Child Welfare and Juvenile Justice: Federal Agencies Could Play a
Stronger Role in Helping States Reduce the Number of Children	 
Placed Solely to Obtain Mental Health Services (21-APR-03,	 
GAO-03-397).							 
                                                                 
Recent news articles in over 30 states describe the difficulty	 
many parents have in accessing mental health services for their  
children, and some parents choose to place their children in the 
child welfare or juvenile justice systems  in order to obtain the
services they need. GAO was asked to determine: (1) the number	 
and characteristics of children voluntarily placed in the child  
welfare and juvenile justice systems to receive mental health	 
services, (2) the factors that influence such placements, and (3)
promising state and local practices that may reduce the need for 
child welfare and juvenile justice placements.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-397 					        
    ACCNO:   A06685						        
  TITLE:     Child Welfare and Juvenile Justice: Federal Agencies     
Could Play a Stronger Role in Helping States Reduce the Number of
Children Placed Solely to Obtain Mental Health Services 	 
     DATE:   04/21/2003 
  SUBJECT:   Health care programs				 
	     Mental health care services			 
	     Welfare benefits					 
	     Children						 
	     Foster children					 
	     Child adoption					 
	     Juvenile correctional facilities			 
	     Juvenile offender rehabilitation			 
	     Program abuses					 
	     Medicaid Program					 
	     State Children's Health Insurance			 
	     Program						 
                                                                 
	     Arkansas						 
	     California 					 
	     Kansas						 
	     Maryland						 
	     Minnesota						 
	     New Jersey 					 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO-03-397

United States General Accounting Office Washington, DC 20548

August 11, 2003 ERRATA CHILD WELFARE AND JUVENILE JUSTICE: Federal
Agencies Could Play a Stronger Role in Helping States Reduce the Number of
Children Placed Solely to Obtain Mental Health Services (GAO- 03- 397,
April 21, 2003)

Page 3, paragraph 1, third sentence should read: *Child welfare directors
in 6 other states and the District of Columbia advised us that their
states do not allow parents to place children voluntarily with child
welfare agencies to access such services. 6 *

Page 3, footnote 6 should read: *The 6 states are Florida, Hawaii,
Missouri, Montana, New Hampshire, and Texas, based on information received
in response to our survey concerning placements in fiscal year 2001.
However, New Hampshire indicated that the state introduced voluntary
services in state fiscal year 2002 and that it anticipates that some
parents will seek placement for their children.*

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

Page 15, Table 2, the following states should have only the following
table notes: *Georgia b* *Kansas b* *Montana c*

Page 16, Table 2, table note *c* should read: * c The practice of
voluntary placement or relinquishment is either not legal in the state or
the state generally does not allow parents to place their children solely
to receive mental health services.*

Report to Congressional Requesters

United States General Accounting Office

GAO

April 2003 CHILD WELFARE AND JUVENILE JUSTICE

Federal Agencies Could Play a Stronger Role in Helping States Reduce the
Number of Children Placed Solely to Obtain Mental Health Services

GAO- 03- 397

Child welfare directors in 19 states and juvenile justice officials in 30
counties estimated that in fiscal year 2001 parents placed over 12,700
children into the child welfare or juvenile justice systems so that

these children could receive mental health services. Nationwide, this
number is likely higher because many state child welfare directors did not
provide data and we had limited coverage of county juvenile justice
officials. Although no agency tracks these children or maintains data on
their characteristics, officials said most are male, adolescent, often
have multiple problems, and many exhibit behaviors that threaten the
safety of themselves

and others. Neither the child welfare nor the juvenile justice system was
designed to serve children who have not been abused or neglected, or who
have not committed a delinquent act. According to officials in the 6
states we visited, limitations of both public and private health
insurance, inadequate supplies of mental health services, limited
availability of services through mental health agencies and schools, and
difficulties meeting eligibility rules for services influence such
placements. Despite guidance issued by the various federal agencies with
responsibilities for serving children with mental illness,
misunderstandings among state and local officials regarding the roles of
the various agencies that provide such services pose additional challenges
to parents seeking such services for their children. Officials in the
states we visited identified practices that they believe may

reduce the need for some child welfare or juvenile justice placements.
These included finding new ways to reduce the cost of or to fund mental
health services, improving access to mental health services, and expanding

the array of available services. Few of these practices have been
rigorously evaluated. Factors Influencing Placement

CHILD WELFARE AND JUVENILE JUSTICE

Federal Agencies Could Play a Stronger Role in Helping States Reduce the
Number of Children Placed Solely to Obtain Mental Health Services

www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 397. To view the full report,
including the scope and methodology, click on the link above. For more
information, contact Cornelia Ashby at (202) 512- 8403 or ashbyc@ gao.
gov. Highlights of GAO- 03- 397, a report to

Congressional Requesters

April 2003

Recent news articles in over 30 states describe the difficulty many
parents have in accessing mental health services for their children, and
some parents choose to place their children in the child welfare or
juvenile justice systems

in order to obtain the services they need. GAO was asked to determine: (1)
the number and characteristics of children voluntarily placed in the child
welfare and juvenile justice systems to receive mental health services,
(2) the factors that influence such placements, and

(3) promising state and local practices that may reduce the need for child
welfare and juvenile justice placements. The Departments of Health and
Human Services (HHS) and Justice (DOJ) should consider the feasibility of
tracking children placed by their parents in the child welfare and
juvenile justice systems to obtain mental health

services. HHS, DOJ, and the Department of Education (Education) should
develop an

interagency working group to identify the causes of the misunderstandings
at the state and local levels and create an action plan to address those
causes. These agencies should also continue to encourage states to

evaluate the programs that the states fund or initiate and determine the
most effective means of disseminating the results of these and other
available studies.

Page i GAO- 03- 397 Children Placed to Obtain Mental Health Services
Letter 1 Results in Brief 4 Background 7 While No Formal Tracking Occurs,
Available Estimates Indicate That Many Children Were Placed with the
State* Primarily

Adolescent Males* to Access Mental Health Services 14 Multiple Factors
Influence Decisions to Place Children 20 States Have Developed a Range of
Practices That May Reduce the Need for Some Mental Health- Related Child
Welfare and Juvenile Justice Placements 31 Conclusions 38 Recommendations
39 Agency Comments 39 Appendix I Scope and Methodology 44

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

Appendix III Comments from the Department of Education 47

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

Appendix V Comments from the Department of Justice 56

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

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

Tables

Table 1: Characteristics of Key Agencies with Responsibilities for
Children with a Mental Illness 8 Table 2: States* Estimated Number of
Children Placed in the Child

Welfare System to Obtain Mental Health Services in Fiscal Year 2001 15
Table 3: Estimated Number of Children Placed in the Juvenile Justice
System in 33 Counties to Obtain Mental Health

Services in Fiscal Year 2001 17 Table 4: Key Features of Health Insurance
Parity Laws in 6 States 22 Table 5: Key Medicaid and SCHIP Programs for
Children with Mental Illness in 6 States 23 Table 6: Survey Numbers and
Response Rates 44 Table 7: Statutes in 11 States Allowing Parents to Place
Children in Child Welfare Systems in Order to Obtain Mental Health
Services While Retaining Custody of the Child 46

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

ACF Administration for Children and Families AFCARS Adoption and Foster
Care Analysis and Reporting System CMS Centers for Medicare & Medicaid
Services DOJ Department of Justice EPSDT Early Periodic Screening,
Diagnostic and Treatment ERISA Employee Retirement Income Security Act
HCBS Home and Community- Based Services HHS Health and Human Services IDEA
Individuals with Disabilities Education Act IEP Individualized Education
Program JADE Juvenile Alternative Defense Effort MHPA Mental Health Parity
Act OSERS Office of Special Education and Rehabilitative Services

OJJDP Office of Juvenile Justice and Delinquency Prevention SAMHSA
Substance Abuse and Mental Health Services

Administration SCHIP State Children*s Health Insurance Program SED serious
emotional disturbances SSI Supplemental Security Income TANF Temporary
Assistance for Needy Families TBS Therapeutic Behavioral Services TEFRA
Tax Equity and Fiscal Responsibility Act

This is a work of the U. S. Government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. It may contain
copyrighted graphics, images or other materials. Permission from the
copyright holder may be necessary should you wish to reproduce copyrighted
materials separately from GAO*s product.

Page 1 GAO- 03- 397 Children Placed to Obtain Mental Health Services

April 21, 2003 The Honorable Susan M. Collins United States Senate The
Honorable Pete Stark The Honorable Patrick Kennedy House of
Representatives

Recent news articles in over 30 states and prominent mental health
advocacy organizations have reported on the difficulty many parents have
accessing mental health services for their children with severe mental

illness. 1 In some cases, parents must choose to keep their children at
home without receiving the mental health and supportive services that they
need or to remove them from their home and seek alternative living

arrangements by inappropriately placing them in the child welfare or
juvenile justice system to obtain mental health services* two systems not
designed to care for children solely because of their mental health needs.
2 Although the people and conditions described in the reports varied, all

documented that many children with severe mental illness needed services 1
Federal agencies and states have varying definitions for children with
serious emotional disturbances (SED). For example, the Department of
Health and Human Services* (HHS) Substance Abuse and Mental Health
Services Administration (SAMHSA) defines SED as a diagnosable mental
disorder found in persons from birth to 18 years of age that is so severe
and long lasting that it seriously interferes with functioning in family,
school, community,

or other major life activities. Because of these differences, we use the
term *children with severe mental illness* throughout this report. 2 Child
welfare systems are designed to protect children who have been abused or
neglected by, for example, placing children in foster care or providing
family preservation services; and juvenile justice systems are designed to
rehabilitate children who have committed criminal or delinquent acts and
to prevent such acts from occurring. Consequently, the goals of these
systems and the background and training of their staff reflect these
purposes. In addition, parents cannot voluntarily place their children in
the juvenile justice system* children are detained in this system as a
result of their delinquent acts or status offenses* that is, according to
the Department of Justice (DOJ), behaviors that are law violations only if
committed by juveniles. However, parents sometimes request that police
arrest their children for delinquent behaviors or status offenses that are
related to or stem from their mental illness when they cannot obtain
services through other means. In this report, we use the term *placed* to
refer both to children who have been voluntarily placed in the child
welfare system and children who enter the juvenile justice system to
receive

mental health services. Because information was not available, we were not
able to report on whether parents relinquished custody of their children
to obtain the services.

