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The Comprehensive Community Mental Health Services for Children and Their Families Program
Annual Report to Congress 2002-2003
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Summary
Many advances in the children’s mental health knowledge base have been made in understanding the determinants of mental illness, the course of the disease, and treatment and service delivery approaches. These advances in the knowledge base have served to illuminate continuing challenges in delivering services and unmet needs, and have thrust the issue of children’s mental health into the public spotlight. The system of care approach to organizing service systems and providing services to children with serious emotional disturbance and their families has become widely accepted and continues to offer a framework for system reform (Stroul, 2002). The information contained in this report provides evidence of the effectiveness of the Comprehensive Community Mental Health Services for Children and their Families Program (CMHI) to support implementation of systems-of-care and improve the outcomes of children with serious emotional disturbance and their families; and highlights the importance of continuing to expand the program’s reach.
The CMHI supports system-level change in the way mental health services are provided to children and their families. As indicated by the system of care assessment results, grant-funded system of care communities were successfully developing organizational and service system infrastructure according to system of care principles. As expected, incorporation of system of care principles into infrastructure and service delivery occurred to a lesser extent in the matched, non-funded communities. While the communities assessed for this report reached at least moderate levels of achievement in the application of all eight system of care principles across all four elements found in the infrastructure domain, they were more successful in applying system of care principles in the service delivery domain. Grant communities were able to provide services in the least restrictive service settings that were therapeutically appropriate. Cultural competence remained a challenge with communities most often having difficulty achieving diversity in governance body membership and among direct service staff, making effective efforts to develop and maintain culturally relevant service arrays, meeting the variety of language needs of children and families who were not primarily English-speaking, and planning and providing a comprehensive range of culturally appropriate services. Clearly, the program should continue to support communities in their efforts to improve in these areas.
These changes at the system level enabled transformation of the service experiences of the children and families served. Most children received only nonrestrictive services, community-based services; and these service experiences translated into increasing satisfaction with services, especially among youth. This finding is in contrast to research involving non-system of care communities (Lavigne et al., 1998), which suggest that a substantial number of children and youth with mental illness have unmet needs because they do not receive services, or receive inadequate or overly restrictive services. Services were financed through multiple funding sources with the majority of funding derived from Medicaid. Community-based services accounted for the largest part of total costs.
These service experiences were associated with improvements in clinical and functional outcomes for children and their families. Emotional and behavioral problems and functional impairment were reduced. School attendance and school performance improved, and children missed fewer days of school due to suspensions or expulsions. All forms of law enforcement contacts decreased, and living situations became more stable. Youth with substance abuse comorbidity experienced significantly greater improvement in their overall functioning. Further, the findings indicate that outcomes for children and families in systems of care are not only shaped by the unique characteristics and experiences of the child and family, but also by the initiative’s values and principles that guide how the service system is developed and implemented. Individualized and accessible service delivery at the system level significantly contributed to improved child functioning, reduced behavioral and emotional problems, and reduced caregiver strain. These findings strongly support the underlying system of care assumptions that children and families will benefit more from a service system that takes into account their unique needs and characteristics and that makes services financially and physically accessible (Pires, 2002; Stroul & Friedman, 1986).
Perhaps the strongest evidence for program effectiveness is provided by the findings from the longitudinal comparison studies conducted through the national evaluation (Foster et al., 2004; Stephens et al., 2005). These studies have provided critical information about children and adolescents with serious emotional disturbance, and have comprehensively explored the structure and function of a system of care and their relationship to child and family outcomes. As noted previously, data from these studies indicate that, at the system level, the grant initiative has been effective in translating system of care principles into reform of a system’s infrastructure and service delivery approach. It is clear from the findings that the system of care approach to serving children with severe emotional needs and families provided a more comprehensive service experience than the non-system of care approach.
Findings from the comparison studies suggest that for those children with greater functional impairment, high delinquency scores, and contact with law enforcement for serious offenses, a federally funded system of care can be more beneficial than services delivered as usual in a matched comparison community, although there is some inconsistency in these findings across pairs of communities studied. Preliminary findings from the second comparison study indicate that children in system of care communities show greater improvements in behavioral and emotional problems, and in their behavioral and emotional strengths.
Although more financial resources were devoted to mental health services within system of care communities, a broader cost perspective suggests that this investment may offset increased costs across other child-serving agencies within the community such as juvenile justice, inpatient and residential placements, child welfare, and education. Other literature from the evidence-based treatment movement within children’s mental health (Burns & Hoagwood, 2002) suggests that systems of care are an area in need of further study, especially with respect to the integration of evidence-based interventions within these community-based programs. Special studies in development within the national evaluation employing randomized clinical trial designs will begin to address these questions.
In conclusion, the findings in this report provide information on how to optimize service delivery for children and families within systems of care.
Originating Office
Office of the Associate Director for Organization and Financing, Center for
Mental Health Services, Substance Abuse and Mental Health Services Administration,
One Choke Cherry Road, 6-1065, Rockville, MD 20857.
DHHS Publication No. SMA-CB-E2002/03
Printed 2007
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