[Senate Hearing 108-682]
[From the U.S. Government Printing Office]



                                                        S. Hrg. 108-682
 
      MENTAL HEALTH IN CHILDREN AND YOUTH: ISSUES THROUGHOUT THE 
                         DEVELOPMENTAL PROCESS

=======================================================================

                                HEARING

                               BEFORE THE

                  SUBCOMMITTEE ON SUBSTANCE ABUSE AND
                         MENTAL HEALTH SERVICES

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             SECOND SESSION

                                   ON



   EXAMINING MENTAL HEALTH IN CHILDREN AND YOUTH, FOCUSING ON ISSUES 
THROUGHOUT THE DEVELOPMENTAL PROCESS, AND S. 1704, TO AMEND THE PUBLIC 
HEALTH SERVICE ACT TO ESTABLISH A STATE FAMILY SUPPORT GRANT PROGRAM TO 
  END THE PRACTICE OF PARENTS GIVING LEGAL CUSTODY OF THEIR SERIOUSLY 
  EMOTIONALLY DISTURBED CHILDREN TO STATE AGENCIES FOR THE PURPOSE OF 
          OBTAINING MENTAL HEALTH SERVICES FOR THOSE CHILDREN

                               __________

                             APRIL 28, 2004

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions





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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  JUDD GREGG, New Hampshire, Chairman

BILL FRIST, Tennessee                EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming             CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri        BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio                    JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas                  JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama               PATTY MURRAY, Washington
JOHN ENSIGN, Nevada                  JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina    JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia             HILLARY RODHAM CLINTON, New York

                  Sharon R. Soderstrom, Staff Director

      J. Michael Myers, Minority Staff Director and Chief Counsel

                                 ______

       Subcommittee on Substance Abuse and Mental Health Services

                      MIKE DeWINE, Ohio, Chairman

MICHAEL B. ENZI, Wyoming             EDWARD M. KENNEDY, Massachusetts
JEFF SESSIONS, Alabama               JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada                  JACK REED, Rhode Island

                    Karla Carpenter, Staff Director

                  David Nexon, Minority Staff Director

                                  (ii)






                            C O N T E N T S

                               __________

                               STATEMENTS

                       WEDNESDAY, APRIL 28, 2004

                                                                   Page
DeWine, Hon. Mike, a U.S. Senator from the State of Ohio, opening 
  statement......................................................     1
Reed, Hon. Jack, a U.S. Senator from the State of Rhode Island, 
  opening statement..............................................     2
Dodd, Hon. Christopher J., a U.S. Senator from the State of 
  Connecticut, opening statement.................................     4
Kennedy, Hon. Edward M., a U.S. Senator from the State of 
  Massachusetts, prepared statement..............................     7
Collins, Hon. Susan M., a U.S. Senator from the State of Maine, 
  prepared statement.............................................     8
Osofsky, Joy D., Professor of Pediatrics, Psychiatry, and Public 
  Health, Louisiana State University Health Sciences Center, and 
  President, Board of Directors, Zero to Three; Marleen Wong, 
  Director, Crisis Counseling and Intervention Services, Los 
  Angeles Unified School District, Los Angeles, CA, and Director, 
  School Crisis and Intervention Unit, National Center for Child 
  Traumatic Stress, UCLA and Duke University; Louise A. Douce, 
  Director, Counseling and Consultation Services, the Ohio State 
  University; Maryann Davis, Assistant Professor, Center for 
  Mental Health Services Research, Department of Psychiatry, 
  University of Massachusetts Medical School, Worcester, MA; 
  Linda Champion, Child Advocate, National Alliance for the 
  Mentally Ill, and Vice President, Alabama Family Ties, 
  Montgomery, AL, and Barbara Altenburger, Family Advocate, 
  Parents Involved Network, Mental Health Association of 
  Southeastern Pennsylvania, Philadelphia, PA....................    12
    Prepared statements of:
        Joy D. Osofsky...........................................    14
        Marleen Wong, LCSW.......................................    23
        Louise A. Douce, Ph.D....................................    34
        Maryann Davis, Ph.D......................................    38
Sessions, Hon. Jeff, a U.S. Senator from the State of Alabama, 
  opening statement..............................................    44
Altenburger, Barbara, prepared statement.........................    51

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Response to questions of Senator Reed from Joy Osofsky.......    20
    Response to questions of Senator Bingaman from Marleen Wong..    28
    Response to questions of Senator Bingaman from Maryann Davis.    40
    Response to questions of Senator Reed from Maryann Davis.....    42
    Response to questions of Senator Bingaman from Linda M. 
      Champion...................................................    46
    The Keeping Families Together Act (S.1704)...................    66
    American Academy of Child and Adolescent Psychiatry..........    67
    Michael Faenza, National Mental Health Association...........    72
    Susan Mikolic, Parent and Advocate...........................    74
    The National Child Traumatic Stress Network (NCTSN)..........    82

                                 (iii)




      MENTAL HEALTH IN CHILDREN AND YOUTH: ISSUES THROUGHOUT THE 
                         DEVELOPMENTAL PROCESS

                              ----------                              


                       WEDNESDAY, APRIL 28, 2004

                                       U.S. Senate,
Subcommittee on Substance Abuse and Mental Health Services, 
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:05 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Mike DeWine 
(chairman of the subcommittee) presiding.
    Present: Senators DeWine, Sessions, and Reed.

                  Opening Statement of Senator DeWine

    Senator DeWine. Good morning. Let me thank all of you for 
being here today, and let me also welcome Senator Reed, with 
whom I have worked on so many issues in the past concerning 
children.
    Today, we are meeting to talk about mental health issues 
concerning children and youth throughout their developmental 
process. The simple fact is that children and youth with 
emotional and behavioral needs face tremendous challenges in 
receiving care in our Nation today. Mental health care is 
dispersed across many systems for children, including schools, 
the juvenile justice system, the child welfare system, the 
substance abuse treatment system, through their primary care 
providers, and within their own families.
    I have seen in my own home State of Ohio serious failures 
in the child mental health system. Just a few weeks ago, a 
series of disturbing stories ran in the Cincinnati Enquirer 
regarding the children's mental health system in Ohio. These 
articles focused on children who are mistreated at treatment 
centers, are in families unable to afford necessary care, and 
children whose parents give them up to child protection 
services in order to receive treatment. The many shortcomings 
of the current system resulted in mental health needs of 
children not being met and actual harm being done to children 
who were in the care of those paid to protect and help them.
    Now, obviously, passing Senator Pete Domenici's mental 
health parity legislation--officially called the Senator Paul 
Wellstone Mental Health Equitable Treatment Act--would be the 
best solution for many of the children in these articles, as 
well as many children facing similar problems in other States. 
We know that these children are many in number.
    Each year, approximately 5 to 9 percent of children suffer 
from serious mental illness or serious emotional disturbances. 
However, fewer than one in five of these children will receive 
needed treatment.
    Early childhood is a critical time period to prevent the 
onset of emotional and behavioral impairments. If these 
children do not receive appropriate treatment or if their 
illness is too severe, these children are more likely to 
continue on paths which lead to expulsion from school and 
child-care facilities for disruptive behavior, separation from 
their family, visits to juvenile justice facilities, and 
dropping out of high school.
    Some of the issues concerning children and youth in the 
mental health system were discussed at a hearing that we held 
to examine the Final Report of the President's New Freedom 
Commission on Mental Health. The report found that 
fragmentation of the mental health system and gaps in care for 
children were serious problems.
    The report also stated that the multiple programs created 
to finance and support children and youth with mental illness 
help foster an approach that is complex, fragmented, and 
inconsistent in its coverage, which makes the entire process 
very difficult for parents or caretakers.
    Mental health is absolutely fundamental to a person's 
overall physical health and well-being and is critical to 
leading a productive and balanced life. Our children and young 
people deserve access to services that are appropriately and 
effectively provided. That is why I have worked with Senator 
Dodd and Senator Smith from Oregon to introduce the Youth 
Suicide Early Intervention and Prevention Expansion Act--a bill 
that would provide funding for the creation and expansion of 
statewide youth suicide early intervention and prevention 
strategies. Tragically, suicide is the third leading cause of 
death of children and youth ages 10 to 24.
    I have also been working with my friend, Senator Reed, on a 
bill we have introduced called the Campus Care and Counseling 
Act that would provide needed funds to mental and behavioral 
health centers on our Nation's college and university campuses. 
We know that rates of university-age students seeking care 
while away at school are rising, and counseling centers are 
struggling to keep up with these rising numbers.
    I look forward to discussing all these issues today and 
hearing the testimony from our witnesses. I believe that this 
testimony will serve to educate us on issues concerning the 
children and youth mental health system, and I am confident 
that these recommendations will serve as a real starting point 
for change and improvement.
    Let me now turn to Senator Reed for his comments.

                   Opening Statement of Senator Reed

    Senator Reed. Thank you very much, Mr. Chairman. Thank you 
for calling today's hearing and also for your devoted and 
consistent attempts to help children of the United States in so 
many ways through the health care system. Thank you, Mr. 
Chairman.
    As we all know, today we are facing a crisis in the mental 
health care system throughout the United States, particularly 
when it comes to the needs of our children and young adults. I 
would like to express my appreciation to the witnesses who are 
here today. Each of today's panelists offer a unique 
perspective on the critically important issue of children's 
mental health. Thank you all very much.
    The recent rash of suicides on college campuses throughout 
this country has illustrated the dire consequences of failing 
to address the mental health needs of our young people. Just 
last week, the Washington Post reported the fifth suicide at 
the George Washington University since December 2003.
    A recent study of counseling center directors found that 81 
percent were concerned about increasing numbers of students 
with severe psychological problems, 67 percent reported a need 
for more psychiatric services, and 63 percent reported problems 
with the growing demand for services without an appropriate 
increase in resources.
    I would like to share with you a sampling of the type of 
cases seen by just one counselor at the University of Rhode 
Island: one student with depression and a recent suicide 
attempt, one student with schizophrenia, two students with 
self-cutting behaviors, three with drug and alcohol problems, 
one victim of rape, two students with eating disorders, two 
with difficulty adjusting to college life, and one with panic 
attacks. And that is not even the entire caseload of this one 
counselor.
    Along with Senator DeWine, we introduced the Campus Care 
and Counseling Act to increase access and enhance mental and 
behavioral health services for our college students. This bill 
authorizes grants to colleges and universities for a range of 
activities, including prevention, screening, early 
intervention, assessment, education, treatment, and ongoing 
case management of mental and behavioral health problems.
    College mental health is just one piece, though, in the 
complicated puzzle of children's mental health. For young 
children in particular, access to care is a critical problem. 
In Rhode Island, as in most communities in this country, we are 
suffering from a severe shortage of child psychiatrists. The 
lack of competent providers, combined with limited outpatient 
mental health services, few substance abuse treatment programs, 
and virtually nonexistent residential treatment facilities, has 
left families literally with no place to turn.
    With few options at hand to access treatment, some parents 
are even forced to give up custody of their children just to 
qualify for public mental health programs.
    According to Dr. Greg Fritz, chairman of child psychiatry 
at Brown University School of Medicine, emergency room visits 
have tripled in the past 3 years. Outpatient clinics have 
waiting lists of 2 months or more. Patients being discharged 
from the hospital wind up being readmitted 6 weeks later 
because they decompensate before their number comes up on the 
waiting list for outpatient treatment.
    We as a nation have failed children with mental illnesses 
on many levels. They are often not diagnosed in a timely 
fashion, they are treated by providers with minimal mental 
health training, they are forced to bounce around between 
various systems of care--if they are able to access mental 
health services at all. Then when they finally figure out how 
the system works and provided that they do not end up as one of 
the many incarcerated mentally ill, they age out of the 
adolescent system and have to start all over in their 
transition into the adult mental health system, a system with 
even less to offer them.
    Last, I would note and echo the comments of the chairman 
that tomorrow marks the 2-year anniversary of President Bush's 
call on Congress to pass mental health parity legislation. I am 
disappointed that, despite having broad support, Congress has 
refused to act upon legislation that would aid millions of 
Americans in obtaining needed mental health treatment and 
renounce the current system that allows private mental health 
insurance plans to discriminate with impunity when it comes to 
mental health coverage.
    I extend to my colleagues the hope that this hearing will 
provide the impetus for us to take action on the Paul Wellstone 
mental health parity act. It would be a fitting tribute to 
literally a giant--well, not literally because we are the same 
size, but a giant in the U.S. Senate.
    [Laughter.]
    Mr. Chairman, I also have a statement from Senator Dodd. As 
you know, he is deeply interested in children's mental health, 
particularly with youth suicide and the use of antidepressant 
medication in children. He unfortunately is unable to attend 
today's hearing but asked that his statement be included in the 
record.
    Senator DeWine. It will be made a part of the record.
    [The prepared statement of Senator Dodd follows:]

                       Statement of Senator Dodd

    Good Morning. I would like to begin by thanking Chairman 
DeWine and Senator Reed, two of the Senate's strongest 
advocates for children's mental health reform, for holding this 
important hearing today. While I am not a member of this 
Subcommittee, both Chairman DeWine and Senator Reed are aware 
that the issue before this Subcommittee today is one that holds 
great meaning to me. Unfortunately, while other Senate business 
prevents me from attending today's hearing, I appreciate the 
Chairman making my statement part of the hearing record.
    I would also like to thank all of the witnesses who are 
testifying today and all of those in attendance. It is very 
encouraging for me to see that, collectively, you represent 
many different specialty areas within the issue of children's 
mental health--from initiatives designed to meet the needs of 
infants to those designed to meet the needs of young adults, 
from services and awareness campaigns designed to improve the 
mental health of our children in primary and secondary schools 
to those designed to improve the mental health of our young 
people in college. I commend all of your hard work, and I 
applaud your professional and personal commitment to this 
issue. If we are to start making a meaningful difference today, 
then we need the continued dedication and support of each and 
every one of you.
    I am heartened to see all of you here this morning; yet, in 
a way, I am also disheartened. The fact that the United States 
Senate needs to hear testimony from professionals and advocates 
who come from across the children's mental health spectrum 
clearly reflects the alarming fact that the problems we face as 
a society in this issue also come from across the spectrum.
    Ensuring that all of our children and young adults have 
access to comprehensive mental health care that adequately and 
fully addresses their individualized needs is one of the most 
acute crises facing our society today. We all know the alarming 
facts. According to most inter-agency studies done by the 
Department of Health and Human Services, approximately 20 
percent of children in our country suffer from a diagnosable 
mental, emotional, or behavioral disorder, while up to 10 
percent suffer from a serious disturbance or multiple 
disorders. Yet, well over half of these children are unable to 
access the appropriate community-based care they require. 
Children and their families across this country, regardless of 
their age, race, ethnicity, socioeconomic status, or location, 
all too often find themselves facing a seriously fragmented 
mental health delivery system--a system that all too often 
fails to assess and diagnose disorders and their possible 
causes accurately, cannot offer complete comprehensive 
community-based care in the child's natural setting, employs 
medical and health professionals who are well intentioned but 
improperly trained, and cannot provide adequate financial and 
emotional support, information, and hope. Clearly, these 
widespread problems, compounded by the relative paucity of 
research on the risk factors and causes of children mental 
health disorders, speak to the urgent need for greater Federal 
involvement in this area.
    In my capacity as a Senator from Connecticut, I have 
recently addressed two areas within the issue of children's 
mental health: youth suicide prevention and the use of 
antidepressant medications in children and young adults.
    We all know that youth suicide is a grave crisis in the 
United States. According to the Centers for Disease Control and 
Prevention (CDC), more than 3,000 young people take their lives 
each year, making suicide the third overall cause of death 
between the ages of 10 and 24. We also know that youth suicide 
is intricately linked to mental health--specifically to 
disorders like depression and substance abuse. More than 90 
percent of young people who attempt suicide are found to suffer 
from a mental, emotional, and behavioral disturbance.
    I am pleased that we have already taken several positive 
steps toward better understanding the tragedy of youth suicide 
and its emotional and behavioral risk factors--both on the 
Federal and local levels. Today, hundreds of community-based 
programs and statewide collaborative strategies across the 
country offer a variety of early intervention and prevention 
services to thousands of children and young adults--services 
that include comprehensive screening, assessment, and 
individualized counseling. However, we still face significant 
challenges in this area. As we all know too well, a large 
number of States and localities are finding themselves with 
unprecedented budget deficits--making the establishment of new 
services and the retention of existing services increasingly 
more difficult.
    I have introduced bipartisan legislation with Chairman 
DeWine along with Senators Gordon Smith and Harry Reid. This 
legislation, the Youth Suicide Early Intervention and 
Prevention Expansion Act of 2004, seeks to support further the 
good work being done on the community level, the State level, 
and the Federal level with regards to youth suicide. Through 
the establishment of a new grant initiative, this legislation 
supports the further development and expansion of statewide 
youth suicide early intervention and prevention strategies and 
the community-based services they seek to coordinate. It also 
encourages greater Federal support in the planning, 
implementation, and evaluation of these strategies and services 
and creates a new inter-agency collaboration that promises to 
focus on research, policy development, and the dissemination of 
data specifically pertaining to youth suicide. Along with 
Chairman DeWine, I am fully committed in working to pass the 
legislation this year.
    Although today's hearing is not focused on prescription 
drug treatment for depression in adolescents and children, I 
would like to touch on the issue briefly. Last Friday, the 
Washington Post reported on the results of a study published in 
the Lancet, a British medical journal, showing an increase in 
the risk of suicidal behavior among children taking four 
popular antidepressants. The study also showed no measurable 
benefit to children. This disturbing report added to the 
growing questions surrounding the use of antidepressants, and 
specifically the class of drugs known as selective serotonin 
reuptake inhibitors (SSRIs), in children.
    SSRIs are prescribed to millions of American children each 
year, and that number continues to increase. Families and 
physicians caring for children suffering from depression are 
desperate for answers about the appropriate use of 
antidepressants. While many experts insist that antidepressants 
can be a critical component of care, parents cannot help but 
take reports of ineffectiveness and increased risk seriously.
    It is imperative that questions surrounding SSRIs are 
answered as quickly as possible. If these drugs do indeed pose 
a risk to children, physicians and the public must be made 
aware of that risk immediately. On the other hand, it is 
equally important to discover the truth in the case that SSRIs 
do not pose a threat to children's well-being, so that doctors 
can continue to prescribe these life-saving medicines without 
fear. In the current environment of uncertainty, there is a 
legitimate concern that children who now benefit, or who may 
benefit, from SSRIs will be inappropriately denied access to 
these drugs.
    Yesterday, I sent a letter to Acting FDA Commissioner 
Lester Crawford urging the agency to bring some clarity to this 
issue as soon as possible. This letter was a follow-up to a 
letter that I sent on March 1 to then-Commissioner Mark 
McClellan, along with nine of my Senate colleagues. In that 
earlier letter, we asked the FDA to consider invoking its 
authority to require additional testing of SSRIs to determine 
once and for all whether or not these drugs benefit our 
children. With the recent report in the Lancet, our request has 
taken on even greater urgency.
    I have asked Acting Commissioner Crawford to share with me 
the FDA's plans to address this issue. I have also offered to 
help in whatever way I can, so that families can be confident 
that their children are receiving the best possible care. We 
must get to the bottom of this issue as soon as possible.
    Lastly, Mr. Chairman, no discussion of mental health would 
be complete without mentioning the critical absence of parity 
between our mental and physical healthcare systems. Two years 
ago this week President Bush endorsed the notion that there is 
need for equity between these two disparate systems. Sadly, 
however, legislation ensuring parity, originally championed by 
our dear friend Senator Paul Wellstone, has yet still failed to 
pass, despite the co-sponsorship of close to 70 members of the 
Senate, including both the Chair and Ranking Member of this 
Subcommittee. Mental health parity is critically essential not 
only if we are to address the mental healthcare needs of our 
children but also the needs of all Americans.
    We have a societal obligation to break through the stigma 
that is still unfortunately attached to children's mental 
health--a stigma that still keeps these issues largely off our 
television airwaves and the front pages of our newspapers. We 
have an obligation to reach out to our young people--to help 
them understand that whatever difficulties or illnesses they 
might be experiencing are only temporary and treatable in a 
comfortable setting. And, most important, we have an obligation 
to instill in our young people a sense of value, self-worth, 
and resilience. Therefore, I am fully committed to working with 
each of you--doctors, psychiatrists, psychologists, counselors, 
nurses, teachers, advocates, and affected families--so that we 
can better understand the causes of mental health disorders and 
develop effective mental health initiatives and services that 
reach every child and young adult in this country--
compassionate initiatives that give them encouragement, hope, 
and above all, life.
    Senator Reed. I thank the chairman again for holding 
today's hearing, and I look forward to working with him on 
these critical issues and listening to these outstanding 
witnesses.
    Thank you, Mr. Chairman.
    Senator DeWine. Senator Reed, thank you very much.
    At this time I would like to submit a prepared statement 
from Senators Kennedy and Collins to be included in the record.
    [The prepared statement of Senator Kennedy follows:]