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

Several federal agencies have various responsibilities for children with
mental health needs. For example, HHS*s SAMHSA provides funds and guidance
to help states and localities address the needs of children with mental
illness. HHS*s Centers for Medicare & Medicaid Services (CMS) administers
both the Medicaid Program and the State Children*s Health Insurance
Program (SCHIP). These programs provide funds to states for public health
insurance programs, which can cover mental health services, for the
approximately 26.5 million enrolled children who are members of low-
income families and certain children with disabilities. Similarly, the
Department of Education*s (Education) Office of Special Education and
Rehabilitative Services (OSERS) provides funding and technical assistance

to help states provide needed services, including mental health services,
to disabled children with special education needs. Title IV- E of the
Social Security Act provides reimbursement for foster care maintenance
payments to states, which is available when child welfare agencies place
eligible children in approved out- of- home settings, including some
residential treatment facilities. 3 , 4 In many cases, these costs are
high; residential treatment facilities can cost over $250,000 a year for
one child. Federal law does not require parents to relinquish their
parental rights to place their children with child welfare agencies.
However, after children have been in care for a specific period of time,
the law requires the court to review the child*s status and determine the
best interest of the child* which, in some cases, may include termination
of parental rights.

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

4 A residential treatment facility is an inpatient facility, other than a
hospital, that provides psychiatric services to individuals under age 21.

Page 3 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

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

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

5 The 11 states are: Alaska, Colorado, Connecticut, Iowa, Maine,
Minnesota, North Dakota, Oregon, Rhode Island, Wisconsin, and Vermont. 6
The 6 states are Florida, Hawaii, Missouri, Montana, New Hampshire, and
Texas, based on information received in response to our survey concerning
placements in fiscal year 2001. However, New Hampshire indicated that the
state introduced voluntary services in state

fiscal year 2002 and that it anticipates that some parents will seek
placement for their children.

7 Child- serving agencies include mental health, Medicaid and SCHIP,
juvenile justice, education, and child welfare.

Page 4 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

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

needs of other children in the family or fulfill job- related
responsibilities. 8 Medicaid is a federal- state health financing program
for certain low- income individuals established by Title XIX of the Social
Security Act; under Medicaid, states must meet minimum federal rules of
coverage in order to receive federal matching dollars. People eligible for
Medicaid can generally be divided into three categories: (1) the mandatory
categorically needy, (2) the optional categorically needy, and (3) the
medically needy.

States have several methods by which they can customize their Medicaid
program to meet the needs of these enrollees. States can choose to cover
certain optional services, such as prescription drugs, or certain optional
populations; for example, several states have expanded eligibility for
Medicaid to certain groups of children who would not otherwise qualify for
the program because their families* incomes are too high. A limited number
of states can also request that HHS waive certain statutory requirements
for a specified period

of time. Results in Brief

Page 5 GAO- 03- 397 Children Placed to Obtain Mental Health Services

A variety of factors influenced whether parents placed their children in
the child welfare and juvenile justice systems to receive mental health
services for them. Some parents we spoke to in all 6 states reported these
factors

often created delays or prevented them from obtaining the mental health
services that their children needed. According to child welfare, child
mental health, and juvenile justice officials, a number of parents placed
children in the child welfare and juvenile justice systems because their
health insurance had limitations, such as restrictions on mental health
services. These same officials said some mental health services, such as

child psychiatric and residential services, were in short supply. In all
the states we visited, some parents who could not afford or access needed
mental health services said they sought help from mental health agencies
and schools but reported these agencies had limited resources. Parents
seeking placements for children in residential treatment facilities faced
further challenges. Mental health and education officials in the 6 states
we visited did not support residential placement for children except in
extraordinary situations because federal law requires that mental health
officials provide services for children in the least restrictive setting
as possible and requires education officials to educate children with
disabilities with children who are not disabled to the maximum extent
possible. These officials believed providing services in a community-
based program is a better option for children and families than providing
services in residential treatment facilities. In addition, some parents in
all 6 states said gaps in services occurred because child- serving
agencies have different eligibility requirements for programs and this
made it difficult for them to access the child mental health and family
support services they needed from various agencies. For example, children
who were eligible for psychological services under Medicaid could lose
these services if their families* income increases beyond eligibility
thresholds. Finally, state and local officials* views of the roles of
their own agency and other agencies, such as mental health, child welfare,
education, and juvenile justice, showed that they misunderstood those
roles and, therefore, could not effectively give parents complete and
accurate information about available services their agency and other
agencies could provide. Federal officials, experts, and service providers
agreed that agencies must work together to meet the needs of children.
Although federal officials work together on

various advisory and information- sharing committees, co- sponsor programs
designed to help children with a mental illness, and disseminate much
guidance regarding their policies and programs, some state and local
officials with responsibilities for children with a mental illness did not
understand the program requirements and capacities of their agencies and
other child- serving agencies.

Page 6 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

children with severe mental illness to identify community supports and
services, such as mentors and after- school programs, which support the
entire family.

To determine the extent to which children may be placed inappropriately in
the child welfare and juvenile justice systems in order to obtain mental
health services, we are recommending that the Secretary of HHS and the
Attorney General investigate the feasibility of tracking these children to
identify the extent and outcomes of these placements. To help reduce
misunderstandings at the state and local level, we also recommend that the
Secretaries of HHS and Education and the Attorney General develop an
interagency working group to identify the causes of these

misunderstandings and create an action plan to address those causes. We
further recommend that these agencies continue to encourage states to
evaluate the child mental health programs that the states fund or initiate

Page 7 GAO- 03- 397 Children Placed to Obtain Mental Health Services

and that the Secretaries of HHS and Education and the Attorney General
determine the most effective means of disseminating the results of these
and other available studies to state and local entities. In commenting on
a draft of this report, Education, HHS, and DOJ generally agreed with our
findings but did not fully concur with the recommendations. Education said
that it did not understand how tracking the children discussed in this
report will increase the likelihood of progressive practices to provide
children*s mental health services and noted that no recommendations were
made for increased grant spending to duplicate or disseminate the positive
features of such practices. HHS said that asking the agencies to track
this population of children in foster care does not address the larger
point of the lack of mental health resources for families and communities
and does not address the problems of the children or their parents. DOJ
agreed that tracking should occur, but only in the short term, and said
that HHS should take the lead in this activity. All three agencies said
they

would participate in any interagency working group that might be
established based on our recommendation and DOJ suggested an existing
group as the forum. HHS, however, said that such a group would do little
to address the lack of resources. Education also said we should be more
specific on the role of the interagency working group and added that such
a group would not have the power to address congressional lawmaking. As
defined by the President*s New Freedom Commission on Mental

Health, the mental health system in the United States collectively refers
to the full array of private and public programs for individuals with
mental illness that deliver or pay for treatment and services. The federal
government plays a major role in funding mental health services through
public insurance* Medicaid and SCHIP* and grants to states and local
agencies, and state and local governments play a major role in delivering
services. Most families depend on private and public insurance to pay for
mental health services because such services are expensive; although, as

we discussed in a previous report, children may face certain limitations
depending on their type of coverage and where they lived. 9 At the federal
level, several federal agencies* including HHS*s SAMHSA,

CMS, and the Administration for Children and Families (ACF); DOJ*s 9 U. S.
General Accounting Office, Mental Health Services: Effectiveness of
Insurance Coverage and Federal Programs for Children Who Have Experienced
Trauma Largely Unknown, GAO- 02- 813 (Washington, D. C.: Aug. 22, 2002).
Background

Page 8 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Office of Juvenile Justice and Delinquency Prevention (OJJDP); and
Education*s OSERS* have a role in addressing the mental health needs of
children. However, all have individual mandates, target different but
often overlapping populations, and share responsibilities to varying
degrees with state and county agencies. (See table 1.)

Table 1: Characteristics of Key Agencies with Responsibilities for
Children with a Mental Illness Department and agency Key activities
related to children*s mental health Authorizing

Statute Population targeted and definition of mental illness

HHS (CMS) Administers the Medicaid and SCHIP programs that provide health
insurance coverage, including some coverage for severe mental illness.
Awards research grants. Provides technical assistance to state agencies.

Title XIX of the Social Security Act

Certain low- income individuals and certain disabled individuals.

