Background

The Comprehensive Community Mental Health Services for Children and their families program

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 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 (SAMHSA), the program was first authorized in fiscal year (FY) 1992 by section 561 of the Public Health Service Act, as amended.

Children with serious emotional disturbance are persons from birth to age 18 who currently, or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-III-R, that resulted in functional impairment which substantially interferes with or limits one or more major life activities. It has been estimated that 4.5 to 6.3 million children and adolescents have a serious emotional disturbance in the United States (Friedman, Katz-Leavy, Manderscheid, & Sondheimer, 1996). This definition encompasses a great variety of disorders. The two main categories of disorders include externalizing behavior disorders (e.g., attention deficit hyperactivity disorder and conduct disorder) and internalizing emotional disorders (e.g., anxiety and depression). In addition to these two categories, there are many other disorders of lesser frequency but often great severity, such as bipolar disorder, pervasive developmental disorder, and psychophysiological disorder. Further, many of these children have multiple diagnoses, a predictor of the long-term persistence of mental illness.

Children with serious emotional disorders face challenges in virtually every aspect of their daily lives--at school, in social situations, in the community, and at home. As a result, they often require intervention from a wide range of service systems including mental health, special education, child welfare, health, vocational, and often, juvenile justice. Family members are also affected, and may experience difficulty retaining jobs because of high absenteeism associated with caring for their child, and difficulty finding child care. Other challenges may include disrupted family relationships, routines, and social activities.

Built on the principles of the Child and Adolescent Service System Program (CASSP), the Comprehensive Community Mental Health Services for Children and Their Families 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 disturbances (Stroul and Friedman, 1994). The system-of-care model is based upon a philosophy that includes three hallmark elements, but allows communities to articulate how they fine-tune their system-of-care approach. The three hallmark elements that are common across community variations of the system-of-care approach are: 1) 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 is 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.

The four primary goals of the CMHS initiative include:

expansion of the service capacity in communities that already have developed an infrastructure for a community-based, interagency approach;
development of a broad array of mental health services that are community-based, family centered, and tailored to the individual needs of children and families;
the provision of services in the cultural context that is most appropriate to the children, adolescents, and families; and
the full involvement of family members in the development of local services and in the care of their children or adolescents.

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 $73 million. It is currently comprised of thirty-one grants, located in 18 different states and the sovereign Navajo Nation. The five-year grants have been funded in four cycles. In September 1993, Baltimore, Maryland; Vermont; Charleston, South Carolina; and Stark County and the Southern Consortium in Ohio (which is one grantee) were funded. The following February, seven grantees were added: Wichita, Kansas; Milwaukee, Wisconsin; Providence, Rhode Island; Ventura, Santa Cruz, San Mateo, Riverside, and Solano Counties in California; Hancock, Penobscot, Piscataquis, and Washington Counties in Maine; Dona Ana County, New Mexico; and Pitt and Edgecombe-Nash communities, North Carolina. In September 1994, eleven more sites were added: Alexandria, Virginia; South Bronx, New York; South Philadelphia, Pennsylvania; Santa Barbara, California; Sonoma-Napa, California; Lyons, Riverside, and Proviso Townships in Illinois; Lane County, Oregon; Oahu, Hawaii; Parsons, Kansas; Navajo Nation; and Bismark, Minot, and Fargo, North Dakota. Finally, in October 1997 nine new grantees were added: San Diego, California; Nebraska; Vermont (early intervention); North Dakota; Wisconsin; Montgomery, Alabama; North Carolina (thirteen to fourteen counties); Detroit, Michigan; and the Passamaquoddy Tribe in Maine.

To develop a system of care consistent with the model requires grantees to focus activities 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). At a minimum, grantees must provide the following core mental health services:

diagnostic and evaluation services
outpatient services
24-hour emergency services
intensive home-based services
intensive day treatment services
respite care
therapeutic foster care
transition services

In addition, grantees are expected to continue to develop and adapt their service array to include the wide range of services found throughout other child and family service sectors. Among these include:

Social Services--protective services, supplementary (e.g., financial assistance) and shelter, foster care and adoption
Educational Services--assessment, special education programs, alternative programs
Health Services--the full range from prevention, screening and assessment, primary care, acute care and long-term care
Substance Abuse Services--residential and nonresidential, prevention and treatment
Vocational Services--job and career training, assessments, placement
Recreational Services--to address relationships with significant others, after school, summer camps, and other special programs
Operational Services--case management, juvenile justice, family support and self-help groups, advocacy, transportation, legal services, volunteer programs.

In addition to providing oversight for the grantees, the Child, Adolescent and Family Branch also has the responsibility for ensuring that training and technical assistance are given to the grantees. This is provided by the National Resource Network for Child and Family Mental Health Services, operating under the auspices of the Washington Business Group on Health. The training and technical assistance for these grants, under the Child, Adolescent and Family Branch's direction, has been field-based and practice-driven. Site-generated technical assistance is implemented through three "hubs" based on the demographic characteristics of the grantees, particularly geographic organization and population density. Urban, small city, and rural hubs, each with a designated director, 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 implement 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. In FY 98, a fourth hub will be added to support Native American grantees.

This unique focus on local level efforts has also been manifested in the Child, Adolescent and Family Branch's four-year Public Awareness Campaign. Now in its third year, Vanguard Communications, under contract to CMHS's Office of External Liaison, in collaboration with the Child, Adolescent and Family Branch, 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.