            Prepared Statement of Senator Edward M. Kennedy

    Thank you, Senator DeWine, for convening this important 
hearing and for your strong commitment to the well-being of the 
nation's children.
    As the report of the President's New Freedom Commission 
stated, our mental health care system is in crisis. The quality 
of care isn't good enough, access, isn't broad enough, and the 
whole system isn't consumer-oriented enough.
    No group in our population bears a greater burden of this 
failure than the young. One in five children and adolescents 
have mental health disorders, but three-quarters of them never 
receive the care they need. The large racial disparities in 
access to care and quality of care are serious problems as 
well.
    The results of this failure are higher school drop-out 
rates, more frequent family conflicts, higher rates of drug 
abuse and violence and higher rates of anxiety disorders, 
depression, and even suicide.
    It is clear that we can do much more to prevent, treat, and 
cure mental illness in children. The panelists here today 
demonstrate that it is a problem we must meet at all stages of 
development.
    The recommendations of the New Freedom Commission offer us 
a unique opportunity to act effectively. One of the key 
recommendations is to improve mental health care services in 
schools.
    Schools have become the de facto providers of mental health 
care for children. In fact, 80 percent of the children who 
receive mental health care services receive them in schools. 
But the care in schools is plagued by the same factors that 
plague other systems of care--not enough funds, not enough 
personnel, poor quality of care, little involvement of parents, 
and few prevention efforts.
    In addition, the lack of research and dissemination of 
evidence-based practices has meant few advances in intervention 
and treatment.
    Complex and costly care has led to families doing the 
unthinkable--giving up custody of their child to the child 
welfare system or juvenile justice system in order to obtain 
services, even though such systems are ill-prepared to meet 
their needs. A lack of parity in financing for mental health 
care for children has contributed greatly to this disturbing 
defect.
    It's clear we can't afford to wait any longer to make 
urgently needed improvements, and I look forward to working 
with Senator DeWine, Senator Reed and other Members of the 
Subcommittee on the recommendations made by today's panelists.
    [The prepared statement of Senator Collins follows:]

             Prepared Statement of Senator Susan M. Collins

    I want to commend the Subcommittee Chairman for holding 
this hearing to examine mental health issues in children and 
youth throughout the developmental process. Unfortunately, I am 
chairing a Governmental Affairs Committee hearing this morning, 
so I am unable to deliver my testimony in person, but I 
appreciate the Chairman's kind offer to make certain that it is 
included as a part of the hearing record.
    Serious mental illness afflicts millions of our nation's 
children and adolescents. It is estimated that as many as 20 
percent of American children under the age of 17 suffer from a 
mental, emotional or behavioral illness. What I find most 
disturbing, however, is the fact that two-thirds of all young 
people who need mental health treatment are not getting it.
    Behind each of these statistics is a family that is 
struggling to do the best it can to help a son or daughter with 
serious mental health needs to be just like every kid--to 
develop friendships, to do well in school, and to get along 
with their siblings and other family members. These children 
are almost always involved with more than one social service 
agency, including the mental health, special education, child 
welfare and juvenile justice systems. Yet no one agency, at 
either the State or the Federal level, is clearly responsible 
or accountable for helping these children and their families.
    My interest in this issue was triggered by a compelling 
series of stories by Barbara Walsh in the Portland Press Herald 
which detailed the obstacles that many Maine families have 
faced in getting desperately needed mental health services for 
their children.
    Too many families in Maine and elsewhere have been forced 
to make wrenching decisions when they have been advised that 
the only way to get the care that their children so desperately 
need is to relinquish custody and place them in either the 
child welfare or juvenile justice system.
    Yet neither system is intended to serve children with 
serious mental illness. Child welfare systems are designed to 
protect children who have been abused or neglected. Juvenile 
justice systems are designed to rehabilitate children who have 
committed criminal or delinquent acts. While neither of these 
systems is equipped to care for a child with a serious mental 
illness, in far too many cases, there is nowhere else for the 
family to turn.
    Last year, I commissioned a GAO report with Representatives 
Pete Stark and Patrick Kennedy that found that, in 2001, 
parents placed more than 12,700 children into the child welfare 
or juvenile justice systems so that these children could 
receive mental health services.
    Moreover, I believe that this is just the tip of the 
iceberg, since 32 States--including the five States with the 
largest populations of children--did not provide the GAO with 
any data.
    There have been other studies indicating that the custody 
relinquishment problem is even more pervasive. A 1999 survey by 
the National Alliance for the Mentally Ill found that 23 
percent--or one in four parents surveyed--had been told by 
public officials that they needed to relinquish custody of 
their children to get care, and that one in five of these 
families had done so.
    While some States have passed laws to limit or prohibit 
custody relinquishment, simply banning the practice is not a 
solution, since it can leave mentally ill children and their 
families without services and care. Custody relinquishment is 
merely a symptom of the much larger problem, which is the lack 
of available, affordable, and appropriate mental health 
services and support systems for children with serious mental 
health needs and their families.
    I chaired a series of hearings in the Governmental Affairs 
Committee last summer to examine this issue further. We heard 
compelling testimony from mothers who told us that they were 
advised that the only way to get the intensive care and 
services that their children needed was to relinquish custody 
and place them in the child welfare system. This is a wrenching 
decision that no family should be forced to make. No parent 
should have to give up custody of his or her child just to get 
the services that the child needs.
    The mothers also described the barriers they faced in 
getting care for their children. They told us about the 
limitations in both public and private insurance coverage. They 
also talked about the lack of coordination and communication 
among the various agencies and programs that serve children 
with mental health needs. One parent, desperate for help for 
her twin boys, searched for 2 years until she finally located a 
program--which she characterized as ``the best kept secret in 
Illinois''--that was able to help.
    Parents should not be bounced from agency to agency, 
knocking on every door they come to, in the hope that they will 
happen upon someone who has an answer. It simply should not be 
such a struggle for parents to get services and treatment for 
their children.
    The Keeping Families Together Act, which I have introduced 
with a bipartisan group of my colleagues, would help to reduce 
the barriers to care for children with serious mental health 
needs and would assist States in eliminating the practice of 
parents relinquishing custody of their children solely for the 
purpose of securing mental health services.
    The legislation authorizes $55 million for competitive 
grants to States to create an infrastructure to support and 
sustain statewide systems of care to serve children who are in 
custody or at risk of entering custody of the State for the 
purpose of receiving mental health services. States already 
dedicate significant dollars to serve children in State 
custody. These Family Support Grants would help states serve 
children more effectively and efficiently, while keeping them 
at home with their families.
    The legislation would also remove a current statutory 
barrier that prevents more States from using the Medicaid home 
and community-based services waiver to serve children with 
serious mental health needs. This waiver provides a promising 
way for States to address the underlying lack of mental health 
services for children that often leads to custody 
relinquishment. While a number of States have requested these 
waivers to serve children with developmental disabilities, very 
few have done so for children with serious mental health 
conditions. Our legislation would provide parity to children 
with mental illness by making it easier for States to offer 
them home- and community-based services under this waiver as an 
alternative to institutional care.
    The Keeping Families Together Act takes a critical step 
forward to meeting the needs of children with mental or 
emotional disorders and their families. Attached to my 
testimony is a more detailed summary of the Keeping Families 
Together Act, and I urge all of the Members of the Subcommittee 
to work with me so that we can get this legislation passed and 
signed into law before the end of the year.
    Again, Mr. Chairman, thank you for allowing me to submit my 
testimony, and I look forward to working with you to ensure 
that appropriate and affordable mental health services and 
support systems are available for all children and young people 
with mental health needs and their families.
    Let me introduce the panel. I will introduce all the 
members of the panel. We will keep your statements to 5 
minutes. We are going to be fairly tight on that because that 
will give us an opportunity to ask some questions and hear your 
comments.
    On our panel this morning, I would first like to introduce 
Dr. Joy Osofsky. She is currently professor of Pediatrics, 
Psychiatry, and Public Health at Louisiana State University 
Health Sciences Center in New Orleans and is the head of the 
Division of Pediatric Mental Health. She serves as director of 
the Violence Intervention Program for Children and Families and 
the Harris Center for Infant Mental Health. The doctor has 
published and edited numerous articles on the effects of 
violence in young children, and in June of this year, she will 
publish an edited book titled ``Young Children and Trauma.'' 
She is president of Zero to Three: National Center for Infants, 
Toddlers, and Families, and in 2002, she was awarded the 
Nicholas Hobbs Award for contributions to public policy by 
Division 37 of the American Psychological Association.
    Next, let me introduce Marleen Li Chen Wong. She is the 
director of Mental Health, District Crisis Intervention Teams, 
and Suicide Intervention Programs for the Los Angeles Unified 
School District, the second largest school district in the 
United States. She has administrative responsibility for four 
outpatient child clinics, a staff of 186 clinical social 
workers and clinical psychologists, child psychiatrists, and 
community workers; and 350 district crisis team members. She is 
also responsible for administering the mental health 
consultation program in over 100 children's day care centers in 
Los Angeles Unified School District schools. She is currently 
serving as director of the School Crisis and Disaster Recovery 
Program at the National Center for Child Traumatic Stress at 
UCLA and Duke University.
    Next, let me introduce Dr. Louise Douse. She is the 
director of the Counseling and Consultation Service at the Ohio 
State University, which serves the full range of counseling and 
mental health needs of the Ohio State University student body. 
She is a specialist in college student mental health and has 
been counseling college students for the past 25 years. She is 
the immediate past president of the Society of Counseling 
Psychology, Division 17 of the American Psychological 
Association, and in the year 2003, the Association of 
University and College Counseling Center Directors presented 
her with the Lifetime Achievement Award.
    Next, I would like to introduce Dr. Davis. Dr. Davis is 
currently an assistant professor in the Department of 
Psychiatry at the University of Massachusetts and a faculty 
member of the Center for Mental Health Services Research. Her 
current efforts focus on the mental health needs of children 
transitioning into adulthood. Dr. Davis has designed and 
implemented a transition support project, Project Nexus, to 
assist children with mental health needs during this difficult 
transitional period. Dr. Davis also serves as a consultant to 
the Center for Mental Health Services of the Substance Abuse 
and Mental Health Services Administration on their evaluation 
program of the Partnership for Youth Transition grant program.
    Let me also introduce Linda Champion. Since 2002, Mrs. 
Champion has served as a data analyst for the Alabama 
Department of Mental Health and Mental Retardation. She is the 
vice president of Alabama Family Ties, an advocacy group which 
advocates for children and adolescents with mental illness. 
Mrs. Champion is also the Children's Issues Advisor to the 
National Alliance for the Mentally Ill in Alabama and serves on 
numerous planning committees working with the State of Alabama 
Department of Mental Health and Mental Retardation.
    Finally, let me introduce Barbara Altenburger. As the 
parent of an adolescent with serious emotional and behavioral 
disorders, she has had to navigate the children's mental health 
system herself and, therefore, can offer great insight to us. 
We commend her commitment to helping us all better understand 
this important and complex issue. She serves as a family 
advocate at Parents Involved Network of Philadelphia, a program 
of the Mental Health Association of Southeastern Pennsylvania. 
In addition to her work with the Parents Involved Network, she 
has shared her experiences at local workshops and conferences 
and is a long-time advocate for improved mental health and 
related services for children, adolescents, and their families.
    We thank all of you very much for joining us, and we 
appreciate it. We look forward to all of your testimony. We 
will start on my right with Dr. Osofsky. Doctor, thank you very 
much.

    STATEMENTS OF JOY D. OSOFSKY, PROFESSOR OF PEDIATRICS, 
   PSYCHIATRY, AND PUBLIC HEALTH, LOUISIANA STATE UNIVERSITY 
HEALTH SCIENCES CENTER, AND PRESIDENT, BOARD OF DIRECTORS, ZERO 
    TO THREE; MARLEEN WONG, DIRECTOR, CRISIS COUNSELING AND 
INTERVENTION SERVICES, LOS ANGELES UNIFIED SCHOOL DISTRICT, LOS 
ANGELES, CA, AND DIRECTOR, SCHOOL CRISIS AND INTERVENTION UNIT, 
   NATIONAL CENTER FOR CHILD TRAUMATIC STRESS, UCLA AND DUKE 
     UNIVERSITY; LOUISE A. DOUCE, DIRECTOR, COUNSELING AND 
   CONSULTATION SERVICES, THE OHIO STATE UNIVERSITY; MARYANN 
 DAVIS, ASSISTANT PROFESSOR, CENTER FOR MENTAL HEALTH SERVICES 
RESEARCH, DEPARTMENT OF PSYCHIATRY, UNIVERSITY OF MASSACHUSETTS 
MEDICAL SCHOOL, WORCESTER, MA; LINDA CHAMPION, CHILD ADVOCATE, 
  NATIONAL ALLIANCE FOR THE MENTALLY ILL, AND VICE PRESIDENT, 
 ALABAMA FAMILY TIES, MONTGOMERY, AL; AND BARBARA ALTENBURGER, 
   FAMILY ADVOCATE, PARENTS INVOLVED NETWORK, MENTAL HEALTH 
   ASSOCIATION OF SOUTHEASTERN PENNSYLVANIA, PHILADELPHIA, PA