Uses a clinical classification of diseases to identify children with a
mental illness. HHS (ACF) Oversees the Adoption and Safe Families Act of
1997

(ASFA) that improves the safety of children and promotes adoption and
permanent homes for children who need them and supports families.
Administers Title IV- B of the Social Security Act that provides funds to
states for services that protect the welfare of children. For example,
these services address problems that may result in the abuse and neglect
of children. The funds may also be used to provide services to families of
children with a mental illness. Administers the Title IV- E Foster Care
Funds Program that provides funds to states to partially cover the costs
of room and board for eligible children from low- income families who are
placed in approved out- of- home living arrangements. Maintains the
Adoption and Foster Care Analysis and Reporting System (AFCARS), to which
states report demographic data on children in foster care, including
diagnoses of mental illness. Awards development, training, research, and
demonstration grants.

Disseminates research. Provides technical assistance. Title IV, Part E of

the Social Security Act

ASFA Children and families.

Uses a clinical classification to identify children with a mental illness
and accepts classifications used by individual states in identifying
children with mental health needs.

Page 9 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Department and agency Key activities related to children*s mental health
Authorizing

Statute Population targeted and definition of mental illness

Education (OSERS) Monitors the implementation of the Individuals with

Disabilities Education Act (IDEA). IDEA established the right of disabled
children* including children with mental illness* to receive special
education and related services, such as mental health services, designed
to meet their unique needs and prepare them for employment and independent
living when such services are needed for children to make adequate
progress in school. IDEA requires schools to evaluate children who are
referred for special education services and, if services are required,
develop an individualized education program (IEP) that documents the type
and

intensity of services that will be provided. Funds formula and
discretionary grants. Provides technical assistance. Disseminates
research.

IDEA Promotes improvement in educational results for infants, toddlers,
and children with disabilities.

Under IDEA, the term *child with a disability* means a child, who by
reason of a physical or mental disability, needs special

education and related services. HHS (SAMHSA) Provides funds to states and
local entities to help them

administer, support, or establish programs that specifically target the
mental health needs of children and provides block grant funding that
enables the states to maintain and enhance mental health services.
Sponsors the Systems of Care Initiative to help children and adolescents
with severe mental illnesses and their families receive a variety of
services from schools, community mental health centers, and social
services organizations and facilitate coordination among these service
providers. Awards formula and discretionary development and demonstration
grants. Disseminates research. Provides technical assistance. Public
Health Service Act Individuals with substance

abuse problems, mental illness or at risk of substance abuse and mental
illness.

Children served meet the following criteria:

 age 0 to 18 and

 have a diagnosed mental, behavioral, or emotional disorder of sufficient
duration to meet diagnostic criteria

that results in impairment that substantially interferes with or limits
the child*s functioning in family, school, or community activities.

DOJ (OJJDP) Helps oversee juvenile justice programs across the nation and
supports states and local communities in their efforts to develop and
implement effective and coordinated prevention and intervention programs.
Helps improve the juvenile justice system*s ability to protect public
safety, hold offenders accountable, and provide mental health treatment
and rehabilitative services. Funds formula and discretionary grants.
Provides technical assistance. Disseminates research.

Juvenile Justice and Delinquency Prevention Act

Children who commit crimes or are delinquent and children at risk for
delinquency. Accepts mental illness classifications used by states to
identify children with mental health needs.

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

Page 10 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

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

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

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

Page 11 GAO- 03- 397 Children Placed to Obtain Mental Health Services

outpatient therapy session can cost more than $100, and residential
treatment facilities, which provide 24 hours of care, 7 days a week, can
cost $250, 000 a year or more. Nationwide, 88 percent of American children
are covered by private or public health insurance plans. Private plans,
such as employer- sponsored or individually purchased plans, provide
health insurance coverage to about 68 percent of American children, and
public programs, such as Medicaid and SCHIP, provide health insurance
coverage to about 19 percent. 11 Most private health insurance plans offer
different coverage for mental

health services than for physical health services. To ensure more
comparable coverage, the federal government passed the federal Mental
Health Parity Act (MHPA) of 1996. MHPA prohibited certain
employersponsored group plans from imposing annual or lifetime
restrictions on mental health benefits that are lower than those imposed
on other benefits. However, the act did not eliminate other restrictions
and limitations on mental health coverage, such as limiting the number of
treatments per year that are reimbursable. In addition, the law does not
apply to plans sponsored by employers with 50 or fewer employees, group
plans that experience an increase in plan claims costs of at least 1
percent because of compliance, and coverage sold in the individual market.
According to the National Council of State Legislatures, as of November
2001, 46 states have passed mental heath parity bills. Most of these laws
meet or exceed the federal MHPA standard. However, the Employee Retirement
Income Security Act (ERISA) of 1974 preempts states from directly
regulating self- funded, employer- sponsored health plans; under such
circumstances, state requirements usually do not apply. For more than 30
years, Medicaid has provided comprehensive health

coverage for children from low- income families. Although individual
states determine many coverage, eligibility, and administrative details,
the federal government has established certain requirements for state
Medicaid programs. These requirements include providing preventive
screening and necessary treatment of any detected health condition for

children. Under Medicaid, a state may apply for waivers from the federal
government, which exempt the state from certain provisions of the Medicaid
statute in order to operate a specific program, change the benefits
offered under Medicaid, or make comprehensive changes to their

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

Page 12 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Medicaid or SCHIP programs. For example, states can use the Home and
Community- Based Services (HCBS) (section 1915( c) of the Social Security
Act) waiver to provide home and community- based long- term care services
to targeted groups of individuals who would otherwise require care in a
hospital, skilled nursing facility, or intermediate care facility. To
receive the HCBS waiver, states must demonstrate that the cost of the
services to be provided under the waiver is no more than the cost of
institutionalized care plus any other Medicaid services provided to
institutionalized individuals. Additional flexibility is available to
states under the *Katie Beckett* option, which enables states to use
federal Medicaid funds more flexibly to cover the costs of health care
services in the home and community rather than just in institutional
settings,

regardless of the income and assets of the family. 12 States choosing this
option provide Medicaid coverage for children under age 19 who meet
certain standards for disability, would be eligible for Medicaid if they
were in an institution, and are receiving medical care at home that would
be provided in an institution. Although family income and resources are
not considered in determining eligibility for services under the Katie
Beckett option, states can require families to contribute to the cost of
the program. The Rehabilitation option allows states to provide optional
Medicaid services such as psychiatric rehabilitation and other diagnostic,
screening, and preventive services. Under this option, children can obtain
services in nonmedical settings, including school- based or other day
treatment and

home- based services. States can expand public health insurance for
uninsured children from low- income families by implementing SCHIP
programs. States have three options in designing SCHIP programs. They may
(1) expand Medicaid programs to include children from low- income families
with earnings too high to qualify for Medicaid, (2) develop a separate
child health insurance program with benefits that differ from those
offered under Medicaid, or

(3) provide a combination of both. Twenty- four states are implementing
SCHIP by expanding Medicaid. Fourteen states are enrolling children into
separate non- Medicaid plans. Other states use a combination of Medicaid
and non- Medicaid plans to serve children in families at different income

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

Page 13 GAO- 03- 397 Children Placed to Obtain Mental Health Services

offer the same benefit package to SCHIP beneficiaries as it does to
Medicaid beneficiaries.

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

Certain disabled children, including children with a mental illness, may
qualify for monthly Supplemental Security Income (SSI) if they and their
families have little or no income and resources and they meet SSI*s
definition of disability. To meet SSI*s definition, a child must have a
physical or mental condition or conditions that can be medically proven,
and which result in marked and severe functional limitations; the
condition or conditions must last or be expected to last at least 12
months or be expected to result in death; and the child may not work at a
job that is considered substantial work. The monthly SSI depends generally
on where the child lives and his or her parents* assets. However, the
monthly SSI payment for children living in certain institutions throughout
a month, where private health insurance paid for their care or when
Medicaid paid more than half of the cost of their care, is currently
capped at $30. 13 13 Not all severely limited children with a mental
illness who meet SSI*s income requirements are eligible for SSI payments
because of SSI*s strict definition of disability. Federal SSI payments for
disabled children range from $1 to $545 and some states

supplement these payments. Although most children who receive SSI payments
are eligible for Medicaid, some are not.

Page 14 GAO- 03- 397 Children Placed to Obtain Mental Health Services

State child welfare and county juvenile justice officials estimated that
parents in their jurisdictions placed over 12,700 children in fiscal year
2001, generally adolescent males, to child welfare and juvenile justice
agencies so that the children could receive mental health services.
Nationwide, the number is likely higher because officials in 32 states,
including the 5 states with the largest populations of children, did not
provide us with estimates. Additionally, officials in 11 states that could
not provide estimates indicated that such placements occurred in their
state. Moreover, we surveyed juvenile justice officials in only 33
counties, with

30 providing estimates. Only estimates were available because no federal
or state agency tracked children placed to obtain mental health services
in a formal or comprehensive manner. Officials in the 6 states we visited
reported that placed children came from families of all financial levels
and said that the seriousness of the children*s illnesses strained
families*

abilities to function. For example, some parents are not able to meet the
needs of children in the home and some found that they were less able to
meet work demands.

The state child welfare officials and county juvenile justice officials
who responded to our surveys estimated that over 12,700 children entered
the child welfare or juvenile justice systems in order to receive mental
health services in fiscal year 2001. Of these children, about 3,700
entered the

child welfare system. State child welfare officials reported estimates
that ranged from 0 to 1,071 children, with a median of 71. Table 2
provides detailed information about the number of children placed in the
child welfare system. 14 Approximately 9,000 children entered the juvenile
justice system. County juvenile justice officials reported estimates that
ranged from 0 to 1,750, with a median of 140. Table 3 provides details on
the estimated number of children placed in the juvenile justice system.

