Annual Report to Congress on the Evaluation of the Comprehensive Community Mental Health Services Program for Children and Their Families

The Comprehensive Community Mental Health Services Program for Children and their Families

Comprehensive Community Mental Health Services Program for Children and their Families provides grants to States, communities, territories, and Indian Tribes to improve and expand their systems of care to meet the needs of children and adolescents with serious emotional disturbance and their families. These include children and youth with a serious emotional disturbance from birth to age 21 who currently have, or at any time during the past year had, a mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified in the Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV), that resulted in functional impairment which substantially interferes with or limits one or more major life activities. Administered by the Child, Adolescent and Family Branch of CMHS, the program was first authorized in fiscal year (FY) 1992 by section 561 of the Public Health Service Act. The CMHS initiative has grown from the initial $5 million in its first year of funding, to $35 million in its second year, to the current level of $78 million. From 1993 to 1998, a total of 45 grants were awarded for 5 years each (see Table 1).

Building Systems of Care

"One year ago, we were considering giving up custody of our son. His behavior, the suspicisions from school, it was too frustrating. We fully expected him to end up in the juvenile justice system. The [system of care] gave us options. Now he's successful in school and getting better grades."

To build a foundation to support children, families, and communities within a system-of-care framework, grantees must enlist a wide variety of partners. Together, the partners craft a system of care using a set of guiding principles that serve as building blocks (see Figure 1). Chapter II of this report provides an in-depth look at the role of partnerships in system building.

As the first two layers of building blocks in the illustration indicate, a fully implemented system of care offers a diverse array of mental health and non-mental health services: social, educational, mental health, juvenile justice, recreational, vocational, health, substance abuse, and other support services. Fundamental to the system-of-care approach is a move away from service systems with an over-reliance on a limited set of choices, particularly on inappropriately restrictive care. Instead, systems rely on a broad range of services that can be matched to the needs of specific children and families. These services are provided by a variety of public and private agencies and organizations. Providers in the system of care have a shared vision of the aims and purposes of the system, which is manifested in policies and procedures, decisionmaking, and service delivery.

The next layer represents the essential characteristics of services provided. Services are individualized—designed for and tailored to the particular strengths and needs of individual families. Children are not placed in a program simply because a "slot" is available or because a treatment protocol indicates a certain therapy. A team consisting of family members, cross-disciplinary service providers representing multiple agencies, and other relevant participants devises a detailed service plan with specific, achievable, strengths-based behavior and treatment goals. This plan guides service provision and delivery and coordinates the work of the various participants.

A fully implemented system of care coordinates services through agreed-upon eligibility criteria and shared intake processes, systematic information sharing, routine updates and recording of all services received, and the institutionalization of sharing the service plan across agencies. Finally, services are accessible to families. They are offered at convenient times and locations, and the system actively works to eliminate language, financial, and other barriers to service.

All services and service delivery practices are influenced by the essential characteristics of the system of care, as represented by the fourth layer. A family-driven system reflects this attribute at all levels. It incorporates the family as the service provision unit and uses a broad definition of family so that noncustodial caregivers are involved in services. Families are full partners in their service planning; their opinions and suggestions are given the same respect as those of system staff.

Families also have a voice in system decisions. They are represented in decision-making bodies, with voting rights when relevant. Further, if necessary, families are provided with the training and support they need to act as full participants on interagency structures and boards. Feedback is actively sought from families as a means of enhancing accountability and making mid-course corrections in system management. Finally, the system of care promotes the development of family advocacy capacity and family empowerment.

Cultural competence is reflected in the system of care’s sensitivity and responsiveness to the cultural needs of children and families and to their needs with regard to race, religion, national origin, sex, physical disability, and other community-specific characteristics. Cultural competence is formalized throughout the system: in policies, procedures, outreach and advocacy efforts, training, the array of services, the service delivery framework, and the recognition of the importance of existing community support networks such as churches, extended kinship networks, and social organizations. Staff and service providers are knowledgeable, skilled, and aware of cultural issues within the diversity of their community.

The locus of decisionmaking in a fully implemented system of care is the community. Decisions about the array of services and the organization of services are made in the community, reflecting its values, resources, needs, and limitations. Community organizations and representatives are called on to participate in the system of care, which they do by providing services, making decisions, leading training, and holding each other accountable.

The principles of family driven, community based, and culturally competent are interconnected. As a system of care becomes family driven and community based, its level of cultural competence increases. As providers and families meet in the community—whether for a play therapy session at the neighborhood center, at a board meeting, or at the annual family fair—relationships, at first tenuous, are cemented; respect and trust mature through genuine understanding of individual circumstances; appreciation grows for each others’ cultures.

Finally, children, families, and the community comprise the fifth layer, simultaneously supported by the system and integral to the system. Education and training form the mortar that holds the system together. Many system-of-care principles represent a significant departure from the medical model of treating children. Formidable adjustments to traditional approaches and standard operating procedures are required of virtually every participant in the system of care. Frequently, families must learn to express their opinions, just as staff must learn to comprehend, appreciate, and fully integrate families’ perspectives. Such change does not come quickly or easily and does not perpetuate itself without substantial, continual investment in human resource development.

Supporting Systems of Care

The CMHS, Child, Adolescent and Family Branch has the responsibility for providing oversight to the grantees and ensuring that training and technical assistance are available to the grantees. This is provided by the National Resource Network for Child and Family Mental Health Services (NRN) operating under the auspices of the Washington Business Group on Health, and by the National Indian Child Welfare Association (NICWA). The training and technical assistance for these grants, under the Child, Adolescent and Family Branch’s direction, is field based and practice driven. Site-generated technical assistance is implemented through "hubs" based on the demographic characteristics of the grantees, particularly geographic organization and population density. Urban, small city, rural, and, most recently, Native American hubs provide support and specific technical assistance for the assigned grantees. Through their hub designations, grantees meet to determine priorities and to learn from one another the successes and barriers to successfully implementing appropriate systems of care or best practices. Primary among the hub concerns is ensuring that grantees have the needed resources to meet the program goals within the specific cultural and community contexts in which they operate.

Another important support function relates to raising public awareness about mental health needs and services for children with serious emotional disorders. Under contract to Vanguard Communications, CMHS instituted a 5-year Public Awareness Campaign. The campaign is focusing on communicating the importance and accomplishments of comprehensive, community-based systems of care to a wide range of audiences, including policymakers, the general public, the private sector, and the research community. These efforts are designed to enhance and support the activities of the grantees through a variety of public education and social marketing initiatives.

CMHS also works in close partnership with the Federation of Families for Children’s Mental Health to support the grant program. The Federation is a national, parent-run organization focused on the needs of children and youth with emotional, behavioral, or mental disorders and their families. The Federation supports the program by providing sites with technical assistance and training to help strengthen the role of families in the system-of-care initiative.

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