    Ms. Osofsky. Mr. Chairman and Members of the Committee, I 
am delighted to have the opportunity to appear before you today 
on behalf of Zero to Three. As you introduced me, I am Joy 
Osofsky, a professor of pediatrics, psychiatry, and public 
health at Louisiana State University Health Sciences Center, 
and president of the board of directors of Zero to Three. Zero 
to Three is a national, nonprofit organization that has worked 
to advance the healthy development of America's babies and 
toddlers for over 25 years. I would like to start by thanking 
the committee for their interest in addressing the mental 
health needs of infants, toddlers, and families, and I would 
particularly like to thank you, Mr. Chairman, for your 
leadership in helping to address the mental health needs of our 
most vulnerable infants and toddlers, those involved in the 
child welfare system through your support of the Court Teams 
for Change Project, an effort that I will describe in a few 
minutes.
    Despite what we know from science and research, discussions 
on children's mental health have consistently excluded babies 
and toddlers, focusing instead on school-age children and 
adolescents. Although they cannot talk to us about what they 
are feeling like older children can, sometimes referred to as 
``silent victims,'' babies and toddlers have many ways of 
communicating, and we have many ways to assess their social and 
emotional needs.
    Unfortunately, some infants and toddlers experience mental 
health problems. Their early social and emotional development 
is vulnerable to such factors as repeated exposure to violence, 
persistent fear and stress, abuse and neglect, severe chronic 
maternal depression, or biological factors such as prematurity 
and low birthweight and conditions associated with substance 
abuse.
    Babies do not exist in isolation. The parent's mental 
health can also affect the young child. Conditions such as 
maternal depression and anxiety disorders can disrupt 
parenting. For example, infants of mothers who have chronic, 
untreated depression often withdrawn, ultimately affecting 
their language skills, as well as their physical and cognitive 
development.
    The message I want to convey today, however, is not a 
pessimistic one. When we do identify these children and their 
parents, we know how to provide effective infant mental health 
interventions for the baby and for the significant adults in 
the baby's life. These interventions can prevent or ameliorate 
the effects of negative early experiences. What we are missing 
is the widespread awareness of the problem, the systems to 
identify children who are affected, and readily accessible 
services to meet their needs.
    So why should we care about infant mental health? First, 
learning to regulate emotions and developing secure attachments 
form the very foundation of a child's ability to learn, and 
infants cannot wait. The early years are a period of extremely 
rapid brain growth, wiring and pruning of neuronal connections. 
The pathways that are laid down in these early years are the 
ones that will guide the child's reactions and emotions for the 
rest of her life.
    Second, science supports our concern. The National Academy 
of Sciences report ``From Neurons to Neighborhoods'' concluded 
that the elements of early childhood programs that enhance 
social and emotional aspects of development are just as 
important as those supporting cognitive and linguistic 
competence. The goal of ensuring that all children are ready 
for school has become a national priority. Young children who 
do not achieve early social and emotional milestones perform 
poorly in the early school years and are at higher risk for 
school problems and juvenile delinquency later in life.
    Infants and toddlers in foster care represent a group of 
children that are extremely vulnerable. Juvenile and family 
court judges are uniquely positioned to improve the well-being 
of infants and toddlers in the child welfare system to ensure 
that they are receiving the resources and supports they need to 
address their social and emotional needs.
    I have been involved in developing an approach to working 
with these young children in Miami-Dade Juvenile Court. Three 
years of data show substantial gains in improving social and 
emotional development of infants, toddlers, and their families. 
Of the families selected to receive the intervention, 58 
percent of the children improved in their developmental 
functioning, 100 percent of the infants were reunified with 
their families, and substantiated reports of abuse and neglect 
were reduced from 97 percent to zero.
    The Federal Government is in a unique position to support 
the documented and growing needs of mental health services for 
infants, toddlers, and families. While some child-related 
services such as early Head Start and Part C early intervention 
address infant mental health, only a small number of children 
meet the eligibility requirements of these programs. Zero to 
Three recommends that the mental health needs of infants, 
toddlers, and families be recognized and addressed in bills 
currently up for reauthorization, including Head Start, 
Individuals with Disabilities Education Act, Child Care 
Development Fund, and Substance Abuse and Mental Health 
Services Administration.
    These recommendations are supported by findings in 
President Bush's New Freedom Commission on Mental Health, as 
well as the National Research Council Institute of Medicine 
report ``From Neurons to Neighborhoods: The Science of Early 
Childhood Development.''
    Our recommendations are as follows:
    One, strengthen infant and early childhood mental health 
services and integrate such services into all child-related 
services and systems.
    Two, assure earlier identification and intervention of 
mental health problems and disorders in infants, toddlers, and 
their parents.
    Three, develop system capacity through professional 
development/training of service providers.
    Four, assure comprehensive mental health services for 
infants and toddlers in foster care.
    Five, provide infant/toddler child-care programs with 
access to mental health consultation and support.
    Six, support and advance evidence-based practices in infant 
and early childhood mental health through the establishment of 
a national infant mental health resource center.
    In conclusion, Mr. Chairman, existing Federal, State, and 
community programs for young children should be used as 
foundations to expand and improve infant mental health 
services. Although research is clear in demonstrating the 
importance of healthy social and emotional development at the 
earliest stages of life in assuring school readiness and 
developing healthy relationships later in life, we have not 
translated this knowledge into what we do for babies and 
toddlers. If we truly desire children to be ready to learn, 
much less to grow up as healthy adults, we need to make a 
concerted effort to address the critical mental health needs of 
our youngest children and families.
    Thank you very much.
    Senator DeWine. Doctor, thank you.
    [The prepared statement of Ms. Osofsky follows:]
                  Prepared Statement of Joy D. Osofsky
    Mr. Chairman and Members of the Committee, I am delighted to have 
the opportunity to appear before you today on behalf of ZERO TO THREE. 
I am Joy Osofsky, a psychologist and Professor of Pediatrics, 
Psychiatry, & Public Health at Louisiana State University Health 
Sciences Center and President of the Board of Directors of ZERO TO 
THREE. ZERO TO THREE is a national non-profit organization that has 
worked to advance the healthy development of America's babies and 
toddlers for over 25 years. I would like to start by thanking the 
committee for their interest in addressing the mental health needs of 
infants, toddlers, and their families. I would also like to 
particularly thank Senator DeWine for his leadership in helping to 
address the mental health needs of our most vulnerable infants and 
toddlers, those involved in the child welfare system through his 
support of the Court Teams for Change Project, an effort that I will 
describe in just a few minutes.
                     what is infant mental health?
    Despite what we know from science and research, discussions on 
children's mental health have consistently excluded babies and 
toddlers, focusing instead on school-age children and adolescents. 
Although they cannot talk to us about what they are feeling like older 
children can, babies and toddlers have many ways of communicating, and 
we have many ways to assess their social and emotional needs.
    Most babies experience healthy social and emotional development. 
They smile and coo, cry and recover, and become social beings. Babies 
and toddlers with typical mental health have the capacity to 
experience, regulate and express emotions; form close and secure 
interpersonal relationships; and explore the environment and learn. The 
healthy mental development of babies and toddlers is dependent upon 
their ability to manage their feelings, develop trust with others, and 
learn about the world in which they live.
    This all happens as infants and toddlers work to make sense of 
their environment. It is then that they first find their efforts 
encouraged--or not; first attempt to concentrate and find that 
possible--or not; first conclude that the world seems organized and 
reasonably predictable--or not; first learn that others are basically 
supportive--or not. It is in the first years of life that the 
foundations for empathy, trust, curiosity, and competence are laid 
down.
    Attachment is one of the most critical developmental tasks of 
infancy. We know from the science of early childhood development that 
early relationships and attachments to a primary caregiver are the most 
consistent and enduring influence on social and emotional development 
for young children.\1\ Infants and toddlers who are able to develop 
secure attachments are observed to be more mature and positive in their 
interactions with adults and peers than children who lack secure 
attachments.\2\ They may also have a better self-concept, more advanced 
memory processes, and a better understanding of emotions.\3\ Those who 
do not have an opportunity to form a secure attachment with a trusted 
adult (for example, infants and toddlers who experience multiple foster 
homes) suffer grave consequences. Their development can deteriorate, 
resulting in delays in cognition and learning, relationship 
dysfunction, difficulty expressing emotions, and future mental health 
disorders.
---------------------------------------------------------------------------
    \1\ Shonkoff, J., & Phillips, D. (Eds.). (2000). From neurons to 
neighborhoods: The science of early childhood development. Washington, 
DC: National Academy Press.
    \2\ Ibid.
    \3\ Ibid.
---------------------------------------------------------------------------
    Unfortunately, some infants and toddlers experience mental health 
problems. The early social and emotional development of babies and 
toddlers is vulnerable to such factors as repeated exposure to 
violence, persistent fear and stress, abuse and neglect, severe chronic 
maternal depression, biological factors such as prematurity and low 
birth weight, and conditions associated with prenatal substance abuse. 
Without intervention, these risk factors can result in mental health 
disorders. In babies and toddlers, the effects of these factors may 
look like excessive and inconsolable crying; a heightened sensitivity 
to touch and cuddling; excessive biting, kicking and hitting; inability 
to focus on activities, flat affect (no expression, no emotions) and 
depression. Infant mental health intervention for the baby, and for the 
significant adults in the baby's life, can prevent or ameliorate the 
effects of negative early experiences.
    Unlike adults, babies and toddlers have fairly limited ways of 
responding to stress and trauma. They may respond through inconsolable 
crying, withdrawal from daily activities, sleeplessness or lack of 
appetite due to depression, anxiety, and traumatic stress reactions, 
poor weight gain, or aggressive behavior in older toddlers. If the 
underlying causes of the stress are not addressed, they can develop 
into serious mental health disorders, including depression, attachment 
disorders, and traumatic stress disorders. Infants can experience 
withdrawal and depression as early as 4 months of age.\4\ 
Unfortunately, despite the severe consequences, these disorders are not 
being identified. Neither parents nor most providers know enough about 
how to identify the early warning signs to make effective referrals.
---------------------------------------------------------------------------
    \4\ Luby, J. (2000). Depression. In C. Zeanah (Ed). Handbook of 
Infant Mental Health (pp. 296-382).
---------------------------------------------------------------------------
    Babies do not exist in isolation. The parent's mental health can 
also affect the young child. Conditions such as maternal depression and 
anxiety disorders can disrupt parenting. For example, infants of 
mothers who have severe chronic, untreated depression often withdraw, 
ultimately affecting their language skills, as well as physical and 
cognitive development. Older children of depressed mothers show poor 
self-control, aggression, poor peer relationships, and difficulty in 
school. \5\
---------------------------------------------------------------------------
    \5\ Embry, L. and Dawson, G. (2002). Disruptions in parenting 
behavior related to maternal depression: Influences on children's 
behavioral and psychobiological development. In J. Borkowski, S., 
Ramey, C. & Bristol-Powers, M. (Eds). Parenting and the young child's 
world. (pp. 203-214) Mahwah, NJ: Erlbaum.
---------------------------------------------------------------------------
    Ultimately, for the very young child, mental health disorders will 
have a significant effect on later school performance and life 
successes. In fact, more and more young children are being expelled 
from child care and preschool for behavior problems, and supports are 
not available for these children, their parents, or their caregivers. 
Without early identification, assessment and effective intervention 
these problems will escalate.
    Given the importance of social and emotional development in the 
first 3 years of life, the scarcity of data on the mental health of 
babies and toddlers is disappointing, but not surprising, considering 
the lack of attention to social and emotional development in infants 
and toddlers. Although no data are available for children under age 3, 
it is estimated that between 2 percent and 8 percent of all children 
under the age of 18 are reported to have a mental/emotional problem or 
functional limitation.\6\,\7\ If these same estimates are 
applied to the birth to 3-age population, between 228,000 to 913,000 
infants and toddlers are at risk of mental health disorders.
---------------------------------------------------------------------------
    \6\ Colpe, L. (2000). Estimates of mental and emotional problems, 
functional impairments, and associated disability outcomes for the U.S. 
child population in households. Retrieved April 24, 2003, from 
www.mentalhealth.org/publications.
    \7\ Halfon, N. & Newacheck, P. (1999). Prevalence and impact of 
parent-reported disabling mental conditions among U.S. children. 
Journal of the American Academy of Child and Adolescent Psychiatry, 
38(5), 600-609.
---------------------------------------------------------------------------
             why should we care about infant mental health?
    Learning to regulate emotions and developing secure attachments are 
not simple, pleasant milestones in a baby's development that take a 
backseat to the growth of cognitive skills as a child prepares to enter 
school. Rather, they are the very foundation of the child's ability to 
learn. A child who has not developed consistent, positive relationships 
with adults, cannot regulate his own emotions, cannot consider the 
emotions of his peers, does not trust adults, has difficulty in being 
motivated to learn, or cannot calm himself to tune into teaching will 
not benefit from early educational experiences.
    There are many good reasons to care about early social and 
emotional development. First, infants can't wait. The early years are a 
period of extremely rapid brain growth, wiring and pruning of neuronal 
connections. The pathways that are laid down in these early years are 
the ones that will guide the child's reactions and emotions for the 
rest of her life. Second, science supports our concern. The National 
Academy of Sciences report From Neurons to Neighborhoods \8\ concluded 
that the elements of early childhood programs that enhance social and 
emotional aspects of development are just as important as the component 
that support cognitive and linguistic competence.
---------------------------------------------------------------------------
    \8\ Shonkoff, J. & Phillips, D. (Eds.) (2000). From neurons to 
neighborhoods: The science of early childhood development. Washington, 
DC: National Academy Press.
---------------------------------------------------------------------------
    The goal of ensuring that all children are ``ready for school'' has 
become a national priority. As a result, programs that support 
children's school readiness are becoming more and more important to 
policy-makers, parents, and the general public. It is becoming very 
clear that efforts to improve school success cannot begin at preschool, 
nor focus exclusively on academics. In fact, studies suggest that 
emotional, social, and behavioral competence is a strong predictor of 
academic performance in elementary school. Young children who do not 
achieve early social and emotional milestones perform poorly in the 
early school years, and are at higher risk for school problems and 
juvenile delinquency later in life.\9\
---------------------------------------------------------------------------
    \9\ Raver, C. (2002). Emotions matter: Making the case for the role 
of young children's emotional development for early school readiness. 
Social Policy Report of the Society for Research in Child Development, 
16(1) 3-23.
---------------------------------------------------------------------------
    Finally, we should all care about early social and emotional 
development because barriers exist for families and providers, and our 
inaction is making the problem of accessing infant mental health 
services worse. Barriers include the scarcity of infant mental health 
providers and supervisors; the lack of awareness by the general public, 
policy-makers, parents, teachers, health care providers and others 
about the importance of early social and emotional development; limited 
funding for infant mental health services; lack of capacity to provide 
mental health services to parents along with their children; reluctance 
by families to use mental health services; and the overall lack of 
application of scientific knowledge to practice.
                        federal recommendations
    The Federal Government is in a unique position to support the 
documented and growing needs of mental health services for infants, 
toddlers, and families. While some child related services, such as 
Early Head Start and Part C Early Intervention address infant mental 
health, only a small number of children meet the eligibility 
requirements of these programs. ZERO TO THREE recommends that the 
mental health needs of infants, toddlers, and families be recognized 
and addressed in bills currently up for reauthorization including Head 
Start, Individuals with Disabilities Education Act (IDEA), Child Care 
Development Fund (CCDF), and Substance Abuse and Mental Health Services 
Administration (SAMHSA). These recommendations are supported by 
findings in President Bush's New Freedom Commission on Mental Health 
(2003) as well as in the National Research Council Institute of 
Medicine report From Neurons to Neighborhoods: The Science of Early 
Childhood Development (2000). \10\,\11\ Our recommendations 
are as follows:
---------------------------------------------------------------------------
    \10\ New Freedom Commission on Mental Health (2003). Achieving the 
promise: Transforming mental health care in America. Executive Summary. 
DHHS Publication No. SMA-03-3831. Rockville, MD: U.S. Department of 
Health and Human Services.
    \11\ Shonkoff, J. & Phillips, D. (Eds.) (2000). From neurons to 
neighborhoods: The science of early childhood development. Washington, 
DC: National Academy Press.
---------------------------------------------------------------------------
    1. Strengthen infant and early childhood mental health services and 
integrate such services into all child-related services and systems.
    Infant mental health services are scarce. Where they do exist, they 
are fragmented and disconnected from the settings and services most 
frequently used by young children and families. Infant and early 
childhood mental health services across the continuum of promotion, 
prevention, and treatment must be created, expanded, and improved. 
Services must be comprehensive: they should promote healthy social and 
emotional development for all young children, provide prevention 
services for families of young children experiencing or at risk of 
experiencing situations that jeopardize healthy social and emotional 
development, and provide individualized treatment services for children 
who have mental health disorders.
    Illinois has utilized this comprehensive approach in addressing 
infant mental health. Evaluation of an integrated mental health 
approach in Illinois documented the effectiveness of including Social 
Emotional Specialists in Part C Early Intervention programs. These 
specialists provide training, technical assistance, as well as mental 
health consultation to the managers, coordinators, and providers of the 
Part C program. Evaluation findings revealed positive improvements in 
practice that are helping programs to address all components of Part C, 
easier access to mental health services, and earlier identification of 
mental health disorders.
    Social and emotional development is not an isolated issue. It 
spills over into all areas of early childhood development. Infant 
mental health services must be integrated into all services that touch 
the lives of infants, toddlers, and their families. These may include 
child care, Early Head Start, pediatric and family health care, public 
health, community mental health, child welfare/social services, home-
visiting, and Part C Early Intervention.
    2. Assure earlier identification and intervention of mental health 
problems and disorders in infants, toddlers and their parents.
    Early identification of risk factors is critical in preventing and 
treating mental health disorders in young children. All professionals 
who have contact with infants and toddlers, and families should be 
aware of early risk factors, how to screen and where to refer for 
assessment and intervention. Developmentally appropriate screening and 
assessment tools for infants, toddlers, and parents are critical for 
the early identification of, planning and delivery of effective 
interventions. Screening and assessment of parental mental health, 
stress and support systems are equally important in enabling providers 
to document the needs of parents. The well-child visit is an important 
opportunity for early identification of developmental, emotional, and 
behavioral problems. Physicians, time-pressured to provide both medical 
care and anticipatory guidance, would be best supported if they had 
ready access to screening tools, (including those that could be 
completed by parents), practical information about referral 
information, and financing strategies.
    To encourage developmental and behavioral screening and assessment 
for all infants and toddlers, barriers to reimbursement must be 
eliminated. Strategies to improve financing include encouraging the use 
of appropriate diagnostic procedures and billing codes; expansion of 
billing options in Medicaid to allow for treatment of parents and 
infants together; maximizing use of Early and Periodic Screening, 
Diagnosis, and Treatment Program (EPSDT) and State Children's Health 
Insurance Program (SCHIP), and recognizing infant, toddler, and parent 
mental health concerns as legitimate treatment issues.
    3. Develop system capacity through professional development/ 
training of service providers.
    Neurons to Neighborhoods informs us that, ``Given the substantial 
short- and long-term risks that accompany early mental health 
impairments, the incapacity of early childhood programs to address 
these concerns and the severe shortage of early childhood professionals 
with mental health expertise are urgent problems.'' \12\ If we hope to 
make a positive difference in the lives of children who are already 
affected by mental health disorders, violence, and trauma and promote 
healthy social and emotional development we must invest in building a 
strong infant mental health workforce.
---------------------------------------------------------------------------
    \12\ Shonkoff, J. & Phillips, D. (Eds.) (2000). National Research 
Council and Institute of Medicine. From neurons to neighborhoods: The 
science of early childhood development. Washington, DC: National 
Academy Press.
---------------------------------------------------------------------------
    The quality of a service system depends on the individuals that 
deliver the services. ``Substantial new investments should be made to 
address the nation's seriously inadequate capacity for addressing young 
children's mental health needs. Expanded opportunities for professional 
training, as recently called for by the Surgeon General, and incentives 
for individuals with pertinent expertise to work in settings with young 
children are first steps toward more effective screening, early 
detection, treatment, and ultimate prevention of serious childhood 
mental health problems.'' \13\
---------------------------------------------------------------------------
    \13\ Ibid.
---------------------------------------------------------------------------
    Greater investments must be made in infant mental health. Both the 
community at large as well as parents and the early care and education 
providers need to be aware of the importance of early social and 
emotional development. In addition, there should be increased support 
for training, continuing education, recruitment, and retention of 
professionals with special training in infant and early childhood 
mental health services.
    There are no national data to document shortages in infant mental 
health personnel. Anecdotally, based on calls and requests that ZERO TO 
THREE receives from States and communities, the need for specialized 
training as well as general awareness of social and emotional 
development is overwhelming. In a recent survey of unmet needs in the 
Illinois early care and education system, 62 percent of programs 
reported inadequate mental health resources. Investing in mental health 
training yields promising outcomes. In 24 Early Head Start programs 
that participated in the ``Pathways to Preventions'' training model, 
three critical objectives were achieved: staff knowledge and skills 
were extended into programs beyond Early Head Start, program supports 
were strengthened, availability of mental health providers were 
increased, and staff retention improved.
    4. Assure comprehensive mental health services for infants and 
toddlers in foster care.
    Infants and toddlers in foster care represent a group of children 
that are extremely vulnerable. Most have been seriously maltreated; 
they exhibit behavior problems such as failure to thrive, tantrums, 
self-endangering, aggression, and inability to be consoled. Nearly 80 
percent are prenatally exposed to substance abuse, 40 percent are born 
prematurely and/or low birth weight, and all of them experience 
repeated and often traumatic separation from caregivers, placing them 
at risk for future mental health disorders. Infants are the fastest 
growing and single largest cohort in foster care. Babies placed in 
foster care before 4 months of age remain in foster care longer than 
other children.\14\ Over 39,000 infants enter foster care each year. 
Infants and toddlers who have suffered physical or sexual abuse, 
neglect, and separation from their parents will also suffer emotional 
and developmental consequences unless they, and their parents, foster 
parents and other primary caregivers, are provided with supportive 
mental health interventions.
---------------------------------------------------------------------------
    \14\ Wulczyn, F., Harden, B. and Hislop, K. (2002). The placement 
of infants in foster care. Infant Mental Health Journal, 23(5), 454-
475.
---------------------------------------------------------------------------
    Juvenile and Family Court Judges are responsible for the well-being 
of the children in their courts and can be powerful agents of change. 
They are uniquely positioned to improve the well-being of infants and 
toddlers in the child welfare system and to ensure that they are 
receiving the resources and supports they need to address social and 
emotional needs. In fact, judges have an opportunity, perhaps the last 
one for these most vulnerable infants and toddlers, to focus on healing 
in the process of adjudicating the case. \15\
---------------------------------------------------------------------------
    \15\ Osofsky, J.D. & Lederman, C.S. (in press). Healing the child 
in juvenile court. In J.D. Osofsky (Ed). Young Children and Trauma: 
Intervention and Treatment. New York: Guilford, 2004.
---------------------------------------------------------------------------
    I have been involved in developing an approach to working with 
these young children in the Miami-Dade Juvenile Court. Three years of 
data show substantial gains in improving social and emotional 
development of infants, toddlers, and their families. In this court, 
all infants, toddlers and their mothers receive screening and 
assessment services. Babies are screened for developmental delays and 
referred for services. A parent-infant psychotherapy intervention is 
available to a select number of mothers. An Early Head Start program 
connected to the court is the first designed specifically to meet the 
needs of maltreated children. Children showed significant improvements 
in enthusiasm, persistence, positive affect and a reduction of 
depression, anger, withdrawal and irritability.\16\ Of the families 
selected to receive the intervention: 58 percent of children improved 
in their developmental functioning; \17\ 100 percent of infants were 
reunified with their families; \18\ and reports of abuse/neglect were 
reduced from 97 percent to 0.\19\
---------------------------------------------------------------------------
    \16\ Lederman, C. (2003). Mental health trends in 2003: Miami's 
infant and young children's mental health program: A place where the 
healing begins. The National Center for State Courts.
    \17\ Adams, S., Osofsky, J., Hammer, J., & Graham, M. (2003). 
Program Evaluation Florida Infant & Young Child Mental Health Pilot 
Project, Year 3, Final Report, Tallahassee, FL: Florida State 
University Center for Prevention & Early Intervention Policy.
    \18\ Lederman, C. (2003). Mental health trends in 2003: Miami's 
infant and young children's mental health program: A place where the 
healing begins. The National Center for State Courts.
    \19\ Ibid.
---------------------------------------------------------------------------
    5. Provide infant/toddler child care programs with access to mental 
health consultation and support.
    Increasingly, young children are being expelled from child care and 
preschool for behavior problems, including biting, tantrums, hitting, 
throwing objects, or inconsolable crying.\20\,\21\ A survey 
of child care providers in New Hampshire found that 53 percent of 
respondents had expelled at least one child, age birth through six. 
Young children with behavior problems are difficult to teach, and if 
disliked by teachers and peers because of behavior, quickly lose 
motivation for learning, withdraw from peers, or face social 
rejection.\22\
---------------------------------------------------------------------------
    \20\ Wheatley, E. (2001). Child care expulsion survey. Bow, NH: New 
Hampshire Association for Infant Mental Health.
    \21\ Cutler, A. & Gilkerson, L. (2002). Unmet needs project: A 
research, coalition building and policy initiative on the unmet needs 
of infants, toddlers and families. Chicago, IL: University of Illinois 
at Chicago and Erikson Institute.
    \22\ McEvoy, A. & Welker, R. (2000). Antisocial behavior, academic 
failure and school climate: A critical review. Journal of Emotional and 
Behavioral Disorders, 8(3), 130-140.
---------------------------------------------------------------------------
    An estimated 7 million babies and toddlers (nearly 65 percent of 
all children under age 3) spend time in non-parental care each day. 
\23\ Good child care can be an excellent early learning environment 
where healthy social and emotional development can be promoted for all 
children. With mental health consultation and training, staff can 
support and promote social and emotional development, prevent 
behavioral problems, and identify early warning signs of mental health 
disorders.
---------------------------------------------------------------------------
    \23\ Oser, C. & Cohen, J. (2002). America's Babies: The ZERO TO 
THREE Policy Center Data Book. Washington, DC: Zero to Three Press.
---------------------------------------------------------------------------
    A Kentucky study demonstrated success of mental health consultation 
in child care. Of the approximately 400 children served through June 
2003, 88 were identified as being at-risk for such discharge. Of these, 
only 8 lost their placement due to behavior problems, while 80 had been 
successfully maintained in these programs.
    6. Support and advance evidence-based practices in infant and early 
childhood mental health through the establishment of a national infant 
mental health resource center.
    Parents and professionals are hungry for information about social 
emotional development. There is new research available and some 
promising models for addressing infant mental health, but providers are 
largely unaware of this information. One way to improve the mental 
health outcomes for young children is by creating a national resource 
center for infant mental health. Such a center would:
     Provide information, technical assistance, training and 
other resources about social-emotional development in infants and 
toddlers with disabilities to early intervention personnel and parents.
     Identify and disseminate infant mental health models.
     Translate current research about effective infant mental 
health intervention and treatment approaches for parents and early 
intervention professionals.
     Develop materials screening and assessment tools, how to 
integrate mental health goals into Part C Individualized Family Service 
Plans, and infusing relationship-based approaches into Part C practice.
     Coordinate with other mental health initiatives such as 
those through the Early Head Start National Resource Center to assure a 
systematic approach across birth to three programs.
    Many States are in the process of developing strategic plans for 
early childhood mental health services, developing financing 
strategies, etc. This is an opportune time to identify and disseminate 
promising evidence-based practices, and translate what is known from 
the science of early childhood education into what we do for infants, 
toddlers and families.
    In conclusion, Mr. Chairman, existing Federal, State, and community 
programs for young children should be used as foundations to expand and 
improve infant mental health services. Although research is clear in 
demonstrating the importance of healthy social and emotional 
development at the earliest stages in life in assuring school readiness 
and developing healthy relationships later in life, we have not 
translated this knowledge into what we do for babies and toddlers. If 
we truly desire children to be ready to learn, much less to grow up to 
be healthy adults, we need to make a concerted effort to address the 
critical mental health needs of our youngest children and their 
families.
         Response to Questions of Senator Reed From Joy Osofsky
    Question 1. Is there evidence of improved outcomes, better 
compliance, and cost savings through providing combined services? For 
example, properly treating an alcoholic's bipolar illness to avoid 
relapsing on alcohol.
    Answer 1. Unfortunately, many juvenile facilities have inadequate 
mental health services and limited programs to help change behaviors 
and provide rehabilitation for incarcerated juveniles. Incidences of 
recidivism are high. Most show antisocial behaviors entering the prison 
and many more show antisocial traits and mental health symptoms while 
in prison related to the harsh treatment and experiences while they are 
in the facility. Most juvenile facilities are understaffed with mental 
health professionals and do not have good individual and group services 
to meet the mental health needs of the youth. To address this issue, it 
can be helpful for correctional facilities to link with universities, 
medical schools, community programs, and other settings that may be 
able to provide services and help to develop more positive programs for 
the youth.

