Executive Summary

The Comprehensive Community Mental Health Services Program for Children and their Families, now in its fourth year, provides grants to States, communities, territories, and Indian tribes to improve and expand their system of care to meet the needs of an estimated 4.5 to 6.3 million children with serious emotional disturbance and their families. Administered by the Child, Adolescent and Family Branch of the Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration, the program was first authorized in fiscal year (FY) 1992 by section 561 of the Public Health Service Act, as amended.

Built on the principles of the Child and Adolescent Service System Program (CASSP), the Children's Services Program promotes the development of service delivery systems through a system-of-care approach. The system-of-care approach proposed by the CMHS initiative is defined as a comprehensive spectrum of mental health and other necessary services organized into a coordinated network to meet the diverse and changing needs of children and adolescents with serious emotional disturbance. The system-of-care model is based upon a philosophy that includes three hallmark elements: 1) the mental health service systems are driven by the needs and preferences of the child and family from a strength-based, rather than deficit-based, perspective; 2) the locus and management of services are derived from multi-agency collaboration and grounded on a strong community base; and 3) the services offered, the agencies participating, and the programs generated are responsive to the cultural context and characteristics of the populations that are served. To develop a system of care consistent with the model requires activities focused on two levels: infrastructure (the physical structure, organizational arrangements, and procedural framework to support the interventions and approaches to serving children and families) and service delivery (the programs and actions taken to provide services and interventions which directly serve/involve families). Communities are given flexibility in how they fine tune their system-of-care approach to meet their unique needs.

The CompComprehensive Community Mental Health Services Program for Children and their Families expanded its grants program in September of 1997. With the award of nine new 5-year grants to develop services using the system-of-care approach, the grants program now totals 31 grantees across the country. In addition to expanding its program, the Child, Adolescent and Family Branch funded the National Technical Assistance Center at Georgetown University to organize a workshop for sites that applied for grants in the 1997 competition but were not funded. The purpose of the workshop was to provide these unfunded sites with group and individualized technical assistance on successful approaches for developing systems of care in their communities. Of the 34 sites who had applied but were not funded, 22 attended the workshop. Participants rated the workshop as highly useful.

At the onset of the CMHS initiative, plans were made and resources were allocated for a national evaluation of the grant program. The purpose of this evaluation is to study the system-of-care approach and explore the system's impact on children with serious emotional disturbance and their families. This report presents data yielded from the second year of the CMHS evaluation. Based on data collected through August 1997, preliminary findings show notable improvements for children who are in services for at least six months. For example, the evaluation indicates that after six months:

average levels of functional impairment as assessed through the Child, Adolescent, and Functional Assessment Scales (CAFAS) decreased by almost 20 percent
the percent of children with average or above-average grades increased by 13 percent
the percent of children with infrequent or very infrequent school attendance was reduced by 42 percent
there was a decrease to "no law enforcement contacts" among 47 percent of the children with one or more contacts at intake
there was a decrease to "one living arrangement" among 49 percent of the children with multiple living arrangements at intake.

Additional findings are summarized in the CMHS Data Highlights that appear after this section. It should be emphasized, however, that these analyses are preliminary and should be interpreted cautiously due to limitations imposed by the absence of a comparison control group and varying numbers of families participating at the intake and six-month evaluation points.

Descriptive data for the children enrolled in the CMHS evaluation during Year 1 and Year 2 are reported on 24,724 children and families, and clinical and functional data are reported on 9,682 children and families sampled in the outcome component of the national evaluation.

A growing source of evidence on the effectiveness of the systems of care in the children's services program comes from the site-level evaluations being conducted at each grantee site. In addition to implementing the national-level evaluation for Macro International, many sites have expanded their evaluations to address site-defined child and system outcomes. For instance,

The Crossroads Program of San Mateo County, California, reported a 61 percent reduction in the number of crimes committed by 101 youths in probation in the 12 months after entry into the program compared to the 12 months prior to entry.
Since the inception of the ACCESS program in the city of Alexandria, Virginia, in 1995, residential placements for children with serious emotional disturbance were reduced by over 48 percent, from 27 to 14.
The Families First Program of the State of Vermont, which provides crisis services for children who are abused or neglected, delinquent, or unmanageable, reported that it costs an average of $18,334 per year to support a child placed in the custody of the state, while the average cost of serving a child in Families First is $600, representing an average savings of $17,734.
In an analysis of a single countywide system of care, service utilization and service mix were differentially related to severity of functional impairment. More impaired children participated in a greater number and broader array of services. The broadest array of service mix produced the most positive outcomes in children and adolescents with serious levels of impairment at intake.

Initial experiences with data reported by evaluators at the site level seem to show positive results that are in some instances more dramatic than the national-level results. This is to be expected, since the national-level data is aggregated and averaged across many sites, thus reducing the strong positive results found among some individual sites. It also is beginning to appear that some sites are able to report findings different from those reported in the national evaluation, primarily because these sites have broadened the scope of the measures and outcomes they are using to collect data.

The challenge for the national evaluation is to show how these improvements are connected to the development of systems of care across 22 grantees. For this purpose, four sites were selected during fiscal year 1997 to conduct quasi-experimental comparison studies between system-of-care sites and similar sites without systems of care fully in place. These studies are expected to generate empirical evidence on whether or not the system-of-care approach may be a better model than other existing service models.

During FY 1997, the Child, Adolescent and Family Branch of CMHS developed several additional initiatives to enhance the impact of the Comprehensive Community Mental Health Services for Children and Their Families program. It continued to promote partnerships among Federal agencies and private organizations, it supported an academy to develop child behavioral health care providers of color, and it commissioned several papers on the findings of the 4-year-old grant program.

In recognition of efforts to promote public and private partnerships, the prestigious Hammer Award was presented to an interagency team organized by the Child, Adolescent and Family Branch for its initiative to consolidate training and technical assistance to Federal grantees serving children and youth. Vice President Albert Gore gives the award to employee and citizen teams who make significant contributions in support of the National Performance Review principles. An important activity aimed at encouraging increased involvement by providers of color in the child mental health field became a reality when the National Technical Assistance Center for Children's Mental Health at Georgetown University organized the first National Academy for Developing Health Care Providers of Color on November 2-5, 1997 in Houston, Texas, with approximately 100 attendees. To disseminate findings and lessons from the children's services program, the Child, Adolescent and Family Branch launched an initiative to write six papers on promising practices in children's services that have potential for replication across the country. The topics of these system of care papers include family and service provider partnerships; lessons learned from the 22 grantees of the 1997 service program; new roles for family members; training strategies; implementing a wraparound approach; and interagency collaboration, governance, accountability, and leadership.

With respect to systems implementation, the majority of sites made more progress in the development of their infrastructure as compared to development at the service delivery level. As expected, sites typically develop an infrastructure first, and build services based on the supportive structures. Generally, more substantive changes occur earlier in the funding cycle. Initially, changes are expected in the development or improvement of system infrastructures. As infrastructures improve, gains in expanded service delivery capacities are noted in many sites. As sites mature, growth in infrastructure tends to level off, as sites are more likely to modify or make adjustments to existing structures in order to further optimize service delivery capacities. Change continues to characterize the service delivery domain as grantees respond to the needs of the children, families, and communities they serve.

Table of Contents | Next