September 11-12, 2002
Michael F. Hogan, Chair
Ex Officio Representatives Present:
Chris Spear, Department of Labor
Staff Members Present:
Claire Heffernan, Executive Director
Presenters who attended portions of the two-day meeting were:
Robert Pynoos, Professor, Department of Psychiatry and Biobehavioral
September 11, 2002
Introduction and Agenda Overview
Chair Michael Hogan convened the meeting at 8:30 a.m. and welcomed participants to the Commission's first gathering outside Washington, DC. He invited participants to join in a moment of silence in memory of those lost on September 11, 2001.
Trauma and Its Impact on Children
Commissioner Steve Mayberg introduced the opening speaker, Dr. Robert
Dr. Pynoos explained that trauma involves experiencing or witnessing an extreme threat of violence, serious injury, or violation of physical integrity. Trauma that commonly affects children includes child physical and sexual abuse; domestic violence; community violence and criminal victimization; medical trauma; life threatening illnesses; traumatic loss (e.g., death of a parent); accidents; residential fires; humanitarian disasters; natural disasters; armed conflict; genocide; and torture. Approximately 10-20 percent of traumatized children will develop chronic, debilitating responses. Dr. Pynoos referred to a study of adolescents where the rate of Post Traumatic Stress Disorder (PTSD) was greater than 20 percent over a lifetime.
Trauma may affect children developmentally (e.g., children appear frozen in time and have difficulty progressing with developmentally appropriate tasks); biologically (e.g., brain changes occur which affect children's ability to modulate their startle mechanism); and academically (e.g., lower grades, more absences, and depression). Trauma also has a measurable effect on children with serious emotional disturbance and adults with serious psychiatric disorders. More research is still needed to determine how a traumatic event or a history of trauma affects the course of a person's psychiatric disorder and response to treatment.
He shared several findings from studies conducted after September 11th which illustrate the attack's traumatic impact:
While mental health systems generally understand how to respond to a traumatic event and provide crisis counseling and support, little or no long term work occurs after the crisis has passed. Mental health professionals can help children understand and reframe trauma, as well as learn how to identify and manage traumatic reminders which may trigger symptoms. As important, professionals can teach parents and teachers about traumatic reminders so they can help children cope and seek social supports.
Dr. Pynoos offered several recommendation to increase professionals' ability to address trauma, including (1) enhanced training and education about trauma for people who interact with children; (2) surveillance and screening, including incorporating trauma-related items into Medicaid's Early and Periodic Screening Diagnosis and Treatment and Head Start reporting; and (3) expansion of school-based interventions through FEMA grants, and (4) ongoing interventions after the crisis.
Following the presentation, Commissioners posed questions to Dr. Pynoos about the technical assistance efforts of the National Child Traumatic Stress Network and its 25 sites; needs of children that have endured mild and persistent trauma; and the importance of treating children with the most severe trauma histories to improve the classroom milieu.
A copy of Dr. Pynoos' presentation is available on the Commission's website, www.mentalhealthcommission.gov.
Youth Panel: Perspectives on the Mental Health System
Commissioner Jane Adams introduced the youth panel and expressed the Commission's desire to hear directly from young people about their experiences with and perceptions of the mental health service system. Illinois Office of Mental Health's (OMH) Amy Starin moderated the panel of five youth from the Chicago area and Kansas.
Several youth panelists shared findings from two surveys of young people conducted by the OMH Teen Advisory Council: a consumer satisfaction survey and a survey on violence. In the consumer satisfaction survey, a significant majority of respondents indicated satisfaction with services and confidence in their counselors. However, respondents also were concerned about counselor turnover, meaningful participation in treatment plans, use of medications, and breaches of confidentiality. The violence survey revealed that approximately 50 percent of the youth respondents had been victims of violent or aggressive behavior both at school and in the home.
Other panelists shared both their positive and negative experiences with the mental health system. On the positive side, youth panelists reported satisfaction with a therapeutic day school placement, support from respite workers, special recreation opportunities, helpful psychosocial community-based programs, and a smooth transition from a residential placement to home. Panelists expressed frustration about inappropriate institutionalization and placement in the foster care system; abrupt loss of services at age 18; and delays in obtaining services from the adult mental health system.