    Question 2. Are different Federal funding streams a barrier to 
quality mental health care?
    Answer 2. Barriers when they transition out of juvenile facilities 
include: (1) Traditional case management services that are often 
inadequate to help youth with the transition; and (2) few good 
community programs to help develop skills and support them when they 
return to their home communities.
    What judges can do to help this situation:
    (1) Judges can help to develop collaborations where youth and their 
families can participate in prevention and intervention programs in 
their communities to prevent their being incarcerated.
    (2) Judges can work together with mental health professionals and 
school systems to try to develop diversionary programs for first time 
offenders who have not committed violent crimes in order to provide 
intervention and, hopefully, prevention in their communities.
    (3) Judges can play an active role in monitoring the treatment of 
juveniles in facilities by periodic review.
    (4) Judges can play a key role with youth being returned to the 
community in establishing and monitoring community programs to prevent 
recidivism.
    (5) Judges need more education about mental health issues in 
juveniles and effective programs and interventions.

    Senator DeWine. Ms. Wong?
    Ms. Wong. Good morning, Mr. Chairman and Members of the 
Subcommittee. I am Marleen Wong, and for the past 30 years, I 
have worked in School Mental Health Services, District Crisis 
Teams, and the Suicide Prevention Unit of the Los Angeles 
Unified School District. For 8 of those years, I was the 
director.
    I have been asked today to comment on the state of school 
mental health services and the priorities that our country 
might establish in response to the recommendations of the 
President's New Freedom Commission on Mental Health, 
particularly the recommendation that school-based mental health 
services be expanded and enhanced. I temper my ``Director of 
School Mental Health'' remarks with my personal experience as a 
mother of two children, a school social worker, a former school 
board member, a past member of the local teachers union, a 
current member of the local administrators union, the director 
of the school unit for the National Center for Child Traumatic 
Stress, a current member of the Institute of Medicine Board of 
Neuroscience and Behavioral Health, and a consumer of mental 
health services.
    What is the scope of the problem for our school children 
who need mental health services? The 1999 Surgeon General's 
Report on Mental Health reported that in any given year about 
20 percent of children have a mental disorder requiring the 
attention of a mental health professional. And yet a recent 
Rand study notes that only 8 percent of children who need 
mental health care actually receive services. This leaves 92 
percent of our children who need are without any services. Of 
the 8 percent who do receive services, 85 percent of the 
children receive them in school mental health programs, making 
schools the de facto primary source of mental health services 
for children K-12 in this country.
    Currently in the United States, there are about 15,000 
school districts and approximately 100,000 schools. During a 
regular school week, 70 percent of the total population of 
children kindergarten through 12th grade in public and private 
schools are in attendance.
    If we are to transform our mental health care system, we 
must establish a true system of care for all children, not just 
those with persistent and chronic mental illness. We must 
include children at every age and stage, those at risk for 
serious disorders, children caught in family or community 
crises, and disabled children. All aspects of children's lives 
are in a fluid state of development. early intervention and 
disability prevention means a shift in thinking to a ``well 
child'' mental health system, one that is adequately resourced 
for each of the components of early identification, early 
intervention, prevention, and effective treatments. One aspect 
of care should not be sacrificed for another because of funding 
disparities. One child should not be left behind because of 
another's needs.
    School mental health services must be supported with 
adequately quality assurance and accountability measures. Most 
importantly, in measuring our success, mental health 
professionals must find a way to integrate the mission of 
mental health with the mission of education. Outcomes must not 
only include a decrease of symptoms but evidence of improved 
academic functioning--support for better grades, improved 
classroom behavior, fewer absences, and increased attendance, 
less dropout. These criteria are generally not within the realm 
of traditional treatment outcome. However, they are solid 
indices of health, rehabilitation, and recovery for children.
    I would also like to speak about the Individuals with 
Disabilities Education Improvement Act, a critically important 
piece of legislation that helps to support children who are 
disabled. I would especially like to thank the committee for 
recognizing the disabling effects that trauma exposure can have 
for young children and for the inclusion of language in the 
bill that can help children who struggle in school as a result 
of trauma and the effects of traumatic events.
    Fragmentation of funding, programs, and personnel is a 
growing problem for school mental health. They suffer from 
service and funding fragmentation. I am proud to say that the 
Los Angeles Unified School District has supported mental health 
services for the past 71 years. However, in the 30 years that I 
have worked in the school district, we have had to fight to 
maintain those services during annual budget deliberations when 
categorical, special education, Title I, and general fund 
dollars wax and wane.
    Finally, I would like to share a personal story, one that 
shows how far we have come. My involvement in this work goes to 
an earlier generation. From the time that I was 6 years old, my 
grandmother told me stories about her early life in San 
Francisco. That beautiful city was part of the Wild West in the 
early 1900s. For Chinese immigrants, it was a vibrant and 
dangerous place.
    My grandmother, Ruth, was 5 years old when she was sold by 
her impoverished mother to a Chinese family emigrating to 
America. As a child, she remembered the day her mother pushed 
her toward a woman she had never seen and said, ``This woman 
will be like your mother now.'' As a young child, she crossed 
an ocean with strangers to confront violence in the new world 
of San Francisco Chinatown.
    Once she saw a group of men refuse to pay the bill for 
their dinner and many bottles of liquor. And when the owner of 
the restaurant insisted upon payment, they drew guns and 
destroyed the place. My grandmother, Ruth, hid in a corner, 
unharmed but traumatized. And in the following weeks, she 
refused to leave her home. She feared that she would be killed 
and that the violence would happen again.
    Not long after that incident, the violence did happen 
again. And the head of her new family was shot and killed as an 
innocent victim during a gang shooting. My grandmother never 
completed elementary school.
    In 1905, there was no counseling available in schools, nor 
was there any recognition of the paralyzing effects of violence 
on children. The year my grandmother died, in 1999, I began my 
association with Rand and UCLA to test our trauma intervention 
for its effectiveness with children in schools. And the results 
can be read in the Journal of the American Medical Association 
in the August 2003 issue.
    We have come a long way in our country in recognizing the 
need for such services to children, and yet we have so much 
more to do.
    The mission of schools is to educate. The mission of mental 
health services is to heal. And our responsibility is to the 
child who will benefit from both. The reality is that the 
mission of one cannot proceed without the success of the other.
    So I thank you, Mr. Chairman and Senator Reed and Mr. 
Kennedy and members of the committee, for the opportunity to be 
here, to present this information, and to express the gratitude 
of those who work in schools. Your work is vitally important to 
the creation of a children's mental health system that truly 
cares for children.
    Thank you.
    Senator DeWine. Ms. Wong, that is a very compelling story. 
Thank you very much.
    [The prepared statement of Ms. Wong follows:]
                Prepared Statement of Marleen Wong, LCSW
    Good morning Mr. Chairman and Members of the Subcommittee. I am 
Marleen Wong, Director of Crisis Counseling and Intervention Services 
for the Los Angeles Unified School District, and Director of the School 
Crisis and Intervention Unit for the National Center for Child 
Traumatic Stress (NCCTS) at UCLA and Duke University. For the past 30 
years, I have worked in School Mental Health Services, District Crisis 
Teams and the Suicide Prevention Unit of the Los Angeles Unified School 
District. For 8 years, I was the Director of those services.
    The Los Angeles Unified School District, (LAUSD) is the second 
largest school district in the United States with a population of 
738,000 students K-12 and over 80,000 employees, over half of them 
teachers. The School Mental Health Service was established in LAUSD in 
1933 to assist special education students with social and emotional 
consequences of serious health conditions or physically handicapping 
challenges. During my tenure as Director, from 1993 to 2001, school 
mental health services grew from 25 to 200 staff members of child 
psychiatrists, clinical psychologists and social workers in outpatient 
clinics and schools.
    In 2001, I was appointed the Director of Crisis Counseling and 
Intervention Services in LAUSD. My responsibility is to train and 
oversee district level crisis teams comprised of 250 school counselors, 
nurses, social workers, school psychologists, school police, and 
attendance counselors. Crisis teams are required at every school site. 
Eleven district crisis teams support and enhance site teams during 
incidents that overwhelm the resources of a school.
    As a school social worker, I have worked with children representing 
every community of our diverse district and responded to hundreds of 
crisis events involving the injury or death of students or staff. 
Twenty years ago, at the 49th Street Elementary School, a man who lived 
in the second floor apartment across the street from the school, opened 
fire with multiple weapons as our students were dismissed for the day. 
He held the school under sniper fire for an hour and a half, killing a 
9-year-old girl and wounding several other students and staff. That 
tragedy prompted the development of the first formal policies and 
procedures in LAUSD, initiating our current system of crisis response, 
i.e., the formation of a crisis intervention team at every school and a 
district level team to support the school response.
    Two large scale disasters in Los Angeles, the Los Angeles riots and 
fires and the Northridge earthquake, required a larger crisis response 
and recovery programs. Our district worked closely with the Los Angeles 
County Department of Mental Health, receiving several FEMA Crisis 
Counseling Grants to reach out to our students and encourage their 
return to school. After the riots, human relationships had to be 
mended. After the earthquake and the hundreds of powerful aftershocks, 
parents sought out school mental health services for their children. 
Many of our children were afraid to return to school, suffering from 
traumatic stress and depression due to the complex interactions of 
fear, ruined homes, multiple residential relocations, and family 
conflict.
    In 2001, I was asked to join the National Center for Child 
Traumatic Stress (NCCTS), a national program initiated by Congress and 
funded by the Substance Abuse and Mental Health Services Administration 
(SAMHSA). The NCCTS oversees the National Child Traumatic Stress 
Network (NCTSN), a mental health network of 54 university, hospital, 
and community programs dedicated to raising the standard of care and 
improving access to services for traumatized children, their families 
and communities across the United States. My work as the Director of 
School Crisis and Intervention for the National Center, builds on my 
focused view of local needs and the problems of organizing and 
sustaining a school mental health program within a local education 
agency. It enables me to have a broader national perspective of the 
range of the needs and challenges confronted by community agencies and 
school districts who wish to establish school mental health services in 
rural, suburban and urban environments.
    I have been asked today to comment on the state of school mental 
health services and the priorities that our country might establish in 
response to the recommendations of the President's New Freedom 
Commission on Mental Health, particularly the recommendation that 
school-based mental health services be expanded and enhanced. I temper 
my ``Director of School Mental Health'' remarks with my personal 
experience as a mother of two children, a school social worker, a 
former school board member, a past member of the local teachers' union, 
a current member of the local administrators' union, a current member 
of the Institute of Medicine (IOM) Board of Neuroscience and Behavioral 
Health, and a consumer of mental health services.

Demographic Information About Children, Schools and School Mental 
                    Health Services

    What is the scope of the problem for our school children who need 
mental health services?
    The 1999 Surgeon General's Report on Mental Health reported that in 
any given year, about 20 percent of children have a mental disorder 
requiring the attention of a mental health professional. In 2002, 
SAMHSA's National Survey on Drug Use and Health reported that an 
estimated 5 to 9 percent of children and youth have a serious emotional 
disturbance in any 1 year.
    And yet, a 1995 RAND study notes that only 8 percent of children 
who need mental health care actually receive services--this leaves 92 
percent of our children who need care without any services. Of the 8 
percent who do receive services, 85 percent of the children receive 
them in school mental health programs. Community agencies, 
pediatricians, public mental health services agencies, even 
correctional facilities, have a role to play in providing care, but the 
reality is that schools have become the de facto primary source of 
mental health services for children.

The Goals and Recommendations of the President's New Freedom Commission 
                    on Mental Health

    I would like to discuss school mental health services within the 
context of the goals and the recommendations of the President's New 
Freedom Commission on Mental Health.
    The Commission has recommended that we:
     Place consumers and their families at the center of 
service decisions.
    Currently in the United States, there are about 15,000 School 
Districts and approximately 100,000 Schools. During a regular school 
week, 70 percent of the total population of children Kindergarten 
through 12th grade are in attendance at one of these schools. If we add 
to this large number, the parents, siblings and families of the 
students, and the families of teachers, administrators and other school 
personnel, over 50 percent of the total United States population is 
connected during the work week to a school somewhere in this country. 
Schools are natural sites of service for children and families.
    The Commission has recommended that we:
     Reduce disparities and the burden of unmet needs and lack 
of access to services among minority groups.
    and
     Develop a model that emphasizes early intervention and 
disability prevention.
    If we are to transform our mental health care system, we must 
establish a true system of care for all children, not just those with 
persistent and chronic mental illness. We must include children at 
every age and stage, those at risk for serious disorders, children 
caught in family or community crises, and disabled children. All 
aspects of children's lives are in a fluid state of development. Early 
intervention and disability prevention means a shift in thinking to a 
``well child'' mental health system, one that is adequately resourced 
for each of the components of early identification, early intervention, 
prevention, and effective treatments. One aspect of care should not be 
sacrificed for another because of funding disparities. One child should 
not be left behind because of another's needs.
    School personnel are intimately aware of the social, psychological, 
and academic toll that mental health disorders, traumatic experiences, 
and mental illness can take on our children and adolescents. Early 
identification and intervention can make a difference at any grade. 
Children may not do well in preschool because their experience of 
domestic violence has interfered with their brain development, capacity 
to learn, and behavior. Elementary school children exposed to trauma 
and violence can lead to poor sleep and poor learning, compromising 
their acquisition of basic educational skills. A child who has done 
well in elementary school may be bullied in middle school or exposed to 
violence in the community, and go on to develop symptoms of 
posttraumatic stress that disturb academic performance, classroom 
behavior, and school attendance. A student in high school may suffer a 
traumatic loss because of the death of a close friend through a traffic 
accident, catastrophic school violence, or suicide, and become 
seriously depressed.
    Middle school and high school students often respond to experiences 
of trauma and loss by abusing alcohol or drugs or by engaging in 
reckless or high-risk sexual behaviors. They may also struggle with 
thoughts of suicide.
    Schools are the place where the loss of motivation for learning of 
such students can be noted as a symptom of depression or trauma, and 
can best be addressed through school mental health programs.
    In our crisis intervention work in the Los Angeles Unified School 
District and in many other parts of the country, we have worked with 
children in a post-crisis school setting. Often, while working with 
their trauma, we discovered children with other mental health problems 
that had never been addressed. Unfortunately, schools are limited by 
the lack of personnel to adequately provide intermediate and long term 
mental health and case management services that children need.
    Our crisis intervention work showed that most students suffer 
silently from trauma or depression, spending their school days ``hidden 
in plain sight''. Schools routinely screen for vision and for hearing, 
two conditions which we would all agree are crucial to learning. Just 
as crucial may be school screening for trauma and depression, where 
fear, disturbing thoughts, feelings and images become barriers to 
school attendance and classroom participation.
    The Commission has recommended that we:
     Establish ``evidence-based practices'' as the bedrock of 
service delivery.
    We can do this by supporting ongoing practical research that is 
embedded in schools and communities, and by providing training linked 
to scientific findings and clinical experience. This is one of the 
central goals of the National Child Traumatic Stress Network.
    The Commission has recommended that we:
     Improve quality and accountability:
    Establishing school based mental health services is not a panacea. 
Services must be supported with adequate quality assurance and 
accountability measures. An example of such requisite oversight is that 
44 percent of the students who seek help at school-based health clinics 
present with mental health disorders or problems. Of the students who 
seek help for depression, few receive evidence-based treatments. The 
average number of three to four visits suggests that few ever receive 
the full ``dose'' of recommended treatment, and follow up is rarely 
done.
    Some disorders, such as psychological trauma and depression, are 
very amenable to identification and treatment within a school setting. 
These are also the disorders that are being identified as leading 
causes of disability among the general population of children in the 
United States. Our work in LAUSD with RAND and UCLA Health Sciences 
Research Center, documented disrupted academic performance, negative 
classroom behavior and less school attendance among students 
traumatized by their exposure to community violence. In fact, 
scientific studies are showing that childhood trauma further affects 
the onset and course of many other child and adolescent health and 
mental health conditions, from attention deficit and bipolar disorder 
to substance abuse and conduct disorder.
    Most importantly, in measuring our success, mental health 
professionals must find a way to integrate the mission of mental health 
and the mission of education. From an organizational perspective, 
mental health services in schools cannot operate outside the structure 
and organization of the educational environment. In order to succeed 
within the educational environment and to gain acceptance from 
educators, the integrity of the academic day must be preserved. 
Outcomes must include not only a decrease of symptoms but also evidence 
of improved academic functioning--better grades, improved classroom 
behavior, fewer absences, and increased attendance. These criteria are 
generally not within the realm of traditional treatment outcomes. 
However, they are solid indices of health, rehabilitation, and recovery 
for children.

IDEA

    I would also like to speak about the Individuals with Disabilities 
Education Improvement Act, a critically important piece of legislation 
that helps to support services for children who are disabled. Although 
IDEA has not yet been enacted, I would like to commend the committee 
for the progress it has made in the Senate. I want to affirm that 
school children with disabilities need the help that can be provided 
through this bill, and they need it now. I would especially like to 
thank the committee for recognizing the disabling effects that trauma 
exposure can have for young children, and for the inclusion of language 
in the bill that will help children who struggle in school as a result 
of trauma and the effects of traumatic events.
    A report on developmental disabilities and trauma was developed by 
the NCTSN, and has been submitted for the record. That report includes 
information from population studies showing that the national 
prevalence rate for developmental disabilities in the United States is 
1.8 percent. This translates into many children in our school systems 
needing the specialized education provided through IDEA. Additional 
studies have shown that individuals with developmental disabilities are 
at increased risk for abuse as compared to the general population. For 
example, 64 percent of maltreated children have a disability, such as 
behavioral disorders; speech, language, or learning disabilities; or 
mental retardation. Children with mental retardation were the most 
severely abused. When we identify a child with special needs, it is 
essential to determine the full context of the child's life and history 
so that the most appropriate services can be provided.
    It is therefore a major step forward for the Senate to recognize 
that the development of vulnerable young children can be thrown off 
course because of traumatic experiences, and that, with timely 
intervention, a child's life can be supported back onto a normal 
developmental path.