14 Nineteen states provided estimates. Eleven states could not provide the
data requested, 6 states and the District of Columbia said the practice
was either not legal in their states or that the state generally did not
allow parents to place their children solvely to receive mental health
services, and 10 states could not provide the data requested but indicated
that voluntary placement happens. Four states did not respond to the
survey. While No Formal

Tracking Occurs, Available Estimates Indicate That Many Children Were
Placed with the State* Primarily Adolescent Males* to Access Mental Health
Services

Some Officials Estimate That Parents Placed Over 12,700 Children to Access
Mental Health Services

Page 15 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Table 2: States* Estimated Number of Children Placed in the Child Welfare
System to Obtain Mental Health Services in Fiscal Year 2001

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

Page 16 GAO- 03- 397 Children Placed to Obtain Mental Health Services

State Number of children placed South Dakota d Tennessee d Texas c Utah d
Virginia d Vermont 60 Washington 423 Wisconsin b West Virginia 135 Wyoming
5

Total 3,680

Source: GAO survey. a State did not respond to our survey.

b State could not provide the data requested. c The practice of voluntary
placement or relinquishment is either not legal in the state or the state
generally does not allow parents to place their children solely to receive
mental health services. d State could not provide the data requested, but
indicated that voluntary placement happens.

Page 17 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Table 3: Estimated Number of Children Placed in the Juvenile Justice
System in 33 Counties to Obtain Mental Health Services in Fiscal Year 2001
State County Number of children placed Arizona Maricopa 60 Arizona Pima
1,750 California Los Angeles a California San Diego 200 Colorado El Paso
40 Colorado Jefferson 100 Florida Broward 0 Florida Miami- Dade 999
Georgia Fulton 172 Georgia Gwinnett 100 Illinois Cook 0 Illinois DuPage 35
Indiana Lake 600 Indiana Marion 100 Louisiana Jefferson Parish 50 Michigan
Oakland 160 Michigan Wayne 400 New Jersey Bergen a New Jersey Middlesex
999 New York Brooklyn 74 New York Queens 49 Ohio Cuyahoga a Ohio Franklin
363 Pennsylvania Montgomery 20 Pennsylvania Philadelphia 500 Texas Dallas
200 Texas Harris 200 Virginia Fairfax 350 Virginia Prince William 840
Washington King 575 Washington Pierce 0 Wisconsin Dane 120 Wisconsin
Milwaukee 0

Total 9,056

Source: GAO survey. a County was unable to estimate the number of
children.

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

Page 18 GAO- 03- 397 Children Placed to Obtain Mental Health Services

officials in 9 additional states that responded to our survey did not
provide an estimate and did not mention whether or not parents turned to
the child welfare system to access mental health services. However, child
welfare workers we interviewed in 2 of these 9 states* California and New
Jersey* confirmed that these placements did in fact occur. Although some
of the state child welfare officials that we visited in California said
children do not enter that system to obtain mental health services, county
child welfare workers said that they knew of such placements and explained
how the cases were coded in their system. Four states did not respond to
the survey. 15 Information on the prevalence of children present

in the juvenile justice system is also limited in this report since we
surveyed only 33 counties. In 3 of those counties, juvenile justice
officials reported that while they were not able to provide estimates,
they knew that children were entering the system to obtain mental health
services because they were not able to access such services in other ways.

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

According to our survey of state child welfare directors, placed children
are more likely to be boys than girls and are more likely to be
adolescent. Child welfare directors in 19 states reported that, in fiscal
year 2001, 65 percent of placed children were male and 67 percent were
between the ages of 13 and 18. While juvenile justice officials could not
provide

information about the gender and ages of children placed in their system,
15 These 4 states were Alaska, Illinois, Louisiana, and South Carolina.
Officials Said Placed

Children Were Mostly Adolescent Males with Severe Mental Health Problems

Page 19 GAO- 03- 397 Children Placed to Obtain Mental Health Services

most children in the juvenile justice population are male and range in age
from 13 to 18. 16 The officials from state and county child- serving
agencies and parents we

interviewed in the 6 states that we visited said that children who were
placed had severe mental illnesses, sometimes in combination with other
disorders, and their parents believed they required intense treatment that
could not be provided in their homes. Many of these children were violent
and had tried to hurt themselves, their parents, or their siblings and
often prevented their parents from meeting the needs of the other children
in

the family. For example, in Kansas, one parent reported that her three
other children refused to remain in the home with her son who has bipolar
disorder, 17 is very aggressive, and has molested other children in the
past. In Maryland, officials from both state and county child- serving
agencies told us about a teenage boy who was mentally ill, developmentally
disabled, autistic, and hospitalized. Because the boy was both violent and
sexually aggressive, the county told his mother that if she brought him

home from a stay in the hospital, they would remove her other children
from the house. Caring for children who are seriously mentally ill can
also prevent parents from obtaining full- time work or cause disruptions
in their

work lives. For example, an Arkansas parent now raising her grandchild
does not work because of the time necessary to care for her mentally ill
granddaughter. State and county officials from child- serving agencies in
5 of the 6 states that we visited told us that finding placements for
children who were mentally ill and who also had other developmental
disabilities was particularly difficult. One such child in Maryland was
rejected by facilities that serve the developmentally disabled because he
was mentally ill and rejected by facilities that serve the mentally ill
because he was developmentally disabled. Moreover, parents and officials
in 4 of the 6 states that we visited also told us of youth who were not
only mentally ill, but who also abused illegal drugs and alcohol as a way
to self- medicate their mental illnesses.

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

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

episodes accompanied by at least one manic episode over a brief time
interval.

Page 20 GAO- 03- 397 Children Placed to Obtain Mental Health Services

child- serving agencies in all 6 states that we visited reported that
families of all economic levels have placed children or are at risk of
doing so. Officials in child- serving agencies in all of the 6 states that
we visited said children from middle class families are more likely to be
placed because

they are not eligible for Medicaid and their families do not have the
funds to pay for treatments not covered by insurance.

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

Almost all state child welfare directors and county juvenile justice
officials who responded to our surveys reported that private health
insurance limitations were increasing the number of child welfare and
juvenile justice placements to obtain mental health services, and well
over half reported Medicaid rules also increased such placements. For
example, according to parents and state and local officials in all 6
states that we visited, many private insurance plans and separate SCHIP
plans offered Multiple Factors

Influence Decisions to Place Children

Limitations in Private and Public Insurance Often Restrict Access to
Mental Health Care, and Some Services are Limited

Page 21 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

The legislatures in the 6 states that we visited passed health insurance
parity laws to increase the coverage that was available for mental health
services by requiring insurance companies to provide mental health

coverage that was comparable to what they offered for physical health
care. Although these laws met or exceeded the standard established by the
federal MHPA, they did not require private plans to cover intensive, long
term, and nontraditional services such as respite care and wrap- around
services, 19 although mental health officials and service providers in the
states that we visited said these services were often necessary to help
families maintain their severely children with a mental illness in their
homes. Furthermore, federal law 20 preempts states from directly
regulating self- funded, employer- sponsored health insurance plans and in
doing so

exempted many families from the enhanced benefits and protections found in
state parity laws. Table 4 shows the key features of these laws.

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

20 See ERISA, 29 U. S. C. sections 1001- 1461.

Page 22 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Table 4: Key Features of Health Insurance Parity Laws in 6 States State
Major provisions Meets

FMPHA Exceeds

FMHPA

Arkansas  Does not apply to state employees and companies with less than
50 workers.

 Exempts any group health plan whose costs increase 1 percent or more due
to the act*s application.

 Does not apply to health insurance plans if the act*s application to
these plans will result in an increase in the cost of the health plan of
at least 1.5 percent.

California  Applies generally to all employers, regardless of size.

 Applies to all health plans that provide benefits.

 Coverage is limited to 20 outpatient visits and 30 days of inpatient
care for mental illnesses that do not meet the state*s SED criteria.

 Covers severely emotionally disturbed children with certain categories
of mental illness.

Kansas  Applies to health insurance plans that provide mental health
benefits.

 Plans must provide coverage for psychotherapeutic drugs used for the
treatment of mental health under conditions no less favorable than for
other drugs.

 Coverage is limited to 45 outpatient visits and 45 days of inpatient
care.

Maryland  Applies to all health insurance policies that provide coverage
on an expense- incurred basis.

 Includes drug and alcohol disorders.

 Co- payments and deductibles must be equal to those for other
conditions.

 Outpatient coverage schedule provides for 80 percent coverage for the
first five visits in a 12- month period, 65 percent for the 6* 30th
visits, and 50 percent for the 31st and subsequent visits.

Minnesota  Applies to all health plans that provide mental health
benefits.

 Applies to all health plans that provide benefits except self- insured
health insurance plans.

 Plans with 100 subscribers or more can limit mental health coverage to
80 percent of the customary charge for the first 10 hours of treatment
over a 12- month period and 75 percent for additional treatment over the
same 12- month period.

New Jersey  Every individual health insurance policy must provide
coverage for biologically based mental illness.  Covers biologically
based mental illness under the same terms as other sicknesses.

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

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

Page 23 GAO- 03- 397 Children Placed to Obtain Mental Health Services

and SCHIP programs. See table 5 for Medicaid and SCHIP programs used in
the states that we visited.

