders, ADHD, and
    depression are the most common mental illnesses occurring in children
    and adolescents.

    Early Intervention

        The barriers to early identification and treatment are the critical
    areas of focus for children and adolescents with mental illnesses. Five
    studies funded by NIMH have consistently identified under-recognition
    of mental illnesses as a major problem. Missed opportunities, because
    of under-identification or no opportunity for identification,
    translates into losing the option of early intervention. For children
    and adolescents, an early diagnosis and adequate treatment may limit
    the severity of a life-time disorder or minimize a less severe
    disorder. After the option of early intervention is lost, the chain of
    life-time devastation from mental illness looms ahead: school failure,
    family crises, substance abuse, entrance into the juvenile justice
    system, more and more costly interventions, and on into adulthood. The
    President's New Freedom Commission on Mental Health listed the
    expansion of early intervention services for children and adolescents
    with mental illnesses as one of its main recommendations in its final
    report, Achieving the Promise: Transforming Mental Health Care in
    America. In the report, the Commission states, `` If the system does
    not appropriately screen and treat them early, these childhood
    disorders may persist and lead to a downward spiral of school failure,
    poor employment opportunities, and poverty in adulthood. No other
    illnesses damage so many children so seriously.'' The increased
    availability and affordability of treatment will enable earlier
    identification and interventions for children and adolescents with
    mental illnesses.

    Coverage

        Today, approximately 85 percent of all privately insured families,
    and a growing number of those covered by Medicaid, are in a managed
    health care plan. Children are being enrolled in managed care plans at
    a higher rate than adults and represent a disproportionately larger
    number of managed care members. The current efforts to contain costs
    increase the risk of compromises in the quality of care for a
    population that is still growing.
        One of the key barriers to treatment for children and adolescents
    with mental illness is a lack of parity in insurance coverage for
    mental illness. Discriminatory coverage, including limiting the number
    of inpatient and outpatient visits, and higher copays and deductibles
    for children and adolescents, is uniquely counterproductive. Reducing
    treatment options contributes to missed school days, involvement with
    the juvenile justice system or even suicide attempts. Too often, a
    misperception of the cost of mental health coverage prevents access to
    care, but the Congressional Budget Office (CBO) estimates that managed
    nondiscriminatory mental health benefits will increase average premiums
    by less than 1 percent the cost of the average benefit. The cost offset
    of not treating a child with a mental illness will prove to be much
    more expensive in the future.
        Due to the risk-adjustment strategies to protect the financial
    interests of managed care organizations, there is little incentive in a
    managed care system to offer parity for services for children with the
    most serious disorders. These children tend to be high service
    utilizers and are often involved in multiple agencies. They pose a
    challenge to managed care systems because they require services at
    various levels of intensity for extended periods of time. These
    children are then left underserved, resulting in shifting the
    responsibilities for care to other systems such as special education,
    child welfare or juvenile justice. Co-pays for children and adolescents
    should not only reflect parity but should be set so moderately that
    families seek early intervention, evaluation and treatment for mental
    and physical illnesses without the fear of financial disaster. With
    early intervention and treatment, children will live healthier,
    productive lives into adulthood. When managed care systems deny
    coverage to children and adolescents, an expedited appeals process
    should be in place to resolve denials.

    Coverage that Meets Developmental Needs

        Children and adolescents are too often treated according to adult
    standards. They are not little adults and need age-appropriate
    treatment coverage that respects developmental needs. Accurate
    comprehensive evaluations are more time consuming for children and
    adolescents. This is recognized in the CPT manuals for interactive
    psychotherapy. Health care plans should not limit the assessment of all
    levels of neurological and behavioral development. There are current
    pressures for child and adolescent psychiatrists to prescribe
    medication without a full evaluation, which is not good medicine or an
    efficient use of resources.
        Most managed care systems for behavioral health have been designed
    without input from a child and adolescent psychiatrist or family
    members of children with serious emotional disorders. Most do not
    understand the importance of strong links among the treatment, home,
    and community environment. Services that support a system of care for a
    child's treatment plan should not be denied automatically if they fall
    outside the inpatient or outpatient benefit or be discriminated against
    because the benefit is for a mental illness. Children and adolescents
    with serious emotional disorders and their families need many kinds of
    services from a variety of sources, such as schools, community mental
    health centers, and social service organizations. Many managed care
    systems are not yet coordinating these services that children with
    serious emotional disorders and their families need, and, too often,
    when the services are implemented, the coverage for their use is denied
    and only partially covered.
        Coverage, with parity, should include a full continuum of
    treatment--including, but not limited to, preventive interventions,
    early identification, assessment and diagnosis, case management,
    outpatient treatment, partial hospitalization, home-based services,
    detoxification and inpatient treatment. Treatment for children and
    adolescents requires that services involve the child or adolescent and
    family as well as appropriate collaboration with other significant
    caregivers, teachers, physicians or providers of other needed services.

    Access

        The health system's denial of access to specialists, such as child
    and adolescent psychiatrists for mental illnesses is a major concern.
    Children and adolescents should have access to all providers in the
    plan, with direct access to specialists with training in treating the
    disorders of childhood and adolescence. Child and adolescent
    psychiatrists are physicians specifically trained to treat children and
    adolescents with mental illnesses. The denial of access to such
    specialists can result in inadequate diagnosis and treatment of the
    illness and delayed treatment.
        Often children and adolescents are faced with discriminatory
    coverage combined with their physicians being eliminated from the
    provider networks. Continuity of care between a child and adolescent
    psychiatrist and his/her patient is crucial to the well being of the
    child. Trust between a doctor and patient is critical, and the
    relationship between a child or adolescent and his/her psychiatrist
    must not be compromised. When a child or adolescent is suddenly
    required to change therapists, the trust and confidence that child
    depends on is undermined, damaging the outcome of the treatment and of
    future treatments.