Obstacles to Mental Health Services Access

    In establishing the New Freedom Commission on Mental Health, 
President Bush noted three key obstacles that keep people with mental 
illnesses from getting the services they need:
    1. The stigma that still surrounds these illnesses;
    2. The fragmented mental health care service system; and
    3. Existing treatment and dollar limits for mental health care.

Lack of Parity

    In our society, and in our health care system, children with mental 
disorders face the same stigma and discrimination as adults. It is 
unfair that an illness that can affect the brain, emotions, 
intellectual development and capacity, and relationships, and can so 
tragically affect the development of a child, is treated as less than 
serious, less than real. Schools can only do so much. When children are 
referred for mental health care, even those whose families have private 
insurance often cannot get medically necessary care because of the lack 
of parity in mental health coverage. This situation is worse than 
unfair . . . it can be lethal. Efforts to enact Federal mental health 
parity legislation have been close to success many times, and even now, 
parity has the widespread support of the Senate, the House, the 
President, and over 360 national organizations. Yet, American families 
are still waiting. It is the hope of all of us who work with children 
and their families that a full and fair mental health parity bill will 
be finally enacted in this Congress.

Overcoming Stigma Through School Mental Health Programs

    In Los Angeles, we have completed 4 years of trauma work with 
students who have been exposed to community violence. Through concerted 
effort, our program of mental health services has overcome much of the 
stigma that often surrounds such programs. Perhaps the greater 
acceptance of our mental health services is that we approach problems 
as developmental challenges and tasks, providing education, case 
management and support to parents; making consultation available to 
teachers; and providing treatment to children so that they can succeed 
in school. In the initial cohort of 20 LAUSD schools receiving special 
trauma intervention, only 3 percent to 5 percent of parents declined 
mental health services for their children.
    Our intervention was tested in randomized clinical trials and the 
results were published as an ``original contribution'' in the August 
2003 Journal of the American Medical Association. A screening of 
thousands of children in LAUSD over the past 4 years found that 90 
percent of students in some neighborhoods had been exposed to multiple 
incidents of violence, as witnesses and victims and that 27 percent of 
them had clinical levels of PTSD and 16 percent of them had clinical 
levels of depression. After 10 sessions of CBITS, the majority of 
children significantly decreased their symptoms of PTSD and Depression 
to the extent that they could no longer be diagnosed as traumatized or 
depressed. In the evaluation of an early group of students, there was a 
significant increase in grade point average as compared not only to 
students who had not yet received the intervention, but also as 
compared to students who had tested negative for either of the 
disorders.
    More importantly, after students completed the Cognitive Behavioral 
Intervention for Trauma in Schools (CBITS), over 92 percent of the 
parents understood that exposure to community violence had created 
serious psychological and academic problems in their children's lives. 
Eighty-five percent of the parents were pleased with the outcomes of 
treatment and 76 percent wanted to refer another family member or 
friend to receive services.

Fragmentation of Funding, Programs, and Personnel

    Like public mental health systems, school mental health programs 
also suffer from service and funding fragmentation. I am proud to say 
that the Los Angeles Unified School District has supported mental 
health services for the past 71 years. However, in the 30 years that I 
have worked in LAUSD, we have had to fight to maintain those services 
during annual budget deliberations when categorical, special education, 
Title I and general fund dollars wax and wane. This year, many mental 
health professionals, such as school counselors and social workers, 
will lose their jobs because of severe budget cuts necessitated by the 
downturn in the economy.
    In 1992, I worked with our Los Angeles County Department of Mental 
Health Services to negotiate the first Medi-Cal (Medic-Aid) contract 
between a school district and a county mental health service. We are 
currently able to draw down ``rehabilitation'' reimbursements for 
services to Medi-Cal eligible students and their families.
    This funding stream, however, does not provide any financial 
support for the work we do with indigent, uninsured children and 
families. Over 73 percent of LAUSD students and their families live 
below the poverty level and receive free and reduced lunch. The budget 
crisis in California has been so severe that there is no longer public 
mental health funding available for indigent, uninsured children, the 
largest socioeconomic group of students within our school district.
    Further hampering the foundation of economic support, reimbursement 
dollars for school mental health services are often absorbed by the 
larger district budget to offset losses in other areas. Locally, 
reimbursements ``earned'' through these programs and others, such as 
designated instructional counseling mandated by the Individual 
Education Plan (IEP) for special education students, or Local Education 
Agency (LEA) Medic-Aid, are not necessarily returned to support the 
programs that provided the services.
    What is needed are multiple sources of funding earmarked for school 
mental health services that is protected within State, Federal and 
local education budgets to establish and sustain programs that serve 
children's needs.

The NCTSN: The National Child Traumatic Stress Network and the National 
                    Center for Child Traumatic Stress (NCCTS)

    In my work with the National Center for Child Traumatic Stress, and 
the 54 affiliated sites that form the larger National Child Traumatic 
Stress Network, we are enacting one of the basic principles in delivery 
of services to children--to make services available to the children 
where they are, in schools and other community settings where they live 
their lives. This is why our network is helping to bring trauma-
informed services to children in schools, residential treatment 
centers, child welfare systems, correctional facilities, rural clinics, 
domestic violence shelters, community-based programs, refugee services, 
and many more. Our goal is to raise the standard of care for 
traumatized children by developing and delivering evidence-based 
treatment and services in a timely and effective way.
    In my role as Director of the School Crisis and Intervention Unit 
of the National Child Traumatic Stress Network, I can attest to the 
increasing acceptance of school-based mental health services by 
families and school communities. These services are critical to meeting 
our nation's mission of promoting academic excellence, good citizenship 
and the well-being of our children.
    Children and adolescents in our schools feel comfortable asking for 
these services, courageously commit to the hard work involved in 
treatment, and even refer their friends. Parents and guardians have 
told us that they are very pleased that the services are being offered. 
Teachers have seen the results in their classrooms, and have 
enthusiastically expressed their support. Integrating mental health 
services in schools can be successful with sufficient support.

Historical Roots: The Story of Ruth

    My involvement in this work goes back many generations. From the 
time I was 6 years old, my grandmother told me stories about her early 
life in San Francisco. That beautiful city was part of the Wild West in 
the early 1900's. For Chinese immigrants it was a vibrant and dangerous 
place. The residents of Chinatown were vulnerable to violence from 
Chinese gangs who victimized businesses, from Tong warfare (kinship and 
clan organizations fighting for economic, social and political 
dominance), and from white Americans who viewed the Chinese as less 
than human.
    The process of immigration from Macao, the island of my 
grandmother's birth, to San Francisco was no less dangerous. Pirates 
and thieves preyed on children and adults who boarded boats to escape 
the effects of the Boxer Rebellion in South China. They fled to find 
their way to ``Gold Mountain'', the name given to California and the 
promises it held for a better life.
    My grandmother, Ruth, was 5 years old when she was sold by her 
impoverished mother to a wealthy Chinese family emigrating to America. 
As a child, she remembered the day her mother pushed her toward a woman 
she had never seen before and said, ``This woman will be like your 
mother now.'' As a young child, she crossed an ocean with strangers to 
confront violence in the new world of San Francisco Chinatown.
    Once she saw a group of men refuse to pay the bill for their dinner 
and many bottles of liquor. When the owner of the Chinese restaurant 
insisted upon payment, they drew guns and shot bullets into the walls, 
ceiling and floors, smashing the furniture and laughing as they left. 
Ruth hid in a corner, unharmed but traumatized. In the following weeks, 
she refused to leave her home. She feared that she would be killed and 
that the violence would happen again.
    Not long after that incident, the violence did happen again. The 
head of her new family was shot and killed as an innocent bystander 
during a gang shooting. My grandmother never completed elementary 
school.
    In 1905, there was no counseling available in schools, nor was 
there recognition of the paralyzing effects of violence on children. 
The year my grandmother died, in 1999, I began my association with RAND 
and UCLA Research to test our intervention for its effectiveness in 
schools.
    The scars of violence can last a lifetime, but with early 
identification and early intervention in schools, the distress, 
anxiety, depression and trauma can be lifted and healed and children 
can be helped to resume productive and successful social, emotional and 
academic lives.
    We have come a long way in our country in recognizing the need for 
such services to children, and yet we do have so much more to do. The 
children are waiting.

In Closing

    The mission of schools is to educate. The mission of mental health 
services is to heal. Our responsibility is to the child who will 
benefit from both. The reality is that the mission of one cannot 
proceed without the success of the other.
    I thank you, Mr. Chairman, Mr. Kennedy, and Members of the 
Subcommittee, for the opportunity to be here, to present this 
information to the subcommittee, and to express the gratitude of those 
of who work in the schools. Your work is vitally important to the 
creation of a children's mental health system that truly cares for 
children.
      Response to Questions of Senator Bingaman From Marleen Wong
    Question 1. Every year, an estimated 9 percent to 13 percent of 
children and adolescents in the United States experience a clinically 
significant mental disorder that warrants treatment. Yet, according to 
the Surgeon General's Report on Mental Health, two-thirds of these 
vulnerable young people do not receive any mental health treatment at 
all. What can we do to improve access to treatment?
    Answer 1. In establishing the New Freedom Commission on Mental 
Health, President Bush noted three key obstacles that keep people with 
mental illnesses from getting the services they need: 1. The stigma 
that still surrounds these illnesses; 2. The fragmented mental health 
care service system; and 3. Existing treatment and dollar limits for 
mental health care.
    If we are to transform our mental health care system, we must 
establish a true system of care for all children, not just those with 
persistent and chronic mental illness. We must include children at 
every age and stage, those at risk for serious disorders, children 
caught in family or community crises, and disabled children. All 
aspects of children's lives are in a fluid state of development. Early 
intervention and disability prevention means a shift in thinking to a 
``well child'' mental health system, one that is adequately resourced 
for each of the components of early identification, early intervention, 
prevention, and effective treatments. One aspect of care should not be 
sacrificed for another because of funding disparities. One child should 
not be left behind because of another's needs.
    Lack of access to treatment is the result of many failures in the 
health care system. One way that access to mental health treatment 
would be improved is through the funding of preventive programs and 
early intervention mental health services in schools. The Early 
Periodic Screening, Diagnosis and Treatment (EPSDT) programs were meant 
to serve this purpose but have never been instituted or sufficiently 
funded to operate effectively in schools. Unlike community mental 
health clinics, hospitals or doctor's offices, schools are natural 
settings for children and parents. School mental health programs have 
demonstrated that children and families accept such services with less 
stigma and are more likely to complete the course of treatment.
    Community agencies, pediatricians, public mental health services 
agencies, even correctional facilities, have a role to play in 
providing care, but the reality is that schools have become the de 
facto primary source of mental health services for children. A 1995 
RAND study noted that only 8 percent of children who need mental health 
care actually received services--this leaves 92 percent of our children 
who need care without any services. Of the 8 percent who did receive 
services, 85 percent of the children received them in school mental 
health programs.
    In our crisis intervention work in the Los Angeles Unified School 
District and in many other parts of the country, we have worked with 
children in a post-crisis school setting. Often, while working with 
their trauma, we discovered children with other mental health problems 
that had never been addressed. Unfortunately, schools are limited by 
the lack of personnel to adequately provide intermediate and long term 
mental health and case management services that children need.
    To improve access, we need to address the barriers to treatment on 
several fronts. One approach is greater detection through improved 
education of professionals who work with children such as teachers, 
pediatricians, DCFS workers, and probation counselors, a principle 
supported in proposed S. 1223. Community leaders, including school 
superintendents, principals, union officials and faith leaders must 
also be included in an educational campaign to ensure that their 
decisions about children's programs are informed by scientific 
knowledge. Developing cultural competency in addition to high quality, 
and effective services, also noted in S. 1223, are crucial to this 
goal. National education and media campaigns about children's mental 
health should address this problem in multiple communities. One of the 
issues pertinent to access and disparity are the racial and ethnic 
differences among groups which include stereotypes that prevent 
appropriate treatment from being provided, language and cultural 
barriers, and lack of resources in disadvantaged communities. The work 
of Drs. Sheryl Kataoka and Ken Wells, UCLA Health Services Research 
Center, has elucidated these issues in details.
    Making mental health screening in schools routine for easily 
treatable problems, such as traumatic stress and depression will 
identify unmet needs and improve access to care. Our crisis 
intervention work showed that most students suffer silently from trauma 
or depression, spending their school days ``hidden in plain sight''. 
Schools routinely screen for vision and for hearing, two conditions 
which we would all agree are crucial to learning. Just as crucial may 
be school screening for trauma and depression, where fear, disturbing 
thoughts, feelings and images become barriers to school attendance and 
classroom participation. Schools are the place where the loss of 
motivation for learning of such students can be noted as a symptom of 
depression or trauma, and can best be addressed through school mental 
health programs.
    In our society, and in our health care system, children with mental 
disorders face the same stigma and discrimination as adults. It is 
unfair that an illness that can affect the brain, emotions, 
intellectual development and capacity, and relationships, and can so 
tragically affect the development of a child, is treated as less than 
serious, less than real. Schools can only do so much. When children are 
referred for mental health care, even those whose families have private 
insurance often cannot get medically necessary care because of the lack 
of parity in mental health coverage. This situation is worse than 
unfair . . . it can be lethal. Efforts to enact Federal mental health 
parity legislation have been close to success many times, and even now, 
parity has the widespread support of the Senate, the House, the 
President, and over 360 national organizations. Yet, American families 
are still waiting. It is the hope of all of us who work with children 
and their families that a full and fair mental health parity bill will 
be finally enacted in this Congress.

    Question 2. Evidence-based treatments are now available for the 
full range of child and adolescent mental disorders. Yet these 
effective treatments fail to reach a majority of those who can benefit 
from them. How can we close the gap between research and real-world 
practice to ensure that evidence-based treatments are available in 
community service settings?
    Answer 2. Closing the gap between research and practice begins in 
graduate training programs. S. 1223 supports the concept that teaching 
evidence based treatments begins in graduate programs of psychiatry, 
psychology, school psychology, psychiatric nursing, social work, school 
social work, marriage and family therapy, school counseling, and 
professional counseling. Support for continuing education through loan 
repayments, scholarships, and grants that increase the number of mental 
health providers expert in child and adolescent mental disorders will 
facilitate the infusion of sufficient numbers of providers in all child 
settings and enhance the quality of evidence-based services for 
children.
    In my work with the National Center for Child Traumatic Stress, and 
the 54 affiliated sites that form the larger National Child Traumatic 
Stress Network, we are enacting one of the basic principles in delivery 
of services to children--to make services available to the children 
where they are, in schools and other community settings where they live 
their lives. This is why our network is helping to bring trauma-
informed services to children in schools, residential treatment 
centers, child welfare systems, correctional facilities, rural clinics, 
domestic violence shelters, community-based programs, refugee services, 
and many more. Our goal is to raise the standard of care for 
traumatized children by developing and delivering evidence-based 
treatment and services in a timely and effective way. And we are doing 
this by directly linking the researchers and the providers in ongoing 
collaborations to improve care based on research and clinical practice.
    The New Freedom Commission stated that ``evidence-based practices'' 
are the bedrock of service delivery and that we improve quality and 
accountability. We can support this effort by supporting ongoing 
practical research that is embedded in schools and communities, and by 
providing training linked to scientific findings and clinical 
experience. This is one of the central goals of the National Child 
Traumatic Stress Network.
    Establishing school based mental health services is not a panacea. 
Services must be supported with adequate quality assurance and 
accountability measures. An example of such requisite oversight is that 
44 percent of the students who seek help at school-based health clinics 
present with mental health disorders or problems. Of the students who 
seek help for depression, few receive evidence-based treatments. The 
average number of 3 to 4 visits suggests that few ever receive the full 
``dose'' of recommended treatment, and follow up is rarely done.
    Some disorders, such as psychological trauma and depression, are 
very amenable to identification and treatment within a school setting. 
These are also the disorders that are being identified as leading 
causes of disability among the general population of children in the 
United States. Our work in LAUSD with RAND and UCLA Health Sciences 
Research Center, documented disrupted academic performance, negative 
classroom behavior and less school attendance among students 
traumatized by their exposure to community violence. In fact, 
scientific studies are showing that childhood trauma further affects 
the onset and course of many other child and adolescent health and 
mental health conditions, from attention deficit and bipolar disorder 
to substance abuse and conduct disorder.
    Most importantly, in measuring our success, mental health 
professionals must find a way to integrate the mission of mental health 
and the mission of education. From an organizational perspective, 
mental health services in schools cannot operate outside the structure 
and organization of the educational environment. In order to succeed 
within the educational environment and to gain acceptance from 
educators, the integrity of the academic day must be preserved. 
Outcomes must include not only a decrease of symptoms but also evidence 
of improved academic functioning--better grades, improved classroom 
behavior, fewer absences, and increased attendance. These criteria are 
generally not within the realm of traditional treatment outcomes. 
However, they are solid indices of health, rehabilitation, and recovery 
for children.

    Question 3. Children with serious emotional disturbance often have 
multiple problems and require services from several systems, including 
the mental health, educational, child welfare, and juvenile justice 
systems. How can we enhance the coordination and collaboration of 
various child-serving systems?
    Answer 3. What is needed are multiple sources of funding earmarked 
for mental health services that are protected within State, Federal and 
local education budgets to establish and sustain programs that serve 
children's needs. Coordination and collaboration of various child 
servicing systems can be enhanced by placing those services at one 
location within an area or geographic region. In addition, a multi-
disciplinary collaborative team approach to serving each child would 
enhance and promote ``wrap-around'' services, tailoring the services to 
the changing needs of the child.
    Many public mental health systems suffer from service and funding 
fragmentation. I am proud to say that the Los Angeles Unified School 
District has supported mental health services for the past 71 years. 
However, in the 30 years that I have worked in LAUSD, we have had to 
fight to maintain those services during annual budget deliberations 
when categorical, special education, Title I and general fund dollars 
wax and wane. This year, many mental health professionals, such as 
school counselors and social workers, will lose their jobs because of 
severe budget cuts necessitated by the downturn in the economy.
    In 1992, I worked with our Los Angeles County Department of Mental 
Health Services to negotiate the first Medi-Cal (Medic-Aid) contract 
between a school district and a county mental health service. We are 
currently able to draw down ``rehabilitation'' reimbursements for 
services to Medi-Cal eligible students and their families.
    This funding stream, however, does not provide any financial 
support for the work we do with indigent, uninsured children and 
families. Over 73 percent of LAUSD students and their families live 
below the poverty level and receive free and reduced lunch. The budget 
crisis in California has been so severe that there is no longer public 
mental health funding available for indigent, uninsured children, the 
largest socioeconomic group of students within our school district.
    Further hampering the foundation of economic support, reimbursement 
dollars for school mental health services are often absorbed by the 
larger district budget to offset losses in other areas. Locally, 
reimbursements ``earned'' through these programs and others, such as 
designated instructional counseling mandated by the Individual 
Education Plan (IEP) for special education students, or Local Education 
Agency (LEA) Medic-Aid, are not necessarily returned to support the 
programs that provided the services.
    In my work with the National Center for Child Traumatic Stress, and 
the 54 affiliated sites that form the larger National Child Traumatic 
Stress Network, we are enacting one of the basic principles in delivery 
of services to children--to make services available to the children 
where they are, in schools and other community settings where they live 
their lives. This is why our network is helping to bring trauma-
informed services to children in schools, residential treatment 
centers, child welfare systems, correctional facilities, rural clinics, 
domestic violence shelters, community-based programs, refugee services, 
and many more. Our goal is to raise the standard of care for 
traumatized children by developing and delivering evidence-based 
treatment and services in a timely and effective way.
    I would also like to speak about the Individuals with Disabilities 
Education Improvement Act, a critically important piece of legislation 
that helps to support services for children who are disabled. I would 
especially like to thank the committee for recognizing the disabling 
effects that trauma exposure can have for young children, and for the 
inclusion of language in the bill that will help children who struggle 
in school as a result of trauma and the effects of traumatic events.
    A report on developmental disabilities and trauma was developed by 
the NCTSN, and has been submitted for the record. That report includes 
information from population studies showing that the national 
prevalence rate for developmental disabilities in the U.S. is 1.8 
percent. This translates into many children in our school systems 
needing the specialized education provided through IDEA. Additional 
studies have shown that individuals with developmental disabilities are 
at increased risk for abuse as compared to the general population. For 
example, 64 percent of maltreated children have a disability, such as 
behavioral disorders; speech, language, or learning disabilities; or 
mental retardation. Children with mental retardation were the most 
severely abused. When we identify a child with special needs, it is 
essential to determine the full context of the child's life and history 
so that the most appropriate services can be provided.
    It is therefore a major step forward for the Senate to recognize 
that the development of vulnerable young children can be thrown off 
course because of traumatic experiences, and that, with timely 
intervention, a child's life can be supported back onto a normal 
developmental path.

