Journal Issue: Children and Managed Health Care Volume 8 Number 2 Spring 1998
Development of Systems of Care for Children's Mental Health Services
In 1969, the Joint Commission on the Mental Health of Children found that children with emotional disorders and their families were typically unserved, or were served inappropriately in excessively restrictive settings such as residential facilities and psychiatric hospitals.2 Numerous subsequent reports have substantiated these findings.3-5 For example, the Children's Defense Fund's 1982 publication, Unclaimed Children, documented that of the 3 million children in the United States with serious emotional disorders,6 two-thirds were not receiving the mental health services they needed, and many more were receiving inappropriate care.7 All of the reports concurred that to serve these children and their families effectively, coordinated systems providing a wide range of services were needed.
Since the publication of Unclaimed Children, the notion of community-based systems of carealso referred to simply as systems of care-has become the prevailing ideology for mental health service systems for children and adolescents and their families. This system-of-care philosophy emphasizes:
- A broad array of services, which includes a range of intensive nonresidential and residential options, such as outpatient therapy, home-based services, day treatment, crisis services, respite care, case management, therapeutic foster care, therapeutic group care, and other services;
- Interagency collaboration among the systems that share responsibility for youths with emotional problems, such as education, child welfare, juvenile justice, public health, mental health, and substance abuse;
- Treatment in the least-restrictive appropriate setting;
- Individualized and flexible treatment and services;
- Family involvement in all aspects of the planning and delivery of services; and
- Culturally competent services that are responsive to the needs and characteristics of diverse ethnic and racial populations.8,9
During the past decade, there has been a great deal of progress throughout the country in the implementation and financing of such systems of care, primarily in the public sector, for children with the most serious needs.10-15 State Medicaid programs increasingly have been used to fund these more coherent service-delivery systems.14,15 The early and periodic screening, diagnosis, and treatment (EPSDT) program, a prevention program for Medicaid-eligible children up to age 21, expanded the opportunity to use Medicaid funds to support a broad array of services necessary for the treatment and support of children and adolescents with emotional disorders and their families.16
For children and families whose mental health services are funded by private health plans, the vast majority of mental health services are still provided in a more traditional, nonsystematic, fragmented manner.17 Lourie and colleagues18 identified several obstacles that have impeded the development of a system-of-care approach to mental health service delivery within the private sector. Perhaps most important, private mental health services traditionally have been delivered using a medical model, which focuses narrowly on the pathology of mental health problems and fails to integrate treatment with supportive aspects of care, such as behavioral aides in home and school settings, respite care, and other family support services. In addition, the model adopted by the private mental health delivery system primarily attends to acute care needs, often relegating care for long-term, disabling conditions-such as serious emotional disorders-to public service systems, including special education, child welfare, and juvenile justice, as well as to the public mental health system.