    Systems of Care

        Currently, most State mental health, education, juvenile justice,
    social service and child welfare agencies do not provide coordinated
    treatment for children and adolescents with mental illnesses; although,
    a number of federal laws and programs, including Medicaid and the
    Individuals with Disabilities Education Act (IDEA) mandate
    comprehensive coverage for low-income children, children in the child
    welfare system and children with disabilities, including children with
    serious emotional disorders. Differing eligibility criteria for
    services and a lack of State mandates or funding streams contribute to
    fragmentation of State service systems. This lack of coordination
    across State service systems, coupled with the lack of parity in the
    insurance system, has forced many families to consider the
    unthinkable--giving up custody of their children to State child welfare
    or juvenile justice agencies in order to access treatment for their
    children.
        No services should be denied that support a system of care for a
    child's treatment plan. Children and adolescents should have direct
    access to the services that support them and their families. A serious
    emotional disturbance touches every part of a child's life. Therefore,
    children and adolescents with serious emotional disturbances and their
    families need many kinds of services from a variety of sources, such as
    schools, community mental health centers, and social service
    organizations.
        Studies suggest that effective systems of care:
         reduce the need for hospital and out-of-home residential
    treatment placements;
         improve how children behave and function emotionally;
         improve school performance;
         reduce juvenile involvement with the justice system; and
         provide services to more children and families who need
    them.

    Model Systems of Care Program

        The Substance Abuse and Mental Health Administration's (SAMHSA)
    Comprehensive Community Mental Health Services for Children and Their
    Families program is a model systems of care program for States. The
    program is a discretionary grant and contract program that supports the
    development of intensive community-based services for children and
    their families based on a multi-agency, multi-disciplinary approach
    involving the public and private sectors. Recent evaluation data found
    notable improvements for children after 1 year of services in the
    following areas: reduced law enforcement contact, improved school
    attendance and academic performance, and improved emotional and
    behavioral problems. The program currently funds 67 programs in 43
    States and services a total of 46, 633 children and adolescents with
    serious emotional disorders. The AACAP recommends an increased
    appropriation for the SAMHSA's Children's Mental Health Services
    Program so that it may be expanded to serve all States.

    Medicaid Access

        The Medicaid program provides low-income families with
    comprehensive health care. Medicaid's Early, Periodic, Screening,
    Diagnosis and Treatment (EPSDT) program mandates that all children
    eligible for Medicaid receive comprehensive mental health treatment.
    Despite this mandate, full implementation in all States has not
    occurred, leaving many eligible children without access to the
    comprehensive care they are entitled to by law. This is due to a lack
    of parity for mental illnesses in State Medicaid systems, differing
    State eligibility criteria and regulations, and a lack of coordination
    between service systems. Allowing middle-income families of children
    with mental illnesses to buy-in to the Medicaid program, for example
    through the Katie Becket waiver currently available in the States of
    Kansas, New York and Vermont, provides access to intensive treatment
    services such as residential treatment centers for these families that
    they would otherwise not be able to afford. Increased access to
    Medicaid coverage for middle-income families and low-income families
    who are ineligible for Medicaid because of family assets such as
    ownership of a home, would remove one of the barriers to treatment for
    these children and their families. The AACAP recommends passage of the
    Dylan Lee James Act, S. 622 and H.R. 1822, to allow families of
    children with serious emotional disorders to buy into the Medicaid
    program.

    Shortage of Children's Mental Health Professionals

        A final barrier to treatment for children and adolescents with
    mental illnesses is the lack of available specialists trained in the
    diagnosis and treatment of these disorders. In particular, there is a
    critical national shortage of child and adolescent psychiatrists. There
    are about 7,000 child and adolescent psychiatrists nationwide while the
    prevalence rate for children and adolescents with mental illnesses is
    between 10 and 15 million. Data on this professional shortage comes
    from several sources including the Surgeon General, the President's New
    Freedom Commission on Mental Health, the Council on Graduate Medical
    Education (COGME), a committee of the Department of Health and Human
    Services and the Bureau of Health Professions. The Abt Associates
    report for COGME concluded that by 1990, the Nation should have over
    33,000 child and adolescent psychiatrists. The Bureau of Health
    Professions projected that between 1995 and 2020, the use of child and
    adolescent psychiatrists will increase by 100 percent, with general
    psychiatry's increase at 19 percent. An increase in the numbers of all
    children's mental health professionals can help reduce one of the
    barriers to treatment for the families of children with mental
    illnesses. The AACAP recommends congressional action in this effort,
    including passage of the Child Healthcare Crisis Relief Act, S. 1223
    and H.R. 1359, which would encourage individuals to enter all
    children's mental health professions through the creation of education
    incentives.