    Question 4. The New Freedom Commission on Mental Health and the 
Surgeon General's report both identified a national shortage of mental 
health professionals trained to treat mental illness in children and 
adolescents. I have introduced S. 1223, The Child Health Care Crisis 
Relief Act, which creates incentives to help train, recruit, and retain 
child mental health professionals through loan repayments, 
scholarships, and grants. Do you feel passage of this legislation would 
be helpful in reducing the shortage of qualified professionals?
    Answer 4. The passage of S. 1223 would significantly reduce the 
shortage of qualified professionals in several ways. First, it provides 
graduate students and working professionals with much needed financial 
support to further their studies with competitive grants. The proposed 
bill also addresses all the major issues and recommendations of the 
President's New Freedom Commission Report, especially the need to:
    Reduce disparities and the burden of unmet needs and lack of access 
to services among minority groups.
    Establish ``evidence-based practices'' as the bedrock of service 
delivery.
    Improve quality and accountability.
    Through my work with the National Center for Child Traumatic 
Stress, and the 54 affiliated sites that form the larger National Child 
Traumatic Stress Network, I am very aware of the difficulties of 
insufficient numbers of trained health care providers who are expert in 
child mental health or child trauma. In our network, we are directly 
linking providers with training programs so that we can enact one of 
the basic principles in delivery of services to children--to make 
services available to the children where they are, in schools and other 
community settings where they live their lives. This is why our network 
is helping to bring trauma-informed services to children in schools, 
residential treatment centers, child welfare systems, correctional 
facilities, rural clinics, domestic violence shelters, community-based 
programs, refugee services, and many more. Our goal is to raise the 
standard of care for traumatized children by developing and delivering 
evidence-based treatment and services in a timely and effective way. 
But without sufficient numbers of providers, and without a decent and 
fair health care reimbursement system, even the best training programs 
may not lead to successful integration of more providers throughout the 
system of child health care. This is why school-based mental health 
programs, IDEA improvements, and mental health parity legislation must 
be pursued at the same time that we enhance training programs for child 
health care providers.

    Senator DeWine. Dr. Douce, thank you.
    Ms. Douce. Good morning, Chairman DeWine and Senator Reed. 
Thank you very much for inviting me here today. As a member of 
the American Psychological Association and as director of the 
Counseling and Consultation Services at the Ohio State 
University, I oversee the provision of a broad range of mental 
and behavioral health services to nearly 50,000 students a 
year. I appreciate this opportunity to speak with you today 
about the growing mental and behavioral health needs of college 
students as you consider the College Care and Counseling Act.
    Let me start with an example. Consider a senior in the 
business school who is struggling with a broken relationship. 
He cannot sleep, he cannot concentrate, he does not go to 
class, and he finds himself sitting outside his ex-girlfriend's 
apartment at night waiting to see whom she is dating. He 
imagines beating that man to a pulp. He is a first-generation 
college student. He works 25 to 30 hours a week in addition to 
going to school, and he is qualified for significant financial 
aid to put himself through college. If he cannot address his 
emotions and his behavior, he is at risk of not graduating and, 
frankly, at risk for stalking. It is hard for him to seek help, 
but seeing his whole future disintegrating has convinced him to 
try counseling.
    In my written testimony, I offer an example of a young 
woman with a severe eating disorder and a young man that is at 
high risk for suicide.
    Situations like those I have just shared are common to 
college and university campuses throughout our country. During 
the period from 1975 to 1995, college and university counseling 
centers saw a dramatic increase in both the numbers and the 
severity of the mental health concerns.
    In fact, many of the students that colleges and 
universities want to retain leave school for personal rather 
than academic difficulties. A number of studies have shown a 
positive relationship between counseling services and actually 
staying in school and graduating. It is a lose-lose situation 
when a student who has taken out loans, received Federal grant 
aid, does not complete his or her degree. The loans do not go 
away. The student is not better off. And neither is our 
government investment in them.
    Now, let me just speak to some of the most serious issues. 
The most serious issue to me is suicide. Suicide is the second 
leading cause of death among college students. A 2000 survey by 
the American College Health Association found that within the 
previous year 22 percent felt they were so depressed that they 
could barely function, 9 percent had seriously considered 
suicide, and 1.5 percent had made attempts. In our own center, 
last year, 273 students admitted to suicidal ideation at 
intake, 11 had plans and means. None of those students died, 
yet tragically three other OSU students did end their lives by 
suicide.
    Suicide is preventable with knowledgeable and skilled 
intervention. Depression and anxiety are often at the root, and 
these are curable diseases. increased awareness, early 
detection, effective referral, and skilled intervention are the 
keys, and I would like to commend you, Mr. Chairman, for your 
leadership on the issue of suicide prevention.
    A second major issue is alcohol and substance abuse. 
Approximately 1,400 college students between the ages of 18 and 
24 die each year from alcohol-related injuries; 500,000 
students are injured while under the influence of alcohol; 
600,000 students are assaulted by another student who has been 
drinking; and 70,000 students are victims of alcohol-related 
sexual assault and date rape. These numbers are astounding.
    We know that facing the consequences of addictive behavior 
is one of the first steps to change. College and university 
counseling centers can play a major role in participating in 
wellness and prevention programs, counseling students in 
trouble, providing court-mandated therapy for students in the 
legal system for alcohol-related behavior. Our services assist 
students in facing their consequences, examining their choices, 
and learning to choose more appropriate alternatives.
    I would like to take my last few minutes to acknowledge the 
leadership of Senators Reed and DeWine in meeting the mental 
and behavioral health needs of college students with their 
introduction of the College Care and Counseling Act. Along with 
the support and involvement of Senators Smith and Clinton, you 
have introduced significant legislation that can really make a 
difference in the lives and successes of our Nation's students 
enrolled in postsecondary education.
    Funds would be made available for use for activities such 
as prevention, screening, early intervention, assessment, 
treatment, management, and education of mental and behavioral 
health needs of students on campus.
    This year, the Federal Government expects to spend $70 
billion in student financial assistance. This investment often 
makes the difference in a student's decision to pursue their 
dream of a college education. While undoubtedly significant, it 
is an investment that may not always yield the results we 
anticipate.
    Mental and behavioral health concerns and how they are 
addressed can make this difference. I sincerely believe it is 
one of the best returns on investment you can make. I hope that 
as the Senate Health, Education, Labor, and Pensions Committee 
moves forward with its reauthorization of the Higher Education 
Act that this legislation will be a priority for inclusion in 
the final bill. It is too important not to.
    Finally, I would again like to thank you, Senator DeWine, 
for having me testify in this important hearing today and for 
cosponsoring this bill.
    I will be glad to respond to any questions.
    Senator DeWine. Thank you very much.
    [The prepared statement of Ms. Douce follows:]
              Prepared Statement of Louise A. Douce, Ph.D.
    Good morning Chairman DeWine and Members of the Subcommittee. Thank 
you for inviting me here today. As an active member of the American 
Psychological Association and as Director of Counseling and 
Consultation Services at the Ohio State University, I oversee the 
provision of a broad range of mental and behavioral health services to 
nearly 50,000 students each year. I appreciate this opportunity to 
speak with you today about the growing mental and behavioral health 
needs of college students as you consider the College Care and 
Counseling Act (S. 2215).
    Let me outline why these mental and behavioral health services on 
college campuses are so important:
     Maximize student success
     Increase rates of retention and graduation
     Provide crisis management and services
     Provide mental health consultation to faculty and staff
     Develop prevention strategies and contribute to a wellness 
culture
     Advance multicultural competency in a global community
     Ensure appropriate continuum of care
    I would like to begin by sharing some real life stories of college 
students that have sought help at our counseling center at Ohio State.
    Consider a senior in the business school who is struggling with a 
broken relationship. He can't sleep, he can't concentrate and he finds 
himself sitting outside his ex-girlfriend's apartment at night waiting 
to see whom she is dating. He imagines beating that man to a pulp. He 
is a first generation college student, works 25 hours a week and has 
qualified for significant financial aid to put himself through college. 
If he cannot address his emotions and his behavior, he is at risk of 
not graduating and, frankly, at risk for stalking. It is hard for him 
to seek help, but seeing his whole future disintegrating has convinced 
him to try counseling.
    Now consider a young woman who is a freshman in the Honors program. 
She is very bright, has very high SAT scores and feels pressure from 
everyone's expectations for her success. She has also had an eating 
disorder since junior high school. She worries constantly, is obsessed 
with her weight and limits food. Since starting school her anxiety has 
been very problematic, she rarely eats and her weight has gone below 
100 pounds. She realizes she needs help and seeks counseling.
    Finally consider a graduate student who is struggling with 
depression. He cannot get to sleep at night until 3 or 4 a.m. and then 
oversleeps his 9 a.m. class. He has trouble getting out of bed some 
days, does not enjoy anything he used to, pushes friends away, knows he 
is failing and blames himself. About the only way he can think to 
escape his despair is suicide. His mother, who lives 1,500 miles away, 
convinces him to find the counseling center.

Increased Need

    Situations like those I have just shared are common on college and 
university campuses throughout our country. During the period from 1975 
and 1995 colleges and university counseling centers saw a dramatic 
increase in both the numbers and severity of mental health concerns. A 
national survey of counseling center directors confirmed that this 
trend of increased demand continued throughout the 1990s.
    More specifically, a research consortium of 36 counseling centers 
found increases in anxiety, fear and worries and dysfunctional behavior 
including eating disorders, alcohol and substance abuse and anger/
hostility. They also reported increases in the impact of violence, 
family dynamics, depression and bipolar disorder.
    This study outlines the major issues in college student mental 
health:
     Depression, anxiety and anger (also referred to as 
Affective Disorders)
     Eating Disorders and body image distortion
     Traumatic Stress Reactions following exposure to
             Violence in community and war (returning veterans 
            & internationals)
             Date rape, harassment and stalking
             Family discord, dysfunction and abuse
             Natural disasters around the world
     Alcohol and substance abuse
     Future, career and crisis of hope
    In the years ahead, I would expect to see the trend of an 
increasing number of students seeking mental and behavioral health 
services to continue--if not grow at a more significant pace. Current 
research suggests that more students are entering college with prior 
treatment histories of severe mental illness now controlled with 
medication, a great thing. However, they may have more difficulty with 
adjustment to change and are at increased risk of relapse or 
reoccurrence without appropriate mental health support. In addition, 
the Institute for Higher Education Policy recently reported that 
between 2000 and 2015, the college-age population will increase by 16 
percent or 2.6 million students, 80 percent of whom will be ethnic 
minorities, and nearly half Hispanic. The report noted that students 
from ethnic minority communities historically suffer most from 
financial, academic, and cultural barriers. This may be especially 
salient for first generation college students. Providing culturally 
competent therapy and prevention programming is a vital element in 
graduating a fully diverse class. A better-educated population is in 
turn necessary for the United States to remain competitive in a global 
economy. We, as a Nation are counting on them to be successful.

Students Who Receive Mental and Behavioral Health Services Have Higher 
                    Retention Rates

    In fact, many of the students that colleges and universities want 
to retain leave school for personal rather than academic difficulties. 
Recent research has demonstrated that students who receive counseling 
for their mental and behavioral health needs reported increases in 
``personal well being, academic success and retention.'' Further, a 
number of studies have discovered a positive relationship between 
counseling services and retention rates. It's a lose-lose situation 
when a student, who has taken out loans and received Federal grant aid, 
doesn't complete his or her degree. The loans don't go away. The 
student is not better off--and neither is our government investment in 
them. On the other hand, both the student and the government win when a 
student who received financial assistance from the Federal Government 
graduates and goes on to future success. That student is better off--
and so is our Nation. Sometimes all that it takes to turn a potentially 
tragic situation into a success story is an interest and commitment to 
a student's mental health needs.

Suicide Prevention

    Let me speak to one of the most serious issues in this population, 
suicide. Suicide is the second leading cause of death among college 
students. A 2000 survey by the American College Health Association 
found that within the last year 33 percent of college students reported 
feeling hopeless, 22 percent said they felt so depressed they could 
barely function, 9 percent seriously considered suicide; and, 1.5 
percent had actually attempted suicide. Last year in our center, 273 
students admitted to suicidal ideation at intake, 11 had plans and 
means. None of those students died yet, sadly, three other OSU students 
did end their lives by suicide.
    The Ohio State University participated in a decade long study of 
suicide at Big 10 Universities in the 1980's. The researcher, Dr. Mort 
Silverman, visited with coroners and traced all student deaths to 
verify all deaths by suicide and determine patterns. The overall number 
of such deaths was less than the rate for the general population aged 
15 to 24. Dr. Silverman attributed this to the relatively greater 
access to mental health care through the Big 10 university counseling 
centers. What were especially helpful from this study were patterns 
specific to each university. At Ohio State we had a significant number 
of deaths by cyanide and a higher rate among international graduate 
students than the other schools. We immediately addressed access to 
cyanide in chemistry labs and developed greater prevention efforts with 
the international population including orientation workshops on family 
stress, dating ``American style'' and stress management. Since then we 
have had no cyanide deaths and reduced our suicide rate by 40 percent 
from 4.5 persons to 2.7 persons over the last 5 years. That is 2.7 too 
many, but lower than one would predict for 50,000 students. Suicide is 
often preventable with knowledgeable and skilled intervention. 
Depression and anxiety are often at the root and those are curable 
diseases. Increased awareness, early detection, effective referral and 
skilled intervention are the keys. I would like to commend you Mr. 
Chairman for your leadership on this issue of suicide prevention.

Alcohol and Substance Abuse

    Approximately 1,400 college students between the ages of 18 and 24 
die each year from alcohol-related unintentional injuries, including 
motor vehicle crashes. Five hundred thousand students are injured while 
under the influence of alcohol and 600,000 students are assaulted by 
another student who has been drinking. Seventy thousand students are 
victims of alcohol-related sexual assault or date rape. These numbers 
are astounding. The related damage in drunk driving, vandalism, 
property damage and police involvement is incredible. In 2001, 
approximately two in five (44.5 percent) college students reported high 
risk or binge drinking. Our own data at Ohio State University indicates 
that this rate continued to climb in 2002 to 52.8 percent (from 44.2 
percent in 2000). We also saw a 10 percent increase for women, students 
of color, students of legal drinking age and seniors. We did see a 
decline in use by first year students, which we attribute to a 
multifaceted education campaign. We have known for years that college 
students engage in high risk drinking. We also know that many of these 
students stop this behavior sometime during their college career. Many 
do not. We also know that facing consequences of addictive behavior is 
one of the first steps to change. College and university counseling 
centers can play a major role in participating in wellness and 
prevention programs, counseling students in trouble and providing court 
mandated therapy for students in the legal system for alcohol related 
behavior. Our services assist students in facing their consequences, 
examining their choices and learning to choose more appropriate 
alternatives.

Counseling and Mental Health Service Reductions

    As you probably know, college tuition continues to rise 
dramatically. State subsidies for higher education continue to be cut 
across the Nation and college administrators are caught in the squeeze. 
They look to cut costs internally wherever possible and mental health 
services have been severely impacted. In the last 10 years colleges and 
universities have had to set session limits (39 percent 1992; 44 
percent in 2002), impose fees (7.4 percent in 1992, 15 percent in 2000) 
and reduce staff. At a time when the mental and behavioral health care 
needs of students are increasing, the means to meet those needs are 
being reduced. Employing usage fees affects students on financial aid 
disproportionately. These students have fewer resources to start with 
and may be at higher risk for leaving school because of personal 
problems--problems that could be resolved with appropriate and 
accessible care.

Campus Care Act

    I would like to take my last few minutes to acknowledge the 
leadership of Senators Reed and DeWine in meeting the mental and 
behavioral health needs of college students with their introduction of 
the College Care and Counseling Act--S. 2215. Along with the support 
and involvement of Senators Smith and Clinton, you have introduced 
significant legislation that can really make a difference in the lives 
and successes of our Nation's students enrolled in postsecondary study. 
This bill will help thousands of students get the help they need, when 
they need it and better insure the return in our Nation's investment in 
them.
    S. 2215 authorizes $10 million in competitive grant funds to 
college counseling centers, mental health clinics, and psychology 
service centers within institutions of higher education to create or 
expand the mental and behavioral health services to students. Funds 
made available can be used for activities such as prevention, 
screening, early intervention, assessment, treatment, management and 
education of the mental and behavioral health needs of students on 
campus. Resources may also be used to better educate families about the 
psychological health of their children. These are critical areas 
identified by counseling centers on campus that need attention. Over 
the past 5 years, counseling center directors reported substantial 
increases in the percentage of students they see with severe 
psychological problems, sexual assault concerns, alcohol problems, 
illicit drug use, and eating disorders with little to no increase in 
resources to support their work.

Why Support College and University Counseling and Mental Health 
                    Services? Why the Federal Government?