Table 5: Key Medicaid and SCHIP Programs for Children with Mental Illness
in 6 States Waivers Types of optional services Types of SCHIP programs
State Home and Community Based Services a Katie Beckett Rehabilitation
Medicaid

expansion Separate (non- Medicaid)

program Combination (Medicaid expansion and separate) program

Arkansas X X X California X X X Kansas X X X Maryland X X X X Minnesota X
X X X New Jersey X X Source: GAO analysis. a Of the 4 of the 6 states that
we visited that had a HCBS waiver, only Kansas had a waiver

specifically for children with serious emotional disturbances.

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

according to their ability as defined by a sliding scale. While states
chose to use different waivers and options to expand access to mental
health services, all 6 states used SCHIP programs to extend

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

Page 24 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

Although Medicaid*s EPSDT provision requires Medicaid coverage for all
medically necessary health services that are identified during routine
periodic screening as long as the treatment is reimbursable under federal
Medicaid guidelines, some state officials said many eligible children are
unable to access necessary services through Medicaid because practitioners
in the states implement EPSDT unevenly. For example, a

Medicaid official in Maryland told us that the implementation of EPSDT
varied from county to county. Medicaid officials in California said
implementation varied from practitioner to practitioner although access to
EPSDT services was increasing as a result of litigation. These officials
explained that some practitioners are reluctant to recommend services if
such services are not available, some do not have the time to question
parents about their child*s mental health, and others are not well
informed about children*s mental health issues. In a previous report, we

recommended that the Administrator of CMS work with states to develop
criteria and time frames for consistently assessing and improving EPSDT
reporting and provision of services. 22 As we stated in that report,
comprehensive national data on the implementation of EPSDT are needed to
judge states* success in implementing EPSDT requirements.

Low Medicaid reimbursement rates may restrict mental health providers*
participation in the program and thus further restrict services. In all 6
states, officials from a variety of agencies said Medicaid rates for some
services are lower than the usual and customary rates in their areas and,
in 22 U. S. General Accounting Office, Medicaid: Stronger Efforts Needed
to Ensure Children*s

Access to Health Screening Services, GAO- 01- 749 (Washington, D. C.: July
13, 2001).

Page 25 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

Even when insurance covered the costs of mental health services, some
mental health officials and parents indicated parents often could not
access services or placements in their community because the supplies of
these services were limited. Fifteen of the 28 child welfare officials and

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

particularly when the services were court- ordered.

Page 26 GAO- 03- 397 Children Placed to Obtain Mental Health Services

In the 6 states that we visited, limited resources in mental health
agencies and public schools to fund mental health services and agency
officials* attempts to minimize the use of residential services posed
additional challenges for parents seeking services and placements for
their children. In addition, some children who needed multiple supports
experienced gaps in services because of differences in the eligibility
requirements for obtaining such services. Moreover, some officials and
service providers often misunderstood the responsibilities and resources
of their own and other agencies and communicated the misunderstandings to
parents, compounding service gaps and delays.

According to some mental health and education officials, budgetary
shortfalls in the 6 states that we visited contributed to agencies*
attempts to cut or control costs, including the cost of mental health
services. Mental health agencies used a variety of strategies to control
costs, such as reducing spending, requiring that services covered by
Medicaid be approved before they are provided, and limiting the number of
children served. In each state we visited, some parents believed the
strategies affected the quality of the services their children received
and created unnecessary delays in getting services. In Arkansas, private,
nonprofit mental health providers that contract with the state to provide
community mental health said that state officials cut their funding and,
as a result, they had to reduce the length of counseling and therapy
sessions and increase the length of waiting lists. In 3 of the states that
we visited* Arkansas, Maryland, and New Jersey* state officials said that
they contracted with private, nonprofit agencies to authorize the medical
necessity of mental health services covered by Medicaid. Arkansas required
preauthorization of all Medicaid- financed mental health services,
including those that were legally required, such as the screening of
foster children for mental health services. A variety of officials in this
state and a

parent reported that the preauthorization agency often denied services for
children because they had not benefited from similar services in the past.
For example, this parent said the preauthorization agency refused her
son*s therapist*s request to hospitalize him to treat his suicidal
behavior because past hospitalizations for suicide attempts had not
reduced the behavior. In New Jersey, state mental health officials reduced
the number

of counties that had been targeted to implement the state*s new child
mental health system and limited the number of children served by the
system. For example, officials from a variety of county agencies reported
that the new system of care limited the number of children receiving the
highest level of care in their county to 180 a year, although juvenile
justice officials said that at least 500 children in their system alone
needed such services. Officials from child welfare, mental health, and
juvenile justice Difficulties Accessing

Services through Certain Agencies, Difficulties in Meeting Service
Eligibility Requirements, and Misunderstandings among Officials and
Service Providers Can Influence Placements

Difficulties Accessing Services through Mental Health or Education
Agencies

Page 27 GAO- 03- 397 Children Placed to Obtain Mental Health Services

agencies said eligible children who did not receive the highest level of
care were placed on waiting lists and provided less intensive services.

Other ways of controlling costs in the states that we visited included
limiting placements of children in residential treatment facilities.
Mental health officials said community- based services supported the right
of children with a mental illness to receive services in the least
restrictive setting, were more effective than residential services in
helping children and their families, and cost less, thus allowing more
children to receive services. To implement the limits and to ensure
placements are necessary, states required interagency review boards to
approve such placements or reduced the time spent in residential
placements. For example, local mental health agency officials in Maryland
explained that they could not place children in private residential
facilities even if they presented a

danger to themselves and others because the state did not allow them to
pay for such placements. These officials further explained that private
residential placements had to be approved by a county interagency
coordinating committee and subsequently reviewed by a state coordinating
committee that could return requests for further

consideration. A parent in this county said the approval process took 6
months. In New Jersey, child welfare officials said a goal of the new
child mental health system is to reduce the average stay at residential
treatment facilities from 18 to 6 months, and some parents in Maryland
told us that funding limits, rather than the success of the treatment,
determine the date children will be discharged from residential treatment.

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

Page 28 GAO- 03- 397 Children Placed to Obtain Mental Health Services

As a result of the difficulties encountered at both mental health agencies
and schools, some parents could not access the community- based services
they needed to care for their child at home nor place their child in a
residential treatment facility. In 4 of the 6 states that we visited, some
teachers and mental health service providers encouraged parents to refuse
to bring their child home from a hospital or other supervised placement,
such as a detention center, when they were informed their child was being
discharged in order to obtain mental services from child welfare agencies.
Although these parents realized they were abandoning their child and, as a
result, could be arrested and lose custody, they believed that this was
the only alternative that remained to obtain services. Some parents that
we interviewed told child welfare workers they would physically abuse
their child in their presence to force them to place the child in their
system if they could not get help for their child any other way, and
juvenile justice officials told us other parents asked the police to
arrest their children.

However, state officials in 2 of the states that we visited said children
often remain hospitalized or in a shelter for months without appropriate
services because child welfare agencies did not have the resources to
provide the needed level of services or specialized placement, could not
obtain resources from other agencies, or could not access appropriate
services or placements that had the capacity to treat another child. In
addition, although federal law does not require custody relinquishment to
obtain mental health services, state child welfare officials in 2 states
that we visited said that their state required parents to relinquish
custody of their child to the state after the voluntary placement period
ends. In 1 state, these officials misconstrued federal requirements and
believed that they required relinquishment and in the other state,
officials said

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

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

Requirements for Mental Health Services

Page 29 GAO- 03- 397 Children Placed to Obtain Mental Health Services

child- serving agencies in their area. For example, school officials in
four districts told us that some children with a mental illness are not
eligible for mental health services through their special education
programs because they were making adequate educational progress or because
behavior problems* rather than mental illness* prevented them from making
adequate progress. However, mental health officials who work with children
attending some of these schools reported that schools often have a narrow
definition of educational progress and do not recognize that inappropriate
behavior might be a symptom of mental illness. For example, a parent of a
child with attention deficit 23 and bipolar disorders said her son*s
school refused to provide special education services for him because his
lack of educational progress was due to his failure to pay attention and
to get his work done, rather than his mental illness, and a parent of a
bipolar, schizophrenic son 24 said school officials told her that she was
responsible for her son*s behavior and poor school performance.

Although a variety of officials said schools had more restrictive
eligibility requirements for mental health than other child- serving
agencies, school officials in a county in California said that their
county mental health agency used a more restrictive definition than the
schools. In California,

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

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

services to children in special education from schools to counties in the
late 1980s.

Page 30 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Some parents bypass eligibility restrictions for special education
services and procedures for receiving child welfare, mental health, and
juvenile justice services by petitioning the court to provide mental
health and specific education services for their child. These petitions
have varying names. For example, Maryland refers to them as CINS (children
in need of supervision) petitions and Arkansas refers to them as FINS
(family in need

of services) petitions. Three of the states that we visited* Arkansas,
Maryland, and Minnesota* allowed parents to directly petition the court to
order mental health services for the child. In Arkansas, a child in a
court- ordered residential placement was automatically eligible for

Medicaid regardless of his or her family*s income. In that state, a
variety of officials told us that court- ordered placement was the most
common way for parents to obtain residential mental health and education
services for their child. Juvenile court officials told us that parents
often come to court requesting residential treatment and lobbying judges
for placement in a specific facility. Some state officials were concerned
that this practice could result in inappropriate placements for some
children because judges can make placement decisions with no clinical
input. Mental health and juvenile justice officials told us staff from
private residential facilities

often evaluate children on a pro bono basis and, based on these
evaluations, recommend that judges place the children in their facility.
These officials said that they were concerned about the objectivity of
such evaluations.