    Conclusion

        Children and adolescents in America, regardless of their family
    income level, should have access to psychiatric treatment, which should
    be provided on a nondiscriminatory basis integrated with other
    necessary medical services. Services should include a full continuum of
    treatment--including, but not limited to, preventive interventions,
    early identification, assessment and diagnosis, case management,
    outpatient treatment, partial hospitalization, home-based services,
    detoxification and inpatient treatment. Treatment for children requires
    that services involve both the child or adolescent, and family as well
    as appropriate collaboration with other significant caregivers,
    teachers, physicians or providers of other needed services.
        Summary of Legislative Recommendations:
         Enactment of the Paul Wellstone Mental Health Parity Act,
    S. 486 and H.R. 953, sponsored by Sen. Domenici (R-NM) and Kennedy (D-
    MA), and Reps. Kennedy (D-RI) and Ramstad (R-MN).
         An appropriation of $140 million for SAMHSA's
    Comprehensive Community Mental Health Services for Children and Their
    Families program.
         Enactment of the Keeping Families Together Act, H.R. 3309
    and S. 1704.
         Enactment of the Dylan Lee James Act, S. 622 and H.R.
    1822, sponsored by Sens. Grassley (R-IA) and Kennedy (D-MA), and Reps.
    Sessions (R-TX) and Waxman (D-CA).
         Enactment of the Child Healthcare Crisis Relief Act, S.
    1223 and H.R. 1359, sponsored by Sens. Bingaman (D-NM) and Collins (R-
    ME) and Reps. Kennedy (D-RI) and Ros-Lehtinen (R-FL).
        The AACAP appreciates this opportunity to submit a statement for
    the record on issues throughout the developmental process for children
    and adolescents with mental illnesses.
        Attachment: Health Care System Leaves Mentally Ill Children Behind.
    Boston Globe, March 26, 2004.http://www.boston.com/news/globe/health
    science/articles/2004/04/27/health	care	ststem	leaves	mentally	ill
    children	behind/

                      Prepared Statement of Michael Faenza
        Mr. Chairman and Members of the Subcommittee: The National Mental
    Health Association (NMHA) is the country's oldest and largest nonprofit
    organization addressing all aspects of mental health and mental
    illness. In partnership with our network of 340 State and local Mental
    Health Association affiliates nationwide, NMHA works to improve
    policies, understanding, and services for individuals with mental
    illness and substance abuse disorders, as well as for all Americans.
    Established in 1909 by a mental health consumer, NMHA's philosophy has
    consistently been that the needs of consumers and communities must be
    at the center of all policy and practice concerns in the mental health
    field.
        We applaud the careful work this committee is undertaking in
    studying the many facets of mental health in this country. The subject
    of your hearing today is critically important because children are
    falling through the cracks of our ``mental health system,'' and those
    cracks are widening. We welcome your focus.
        As a society, we attach a high value to children's well-being. Yet
    our country is failing children and adolescents by not addressing or
    treating their mental and emotional health. We are failing because we
    are not addressing the issues that keep children and adolescents from
    receiving appropriate care: these include the limited access to
    treatment and services; the fragmentation of services; the lack of
    investment in prevention; the shortage of providers with sufficient
    expertise; stigma of mental illness; and the failure to engage families
    and children in mental health and substance abuse prevention and
    treatment efforts. Sadly, even the limited research information we
    possess about children's mental health is not being translated into
    clinical practice. If we do not change this trajectory, we will
    continue to foster a cycle of emotional and behavioral problems for our
    children resulting in school failure, substance abuse, violence,
    imprisonment, and most tragically, wasted lives that could have been
    changed.