In addition to these diverse support activities, the Child, Adolescent and Family Branch works in close partnership with the Federation of Families for Children's Mental Health. 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 National Evaluation

In 1994, the Center for Mental Health Services supported a five-year, outcome-based evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. Designed and now conducted by Macro International Inc., in collaboration with partners at the University of South Florida (USF), and with staff from the Federation of Families for Children's Mental Health, this evaluation addresses the congressional mandate and supports continued quality improvement for children's mental health.

The purposes of the national evaluation are to:

provide descriptive data to portray the children being served by the initiative, including their demographic, diagnostic, and functional characteristics, and types of services they received
examine how systems of care are defined at the local level and track the process of their development
explore the effects of the system-of-care approach on child and family outcomes.

The evaluation uses both formative and summative approaches. A formative approach guides the collection of data on the implementation process and provides a feedback loop to system-of-care program staff at the local level. Information and data are collected, analyzed, and shared with each grantee site to assist in local decision-making concerning the implementation process of the system-of-care approach in each community. A summative approach provides insight on the extent to which the system of care is implemented in each site, the variations in how the system of care is articulated in each site, and the overall effects the system-of-care approach has on child and family outcomes.

Aggregate analyses across grantees have generated profiles of how systems of care develop and operate, and what relationships exist between the system-of-care approach and child and family outcomes. Grantee-level information is collected, analyzed, and provided to CMHS, to the technical assistance effort of the National Resource Network on Children's Mental Health, and to the grantees themselves, so that the performance of the system of care can be monitored at both aggregate and site-specific levels. Timely access to this information will allow grantees to consider mid-course modifications that can further augment their system-of-care efforts. Moreover, the findings from the evaluation will provide Congress, CMHS, other Federal agencies, and the grantees with empirical data upon which to make policy and programmatic decisions regarding the system-of-care approach.

Figure 1 illustrates a conceptual framework for the system of care. The system-of-care approach is predicated on addressing the needs of children challenged by serious emotional disturbance and their families. Using a system-of-care perspective, the needs of the child and family determine the mental health service response. This is decidedly different from a traditional perspective that allocates mental health treatment according to existing, already available services. In order to partner with families to meet the challenges of serious emotional disturbance, systems must have strong and flexible infrastructures and accessible, cross-agency, community-based and culturally appropriate services. The links between the system infrastructure, service delivery, and child and family outcomes must be adaptive and strong, and they must provide a constant feedback loop of information, as indicated in the conceptual framework. This conceptual framework was used as a guide for developing the evaluation design and measures.

A longitudinal, multi-method design including qualitative and quantitative approaches is used to address the issues examined in the CMHS initiative. Data for this report represent 24,724 children and families enrolled in the descriptive component of the evaluation, and a subsample of 9,682 children and families enrolled in the clinical and functional outcome component. The CMHS evaluation contains the following interrelated components:

child and family demographic and descriptive information (e.g., age, sex, race/ethnicity, income, diagnosis, service history), obtained from grantee databases, on children served by the system of care each year;

child and family outcome data, collected on a sample of children and families, related to behavioral and functional strengths and challenges measured by standardized instruments [i.e., Child Behavior Checklist (CBCL, Achenbach, 1991), Youth Self-Report (YSR, Achenbach & Edelbrock, 1987), and the Child and Adolescent Functional Assessment Scale (CAFAS, Hodges, 1990)] and available data from schools and juvenile justice programs such as school attendance, grade performance, and court contact with juvenile justice. (Note: These data are collected at six months, at twelve months, and annually thereafter as long as the child continues in services.);

consumer satisfaction data collected from the child and family outcome sample at six months, twelve months, annually thereafter, and at exit from services;

service system descriptive information, obtained from annual site visits, documenting the development of system of care, the extent to which grantees apply the system-of-care approach to their service delivery system, and the changes in system development over time;

longitudinal comparison study examining the child and family outcomes, service utilization patterns in four system-of-care sites using a system-of-care approach, and four matched communities. (Note: Children and families in this study will be followed for two years independent of whether they are currently receiving mental health services.);

service utilization and cost study conducted with a sample of grantee sites and sites participating in the longitudinal comparison study, using available management information system (MIS) service data to describe how children and their families use services, examine the associated costs, and explore their relationship to outcomes;

family centered interviews using a case study approach examining the match between the needs of the families and the response by the system of care in a sample of 10 sites; and

a study of managed care initiatives and the system-of-care approach examining the impact of health care reforms on the organization of the systems of care established by the grantees, and the ensuing effects on the delivery of services to children and families.

These evaluation components are summarized in Table 1. The grantees and their locations are listed in Table 2.

Note: The grants funded in October 1997 are now beginning data collection. Data from these sites are not included in this report.

The following sections report the activities and findings related to the national evaluation that occurred in FY 97 for the twenty-two grantees funded in the first three phases. The nine new grantees will be included in the FY 98 analyses. The first section of the report summarizes the findings from the second year of system site visits and related findings from the family centered interviews conducted by USF. Aggregate Year 1 and Year 2 child and family descriptive and baseline data, totaled across participating sites, is presented next. This is followed by sections that describe the longitudinal comparison study and progress in its implementation, the services and cost component, and an update on the managed care study. The last section of the report examines how evaluation data are being used to guide other Child, Adolescent and Family Branch activities, specifically training and technical assistance. In conclusion, activities for FY 98 are outlined.

Table of Contents | Previous | Next