Coordinating Care for Children with Serious Mental Health Challenges
By Rebecca A. Clay
Justin* was only 4 years old, but he and his family were already in distress. He had been kicked out of several childcare centers for biting, kicking, and hitting. He had destroyed property. His temper tantrums would go on for hours.
Needing help, his mother took him to the local medical school where they came up with a diagnosis, a set of recommendations, and a treatment plan. Justin’s mother also took him to a mental health clinic where they provided a different diagnosis, recommendations, and treatment plan. Then the boy’s school came up with a third diagnosis and plan.
“But when the mom chose one plan and began to follow it, the other two systems labeled her as ‘resistant,’ ” recalled Rob Abrams, M.S.W., Project Director of Wraparound Oregon: Early Childhood at the Multnomah Education Service District in Portland, OR. “Nobody was getting along very well.” (Read more about Wraparound Oregon.)
This is the type of scenario SAMHSA’s Comprehensive Community Mental Health Services Program for Children and Their Families is designed to prevent. Launched by SAMHSA’s Center for Mental Health Services (CMHS) in 1992, the program promotes a coordinated, community-based approach to care for children and adolescents with serious mental health challenges and their families.
There are currently 59 active grantees, including Mr. Abrams’ program. They bring together everyone involved in a child’s life to formulate a plan—a “system of care.” With the child and family at the center of the decision-making process, a workable plan is created.
“The different child-serving systems, such as child welfare, juvenile justice, and education, need to speak to each other,” emphasized Gary M. Blau, Ph.D., Chief of the Child, Adolescent, and Family Branch at CMHS. “What we’re trying to do through this program and the grants we provide is avoid fragmentation and allow the communities that receive our funding to integrate their services. Our goal is to ensure a coordinated network of care.”
As a testament to the success of this integrated approach, last spring Harvard University’s Ash Institute for Democratic Governance and Innovation named this SAMHSA program one of the top 50 innovations in government.
Of children between ages 9 and 17, 5 to 9 percent have emotional disturbances severe enough to impair their functioning, according to SAMHSA’s Children’s Mental Health Facts: Systems of Care (see Resources). Yet most of them do not get the care they need because services are either too expensive or unavailable.
“Before this program, community-based services didn’t really exist,” explained Diane L. Sondheimer, M.S.N., M.P.H., C.P.N.P., Deputy Chief of the Child, Adolescent, and Family Branch at CMHS.
Often the only choices parents had were the standard 50-minute hour with a psychologist or psychiatrist or a residential treatment program. “Still today, if parents can’t get mental health treatment for their kids, they may have to give up custody to the state. The child may be sent out of the community—or even out of state—to receive care,” she said.
The Comprehensive Community Mental Health Services Program for Children and Their Families is designed to transform the way mental health services and supports are delivered, allowing communities to provide coordinated treatment in the least restrictive way possible.
“A system of care is not a program,” Dr. Blau added. “It’s a philosophy.”
Partnership is one of the core values behind that philosophy; everyone involved in a child’s life collaborates to come up with a treatment plan for the child.
The child and family themselves are participants in that team, instead of simply being recipients of services. Because the teams are “family-driven” and “youth-guided,” said Dr. Blau, the child and family can also choose to involve grandparents, teachers, coaches, neighbors, or others who might be of assistance.
As the team crafts the treatment plan, they focus on the child’s strengths as opposed to the child’s deficits, said Ms. Sondheimer. “In contrast to the traditional medical model, which tends to be deficit-based, our philosophy is to be strengths-based.”
A system of care is not limited to traditional mental health services, Dr. Blau added. Grantees may also offer services such as respite care, tutoring, vocational counseling, legal services, peer-to-peer and family-to-family support systems, and therapeutic recreation.
The goal, said Dr. Blau, is to “wrap services around the child and family.”
Data from the program’s ongoing evaluation show just how effective this approach is.
- Improved mental health. Emotional and behavioral problems dropped significantly or stayed stable for 89 percent of children 2 years after entering a system of care. Suicide attempts also dropped significantly, with attempts among children age 14 to 18 dropping by more than half within 6 months of entering a system of care and by more than two-thirds after 18 months.
- Improved school performance. The percentage of children attending school regularly increased from 74 to 81 percent 6 months after entering systems of care. Academic achievement increased as well, with the percentage of children with passing grades increasing 31 percent after 18 months in systems of care.
- Fewer arrests. Arrests fell by more than half, from 27 percent upon entering systems of care to 11 percent at 18 months. This resulted in a cost savings of $829 per youth.
“Those outcomes are not just of interest to the mental health field, but to everyone,” said Ms. Sondheimer.