    ``Symptoms'' Compromising Quality of Care

        While there are many serious problems in the mental health system
    that cross the age span, a unique set of ``symptoms'' too often
    compromise the quality of children's mental heath care. They include:
         Requiring diagnosis prior to treatment. As noted by the
    U.S. Surgeon General, due to the ongoing physical, emotional, and
    cognitive development of children, it can be difficult to accurately
    diagnose mental disorders. Premature or inaccurate diagnosis can result
    in inappropriate treatment and labeling. In addition, a key aim of
    children's mental health should be to address mental health problems
    before they progress into conditions that meet the diagnostic criteria
    for a mental disorder. Unfortunately, both public and private financing
    mechanisms tend to require that a child be diagnosed prior to receiving
    treatment.
         Treating only ``ED children.'' Many public systems require
    not only that a child have a diagnosis, but that the child meet the
    diagnostic, durational, and functional requirements set by the State/
    county for a ``serious emotional disturbance.'' In other words, systems
    purposely avoid treating children until their condition reaches a point
    where functioning is severely impaired.
         Lack of child- and family-centered services. When
    children's mental health needs are addressed at all, the system for
    serving them is often treated as an extension of the adult system, and
    as a result truly child- and family-focused service planning and
    delivery is in short supply. In many cases, children with mental
    disorders are not served at all by the mental health system, but end up
    instead in other systems, such as juvenile justice.
         Shortage of practitioners specifically trained in
    children's mental health.
         Too many children inappropriately placed in the juvenile
    justice and child welfare systems due to lack of MH services for
    children and families. Some families are even forced to relinquish
    custody to these systems just to get MH services for their children.
    Increasing numbers of children with emotional or behavioral disorders
    are entering the juvenile justice system. Researchers estimate that
    between 50-75 percent of youth in the juvenile justice system have
    diagnosable mental health disorders; one in five has a serious
    emotional disorder (ED). Correctional systems are simply not designed
    to provide mental health services and are ill equipped to meet and
    often even recognize the mental health needs of children.
         Lack of prevention and early intervention.
        This committee, in its oversight capacity and as an architect of
    SAMHSA reauthorization legislation, has an opportunity to address these
    problems, and make children's mental health and well-being the priority
    it must be. We urge the Committee to make the needs of America's
    children and youth with, or at risk of, mental disorders a major focus
    of SAMHSA's authorizing legislation. We recommend that you develop
    legislation that places major emphasis on high-quality community-based
    mental health treatment services and prevention (to include screening,
    preventive services and early intervention) of mental disorders in
    children and youth.
        Core Principles:
        We believe the following core principles should shape the
    development of that needed policy direction:
        (1.) The promotion of good mental health, prevention and treatment
    for children and youth with mental disorders is the responsibility of
    every family, school, social service agency including child welfare,
    law enforcement, and juvenile justice system.
        (2.) Effective mental health services for young people are based
    and administered in the communities where children and families live.
        (3.) Parents, siblings and other caretakers are central to the
    treatment of children with mental disorders, and should be seen as
    critical partners and participants in every child or youth receiving
    treatment.
        (4.) In addition to specific centers or agencies that need to be
    developed and funded to deliver community-based services for children
    and youth with mental health needs, organizations that serve children
    and families--including child welfare, juvenile justice and schools--
    need adequate resources to screen and identify children and youth at
    risk of increased mental health challenges.
        (5.) Schools, child welfare agencies, and juvenile justice systems
    need to provide preventive mental health services, identify and provide
    basic services for children and youth who are screened and known to
    have mental disorders, and work collaboratively with other community
    organizations to ensure good outcomes for each child.
        (6.) Many youth with mental disorders also have substance abuse
    problems, and substance abuse prevention and treatment should work in
    an integrated fashion with children and youth, not separately, for good
    outcomes for children.
        (7.) Children and youth are often the most adversely affected
    individuals regarding the experience of living through any disaster,
    witnessing or being exposed to violence, loss of family members, living
    in poverty, having poorly met physical health care needs, and
    experiencing acute medical problems. Community organizations that
    address these issues need the resources to identify the mental health
    needs of children and youth and ensure that appropriate treatment is
    accessed.
        Policy recommendations:
        Building on those principles, we urge that a SAMHSA reauthorization
    bill, and this committee's oversight of SAMHSA, address the following:
        (1.) SAMHSA leadership must address the reality that mental health
    services and preventive programs for children and adolescents are
    scarce in number and poor in quality; given the magnitude of the need,
    the situation could aptly be termed a national crisis.
        (2.) Mental health services and prevention programs targeting the
    needs of vulnerable children and families should be near the top of
    SAMHSA's goals and investments in community.
        (3.) Federal agencies including the Department of Education, Office
    of Juvenile Justice and Delinquency Prevention, Maternal and Child
    Health and other URSA programs, CDC, NIGH and Homeland Security should
    all be linked formally and with clear charges to SAMHSA. SAMHSA needs
    support and direction to move much more vigorously towards
    collaborative planning and pooled resources with other Federal agencies
    to meet the challenges to the mental health of children across the
    United States.
        (4.) Prevention resources within CMHS need to be greatly expanded,
    and should be a public health cornerstone of the agency.
        (5.) A fourth SAMHSA center that focuses on the promotion of mental
    health and the prevention of mental disorders in children and youth, as
    well as the risks and solutions for adults, is needed.
        (6.) The Children's Mental Health Services Grant program
    (hereinafter the ``Systems of Care'' program) within the Center for
    Mental Health Services should have greater flexibility to meet the
    needs of youth. We urge that you revisit eligibility rules that limit
    program access to youth who meet the criterion of having a ``serious
    emotional disturbance,'' and, as a result, too-frequently deny needed
    services until a youngster's condition deteriorates.
        (7.) The needs of children in communities who are at risk because
    of traumatic events or disaster argue for a robust new Grant program
    within SAMHSA.
        (8.) A new Grant program to support community-based planning would
    help move many more communities toward developing needed systems of
    care.
        The National Mental Health Association looks forward to working
    with this Committee to make its vision for meeting the special needs of
    children a reality for tomorrow.
                 Statement of Susan Mikolic, Parent & Advocate
        Chairman DeWine and members of the Committee, I am Susan Mikolic of
    Lake County, Ohio. I have two children with mental illness. My oldest
    son, now 16, has been ill since age 5. His challenges include Bipolar
    Disorder, Attention Deficit Disorder, Oppositional Defiance Disorder,
    Post-Traumatic Stress Disorder, multiple medical problems, and several
    learning disabilities. My youngest son, now 14, has been ill since age
    6. His challenges include Bipolar Disorder, Attention Deficit Disorder,