    This year, the Federal Government expects to spend nearly $70 
billion in student financial assistance. This investment often makes 
the fundamental difference in a student's decision to pursue the dream 
of a college education. It is the most significant contribution the 
Federal Government makes to our Nation's postsecondary students. And 
while undoubtedly significant, it is an investment that may not always 
yield the results we anticipate--for a variety of reasons, but often 
due to undiscovered, unaddressed or unmet needs related to mental and 
behavioral health problems.
    Mental and behavioral health concerns and how they are addressed--
can make the difference between a student that finishes in 4 years 
versus 7; a student that graduates and one who drops out; and a student 
who takes his or her own life and one that goes on to live a healthy 
life. The Campus Care and Counseling Act calls for a small contribution 
of resources but it offers a sound, targeted, intervention, based on 
research, that can yield big contributions in areas including academic 
success, retention, graduation rates and life and death.
    I sincerely believe it is one of the best returns on investment you 
can make. I hope that as the Senate Health, Education, Labor, and 
Pensions Committee moves forward with its reauthorization of the Higher 
Education Act that this legislation will be a priority for inclusion in 
the final bill. It is too important not to. Finally, I would again like 
to thank you, Senator DeWine for having me testify at this important 
hearing today and for cosponsoring S. 2215.
    I will be glad to respond to any questions.
    Senator DeWine. Dr. Davis?
    Ms. Davis. Mr. Chairman and members of the subcommittee, I 
am grateful for this opportunity to talk with you today about a 
developmental stage that is ignored and a group of young people 
that we cannot afford to lose. I study the transition into 
adulthood of youth with the most serious mental health 
conditions and the public systems with which they are involved. 
I hope my testimony, which is based on my and my colleagues' 
research, convinces you that we need to change our service 
systems to help these young people become contributing members 
of society rather than what our service systems do now, which 
is to abandon them and their families in the middle of this 
critical developmental stage.
    The transition period covers ages 14 to 25. Of those who 
are 14 to 25, 2 to 3.5 million of them have the most serious 
mental health conditions. The typical transition to adulthood 
that most of us experience is based on the steady accumulation 
of cognitive, emotional, and social maturity and increased 
skills and knowledge so that by age 25 society reasonably 
expects us to have finished school, to be working, and to move 
out of the family home.
    For adolescents with serious mental health conditions, 
particularly those in public systems like special education, 
child welfare, or child mental health, their odds of becoming 
successful young adults are bleak. Disability and circumstance 
slow their steady accumulation of maturity skills and 
knowledge. By young adulthood, about 30 percent have 
experienced homelessness. The rate of school dropout, 
unemployment, drug or alcohol problems, and pregnancy covers 
around 50 percent. And by age 25, up to 65 percent have been 
arrested. In essence, they are failing in every domain of adult 
functioning.
    But the real failure is our inadequate service systems. 
While their need for services does not go away, our service 
systems do, right in the middle of this critical developmental 
stage.
    This mid-transition service loss is caused by unintentional 
barriers that are produced by the separateness of our child and 
adult funding streams, entitlements, and service systems. Not 
only do individuals lose services, but the services that do 
exist rarely address the particular needs of youth with serious 
mental health conditions.
    Let me illustrate some of these barriers through real life 
stories. Matt, who had been involved with special education, 
child welfare, and the State child mental health system since 
age 5, could not access the State's adult mental health system 
when he turned 19. Matt lived in a State, like many other 
States, in which child and adult mental health systems restrict 
access to their services to those who have one of a list of 
qualifying psychiatric diagnoses. In 62 percent of States, the 
list of diagnoses for adult services is more restrictive than 
they are for child services. Matt did not have one of those 
qualifying adult diagnoses, and he was denied any further 
access to the State's mental health system.
    Hannah, who developed a major depressive disorder when she 
was 16, had been on an adolescent psychiatric hospital unit for 
6 months when she turned 18. With little notice, she was 
transferred to the adult unit. There she was the only patient 
under age 30. The sudden shift of unit that broke off her 
relations with those on the adolescent unit and put her with 
older adults that she found frightening led to despair and 
suicide attempts. When she eventually left the hospital, like 
most young adults in the adult mental health system, she found 
few programs that had any younger adults in them and no 
recognition of her transition support needs.
    We have learned that the causes of this service inadequacy 
and the mid-transition service loss are complex. For example, 
State mental health systems are greatly dependent on Medicaid 
funding. Child eligibility for Medicaid is different from adult 
eligibility. And as a result, each day some young people with 
serious mental health conditions lose the payer of their needed 
services because of the passage of a birthday that marks entry 
into adulthood.
    While the solution to these problems is complex, the goal 
is clear. Give these young people a chance for successful 
adulthood by providing supportive services throughout the 
transition age, until adult functioning has been attained. No 
States have come close to this goal, although most are making 
efforts.
    To achieve this goal, we need to motivate our systems to be 
creative in solving the system problems, to embrace this 
developmental stage, and to embrace these young people. We also 
need to develop more knowledge to guide these efforts.
    I thank you for providing a forum from which greater 
progress may evolve. I would especially like to thank you, 
Chairman DeWine, and Representative Stark for your focused 
effort in the transition issue.
    Senator DeWine. Doctor, thank you very much.
    [The prepared statement of Ms. Davis follows:]
               Prepared Statement of Maryann Davis, Ph.D.
    Mr. Chairman and Members of the Subcommittee, I am Maryann Davis, 
Ph.D., a psychologist on the faculty of the Center for Mental Health 
Services Research, in the Department of Psychiatry at the University of 
Massachusetts Medical School. Over the past 10 years I have conducted 
research on the developmental needs of youth with serious mental health 
conditions during the transition to adulthood and the public systems 
with which these young people are involved. I am very grateful for the 
opportunity to talk with you today about a developmental stage that is 
ignored, in a group of young people we can't afford to lose. I hope my 
testimony convinces you that we need to change our service systems to 
help these young people become contributing members of our society, 
rather than what our systems do now, which is to abandon them, and 
their families, in the middle of this developmental stage.
    The transition period covers ages 14 through 25. At any given time, 
there are 2-3.5 million individuals in the transition age who have the 
most serious mental health conditions. The typical transition to 
adulthood that most adolescents experience involves the steady 
accumulation of cognitive, emotional, and social maturity, that under 
most conditions, results in increased skills and knowledge so that by 
age 25 we reasonably expect young people to finish school, be working, 
move out of the family home, develop adult friendships and loving 
relationships, and begin to contribute to our society. For adolescents 
with serious mental health conditions involved with public systems, 
like special education, child welfare, or child mental health services, 
their odds of becoming successful young adults is bleak. During 
adolescence their psychosocial development is delayed in every area. By 
young adulthood about 30 percent have experienced homelessness, almost 
half have a developed drug or alcohol abuse or dependence, half have 
dropped out of high school, about half are unemployed, up to half of 
these young women have become pregnant, and, by age 25, up to 65 
percent have been arrested. In essence, as a group, they largely fail 
in every domain of adult functioning.
    But the real failure is our inadequate support system. While their 
psychiatric disability does not go away, our support system for them 
does. In the midst of this important developmental stage there is an 
abrupt loss of services that has no correlation with an improvement in 
their state of mental health. Rather it is the result of myriad system 
barriers erected by the separateness of our child and adult services, 
agencies, funding streams, and entitlements. Adolescent services that 
address the particular transition needs of those with serious mental 
health conditions are too rare. Few of these adolescents gain access to 
the adult mental health system, which contains vocational, supported 
education, housing, and substance abuse services in addition to mental 
health treatment. However, the few who are given access to adult 
services encounter find that adult systems typically have no 
developmental framework in their policy or practice. There is little 
recognition that a 22-year-old needs different types of services than a 
40-year-old. Thus the adult system, that frequently denies them any 
entry, also typically offers few services that are appropriate or 
appealing to this young adult population. Currently, there is no State 
that has been able to overcome these system problems.
    I'd like to relate one young person's story to demonstrate this 
point. Matt became involved with special education, child welfare, and 
the child mental health system since age 5. By age 17 he had a social 
worker from each of these systems who were responsible for finding 
services for him. He had a single mother and younger siblings. His 
residential treatment ended at age 17. He was sullen, depressed, and 
had angry outbursts. He was on numerous psychotropic medications. He 
yearned for acceptance, but put up a gruff unfriendly exterior to ward 
off the expected rejection.
    His special education program couldn't find a school program for 
him for months. Things got worse at home. He joined a gang, fathered a 
son, and turned 18 in the ensuing months. Like so many youth with 
serious mental health conditions he dropped out of school. His 
transition plan, mandated by the Individuals with Disabilities 
Education Act became moot upon his dropping out. The school made an 
application for him to access adult mental health services which could 
start serving him when he turned 19. But, in his State, like many 
States, the child and adult mental health system restricts their 
services to those who have one of a narrow list of qualifying 
psychiatric diagnoses. In 62 percent of States the list of diagnoses is 
more narrow in the adult than child mental health system. Matt didn't 
have one of the adult diagnoses, and was denied any further access to 
the State's mental health system after age 19.
    Upon his 18th birthday his child welfare case was closed. The John 
Chaffee Foster Care Independent Living Act allows many youths to 
continue voluntarily in child welfare services after age 18, receive 
independent living supports, and extends their Medicaid coverage to the 
age of 21. But, like many young people in his position Matt was not 
interested in any further involvement with this Agency.
    By age 19 he was a legal adult, with little guidance, who had lost 
all his child services. He didn't know how to apply for disability. He 
was uninsured. He had no diploma. No steady source of reliable income. 
And no hope. He was soon hospitalized for a suicide attempt, and was 
never able to provide financially or emotionally for his son.
    Matt's situation is unfortunately common among the young people 
with serious mental health conditions in our public systems. While 
special education and child welfare systems have developed many 
programs and approaches to aide the transition to adulthood, those 
approaches are targeted at nor well suited for youth with serious 
mental health conditions. Transition supports in the State child mental 
health system are sparsely distributed across the country, and adult 
mental health system has not begun to address the needs of the younger 
adult population. We miss a critical window of development. We have an 
opportunity to help these youths become productive adults in our 
society, to work, have homes, have friends, and start families. But we 
squander that opportunity, to the detriment of us all.
    The solution to these system problems is complex, but the goal is 
clear. We need to provide appropriate transition supports continuously 
into adulthood until the services are no longer needed. If we are to 
achieve this goal we need to encourage innovation and creative 
solutions to the current system barriers. We need to create the 
motivation to change these systems and we need to develop more 
knowledge to guide us as we solve this complex problem.
    There are solutions to be had at every level. At the Federal level, 
changes such as extending eligibility for Medicaid coverage for youth 
with disabilities to age 25, would facilitate the provision of 
continuous services throughout the transition stage. State mental 
health authorities can work to make their eligibility criteria the same 
for adult and child services. At the local level, young people can be 
invited into the change process, to help guide the changes so that they 
are appealing to them. We also need more research to develop and 
demonstrate treatments or services that are effective with this age 
group. Achieving our goal will prevent crime, homelessness, lost 
productivity, and lost members of society.
    Thank you, Mr. Chairman and Members of the Subcommittee, for 
providing a forum from which greater progress may evolve. I would 
especially like to thank Senator DeWine and Representative Stark for 
their focused interest in the transition issues.
      Response to Questions of Senator Bingaman From Maryann Davis
    Question 1. Every year, an estimated 9 percent to 13 percent of 
children and adolescents in the United States experience a clinically 
significant mental disorder that warrants treatment. Yet, according to 
the Surgeon General's Report on Mental Health, two-thirds of these 
vulnerable young people do not receive any mental health treatment at 
all. What can we do to improve access to treatment?
    Question 2. Evidence-based treatments are now available for the 
full range of child and adolescent mental disorders. Yet these 
effective treatments fail to reach a majority of those who can benefit 
from them. How can we close the gap between research and real-world 
practice to ensure that evidence-based treatments are available in 
community service settings?
    Question 3. Children with serious emotional disturbance often have 
multiple problems and require services from several systems, including 
the mental health, educational, child welfare, and juvenile justice 
systems. How can we enhance the coordination and collaboration of 
various child-serving systems?
    Question 4. The New Freedom Commission on Mental Health and the 
Surgeon General's report both identified a national shortage of mental 
health professionals trained to treat mental illness in children and 
adolescents. I have introduced S. 1223, The Child Health Care Crisis 
Relief Act, which creates incentives to help train, recruit, and retain 
child mental health professionals through loan repayments, 
scholarships, and grants. Do you feel passage of this legislation would 
be helpful in reducing the shortage of qualified professionals?
    The first three questions are covered very thoroughly in the New 
Freedom report for children and adolescents. What is not covered very 
well in that report are the specific needs of youth during the 
transition into adulthood. I will focus my answers on that age group.
    (1) INCREASING ACCESS. Your question is particularly important for 
youth with mental health conditions during the transition to adulthood. 
All studies converge on the fact that there is a critical loss of 
services between ages 16-23. Thus, that figure of 67 percent not 
receiving needed services increases dramatically during these ages. I 
will address some of the factors that contribute to the loss of 
services and to not accessing service in the first place.
    (A) Stigma. Teens and younger adults want to fit in with their 
peers, they do not want to be labeled as mentally ill. In this age 
group it is the young people themselves who need to be encouraged to 
identify their mental health need and to access services that can help 
them. The social stigma of mental illness is the worst of any 
disability group. Thus, more young people can be identified and treated 
if access is destigmatized. Reducing the stigma of screening or 
treatment can be achieved in various ways. The first principal is to go 
to where they are; the internet, schools, the mall, public transit, 
etc. For example, USE THE INTERNET. Having an internet screening device 
with some link to services is an anonymous way that any teen or young 
adult, who is struggling in their functioning can get some sense of 
whether they have a mental health condition that could benefit from 
treatment. The second principal is to imbed the screening and treatment 
into issues that youth care about. For example, youth might not want to 
take a mental health screening test, but they may be very interested in 
finding out why they're struggling to work, finish school, earn money, 
or move out on their own. Imbedding screening for mental health, and 
other conditions, into tools that they can readily access to help them 
figure out how to do these things better is a friendly way to help them 
find out that not only do they have a mental health condition, but that 
its getting in the way of things that they want to achieve, and there's 
help to be had. The third principle is ensure that the development of 
screening and treatment mechanisms is guided by young person input 
(young people with mental health conditions). They are the only ones 
who can really indicate what approaches will attract or repel young 
people. Making these kinds of innovative approaches work, and making 
them ethical could be the focus of Federal programs, like SAMHSA, NIMH, 
OSERS, NIDRR, NIDAA. Encouraging these agencies to work collaboratively 
increases the likelihood that the issues that young people care most 
about will help overcome the issue of stigma.
    (B) Disappearing Payors. Many young people who have mental health 
conditions, and are receiving treatment for them, lose access to 
treatment upon the passage of an ``adult'' birthday. Essentially the 
payor of their ``child'' treatments no longer covers them at this age, 
and the payors of ``adult'' treatments will not fund them. This occurs 
across numerous payors. Each suggestion below focuses on the kind of 
action that would increase access to mental health services because of 
the continued presence of a payor for those services. Parents' 
insurance can cover a young adult child as long as they remain in 
school. However, for young people with serious mental health 
conditions, this offers little help because fewer than half finish high 
school and only a small fraction go on to post secondary school. 
Encouraging insurance companies to allow parents of youth with 
disabilities to maintain their coverage until age 25, regardless of 
school status, would help maintain the continuity of services. It might 
also be a motivator for screening--since they would have to document 
disability. Medicaid eligibility is much broader for children than for 
adults. The changes take place somewhere between age 18 and 21. 
Extending eligibility for Medicaid automatically for anyone with a 
disability up to age 25 would go a very long way toward providing 
access to needed services. Changing the definition of disability, as 
used for Medicaid or social security, so that those between the ages of 
18 and 25 could qualify as disabled under EITHER the child or adult 
definition of mental health disability would also ensure that those who 
were considered disabled as a 17.99 year old, would still be considered 
disabled throughout the period of transition. Extend the eligibility 
for independent living supports provided through the John Chaffee 
Foster Care Independent Living program to the age of 25 for those with 
disabilities. Provide an extra pot of money in the Federal mental 
health block grants administered through SAMHSA for States to access to 
increase the numbers of youth who receive State mental health care 
during ages 16-25.
    (C) Embrace the developmental stage of emerging adulthood. In 
``normative'' or ``typical'' development there is a new stage of 
development that has been recognized and described; emerging adulthood, 
which starts around age 18 and ends around age 25. There is all kinds 
of legislation around entitlements and programs that defines childhood 
as ending at 18, or 21. For youth with disabilities, their development 
is delayed, and society's expectation that they function as adults at 
18 or 21 is misplaced. Supports for youth with disabilities need to 
uniformly be extended to at least age 25. If ``typical'' development 
means full adult functioning at 25, then, really, supports, 
entitlements, programs, etc., should be extended to age 28 for youth 
with disabilities. This is a guiding principal that should be applied 
to many legislative efforts that affect the population of adolescents 
and young adults with mental health conditions.
    (2) Evidence-based practices do not exist for youth in transition. 
Like so many other realms, we have focused our evidence-based 
approaches on either child/adolescent or adult populations. The 
efficacy Multi-Systemic Treatment that is so impressive for reducing 
delinquency is unknown for youth aged 18-25. The efficacy of the 
Assertive Community Treatment Program is unknown for 14-21 year olds. 
The first step for youth in transition to adulthood is to develop 
evidence-based practices; perhaps emphasizing the need to test and 
perhaps modify existing models for this age group. NIMH should be 
encouraged to offer funding in this area. The various other 
recommendations from the New Freedom report for extending the evidence 
base to real world setting holds for this age group as well.
    (3) Youth in transition have needs that extend from the child to 
the adult system. Thus, not only do the various child-serving agencies 
need to be involved, but the various adult-serving agencies as well; 
adult mental health, housing, vocational rehabilitation, substance 
abuse services, supported education, corrections, etc. The 
recommendations in the New Freedom Commission Report for reducing 
fragmentation are excellent. I would encourage one particular aspect 
for youth in transition; the embracing of outcomes across domains of 
functioning to guide funding. Many of the ``costs'' of not treating 
youth during the transition to adulthood aren't mental health costs but 
they are broader societal costs; homelessness, unemployment, crime, 
substance use, youthful pregnancy. We need to bring together the 
Federal, State and local agencies that are involved in these domains of 
functioning so that their accountability cannot be shifted off to the 
other. If we use young adult outcomes as our guides we will definitely 
improve services for this age group, and improve our society.
    (4). Child Health Care Crisis Relief Act. Looks good to me, except 
that it does not include professionals specializing in young adults, 
I'd VERY MUCH like to see that age group included. Again, if we can 
conceptualize the developmental process leading to adulthood as 
including the ``emerging adult'' stage rather than ending at that stage 
we will be more closely aligned with the real development of these 
individuals, and with the supports that they need to be launched into a 
successful adulthood.
        Response to Questions of Senator Reed From Maryann Davis
    A significant number of mentally ill patients also suffer from 
substance abuse problems, known as ``co-morbid conditions''. As you 
well know, there are different funding sources for each. Likewise, 
these individuals access services in a variety of settings, such as 
residential facilities and the juvenile justice system. Many of you 
spoke to the fragmentation of mental health care and the difficulty of 
accessing services.
    Question 1. Is there evidence of improved outcomes, better 
compliance, and cost-savings through providing combined services? For 
example, properly treating an alcoholic's bipolar illness to avoid 
relapsing on alcohol.
    Answer 1. The simple answer is yes.
    Comorbid mental health conditions and substance abuse. Let me say 
that I am not an expert on the dual diagnosis/comorbidity literature. 
So I have examined the literature to provide an answer to you for this 
specific population. Two current critical analyses of the existing 
research on the subject indicate that, there are still many holes in 
our knowledge, the most common finding is that treatment of both 
disorders (combined services) is more successful in terms of improved 
functioning, symptomatology, or drug/alcohol use, than either alone. 
For those with comorbid mental illness and substance abuse disorders, 
there is evidence of improved outcomes when both conditions are 
treated.
    This said, both reviews were quite clear that the evidence at this 
point is thin. There have not been many or many well-designed studies 
to draw from, and the specifics of the question are vast. Just as 
specific disorders of mental illness differ, so do the specific 
disorders of substance abuse, and we don't have a complete picture 
about combined treatments for all of the different combinations. One 
specific study even found that subjects with social anxiety disorder 
and alcohol dependence who were treated for both conditions 
simultaneously actually fared worse in their subsequent alcohol use, 
than those who were treated only for their social anxiety disorder. 
However even this finding argues for the coordination of substance 
abuse and mental health treatment; if for some conditions it is 
advantageous to hold off on treatment of one condition that needs to be 
coordinated. Thus, all evidence points to the need for well-coordinated 
services.
    Overall, the specifics of good, evidence-based treatments for 
individuals with dual diagnoses are just beginning to emerge. Even less 
is known about combined treatments for adolescents, for youth in 
transition to adulthood, or for different cultural groups. I saw no 
literature on cost savings or specific findings on combined services 
improving treatment compliance. Cost improvements are implied by some 
of the findings that combined services reduce emergency room/detox 
visits, but cost analyses have not been conducted. These questions have 
simply not been addressed through research. Many more studies are 
needed.
    My own research indicates that for transition-aged youth with dual 
mental health/substance abuse conditions, the combined condition is 
exponentially worse in terms of high school dropout, not living with 
family, and trouble with the law. Again, the little bit of evidence 
from the research literature is supportive of coordinating treatment 
for both conditions. One study found that youths with SED, whose 
substance use disorder went undiagnosed by clinicians during 
adolescence, fared much worse than either youth with identified dual 
conditions, or youth with mental health conditions alone. One 
interpretation of the findings is that those who were identified as 
comorbid received some treatment for both conditions, while those whose 
substance use disorders were unrecognized deteriorated from lack of 
treatment for the substance use disorder. Similarly, a study of 
adolescents with ADHD (Attention Deficit/Hyperactivity Disorder) found 
that adult substance use disorders were much higher in adolescents who 
had not received pharmacological treatment for their ADHD. Taken 
together these studies suggest that either untreated substance use or 
mental health conditions can both lead to increased substance abuse in 
young adulthood.
    Combined services in other areas of multiple needs. There is no 
direct evidence about better outcomes, engagement, or cost 
effectiveness of combined services in the transitioning population. The 
circumstantial evidence is strong.
    (1) They clearly are involved across multiple systems; mental 
health, education, child welfare, juvenile justice, substance abuse, 
homeless-runaway youth, etc.
    (2) Their functional impairments span different agencies' 
expertises; jobs/career, education, housing, adequate parenting.
    (3) Their ``conditions'' are often multiple, mental health combined 
with substance abuse, learning disabilities, developmental 
disabilities, and chronic health conditions are common, and treatment 
for these other conditions are most commonly offered through non-mental 
health agencies.
    (4) Services that address multiple needs have been shown to be 
associated with better outcomes in various domains of functioning, 
which can be translated into cost savings.
    The general literature on well-coordinated services across 
different service domains is supportive of the notion that coordination 
alone is insufficient. That is, coordinating average care may not be 
any more effective than not coordinating it, though families are more 
satisfied when even insufficient care is coordinated. What is really 
needed is the coordination of high quality care. Several clinical 
trials are now showing things like combined pharmacotherapy with highly 
specified cognitive behavioral therapy is more effective than either 
alone. Although these particular services wouldn't necessarily come 
through different funding streams, it does highlight that combined and 
high quality services are more effective than ill-informed 
uncoordinated services.