Program officials* and service providers* misunderstandings of agencies*
responsibilities and resources also affect service provision. 26 For
example, misunderstandings about Medicaid coverage created gaps and delays
in services. In 3 states, some state and county officials did not know the
Katie Beckett option could expand Medicaid coverage for children with a
mental illness regardless of family status. In 1 of these states, a parent
told us that county Medicaid officials incorrectly told her that her son
was

ineligible for coverage under this option because he had a two- parent
family. In 2 other states, county mental health officials erroneously told
us that this option applied only to children with very severe medical
conditions. In another state, a Medicaid official did not know that
children enrolled in SCHIP Medicaid expansion programs were entitled to
EPSDT services. Furthermore, state child welfare officials in 2 states and
mental

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

Responsibilities and Resources

Page 31 GAO- 03- 397 Children Placed to Obtain Mental Health Services

health workers in a third did not know Medicaid*s EPSDT provision includes
mental health screenings, diagnosis, and treatment and thought the
provision covered only physical health services.

In all 6 states, some parents, a variety of state and local officials,
mental health service providers, caseworkers, and judges misunderstood the
role and responsibilities of schools in implementing IDEA. For example,
some parents we interviewed in 5 of these states said that their children
waited over a year to receive special education services because they and
the mental health professionals they worked with did not understand the
procedures IDEA required schools to follow. For example, some parents were
told that referrals for special education had to be in writing. Also, some
parents and professionals misunderstood that IDEA gives all eligible
children, including children with a mental illness, the right to a free

appropriate education and parents did not know that they could appeal a
school*s decision about providing special education services. For example,
a parent in Kansas agreed to home- school her 10 year old, sexually
aggressive, child with a mental illness because the school would not put
the child in a setting that would ensure the safety of his classmates.

Despite her long- term involvement with a community mental health agency,
this parent believed home schooling was her child*s only option.

Although few strategies were developed specifically to prevent mental
health- related child welfare and juvenile justice placements, state and
local officials identified a range of practices that they believe may
prevent such placements by addressing key issues that have limited access
to child mental health services in their state. State and local practices
focused on

three main areas: finding new ways to reduce costs or to fund services,
consolidating services in a single location, and expanding community
mental health services and supporting families. Many of these practices
were developed to reduce treatment costs and provide a better way to treat
children with a mental illness in their communities. Although some
programs were modeled on practices that had been evaluated in other
settings, the effectiveness of the practices is unknown because many of
them were implemented on a small scale in one location or with a small
target group or were too new to be rigorously evaluated. States Have

Developed a Range of Practices That May Reduce the Need for Some Mental
HealthRelated Child Welfare and Juvenile Justice Placements

Page 32 GAO- 03- 397 Children Placed to Obtain Mental Health Services

According to officials in the 6 states that we visited, one way to reduce
the cost of services is to better match children*s needs to the
appropriate level of service. One goal of some of the programs we reviewed
was to ensure

that children with lower- level needs were appropriately served with
lowerlevel and less expensive services, reserving the more expensive
services for children with more severe mental illnesses. Under New
Jersey*s Systems of Care Initiative, the state contracted with a private,
nonprofit organization for a variety of services, such as mental health
screenings and assessments to determine the level of care needed,
authorization of service, insurance determination, billing, and care
coordination across all agencies involved with the children. When the
Initiative is fully

implemented statewide, the contractor in each county will use standardized
tools to assess children*s mental health and uniform protocols to
determine appropriate levels of care* children requiring lower levels of
care will be referred to community- based providers, while children
requiring a higher level of care will be approved to receive services from
local Care Management Organizations specifically created to serve them.
Presently, the System of Care Initiative has been implemented in 5 of the
state*s 21 counties.

As another cost- saving method, some programs substituted expensive
traditional mental health providers with nontraditional and less expensive
providers. Many state and local officials we interviewed in 5 of the
states we visited told us that the historic way to treat children with a
mental illness included psychiatrists and residential placements. However,
officials in New Jersey, Kansas, and Minnesota said their states had
switched their focus to using less expensive providers such as using
nurses to distribute medicines instead of psychiatrists or nontraditional
bachelor- level workers for case management instead of masters- level
social workers. For example, Uniting Networks for Youth* a private,
county- based provider in Minnesota* used two commercially available,

highly structured programs that allowed them to substitute
lowercredentialed bachelor- level staff under the supervision of a
masters- level clinician as the primary service provider instead of using
higher- level clinicians. County officials told us this structured program
has many safeguards, including the collection of extensive data from
providers, teachers, and families that allow masters- level clinicians to
review the appropriateness and effectiveness of provided mental health
services.

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

Reduce Costs or to Fund Services May Help Agencies Pay for Mental Health
Treatment

Page 33 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

In addition to reducing the cost of services, state officials in all 6
states identified the blending of funds from multiple sources as another
way to pay for services, thus working around agencies* limitations on the
types of mental health services and placement settings each can fund. For
example, in a county in Maryland, a local Coordinating Council blends
funds from multiple agencies to provide community- based services to
children with a mental illness involved with the judicial, child welfare,
and mental health systems and with district special education programs.
The Council, headed

by a judge, leveraged funding by inviting key decision makers* those that
could commit resources* from a variety of child- serving agencies and
organizations, including the local departments of social services and
juvenile justice, the public defenders office, prosecutors, attorneys, and
Catholic Charities, to serve on the Council. The Juvenile Alternative
Defense Effort (JADE), a county juvenile justice diversion program in
California, combines funds from a federal Juvenile Accountability
Incentive Block Grant and the state Temporary Assistance for Needy
Families Program (TANF) 27 to provide the range of mental health services
necessary to prevent a juvenile justice placement for mentally ill youths.
In Kansas, the Family Service and Guidance Center blends funds from
federal

Medicaid and Department of Transportation programs, designated funds from
the state*s Master Tobacco Settlement and Attorney General*s Office, funds
from county juvenile justice and social services agencies, county general
funds, the United Way, and several local philanthropic clubs to provide a
wide range of mental health and supportive services for children who are
seriously mentally ill in its county.

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

Page 34 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

community. To improve access to mental health services and bring clarity
to a confusing mental health system, 3 of the states that we visited
developed a facility to be a single point of entry into the mental health
system.

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

Services into a Single Location May Improve Access

Page 35 GAO- 03- 397 Children Placed to Obtain Mental Health Services

develops a diversion 28 plan all can agree to that is aimed at preventing
the need for juvenile justice or child welfare custody, or residential or
other out- of- home placements with the goal of keeping the child at home
with the child*s own family.

State officials in all 6 of the states that we visited also identified
colocating services in public facilities such as schools and community
centers as another way to improve access. In California, Los Angeles
county officials told us that integrating mental health services into the
school system has been a very effective way of reaching poor families
without transportation and working families, and helps to ensure regular
participation in mental health services. In Harford County, Maryland, for
example, mental health services are collocated at an elementary school
specifically to improve access to care for students with mental illness.
Using county health and mental health funds, the school developed an
inhouse mental health clinic that provides mental health services through
a bachelor- level social worker, a nurse practitioner, and consultative
services from a physician and a psychiatrist. In addition, the school has
a variety of internal support staff available to children with a mental
illness, including a guidance counselor, a behavior specialist, a home
visitor who

supports families and assesses the home situation, and a pupil personnel
worker who visits homes and helps with transportation issues. The school
has several programs available to children with a mental illness,
including the Classroom Support Program, an intensive, in- school program
for children with a mental illness staffed with a full- time school
psychologist for individual counseling; the Teen 2000 program, a mentoring
program for teens that uses paid school staff, high school students, and
volunteer community members to provide a combination of homework support,
play, and social skills development; the School Outreach Advocacy Program,
a program that provides counseling, tutoring, recreation, social skills
groups, home visits, referrals and some psychiatric rehabilitation
services; Project Prepare, a program to identify mentally ill elementary
school children and increase their access to services; and two
collaborative programs with contracted mental health providers that

provide community support and prevention services and intensive case
management services.

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

Page 36 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Officials from child- serving agencies in all 6 states we visited
identified the expansion of the number and range of community- based
services to provide an entire continuum of care as a way to improve
treatment for children with a mental illness. Some programs we reviewed
developed a complete range of community- based mental health services for
children, including early intervention, diversion, transitional services,
and crisis

intervention. In addition, some programs supported families of children
with a mental illness and encouraged parent involvement in their
children*s care. State and county officials we spoke with in all 6 states
stressed the importance of early identification of children at risk of
mental illness and the provision of therapeutic services when they were
young in hopes of preventing the need for extensive, and costly,
residential services later on. Examples of these programs follow.

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

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

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

Mental Health Services and Supporting Families May Improve Treatment for
Children with a Mental Illness

Page 37 GAO- 03- 397 Children Placed to Obtain Mental Health Services

is a secure juvenile justice facility that provides in- house mental
health services and places a strong focus on transitional services so
youth can successfully reenter their own community. Red Wing officials
told us that

transition planning and reintegration efforts are very important in
preventing recidivism and they take several steps to ensure a successful
transition. The program is designed in levels that reward good behavior by
allowing youth to move to lower levels of supervision. For instance, at

level 4, youth begin to transition back to the community by making
periodic visits, called furloughs, to their homes. Officials see furloughs
as an opportunity for youth to try out the new positive behaviors that
they have learned. At level 5, youth move to a transitional living unit at
Red Wing that focuses on applying new skills to activities in their homes
and communities. After youth leave Red Wing, a county juvenile justice
worker monitors them for 90 days.