    Anxiety Disorder, multiple medical problems, and several learning
    disabilities.
        I am a registered nurse by education and experience. I have,
    however, out of necessity, devoted the last 6 years to mental health
    advocacy. Today I present to you as a very concerned parent and
    citizen. It wasn't long after my children were diagnosed and I
    attempted to access services that it became clear to me that a large
    portion of the services my children needed didn't exist, or if they did
    exist, were either of poor quality, ineffective, inaccessible, or cost
    prohibitive. I rolled up my sleeves and got involved in an attempt to
    make the system better for my children and all others to walk in their
    footsteps. I served as President of National Alliance for the Mentally
    III (NAMI) Lake County, member of the NAMI Ohio Board of Directors, Co-
    chair of the NAMI Ohio Children's Committee, co-chair of the Ohio
    Department of Mental Health Children's Division Strategic School
    Success Committee, co-chair of the Professional Development work group
    of the ``Mental Health, Schools, and Families Working Together Toward a
    Shared Agenda'' Initiative, and countless other task forces,
    committees, work groups, panels, and advisory groups. Due to the extent
    of my involvement, visibility, and expertise I have become an
    established advocate for childhood mental health issues, assisting
    families around the entire State as they attempt to secure needed
    services for their children.
        I mention all this to provide a framework for your interpretation
    of my testimony as I will not only relate my personal family
    experience, but will also reflect those of struggling families all
    around the State of Ohio. I will focus my comments primarily in the
    area of middle-income families as this is my area of expertise and
    experience.
        I stated earlier that it became clear that the services my children
    needed were either non-existent, poor quality, ineffective,
    inaccessible, or cost prohibitive. I will expand.
        1. High quality, effective, accessible, and affordable psychiatric
    care--My children, and all these children, need high quality,
    effective, accessible, and affordable psychiatric care for our
    children.
        As you know, there is a critical shortage of Child Psychiatrists. I
    am blessed to live in Cleveland, a medical hub in the State of Ohio. We
    have a large number of Child Psychiatrists, yet waiting lists remain at
    3 months for an initial appointment, with many practices closed to new
    patients. We are blessed. There are areas around the State and nation
    that have few, if any, Child Psychiatrists. I see the initiative to
    stem this gap with use of Pediatricians. This practice concerns me. As
    a healthcare professional, it is clear to me that in this information
    age one cannot know all there is to know in multiple specialties. Many
    pediatricians have a special interest in Attention Deficit
    (Hyperactivity) Disorder (ADD/ADHD), for example, and diagnose and
    treat the child for ADHD with stimulants. Because they rarely are well
    versed in the entire field of Child Psychiatry, they often miss co-
    morbidities, as well as exacerbate other undiagnosed illness by
    medication management. Specifically, I refer to the use of stimulants
    and antidepressants, the use of which can unmask an underlying Bipolar
    Disorder. Children are given stimulants for ADHD, and antidepressants
    for Depression, Anxiety Disorder, and Obsessive-Compulsive Disorder,
    and often no one is watching for a potentially emerging mania. Both of
    my children were originally treated with antidepressants and mood
    stabilizers for depression, anxiety, and ADHD, and both were triggered
    into mania. Had they not been under the care of a Child Psychiatrist I
    believe the mania would have been identified as the ``impulsiveness''
    of ADHD and they would not have been appropriately diagnosed and
    treated until some time later when untold health and social damage
    would have taken place.
        I will relate a personal experience where such a thing happened
    even with the oversight of a Child Psychiatrist. My youngest son was
    diagnosed with Bipolar Disorder. His Psychiatrist eliminated pediatrics
    from her practice. It was too time-consuming. It was better for her
    economically to only treat adults who didn't need interaction with
    school systems, etc. We changed care to another local Child
    Psychiatrist. He did not concur with the Bipolar Diagnosis and promptly
    took my son off his mood stabilizer, remaining on antidepressants and a
    stimulant. My son went into a manic mood swing shortly thereafter. He
    was walking on the roof on one foot, was extremely activated, etc. When
    notified that my son was walking on the roof the Psychiatrist
    responded, ``Is that dangerous?'', saying my son was getting more
    impulsive and increased his stimulant dose. Eventually he ended up on
    triple the recommended dosage when I sought a 2nd opinion, where the
    Psychiatrist looked at his mood charts and promptly concurred that he
    indeed had Bipolar Disorder. If I did not know what mania looked like,
    from having experienced with my other child, the mania would have
    continued unchecked, indeed, exacerbated, by his medication management.
        I hear stories like this all around the State. It is my personal
    opinion that these children's illnesses need to be managed by a
    psychiatric specialist.
        Now, one decides their child needs to see a Child Psychiatrist.
    They must next determine if that Psychiatrist is a provider on their
    insurance panel. Most are not on all panels and now the family finds
    that the pool of Child Psychiatrists available shrinks by perhaps 50
    percent or more. Then the family calls to make an appointment with the
    Psychiatrist only to BE scheduled 3 months out even though their child
    is in crisis. One is then guided in the meantime to go to the Emergency
    Room for any crisis situations. This is not a helpful option. The staff
    in most Emergency Rooms are not adequately trained to assist with this
    population. If indeed the child is admitted to a psychiatric hospital
    based on the Emergency Room visit, which only occurs if the child is
    actively homicidal or suicidal, the child only stays 3-5 days and is
    discharged with poor follow-up care. Essentially hospitalizations are
    non-productive in terms of helping stabilize a child.
        In this area of discussion I will relate two personal experiences
    to highlight some of today's realities.
        We have a family history of 5 suicides. I took my son to the
    Emergency Room hoping to have him hospitalized for his safety. He was
    not admitted because he was not suicidal ``enough'' I ask you, if you
    had a significant family history of suicide, your child has a personal
    10 year history of profound depression and suicidality, and is now
    actively suicidal, would you feel that suicidality is so measurable
    that one's suicide risk could be nonchalantly dismissed?
        I now relate another example of how Emergency Room care may be
    used. My son's illness was increasingly unstable. At one point he
    refused an appointment with his Psychiatrist due to this instability
    and limited energy to make the trip to the physician's office. His
    illness continued to escalate. I called his attending Child
    Psychiatrist asking for an urgent appointment, a med change over the
    phone, or some guidance. His Psychiatrist told me to take him to the
    Emergency Room. I said that would do no good as he was not suicidal or
    homicidal. She said, ``Yes, I know, but maybe if he waits in the
    Emergency Room for 4 or 6 hours he will think twice about canceling an
    appointment with me.'' My, what a cost-effective, compassionate, and
    humane approach to a cry for help. We changed Psychiatrists.
        Now, in the area of changing Psychiatrists I would like to address
    an increasingly common complication. The parent who carries the family
    health insurance changes jobs or the employer changes carriers, and,
    the child's established Child Psychiatrist is not a provider on the new
    insurance panel. One must then choose if they will self-pay or put
    their child through the distress and care lag inherent in relaying
    history and trying treatments already attempted, once again. In
    addition, changing Psychiatrists is not equivalent to changing
    orthopedists or pulmonologists. One has to build a relationship with
    the Psychiatrist to trust them enough to share troubling symptoms.