During the question and answer period, Commissioners invited the youth panelists to comment on the impact of hospitalization, their interaction with the courts, challenges in accessing information about treatment options, adequacy of school services and supports, and problems caused by high turnover among treatment staff. Commissioner Jane Adams also acknowledged and congratulated the parents of the panelists for their supportive efforts. Dr. Hogan expressed his appreciation to the youth panel for the survey data and their practical advice.
A copy of the Illinois OHM Teen Advisory Council survey results presented during the youth panel is available on the Commission's website, www.mentalhealthcommission.gov.
Comprehensive Community-Based Service Systems for Children, Youth and Families: Family, State and Community Perspectives
After Commissioner Larke Huang introduced the panel, Moderator Sheila Pires provided a context for the discussion by detailing the wide and varied population of children and families that depend on the public mental health system. Ms. Pires suggested that funding be redeployed from intensive treatment to early intervention in order to more effectively meet the needs of children and families. She encouraged the Federal government to support development of community-based models through (1) providing leadership and visibility, (2) supplying additional funding, (3) easing administrative burden and creating more rationale regulations, and (4) providing technical assistance.
Bruce Kamradt, Director of Wraparound Milwaukee, described the positive outcomes achieved by the program, including better clinical outcomes for children; reduced recidivism for delinquent youth; improved school attendance and school performance; reductions in use of residential treatment and psychiatric hospitalization; and reduction in cost of care. He commented that Wraparound Milwaukee could be replicated in any community, given the necessary political will.
Serving 600 children at any one time, the program's wrap-around approach involves building upon children's and family's strengths. The target group is children with serious emotional and mental health needs who are at immediate risk of residential treatment, correctional placement or psychiatric hospitalization. The program operates 24-hour mobile crisis management teams, care management teams, and a provider network offering 80 services through 230 agency and individual providers. Because Wraparound Milwaukee is a Medicaid certified agency, more providers have been able to join the network, including minority providers and those who offer nontraditional services (e.g., mentoring, respite).
Wraparound Milwaukee has a $30 million annual budget with funding primarily from child welfare, juvenile justice, and Medicaid. The pooled funding allows the system to serve many more children and minimize out-of-home placements. Wraparound Milwaukee also created its own public care management organization and pays a capitated rate which covers any required service, including residential and juvenile justice placements.
Julie Caliwan, Director of the Children's System of Care Initiative in New Jersey, explained the state's single statewide integrated system of care, which began serving children and families in February 2001. The state completely restructured its system, changing the way it financed, organized and provided services to children.
A key element of New Jersey's revamped system has been the development of family support organizations which provide education, advocacy, training, and monitoring, as well as information and support to families. Another important feature is that families and providers experience a seamless system since funding is drawn down from one pot with financial eligibility determined in the central office. Other components of New Jersey's system include a single point of entry, care management services, mobile response and stabilization services, an expanded array of flexible services and provider network, and comprehensive information management support system.
Deborah Howard, a parent advocate from Kansas, shared her challenging
experience as a grandparent trying to access appropriate mental health
and educational services for her granddaughter. Eventually, she teamed
up with community mental health staff and now self directs her granddaughter's
Medicaid waiver. Ms. Howard credited support received from family
support organizations for enabling her to assume such an active role
in overseeing her granddaughter's care. She urged the Commission to
recommend policies that support and empower families.
Ms. Pires proposed several changes at the Federal-level to enhance integration among child-serving systems and development of community-based models. Her recommendations were to: (1) educate and work with Medicaid directors to identify arcane Medicaid regulations which impact services for children; (2) require that SAMHSA grant programs involve state/local partnerships; and (3) conduct joint projects with Medicaid and Child Welfare (IV-E) funding. Commissioner Ruben King-Shaw relayed that the Center for Medicare and Medicaid Services will be issuing a new wave of "mega waivers" that allow more coordination and flexibility, in accordance with Health and Human Services Secretary Tommy Thompson's "One Department" vision.
The presentations of Ms. Pires, Mr. Kamradt and Ms. Kaliwan are available on the Commission's website, www.mentalhealthcommission.gov.