Out of frustration with the difficulties it had finding appropriate
services for mentally ill youth who were aging out of child mental health
programs, The Sycamores, a residential mental health facility in Los
Angeles County, California, created community- based transitional homes
for older teens

who were leaving their facility and were unable to return to their own
homes. Its Emancipated Youth Program provides an apartment for every two
residents, a youth advocate worker to provide support, and case managers
to coordinate services. For this program, the Sycamores uses reasonably
priced private apartments in the community, instead of a group home that
would house several mentally ill youths in the same building. When the
youths become able to live independently, the Sycamores turns

the leases over to them. They also started a business card company at one
community center to provide vocational training for adolescents aging out
of their program.

Crisis Intervention: Programs we reviewed in 4 states had a mobile crisis
unit. These units consist of teams of staff that visit homes to stabilize
crisis situations. Funding, staffing, and authority of these teams vary.
Some of the crisis teams can provide direct mental health services; others
conduct assessments and make emergency petitions to psychiatric hospitals
on behalf of the family. One of the difficulties noted by program
officials is determining how to pay for crisis services since these
services may not be covered by insurance and families may not have the
ability to pay. In Harford County, Maryland, the mobile crisis team is not
a fee- forservice

provider but is funded by a grant. The team* a psychiatrist, a
psychologist, and a licensed social worker* provide direct mental health
services and are authorized to do an emergency petition to get a child
with a mental illness admitted to a hospital psychiatric unit.

Page 38 GAO- 03- 397 Children Placed to Obtain Mental Health Services

A second way some states improve treatment for children with a mental
illness is to provide services to support families and encourage parental
involvement in their child*s care. State and local officials in all 6
states pointed out that involving parents was a fundamental change in
philosophy. Previously, services were provided solely to the children and

parents were not included in the decisions about their child*s care. Now,
the focus is on providing the services parents need to maintain the child
in the home and helping parents make informed decisions about their
child*s

care. For example, The Sycamores works extensively with parents of
children who are seriously mentally ill at the facility and requires their
participation. To help parents successfully prepare for and keep their
child with a mental illness at home, The Sycamores provides a variety of
supportive services* anything the family needs to make a child*s return
home successful* including household items like refrigerators, washers,
dryers, stoves, and car seats, and services such as transportation to and
from the facility. In addition, as part of its transitional Home- Based
Program, The Sycamores trains parents to use Therapeutic Behavioral
Services (TBS), one- on- one, in- home services provided whenever needed
24 hours a day, 7 days a week. TBS workers model good parenting skills so

parents will be prepared for their child*s return home, such as modeling
for the parents how to get their child with a mental illness who may have
violent outbursts ready for the school bus in the morning without
incident. The Four County Mental Health Center in Kansas*s provides free
parenting classes designed to teach effective parenting skills for
children with mental illness and a parent support coordinator who can
provide support and information on mental health services for children.
The Center also works with Kansas*s Keys for Networking, a statewide
parent advocacy organization that educates parents about their child*s
right to services and

advocates on their behalf to obtain needed services. Some parents are
placing their children, mostly adolescent boys with severe mental illness,
in the child welfare and juvenile justice systems to access mental health
services. Although these children may not have been abused or neglected,
or may not have committed a criminal or delinquent

act, parents are turning to these agencies because they see no
alternatives for obtaining comprehensive services for them. Because
federal, state, and local agencies do not systematically track these
children, the extent and outcomes of these placements are not fully known.

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

Page 39 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

Although states and counties are implementing practices that may reduce
the need for parents to place their children with child welfare or
juvenile justice agencies, many of the programs are new, small, and only
serve children in specific localities. Furthermore, their effectiveness in
achieving their multiple goals* such as reducing the cost of mental health
services,

supporting families, and helping children overcome their mental illnesses*
has not yet been fully evaluated. Given that states and localities are
developing new approaches to meeting the needs of children with mental
illness, it is important that the federal government continue its role in
supporting evaluations of these programs and disseminating the results. To
determine the extent to which children may be placed inappropriately in
the child welfare and juvenile justice systems in order to obtain mental
health services, we recommend that the Secretary of HHS and the

Attorney General investigate the feasibility of tracking these children to
identify the extent and outcomes of these placements. To help reduce
misunderstandings at the state and local level, we also recommend that the
Secretaries of HHS and Education and the Attorney General develop an
interagency working group (including representatives from CMS,

SAMHSA, and ACF) to identify the causes of these misunderstandings and
create an action plan to address those causes. We further recommend that
these agencies continue to encourage states to evaluate the child mental
health programs that they fund or initiate and that the Secretaries of HHS
and Education and the Attorney General determine the most effective means
of disseminating the results of these and other available studies to state
and local entities.

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

Agency Comments

Page 40 GAO- 03- 397 Children Placed to Obtain Mental Health Services

in appendixes III, IV, and V. These agencies also provided technical
clarifications, which we incorporated when appropriate.

Education generally agreed with the findings of our report, but asked that
we change some terminology to be consistent with terminology used in IDEA.
We changed this terminology to reflect IDEA when needed. HHS also
generally agreed with the findings and said that the report is
comprehensive, interesting, and provides an informative overview of the
concerns with which child welfare agencies and juvenile justice systems
are confronted when children and youth do not receive adequate mental
health services within the community. However, HHS also said that the
report is relatively critical of state and local agencies for
*inappropriately*

using child welfare and juvenile justice placements to get services to
children who need them and cannot access them through other channels. HHS
further stated that a broader look at the status of children*s mental

health services in general would be useful because the problems leading
parents to place their children in child welfare and juvenile justice
systems to obtain mental health services are part of the bigger problem of
children*s mental health services in general, such as limited or
nonexistent services, a lack of access, and a lack of quality providers.
Although a broad assessment of the availability and effectiveness of
children*s mental health services was beyond the scope of this report, we
have conducted studies relevant to these problems and reference to them
can be found in the related products list at the end of this report. The
purpose of this report was to shed light on the number of children placed
in the two systems solely to receive mental health services and the
factors

that lead to those placements. In doing so, this report does not criticize
state and local child welfare and juvenile justice agencies that place
these children, but instead identifies the circumstances under which these
agencies play a role in meeting mental health needs, as well as the roles
that other agencies should play. DOJ also generally agreed with our
findings but was concerned that the estimates of children placed provided
by child welfare and juvenile justice officials would be taken as solid
and conclusive and be used for policy changes without further study being

undertaken. We explicitly acknowledged the limitations of these estimates
in the report and we recommended that the Secretary of HHS and the
Attorney General investigate the feasibility of obtaining more precise
numbers by tracking these children. Doing so will allow the agencies to
determine the extent of the problem.

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

Page 41 GAO- 03- 397 Children Placed to Obtain Mental Health Services

mental health services. HHS said that asking the agencies to track this
population of children in foster care does not address the larger point of
the lack of mental health resources for families and communities and does
not address the problems of the children or their parents. HHS also said
we failed to identify to what end these data would be used and that a
request for appropriate funding for states and federal agencies involved
in tracking should accompany the recommendation for tracking. DOJ agreed

that tracking should take place, but only in the short term, and that HHS
should take the lead in such an effort. As we stated in our
recommendation, we believe HHS and DOJ should determine the feasibility of
tracking children to identify the extent and outcomes of the mental health
placements discussed in the report. Knowledge of the extent of this
practice is a necessary first step to determine what corrective actions
might be taken and might be useful in identifying which

progressive practices will most benefit these children. In addition,
without this basic information, the agencies may unknowingly limit the
action steps that they develop to alleviate state and local officials

misunderstandings and thus fail to maximize access to and the use of
existing resources. While the report recognizes that some mental health
resources may be limited, it also describes the misunderstandings that

exist among state and local officials regarding each agency*s service
requirements, responsibilities, and resources. If such misunderstandings
could be corrected, more children could possibly be served by the agencies
better designed to meet their mental health needs. Since HHS and DOJ
already track various characteristics of all children placed in the child
welfare and juvenile justice systems, these agencies should determine the

feasibility of adding data elements regarding placement solely to receive
mental health services and determine appropriate time frames for
collecting these data.

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

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

Page 42 GAO- 03- 397 Children Placed to Obtain Mental Health Services

may be appropriate and that the member agencies forming this group should
determine the entity that is best suited. HHS, however, said that an
interagency working group would do little to address the lack of

resources. We believe that identifying the causes of the misunderstandings
that are occurring is a first step toward addressing the lack of
resources. Such a group, by promoting a more consistent understanding of
the roles and resources of state and local agencies, may improve access to
services and result in more effective utilization of existing resources.
Education commented that we should be more specific on the role of the
working group in addressing major differences in terminology and
definitions across various legislation, enormous differences in local
interpretation of federal definitions, and in local practices for
establishing eligibility. Education added that such a group would not have
the power to address congressional lawmaking and noted that no
recommendations were made for increased grant spending to

duplicate or disseminate the positive features of such practices. We
believe that our recommendation is broad enough to encompass the list of
issues Education mentions. We also believe that our recommendation does
not preclude the group from recommending legislative changes as part of
its action plan. Regarding Education*s comment on information
dissemination, we added a recommendation to that effect.