    Changes in the treatment team create excessive and unnecessary distress
    as well as treatment delays as the new physician learns the patient.
        2. Financial Burdens--Let's talk cost. If you stay with the child's
    current Psychiatrist on a self-pay basis, you will pay $65-$150/hour.
    Also, virtually all insurance plans limit the number of appointments
    per year that are covered for psychiatric care. If your child has a
    typical care schedule they will see the Psychiatrist once per month,
    and their therapist once per week. This totals 64 appointments per
    year, of which greater than 2/3 will be self-paid by the family. And if
    they self-pay for an out of network psychiatrist that cost increases.
    At one time our family paid $500/week out of pocket for psychiatric
    care. Historically, for the last 11 years, our family has spent
    $20,000-$25,000/year out of pocket on medical expenses. My husband and
    I are college educated, professional people, earning good wages, but a
    family cannot sustain bills like this on an ongoing basis. We took 3
    home equity loans against our home and eventually could no longer
    afford all the loan payments. Last fall we sold our home.
        If my child had leukemia, we would not have lost our home, we would
    not be broke. The lack of insurance parity creates an unconscionable,
    unnecessary burden on families. It is truly a present day
    discrimination as clear as lack of voting rights for women or the
    historical discriminatory practices against minority populations. I
    read somewhere a great analogy regarding this practice. I do not recall
    where I read it and therefore cannot credit the author, but the author
    noted that the illness of Parkinson's Disease is thought to be related
    to a deficit in the neurotransmitter Dopamine and that Schizophrenia is
    associated with abnormally high levels of dopamine. Yet Parkinson's
    Disease is well covered under insurance plans and Schizophrenia is not.
    The author suggests that this practice is as ludicrous as insuring the
    right leg but not the left. This practice is plain and simple,
    unadulterated discrimination and this country should be outraged at the
    discriminatory nature of this practice.
        But they aren't . . . and why not? I believe insurance parity has
    not been achieved yet, in large part, due to misunderstandings and
    stigma about mental illness. In our old neighborhood the children were
    forbidden to play with my children because of their illness. This was a
    professional, educated community. But they were afraid, out of a lack
    of knowledge. They assumed mentally ill children were violent children.
    For 10 years my children had no friends. The families would not even
    acknowledge us if we said hello. We have to do better than this for our
    children. We recently moved when we had to sell our home. My son is
    trying to make friends in his new environment, which has truly been a
    blessing in this one sense. He said to me last night, ``Mom, I can't be
    myself. I want friends and if I act myself I won't make any friends. Do
    you have any idea what it was like to not have any friends for 10
    years. I don't want that again . . . so I pretend to be someone else
    with them.''
        The need for friends and to fit and to be accepted is at it's
    strongest in the school environment. The children use what little
    coping energy they have to try to fit in and be accepted. This leaves
    little reserves to devote to education.
        3. Educational Issues--School related issues are the number one
    reason families call me for assistance. They are in tears, desperate to
    find help. The biggest common denominator in this struggle has been the
    lack of knowledge about mental illness among the school staff
    interacting with our children as well as ingrained judgments about
    children with mental illness. We, as most all parents of mentally ill
    children, have been told that our child was just being lazy, refusing
    to do work. Yes, on the most surface level this would be the
    observation. But our children's struggles are much more complex than
    that superficial assessment. My children are coping with extreme
    emotion swings, concentration problems, attention problems, medication
    side effects, poor sleep, and the list goes on. We need to ask, ``What
    are the child's behaviors telling us? What do they need?'' and work to
    meet those needs so that our children can involve themselves in
    learning. One cannot learn when they are falling asleep from powerful
    medication, when their thoughts are racing in a mania, when they have
    entirely lost initiative from a depression. When children are in
    exacerbations of their mental illness, they cannot access the general
    education curriculum. Instead of providing accommodations to help our
    children, we are repeatedly told by school staff that we are enabling
    our children as they push our children beyond their limits and
    sacrifice their health. I have repeatedly heard this scenario over and
    over again in my advocacy work with families. And I have experienced it
    first-hand throughout my children's school careers.
        We have had to pay a Psychiatrist to come to a school meeting to
    explain, in her words, ``that we are dealing with a situation where my
    son is making a choice between `should I kill myself today' and
    algebra.'' We had to bring the doctor because we, as parents, are not
    believed when we inform the school of our children's challenges. We
    have been offered a ``choice'' of home instruction Mon./Wed. and Tues./
    Thurs. at 2:45 or 3. What if a parent's work schedule necessitated them
    never being home from work prior to 5 p.m.? When I pointed out to the
    school that this hardly reflected true choice, I was told again, ``You
    have a choice. You may CHOOSE between Tues./Thurs. and Mon./Wed. And
    you can choose either 2:45 or 3 p.m.'' That's hardly a variety of
    choices. My son at one point could only handle 1 hour of home
    instruction per day, but the district couldn't secure a tutor who would
    tutor 1 hour/day 5 days a week. So his services were reduced to 1/hour
    day twice a week.
        As a more complete example of what our children are up against, I
    will briefly describe the challenges our family fought when my oldest
    son was in 7th grade. In the spring we met to plan his 7th grade
    Individual Education Plan (IEP) with services in an Serious Emotional
    Disturbance (SED) inclusion setting. Yes, plan for what 7th grade would
    bring. However, none of the 15+ school personnel at that meeting
    informed us how very different the structure of 7th grade would be,
    requiring him to change classes for every class, 11 different
    personalities to adjust to, 11 different sets of expectations, chaos in
    the halls, gym and hall lockers. These things may seem insignificant to
    a healthy adult, or even a healthy child, but for my child and most
    children with mental illness, these are huge barriers. Again, I imagine
    out of lack of knowledge, those at the IEP meeting felt these things
    weren't worthy of mention. They were, however, to prove to be the
    antecedent of my son's decompensation into suicidality and catatonia.
    Fall classes began and within 2 weeks my son was identifying how
    stressed and pressured he was feeling. I began to communicate with the
    school about the need to reduce his stress and the need to access the
    accommodations planned for in his IEP. At 1 month into school his Child
    Psychiatrist was alarmed at the decompensation that had occurred in
    just 1 month. She cautioned we must reduce his stress immediately. I
    sent letters, notes, made calls, and had meetings with school personnel
    as we tried to implement his IEP plan that allowed for him to return to
    his SED class if he was feeling stressed or having a bad day. I asked
    that the school use my son as his own barometer of what he could handle
    for the day. He knows best how he is feeling. This suggestion was met
    with disdain. I was ``called to the principal's office'' and told I was
    enabling my son. I was actually supporting my son's survival strategy.
    During exacerbations of his illness he cannot handle large groups of
    people, sometimes any people at all. He was feeling very volatile and
    was asking to accommodate his need for less chaos and stress. As I said
    in a recent letter to our Special Education Director, ``If my child had
    leukemia and was asking to go to the nurses office because he was
    feeling nauseated, he would be escorted there--no questions asked--and,
