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Mental Health and EPSDT: Systems of Care

Children’s Mental Health Services are Often Limited and Fragmented

Coordinating mental health services for children is a challenge for both families and service providers due to fragmented and limited services.  Families seeking counseling, psychiatric assessment and perhaps medication, may experience a number of barriers:  

• Lack of health coverage for mental health services;
• Long waits and potentially long drives to see one of the limited number of child psychiatrists;
• Lack of communication about the child’s mental health treatment between the primary care physician and behavioral/mental health providers;
• Varied and complex eligibility criteria for public programs.  

While the availability and use of mental health services for children appears to have increased in recent years, many children and youth are underserved, particularly members of racial/ethnic minority groups. Studies indicate the quality of services is often poor and the cost very high. While some mental health prevention and treatment programs have been demonstrated to be effective, evidence-based practices have not been widely adopted. (McMorrow & Howell, 2010 PDF - 371 KB)

Changes are taking place in the children’s mental health system to an effort to make it more responsive to families and reduce the fragmentation of services.  These changes are built on a set of defined principles and incorporate new types of services.  

Systems of Care

Over the past two decades, parents have created a movement to bring mental health resources for children with SED together into a more functional “system of care” founded upon Child and Adolescent Service System Values (CASSP). (Lourie, 1994; Stroul & Friedman, 1996) The Substance Abuse and Mental Health Services Administration (SAMHSA) has provided funds to States to support systems of care.  
CASSP principles and practices are entirely consistent with those of medical homes and family centered care in the primary care arena.  

Many States have implemented a formal system of care or are adapting service systems to better reflect CASSP principles.  Similar to the Title V goal of a comprehensive, family-centered, community-based, coordinated systems of care for CSHCN for children with special care needs, CASSP has principles that include the following:

•  Child-centered: meet the individual needs of the child.
• Family-driven: recognize the family is the primary support system for the child and the family is a full partner in service planning.
• Community-based: whenever possible, delivered in the home and obtained from community resources.
• Culturally and linguistically competent: recognize and respect the behavior, ideas, attitudes, customs, language, rituals, ceremonies, and practices of the family's ethnic group.
• Integrated service delivery, with care coordination and seamless service delivery.
• Comprehensive service array, with individualized services based on individualized service plans.
• Clinically-appropriate, age-appropriate, and least restrictive/least intrusive: take place in settings that are the most natural for the child and family and are the least restrictive and intrusive to meet the needs of the child and family.

Wraparound and Other New Services

Systems of care have developed wraparound services, which are individualized community-based services. Wraparound services use the natural supports and community resources in the development of a comprehensive family service plan. The planning process for wraparound involves a team of individuals relevant to the well-being of the child (such as family members, service providers, teachers, and representatives from any involved agency) who collaboratively develop and implement an individualized wrap-around care plan.  Studies have found that wraparound services are among the most effective interventions for children with emotional, behavioral and mental health needs and that most children make substantial improvements when provided wraparound services instead of institutional care.

Wraparound services might include:

• in-home therapy
• respite for caretakers
• parent to parent support
• mentors (a trained individual who spends time with a child and, in addition to the therapeutic advantages of the mentoring, can facilitate participation in community recreational activities)
• in-home crisis intervention
• advocacy to obtain other needed services for the child, family and other children  

In combination with conventional outpatient treatments, these services are designed to prevent children from unnecessarily being removed from their homes and communities in order to receive some form of residential treatment.   

The National Wraparound Initiative has resources for families, providers, and communities. 

See examples of State wraparound programs:

Connecticut 
Iowa 
Michigan 
Montana 
Oregon 
Pennsylvania
Tennessee
Texas 
Vermont   

Parent and Youth Voice and Choice

In mental health systems of care, the service planning process is driven by families and directed by youth according to their own preferences and needs.  In addition, systems of care projects include parent and youth representation on their advisory boards, and have created and supported parent and youth organizations.  Parent peer support has been important in providing education, support and advocacy services.  Overall, these organizations are strengthening and amplifying the voices of family and youth in their own care and in the broader children’s mental health system. (Hoagwood et al, 2010)

Blended Funding

Blending and braiding different funding sources is essential for financing systems of care. No one source of funds will support an integrated and coordinated network of community-based services and supports organized around the needs of children and youth with serious mental health needs and their families.  While the funding sources and specific target populations vary, Medicaid/EPSDT services are almost always included for low-income children.