Chairman Hogan recessed the public session at 3:35 p.m.
September 12, 2002
Models of School-Based Mental Health Services
Commissioner Bob Pasternack introduced the panel on school-based mental health services. Dr. Adelsheim began the presentation by providing prevalence data on mental disorders in children and reported that 70 percent of children with identified mental disorders are unable to access the mental health services they need. He recommended a public health approach to mental health and mental illness, comparable to the public health response to infectious diseases (i.e., education, screening, awareness, early identification and treatment). Citing the strong Federal commitment to childhood immunization, he urged a similar level of commitment to addressing children's mental health needs.
As schools are the most universal and natural setting for children,
school-based mental health services improve access, minimize stigma,
and build trust among children receiving services and their families.
In addition, school-based mental health professionals can collaborate
with education professionals; observe and interact with children and
teachers in the classroom; and identify and reach those children with
internalizing disorders (quiet, depressed children).
Ms. Jennings described Youth and Family Centers, school-based health centers providing primary and mental health care to 3,000 students in Dallas at no cost to families. Aimed at enhancing students' academic success by reducing health-related barriers to learning, the Centers operate under a partnership between the Dallas Independent School District and Parkland Hospital, which delivers the primary care. Schools and local community mental health centers provide mental health care to students. Mental health interventions involve individual and family therapy and include classroom and home visits for each child. Ms. Jennings reported several positive outcomes for children served, including improved grades, promotion rates, and standardized test scores.
Dr. Adelsheim and Ms. Jennings concluded with a set of recommendations, including (1) allocate funding for school based mental health services in school health centers through Federal programs (e.g., Medicaid's Child Health Insurance Program (CHIP) and Education's Safe and Drug Free Schools); (2) expand incentives to increase the number of child-trained mental health providers and require training in working with schools; (3) implement screening and assessment for behavioral health issues similar to vision and hearing screenings for children when they enter school; and (4) conduct mental health assessments at critical junctures (e.g., transition to middle and/or high schools or after disciplinary incidents).
Commissioners were interested in learning about the amount of funding needed to implement school-based services; strategies for meeting diverse cultural needs in school; additional training for general practitioners about specialized mental health needs of children; interaction between school-based professionals and the court system; school liability; and the role of Medicaid in paying for services.
The presentations by Ms. Jennings and Dr. Adelsheim are available on the Commission's website, www.mentalhealthcommission.gov.
Dr. Hogan introduced the period for public comment by reviewing procedures for speakers, including a three-minute time limit for remarks. Individuals who spoke and submitted written testimony were:
Chair Hogan requested that the Commission approve the draft minutes from the July 17-18, 2002 and August 7-8, 2002 meetings. Commissioner Huang moved to accept the minutes and Commissioner Godbole seconded the motion. The minutes were accepted unanimously without revision.
Commissioners then provided brief summaries of their site visits to exemplary programs in Chicago on September 10, 2002. Commissioners visited and met with representatives from the Cook County Juvenile Court, Dixon Elementary School, Thresholds, Community Mental Health Council, Kaleidoscope, and the Ounce of Prevention Fund. Several Commissioners also hosted a town hall forum and talked with thirty stakeholders from the public mental health system in Illinois. Chair Hogan expressed appreciation to the site visit representatives for their hospitality and thanks to Commissioner Godbole and the Illinois Office of Mental Health staff for coordinating the site visits.
Finally, Commission Subcommittees that met in Chicago gave brief updates on their progress. The Subcommittees on Rural Issues, Mental Health Interface with General Medicine, Older Adults, Rights and Engagement, Consumers, Children and Families, Interim Report, and Evidence-based Practices provided reports.
Adjournment and Next Meeting Announcement
Dr. Hogan thanked all the presenters and adjourned the meeting at 3:35 p.m. The next Commission meeting will occur October 2-4, 2002 in Arlington, Virginia.
I hereby certify that, to the best of my knowledge, the foregoing minutes are accurate and complete.
Michael Hogan, Ph.D.
These minutes were considered and approved by the Commission at its
September 11, 2002 meeting and any corrections or notations incorporated
into the text.
Last Modified 10/07/02