    with much empathy.'' At a minimum, my child should be able to state his
    needs and have them honored. Instead, they labeled him and pushed him
    relentlessly to go to inclusion classes. Eventually he became so
    unstable, depressed, and suicidal that we had to remove him from
    school. He was hospitalized twice that fall and was so severely
    depressed he was unable to dress, talk, or leave the house. He slowly
    emerged from the depression with the stress of school eliminated. He
    returned to school the following spring to a self-contained SED class,
    attending 3 periods of school a day. It took him 1/1/2/ years to return
    to a full school day. He lost nearly 2 years of education because the
    staff refused to believe that his disability was getting in the way of
    his education and reduce his stress. Had his stress been reduced via
    strategies agreed to in his legal IEP, it is likely this exacerbation
    and 2 year recovery would have been avoided.
        Another major challenge once there is agreement to provide
    services, is that the type of services our children need are, for the
    most part, unavailable. Our children need a therapeutic approach. Some
    also need a behavioral approach, but that's just a portion of the
    affected children. Most programs available to our children are
    behavior-oriented programs. They are missing the mark. Our children
    need therapy in their day. My son did transfer into a behavior-oriented
    SED class. We placed him there because he needed a small group setting.
    He does not need to be with SED kids all day, but that is the only way
    to get him into a small group setting with the present menu of program
    options. We do not design services for kids . . . we place kids into
    existing programs. We as parents must pick the ``least of the evils''
    among the ``programs'' offered. My son might just make it in a self-
    contained SED class, but what he will achieve will not be ``school
    success'' he will survive school.
        Not only are our children not learning, but the stressors place on
    the child by an uninformed educational system exacerbate their
    illnesses even further. As the stressors continue their health
    continues to decompensate . . . their illness becomes unstable. And
    with every exacerbation the possibility of them returning to their
    previous functioning level declines. So if they were operating at a 90
    percent functioning level, then decompensated into another episode,
    they may only return to a functioning level of 86 percent next time,
    and so on the spiral goes, until 1 day we reach the current outcomes
    detailed in the National Longitudinal Transition Study of Special
    Education Students commissioned by Congress. The study was initiated in
    1987 and completed in 1994. The study showed the following outcomes for
    students with Serious Emotional Disturbance (SED).
         41.7 percent of students with SED graduate from high
    school
         They earn a grade point average between 1.7-2.1
         They earn an average of 2.1-3.0 credits per year.
        In Ohio a child needs to earn 21.5 credits to graduate from high
    school. At this credit rate it would take a typical SED child 7-10
    years to complete high school. And we wonder why they don't graduate
    from high school?
        Post-graduation statistics showed that at 3-5 years post-
    graduation:
         Less than half were competitively employed (47.4 percent)
         A little less than half were already mothers (48.4
    percent)
         More than half were already arrested (57.6 percent)
         Nearly half were living with their parents (45.4. percent)
        4. Recommendations--Clearly, our nation needs to do better for this
    vulnerable population than this. I implore you to search your souls. Be
    afraid of mental illness if you need to. But do the right thing. I
    think a great deal of stigma is related to fear that these tragic
    illnesses might strike one's own family. And indeed they often do. One
    in 4 families are affected by mental illness. It will strike someone
    you know and love and all of this could happen to them. PLEASE stop
    this atrocity today. Search your souls and roll up your sleeves. Make
    changes to this horribly broken system that is as much a tragedy as the
    children's and families struggles themselves. Make a difference for
    future generations. In the ``The Report of the Surgeon General's
    Conference on the Children's Mental Health: A National Action Agenda''
    released January 3, 2001 David Satcher states, quoting The World Health
    Organization, that ``by the year 2020, childhood neuropsychiatric
    disorders will rise proportionately by over 50 percent to become one of
    the five most common causes of morbidity, mortality, and disability
    among children.'' The time is now. If we don't change this, who will?
        So, what do we need to do? First and foremost, what is critically
    needed, yesterday, is a national educational media blitz. Every mental
    health board, mental health agency, advocacy group, etc. knows this
    needs to be done, but it is expensive. No groups budget can handle the
    cost of this initiative alone. It is done for AIDS. It is done for drug
    abuse. It is time to do this for mental illness. Once people understand
    that mental illness is like any other illness, other changes will fall
    into place naturally. Many of this countries citizens are wealthy.
    Every day they donate millions of dollars to museums, parks, and other
    assorted groups. The money is out there. It's just that mental illness
    is not yet identified as a worthy recipient for a variety of reasons.
    But information, education, splashed everywhere, will open eyes. We
    know that. It happens time and time again. If you do nothing else, help
    this country establish an anti-stigma campaign. A lot of the rest will
    fall into place then. Parity will occur because people will understand
    that is the only right and decent thing to do. College students will
    see the need and the rewards of pursing a career in Psychiatry.
    Teachers will approach children with compassion. The tasks to improve
    the system will all be easier.
        Goal 1 of the President's New Freedom Commission Report clearly
    states this recommendation as follows: Recommendations 1.1: Advance and
    implement a national campaign to reduce the stigma of seeking care and
    national strategy for suicide prevention.
        Recommendations 1.2: Address mental health with the same urgency as
    physical health.
        Secondly, school issues for children with mental illness need to be
    addressed immediately. Changes will only be made through collaboration.
    These are complex inter-system issues. Collaborative projects need to
    be supported. In the Ohio ``Mental Health, Schools, and Families
    Working Together Toward a Shared Agenda'' initiative, the mental
    health, educational, and family/advocacy communities are uniting to
    make a difference. We can only make this very complex system effective
    if we unite. Education about childhood mental illness for all teachers,
    on an preservice and in-service basis, is essential. The education
    community cannot know how to help our children unless they are educated
    on how to do this. Mandatory education on how to support academic
    success for children with mental illness is crucial.
        The President's New Freedom Commission was charged to ``make
    recommendations that would enable adults with serious mental illnesses
    and children with serious emotional disturbance to live, work, learn,
    and participate fully in their communities.'' \1\ Please help to assure
    that the recommendations in that report are enacted. Our children, your
    children, will thank you.
    ---------------------------------------------------------------------------
        \1\ Report of The President's New Freedom Commission on Mental
    Health, July 22, 2003
    ---------------------------------------------------------------------------
        5. Conclusion--Chairman DeWine and Members of the Committee, I
    thank you for the opportunity to share my views on this important
    issue. And I stand ready to serve and work with you as you move forward
    on your work.
        In closing I would also like to add that I have attached an
    addendum to this testimony. It is a newspaper article that appeared in
    the Cincinnati Enquirer on Sunday, March 21, 2004. The Enquirer ran a
    special report on Childhood Mental Illness. My family and it's story
    was one of the families highlighted in that report.