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

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

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

Page 43 GAO- 03- 397 Children Placed to Obtain Mental Health Services

officials, and others who are interested. We will also make copies
available to others upon request. In addition, the report will be
available at no charge on GAO*s Web site at http:// www. gao. gov. If you
or your staff have any questions, or wish to discuss this material

further, please call me at (202) 512- 8403 or Diana Pietrowiak at (202)
512- 6239. Key contributors to this report are listed in appendix VI.

Cornelia M. Ashby Director, Education, Workforce,

and Income Security Issues

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

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

local juvenile justice officials allowed us to obtain information from
individuals who were more likely than state officials to have direct
knowledge of how children enter the juvenile justice system.

We asked both groups to estimate 1 the number of children voluntarily
placed in their system by actions of their parents in order to obtain
mental health services, the characteristics of the children, and factors
influencing the rate of placements. Table 6 provides survey numbers and
response rates for the surveys.

Table 6: Survey Numbers and Response Rates Survey of Number of

surveys conducted Number of survey responses received

Child welfare directors 51 47 Juvenile justice officials 33 33 Source:
GAO. Not all respondents to the surveys answered every survey question.
For

example, 19 respondents to the child welfare survey and 30 respondents to
the juvenile justice survey provided estimates of number of children

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

health services. Appendix I: Scope and Methodology

Appendix I: Scope and Methodology Page 45 GAO- 03- 397 Children Placed to
Obtain Mental Health Services

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

To determine the factors that influence child welfare and juvenile justice
placements for mental health services, we included questions on these
issues in our surveys and interviewed federal, state, and local officials
and national child mental health experts. We interviewed officials at the

Department of Health and Human Services (HHS), the Department of Justice
(DOJ), and Education. We spoke with state and local officials in 6 states*
Arkansas, California, Kansas, Maryland, Minnesota, and New Jersey* and in
one county in each of these states. The officials represented state and
county agencies that were responsible for child welfare, child mental
health, Medicaid, juvenile justice and education services. We also
interviewed judges in 5 states and caseworkers and parents in all 6
states. Staff of community mental health centers and other programs
serving families with children with a mental illness, such as a Family
Support Organization and a residential treatment facility, selected
parents of children with, or who had, severe mental illness and invited
them to attend our interviews. We selected states that varied in
geographical location, legal requirements concerning placement, the use

of Medicaid options and waivers, and the authority of state and county
agencies in administering child welfare and juvenile justice programs; and
counties that varied in demographic characteristics.

To identify promising practices that may reduce the need for some child
welfare and juvenile justice placements by meeting the needs of children
with a mental illness and their families, we asked national experts and
state and local officials to identify such practices in the states that we
visited. We visited 16 programs that embodied these practices. We
conducted our work between March 2002 and February 2003 in

accordance with generally accepted government auditing standards. Site
Visits

Appendix II: State Statutes Containing Language Allowing Voluntary
Placement to Obtain Mental Health Services Page 46 GAO- 03- 397 Children
Placed to Obtain Mental Health Services

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

Alaska M. S. A. Section 260C. 201 (3) Where a parent enters into a
voluntary placement agreement, the agreement may not preclude the parent
from regaining care of the child at any time. Colorado C. R. S. A. Section
19- 3- 701( 1) Where a parent voluntarily places a child out of the home
for the purpose of obtaining treatment for an emotional disability solely
because the parent is

unable to provide care, relinquishment of legal custody is not required.
Connecticut C. G. S. A. Section 17a- 129 Their shall be no requirement for
the Department to seek custody or

protective supervision of a child or youth who needs or is receiving
voluntary services unless the child or youth is otherwise alleged to be
neglected or abused. Iowa I. C. A. Section 232.1784 and 232.182

(5) (d) Petitions for voluntary placements shall describe the child*s
emotional disability which requires care and treatment; the reasonable
efforts to

maintain the child in the child*s home; a determination of whether
services or support provided to the family will enable the family to
continue to care for the child in the child*s home; and the reason the
child*s parent has requested a foster care placement. A court may only
order foster care placement if it makes a determination that services or
support provided to the family will not enable the family to continue to
care for the child in the child*s home. If the court finds that reasonable
efforts have not been made and that services or support are available to
prevent placement, the court

may order the services or support to be provided to the child. Maine 22 M.
R. S. A. Section 4004- A( 1) and (2) If certain conditions are met, a
parent may enter into a voluntary placement agreement in which the parent
retains legal custody of the child.

Minnesota M. S. A. Section 260C. 201( 3) If a court determines a child is
in need of special services to treat a mental disability, the court may
order the child*s parent or health plan company to provide such services.
If the parent or the health plan is unable to provide care, the court may
order that treatment be provided. If the child*s disability is not the
result of abuse or neglect by the parent, the court shall not transfer
legal custody of the child in order to obtain treatment solely because the
parent is unable to provide care. North Dakota N. D. C. C. 50- 06- 06.13
The Department of Human Services may not require a parent to relinquish

legal custody in order to have the child voluntarily placed. Oregon O. R.
S. Section 418.312( 1) and (2) To have a child placed in a foster home,
group home, or institutional child

care setting for the sole purpose of obtaining services for the child*s
emotional or mental disorder, a parent is not required to transfer legal
custody. Rather, the child is placed pursuant to a voluntary placement
agreement that specifies the rights and obligations of the parent, the
child, and the Department of Human Services. Rhode Island R. I. S. T.
Section 14- 1- 11.1 Where a parent voluntarily places a child with an
emotional disorder with

the Department of Human services for the purpose of accessing an out-
ofhome program, relinquishment of legal custody is not required. Wisconsin
W. S. A. Section 48.13( 4) and

938.34( 6)( a) and (ar) Where a parent is financially unable to provide
treatment for a child, the parent may sign a petition giving a court
exclusive jurisdiction. The court

may then order an appropriate agency to provide treatment whether or not
legal custody has been taken from the parent. Vermont 33 V. S. A. Section
4305( g) A child with an emotional disorder may receive services,
including an outof- home placement, without a parent surrendering legal
custody. Source: GAO analysis.

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

Appendix III: Comments from the Department of Education

Page 47 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Appendix III: Comments from the Department of Education

Appendix III: Comments from the Department of Education

Page 48 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Appendix III: Comments from the Department of Education

Page 49 GAO- 03- 397 Children Placed to Obtain Mental Health Services

Appendix III: Comments from the Department of Education

Page 50 GAO- 03- 397 Children Placed to Obtain Mental Health Services

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

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

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

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

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

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

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

Appendix V: Comments from the Department of Justice

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

Appendix V: Comments from the Department of Justice Page 58 GAO- 03- 397
Children Placed to Obtain Mental Health Services

Appendix VI: GAO Contacts and Acknowledgments Page 59 GAO- 03- 397
Children Placed to Obtain Mental Health Services

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

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

GAO Contacts Acknowledgments

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

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

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

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

Foster Care: Recent Legislation Helps States Focus on Finding Permanent
Homes for Children, but Longstanding Barriers Remain.

GAO- 02- 585. Washington, D. C.: June 28, 2002.

Long- term Care: Implications of Supreme Court*s Olmstead Decision Are
Still Unfolding. GAO- 01- 1167T. Washington, DC: September 24, 2001.
Medicaid and SCHIP: States* Enrollment and Payment Policies Can

Affect Children*s Access to Care. GAO- 01- 883. Washington, D. C.:
September 10, 2001.

Medicaid: Stronger Efforts Needed to Ensure Children*s Access to Health
Screening Services. GAO- 01- 749. Washington, D. C.: July 13, 2001.

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

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

Mental Health Parity Act: Employer*s Mental Health Benefits Remain Limited
Despite New Federal Standards. GAO/ T- HEHS- 00- 113. Washington, D. C.:
May 18, 2000.

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

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

(130098)

The General Accounting Office, the audit, evaluation and investigative arm
of Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability of
the federal government for the American people. GAO examines the use of
public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO*s commitment to
good government

is reflected in its core values of accountability, integrity, and
reliability. The fastest and easiest way to obtain copies of GAO documents
at no cost is through the Internet. GAO*s Web site (www. gao. gov)
contains abstracts and fulltext files of current reports and testimony and
an expanding archive of older products. The Web site features a search
engine to help you locate documents using key words and phrases. You can
print these documents in their entirety, including charts and other
graphics. Each day, GAO issues a list of newly released reports,
testimony, and

correspondence. GAO posts this list, known as *Today*s Reports,* on its
Web site daily. The list contains links to the full- text document files.
To have GAO e- mail this list to you every afternoon, go to www. gao. gov
and select *Subscribe to daily E- mail alert for newly released products*
under the GAO Reports heading.

The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent of
Documents. GAO also accepts VISA and Mastercard. Orders for 100 or more
copies mailed to a single address are discounted 25 percent. Orders should
be sent to: U. S. General Accounting Office 441 G Street NW, Room LM
Washington, D. C. 20548 To order by Phone: Voice: (202) 512- 6000 TDD:
(202) 512- 2537 Fax: (202) 512- 6061 Contact:

Web site: www. gao. gov/ fraudnet/ fraudnet. htm E- mail: fraudnet@ gao.
gov Automated answering system: (800) 424- 5454 or (202) 512- 7470 Jeff
Nelligan, managing director, NelliganJ@ gao. gov (202) 512- 4800 U. S.
General Accounting Office, 441 G Street NW, Room 7149 Washington, D. C.
20548 GAO*s Mission Obtaining Copies of

GAO Reports and Test i mony Order by Mail or Phone

To Report Fraud, Waste, and Abuse in Federal Programs

Public Affairs
*** End of document. ***