                         everything spent, and no help
                     mother fights to save her bipolar sons
           by debra jasper and spencer hunt enquirer columbus bureau
        After 14-year-old Matthew Mikolic chased his younger brother with a
    knife, his mother asked Lake County officials to pay to send him to a
    psychiatric center. They refused.
        ``They said he wasn't violent enough, that he had only tried to
    kill his brother once,'' Susan Mikolic says.
        Now, the Eastlake, Ohio, mom lives in fear that next time, Matthew,
    who is now a 220-pound, mentally ill 16-year-old, will succeed. She
    hides tools and poisonous household cleaners in a locked fishing tackle
    box in the garage. She started locking up kitchen knives after Matthew
    tried to stab Brian, then 12.
        ``Brian locked himself in the bathroom, called me and said, `Get
    home, Matthew's got a knife and he's trying to kill me,'' Mikolic, 44,
    recalls.
        ``I called the police, and a whole SWAT team came. By the time I
    got there, Brian was crying in the driveway, and Matthew had his hands
    in the air.''
        Mikolic sought help from the county because she had no money left
    for more care. When her insurance ran out, she sold her $287,000
    suburban home to cover treatment for both of her sons, who have bipolar
    disorders that cause them to swing from overly hyper to depressed or
    violent.
        At first, the boys needed weekly counseling, but insurance only
    covered half the cost of 20 sessions with a psychiatrist a year at $125
    each per child. Eventually, Mikolic and her husband were shelling out
    more than $20,000 a year for family therapy. They took out three home
    equity lines of credit to pay for treatments, including lightbox
    therapy, music therapy, and anti-psychotic drugs.
        For Mikolic, the pressures finished off her marriage and forced the
    couple to sell their home to pay off their loans. In the end, she was
    left with just enough to put a small downpayment on a modest white
    house that needs a $3,000 roof.
        She also developed diabetes and such deep depression that she could
    no longer work as a nurse.
        ``It was a process of letting go, selling the house, the furniture,
    everything,'' she says. ``I've had relatives look at me and say, `How
    could you lose your home, your husband, your job?' And I say, `Where
    would you have stopped? What would you do to save your kids?' ''
        Mikolic says what happened to her shows just what families with
    mentally ill children are up against. She and other advocates are
    pushing Ohio lawmakers to pass a bill that would force insurance
    companies to cover a mental illness in the same way they cover a
    physical illness.
        If her sons had leukemia, Mikolic reasons, she wouldn't have had to
    sell her home. ``Why should it be different for us because they are
    bipolar?'' she asks.
        Roberta Barb, an administrator of child protection services in Lake
    County, says her agency opted not to send Matthew to a treatment center
    because, ``As a group, we decided he was not in need of placement. We
    can't make everybody happy, and we're not placing a kid in treatment
    just because a parent believes he needs to go.''
        The teen has tried everything to get his emotions under control,
    even shock treatments that applied electric jolts to his brain. So far,
    nothing's worked. He refused more shock treatments after he was given
    two drugs during a procedure--one to paralyze him and one to put him to
    sleep. The drug to paralyze him took effect first.
        ``I could hear the machine start, but I couldn't tell them I was
    awake,'' Matthew says. ``I kept thinking, I should put my hand up, but
    I couldn't. It was scary. Once they started the procedure, I didn't
    know if I'd feel it.''
        He's frustrated, but grateful for his mom for refusing to give up
    on him. ``If it weren't for her, I'd be dead. If she didn't support me,
    I would have killed myself.''
        He pauses and lowers his voice.
        ``The illness puts that in your head,'' he says. ``People say you
    can control it, but I don't think so. I know I can't control it.''

        [Whereupon, at 11:48 a.m., the subcommittee was adjourned.]