    Question 2. In your experience, are different Federal funding 
streams a barrier to quality mental health care?
    Answer 2. Yes.
    Quality mental health care, particularly during the transition 
stage, depends on being able to fluidly address functional needs as 
they arise. A young person is not going to focus on their mental health 
treatment needs if they are imminently homeless, if they can't get a 
job and they need to support themselves, or if their lives are 
miserable at school. Similarly, not attending to their mental health 
care will interfere with their abilities to address these problems.
    Funding streams are service-based, not people-based. They help 
foster the silos of agencies at the State level. Those silos are not 
well coordinated at the individual or State level. As a result of that, 
families and youth experience gaps and redundancies in services and 
treatments, and providers are frustrated with an inability to access 
needed services. More subtly, the silos foster silo-think. That is 
those working with these young people tend to think about only the 
services that their systems offer in addressing their needs, and know 
less, have less access to, and less often consider services offered 
through other systems.
    My research has also shown that one of the barriers to accessing 
transition support services for adolescents in State mental health 
systems was that other agencies held the purse strings for many of the 
needed services, and were not motivated to address the unique needs of 
the youth in their systems that had mental health conditions. For 
example, many administrators described that there were foster care 
independent living dollars (Chaffee funds) that were available to youth 
in foster care. However, those funds were invested preferentially in 
youth who were succeeding (i.e. expected to complete high school), or 
were used for generic independent living supports that didn't address 
the needs of youth with mental health conditions.
    Administrators also described that the differing eligibilities for 
different Federal programs, such as Medicaid, EPSDT, etc., added to the 
complexity of how long they could provide services to youth. Some youth 
were eligible for Federal programs until they were 18, while others 
were eligible until age 21, so the child system ``covered'' to age 21, 
but only if an individual had health care coverage to that age.
    Finally, an analysis of ``transition support'' programs for youth 
with serious mental health conditions revealed that service providers 
attempting to serve this population must currently expend tremendous 
effort cobbling together fragments of funding that are generally time-
limited, service-limited, age-limited, disability-limited, or income-
limited. In a study of 18 providers serving the transitioning 
population, researchers found that these 18 providers used 40 different 
fund sources, most of which were not shared by more than 2-3 providers. 
The most common category of funding was private (i.e. private 
foundations), rather than public sources. Without a stable, 
comprehensive funding base, the system of care for youth in transition 
will develop at a snail's pace.
    Similar issues of silos exist within children's services. An 
excellent publication analyzing the impact of separate Federal funding 
streams in children's systems is Help or Hindrance?: The Federal 
Government and Interagency Systems of Care for Children with Serious 
Mental Disorders.
    Fragmentation of services and conflicting program rules have long 
impeded children's and families' access to needed care. This issue 
brief examines the Federal Government's role from the perspective of 
State officials responsible for children's mental health programming. 
(February 2003), which can be found at http://store.bazelon.org/
children.html.

    Senator DeWine. Senator Sessions has joined us. Jeff, do 
you have any opening comments?

                 Opening Statement of Senator Sessions

    Senator Sessions. I am delighted to have Linda Champion 
here. She is a champion for the mentally ill and has been a 
friend of mine for a number of years, has always been 
exceedingly helpful in helping me understand these issues, and 
is a leader in Alabama in it.
    I thank you for inviting her to testify. Good to see her 
husband, Graham, back there. They are really fine Alabama 
citizens and leaders in particular on this issue.
    Senator DeWine. Very good.
    Mrs. Champion, with that introduction, you are next.
    Mrs. Champion. Thank you so much, Chairman DeWine, Senator 
Sessions, Senator Reed, and Members of the Committee. Thank you 
so much for holding this critically important hearing today. I 
am truly honored to be part of this panel and to speak on 
children's mental health issues.
    I am Linda Champion of Montgomery, AL. Since 2000, I have 
been a member of NAMI Alabama working as a child advocate. I am 
also vice president of Alabama Family Ties, an advocacy group 
that collaborates with NAMI Alabama to provide support and 
education to parents of children and adolescents with mental 
illness. I am first and foremost the mother of a 17-year-old 
son who has been struggling with mental illness since the age 
of 7. It is from the perspective of both a mother and a child 
advocate that I am honored to come before you today and provide 
this testimony on the current state of the children's mental 
health system.
    NAMI is the Nation's largest grassroots advocacy 
organization, with 220,000 members representing children and 
adults with mental illness and their families.
    So often I have listened to families pour out their 
heartfelt stories of failed attempts to access mental health 
services for their child in a system that is fragmented, overly 
bureaucratic, and not at all family-friendly. The system fails 
to offer support, adequate information, and resources to 
parents and caregivers of children with mental illness. The 
opening statement of Surgeon General Satcher's Report on 
Children's Mental Health really says it all: ``the burden of 
suffering experienced by children with mental health needs and 
their families has created a health crisis in this country.'' 
For families of children with mental illness, this is, quite 
frankly, an understatement. Our family's experience is right in 
line with the finding of the President's New Freedom Commission 
that our Nation's mental health system is in shambles, with no 
defined or coherent system at all. At various times, we are 
accused of being ambivalent and uncaring. It is also suggested 
to us that the sins of the father are visited on sons, a direct 
reference that Lee, who is my adopted son, was being punished 
for the sins of his father. Parents and caregivers of children 
with mental illness in my State and communities across this 
country are forced to navigate a fragmented, overly 
bureaucratic, and family-unfriendly system.
    You have my family's personal story in the written 
testimony submitted for the record. I would like to highlight 
some of our struggles in attempting to access mental health 
services for Lee. I will do so in referencing numbers: three, 
the number of acute-care placements Lee has had in his short 
life thus far; five represents the number of residential 
treatment facilities Lee has lived in before he was finally 
stabilized so that he could function in a less restrictive 
environment; six is the number of different psychiatrists he 
has seen in his short life because of changes in residential 
treatment places; seven represents the number of changes that 
have occurred in medication combinations; 10,000-plus is the 
number of miles each year that we have traveled to visit Lee 
and stay involved in his treatment in the various residential 
treatment facilities he has been placed in; two is the number 
of custody changes that have occurred in Lee's life with our 
family. We gained custody through adoption, lost custody to 
obtain mental health treatment, and fought for custody of Lee, 
and he is now with us.
    But one represents the life of a child who has missed out 
on far too many normal childhood things--scouting, dating, 
going to proms, the normal things that parents usually 
experience with their children.
    As a parent who has lived through a difficult struggle in 
attempting to secure appropriate mental health services for 
Lee, I have the following suggestions of immediate actions that 
should be taken to help eliminate the burden that families are 
forced to endure and to improve services for children with 
mental health illnesses:
    End the discriminatory cap on private insurance coverage 
for mental health services. Our family was forced to give up 
custody because we quickly exhausted our lifetime private 
health benefits to provide the treatment for Lee. Please 
support the mental health parity legislation, S. 486.
    End the practice of forcing families to give up custody of 
their child to access mental health services. There is no 
greater injustice than forcing a parent to choose between 
maintaining custody of their child or seeking services for him. 
No parent should ever face this choice, yet it happens every 
day in this country, and families like ours are forced to give 
up custody and live with the consequences. Please support the 
Keeping Families Together Act to help end this practice, S. 
1704.
    Encourage States to develop effective interagency 
collaboration and partnerships between all child-serving 
agencies and with families. We were forced to act as case 
manager for Lee over and over again to work with the multiple 
agencies that failed to communicate.
    Train and educate all child-serving professionals about the 
early warning signs of mental illnesses in children. All child-
serving professionals, especially school professionals and 
those working in child welfare and juvenile justice, should be 
trained to recognize the early warning signs of mental health-
related concerns in children and know what to do when they 
exist.
    Build an effective children's mental health treatment 
system. Alabama and every other State must invest in building 
an effective children's mental health treatment system that 
provide a full array of services for children and families.
    Parents need to be provided with appropriate information 
about their child's diagnosis and treatment. We were often left 
in the dark about Lee's diagnosis and treatment options that 
were available to us. Much of what we learned we had to learn 
on our own.
    The good news is that the scientific community has made 
great strides in understanding childhood mental illnesses and 
treatment works for many children, if you can get it. Of 
course, we deeply regret that it took so long to access 
services for Lee and what we have missed along the way.
    Mr. Chairman, my dream is that the U.S. Senate and the 
House of Representatives will realize the precious treasure we 
have in our Nation's children. We can only help them reach 
their full potential if we can ensure that children who suffer 
from mental illnesses receive appropriate treatment and 
services. The health care needs of our children should be a 
national priority just like it is for juvenile diabetes, 
obesity, cancer, and other childhood illnesses.
    You and your colleagues are in a unique position to truly 
impact the quality of the lives of our children. We ask that 
you do so by doing the right thing today for our children and 
their families.
    I want to thank you for the opportunity to present one 
parent's story. I hope and trust that in some small way I have 
raised questions in your mind about what we can do to help our 
children.
    Thank you so much. I will be glad to answer any questions.
    Senator DeWine. Mrs. Champion, thank you very much.
    Response to Questions of Senator Bingaman From Linda M. Champion
    Question 1. Every year, an estimated 9 percent to 13 percent of 
children and adolescents in the United States experience a clinically 
significant mental disorder that warrants treatment. Yet, according to 
the Surgeon General's Report on Mental Health, two-thirds of these 
vulnerable young people do not receive any mental health treatment at 
all. What can we do to improve access to treatment?
    Answer 1. Improve Access to Treatment--Early Identification and 
Intervention
    The majority of children and adolescents suffering from a mental 
illness largely go undiagnosed due to a number of reasons: parents are 
uninformed of normal childhood development, schools label their erratic 
behavior as delinquent thus forcing them into a juvenile justice system 
that we already know from private and governmental studies are ill 
equipped to handle mental illness within their systems, and the 
appalling gaps in our child and adolescent mental health system force 
families to seek treatment far from their communities or none at all, 
and the lack of coordination within child serving agencies who serve 
some of these children in different capacities or not at all. Our child 
serving systems must be given opportunities and challenges to work 
together in identifying and treating children and adolescents with 
mental illnesses. From a parent's perspective, child-serving agencies 
do not work together and will point to their sister agencies for 
treatment services--forcing parents to become case managers for their 
child's treatment. My recommendations would be as follows:
    Train and educate all children-serving professionals about the 
early warning signs of mental illnesses in children. All child-serving 
professionals: day care providers, teachers, pediatricians, child 
welfare, juvenile justice professionals must be trained to recognize 
the early warning signs of mental health concerns.
    Build an effective children's mental health system. Federal, State 
Government, and commercial insurers should be encouraged to realign 
funding policies related to children's mental health needs and develop 
a comprehensive array of services to meet their needs. Alabama and 
every other State must invest in building an effective children's 
mental health treatment system that provides the full array of services 
for children and families. This includes home and community-based 
services, school-based services, respite services and more. We learned 
first hand about the critical shortage of qualified children's mental 
health providers and the lack of appropriate services. Our nation needs 
to address the critical shortage of children's mental health 
professionals and the lack of appropriate services, especially in rural 
communities.

    Question 2. Evidence-based treatments are now available for the 
full range of child and adolescent mental disorders. Yet these 
effective treatments fail to reach a majority of those who can benefit 
from them. How can we close the gap between research and real-world 
practice to ensure that evidence-based treatments are available in 
community service settings?
    Answer 2. Close the gap between research and real-world practice to 
ensure that evidence-based treatments are available in community 
service settings.
    We know there is a large, reliable, and evidence-based body of 
knowledge in the research community to know what works for our 
children, yet there is a definite delay in the transference of this 
knowledge to the very people who would benefit from it. From my 
perspective, professionals often do not have sufficient knowledge to 
make both accurate diagnosis and effective pharmacological 
interventions. Parents must then do the research themselves and 
advocate for their children. Not all parents are able to do this and 
our children languish in ineffective mental health systems. A 
collaborative public/private oversight organization comprised of both 
Federal representatives and private professionals from the child and 
adolescent psychiatric community should be established to review; 
approve and certify; publicize, their findings; and lastly educate all 
mental health care professionals on these findings. Federal grant 
programs should follow their recommendations. Accurate information on 
evidence-based practices must be disseminated to States, training 
initiatives on these practices should be established, and policy 
changes in Federal funding to States willing to effect change should be 
made. And lastly, families should be involved in the process to ensure 
fidelity to the process.

    Question 3. Children with serious emotional disturbance often have 
multiple problems and require services from several systems, including 
the mental health, educational, child welfare, and juvenile justice 
systems. How can we enhance the coordination and collaboration of 
various child-serving systems?
    Answer 3. Enhance the coordination and collaboration of various 
child-serving agencies.
    Encourage States to develop effective interagency collaborations 
and partnerships between all child-serving agencies and with families. 
Encourage all Federal child serving agencies to establish performance 
based indicators for collaboration programs--reward those States that 
are willing to work together by blending and braiding Federal and State 
dollars. Provide Federal seed money to States so that data systems can 
be created to provide both monitoring of collaborative programs, but 
accountability for agencies back to their respective Federal grantor. 
On the flip side, penalize those States that are not willing to set up 
true collaborative efforts.

    Question 4. The New Freedom Commission on Mental Health and the 
Surgeon General's report both identified a national shortage of mental 
health professionals trained to treat mental illness in children and 
adolescents. I have introduced S. 1223, The Child Health Care Crisis 
Relief Act, which creates incentives to help train, recruit, and retain 
child mental health professionals through loan repayments, 
scholarships, and grants. Do you feel passage of this legislation would 
be helpful in reducing the shortage of qualified professionals?
    Answer 4. Passage of S. 1223, The Child Health Care Crisis Relief 
Act.
    Absolutely, as we know the bill creates incentives to help recruit 
and retain child mental health professionals providing direct clinical 
care, and to improve, expand, or help create programs to train child 
mental health professionals. The passage of this legislative would 
create a richer infrastructure of child and adolescent professionals. 
The lack of qualified mental health providers is part of the reason for 
the unacceptably high number of youth with mental illnesses that fail 
to receive treatment and why families are often told that they must 
wait on long waiting lists for services for a seriously ill child.
    The Surgeon General put it best in stating that there is a 
``dearth'' of child psychiatrists, appropriately trained clinical child 
psychologists, and social workers in this country. Here are the facts:
    The Federal Government has designated 3,543 urban, suburban, and 
rural localities as Mental Health Professional Shortage Areas due to 
their severe lack of psychiatrists, psychologists, social workers and 
other professionals to serve children with mental illnesses;
    According to the U.S. Bureau of Health Professions, the demand for 
the services of child and adolescent psychiatrists is projected to 
increase by 100 percent by 2020, while the number of these 
professionals is expected to increase by only 30 percent resulting in a 
severe shortage of child and adolescent psychiatrists;
    According to the American Academy of Child & Adolescent Psychiatry, 
there are currently approximately 6,300 child and adolescent 
psychiatrists in this country with a need at 32,000;
    The National Center for Education Statistics within the U.S. 
Department of Education reports that the national average student-to-
school counselor ratio in U.S. schools is 513:1, more than double the 
recommended ratio of 250:1.
    The consequences of untreated mental illnesses in children are 
devastating. These youth are at higher risk for school failure and drop 
out, alcohol and drug use, suicide (the 3rd leading cause of death for 
10-24 year old young people), and engaging in high risk and unlawful 
activity.
    In Alabama, our families know on a very personal basis the effect 
of mental health professionals. Many times, parents will see three or 
four different therapists and/or psychiatrists per year in visiting 
mental health clinics, or need to travel great distances to seek 
services for their children.

    Senator DeWine. Ms. Altenburger?
    Ms. Altenburger. Mr. Chairman, Members of the Subcommittee, 
my name is Barbara Altenburger, and I am from Philadelphia, PA. 
I am the mother of Bruce Altenburger, who is a 15-year-old. I 
would like to thank you for the opportunity to speak about a 
serious problem I and many other parents across the country 
have encountered in trying to access services for our children 
through the public mental health system. We struggle to become 
our child's advocate--often learning how to make the system 
respond through a trial-and-error process. We become 
overwhelmed, frustrated, confused, and emotionally drained by 
the process. Many parents give up.
    It is important for you to know that the range of needed 
mental health services is frequently unavailable, that there is 
very little coordination among the systems that are mandated to 
serve our children, and that there is usually no plan to 
determine which public agency should be responsible for serving 
a particular child. This evasion of responsibility results in 
long delays in providing children with desperately needed 
mental health and related services. Consequently, our children 
are unserved, underserved, and inadequately served.
    The mental health needs and problems of children are 
diverse in nature and intensity. Some children have disorders 
that respond to intervention, diagnosis, treatment, and 
services. Others with more complex disorders and needs often 
find that their tragic plights are made more extreme by 
inadequate mental health services. Although every parent's 
story is unique, let me outline generally what my experience 
has been and how it is relevant to the experience of many other 
parents and children with severe emotional disturbances.
    My story and that of my son Bruce is a story of the 
difficulty of diagnosing mental disorders in children and 
adolescents. It is about the difficulty of finding qualified 
specialists to care for a very troubled child, and the even 
greater difficulty of getting access to needed care because of 
health insurance barriers. It is about the pressures put on 
parents to give up custody of their children to get needed 
mental health services. Finally, for children who are eligible 
for publicly funded care, it is about what some call the 
``public mental health system.'' Parents across the country can 
tell you that there is no system. But it is worse than that. It 
is a maze.
    My child and many other children have gotten services 
through a variety of different, uncoordinated programs. The 
school system has provided certain services. Behavioral issues 
have led to contact with the juvenile justice system and its 
services. We have gotten services through other publicly funded 
programs. But there has never been any coordination between 
these agencies and no true system of care providing needed 
wraparound services.
    As a result, parents must become their child's best 
advocate and case manager. I have no reason to think that 
mental health services in Philadelphia are markedly better or 
worse than those elsewhere. My experience is that rather than 
enlisting parents in their child's recovery, too many programs 
lack respect for parents. In the children's recovery too many 
programs lack--I am sorry. Parents are seldom given a role in 
planning or even decisionmaking concerning their child's care. 
My experience is that while public programs are intended to 
help our children, they too often fail them. Yet the philosophy 
too often is that the ``child failed the program'' rather than 
vice versa.
    What is it like to have a child with bipolar disorder and 
learning disabilities? What is it like to be a mother perceived 
as incompetent? What is it like to be the parent of a child 
who, from an early age, always seemed to require more? A child 
who was noticed, but often for negative reasons. A child whose 
school, from nursery school on, continually suggested 
conferences. A child whose years in elementary schools were 
marked by frequent contact with principals, teachers, 
counselors. A child who seemed to be almost but never quite 
okay.
    At different times my house has been a battleground. My son 
has been severely depressed, angry, out of control, hysterical, 
and manic. At times he would be full of remorse--[Pause.]--
excuse me--and experience great bewilderment over his 
behaviors. I felt helpless and pained by his apparent distress.
    My family had urged me to have my son evaluated by a child 
psychiatrist. It took over 90 days for our first appointment 
paid for by my personal insurance. As a result of the 
evaluation, my son was diagnosed as having severe emotional 
problems and possible bipolar. From that time on, Bruce has 
been seen by a variety of psychiatrists, and every one tried a 
different approach, different medication, and gave a different 
diagnosis. And during this period, Bruce was evaluated by the 
school psychologist because of a variety of behaviors, 
including running out of school, crying in the classroom, 
walking in the hallway while class was in session, and yelling 
that he wanted to go home. It was at this time that I could no 
longer afford private insurance because of the high out-of-
pocket costs it required me to bear. I then turned to the 
county mental health system.
    My first experience at a community mental health center was 
devastating as I was told that I was the cause of my son's 
problems--the cause of my son's problems and that I needed 
treatment, that he was perfectly okay. I was stunned that a 
professional could make this statement after meeting with me, 
not my son, for approximately 40 minutes and when the 
psychiatrist wanted to give me a prescription for Bruce which 
would calm him down and enable me to handle him. I went to 
another community mental health center and was put on a long 
waiting list.
    And the process continues across our country of long 
waiting lists, inexperienced mental health workers, and a 
dramatic lack of public health system psychiatrists, and of 
parents being told that their child has failed the program.
    What I thought would make a difference never made enough of 
a difference. My child does not stay on an even keel for longer 
than a month or two.
    My child has attended many different special education 
programs for children with severe emotional disturbance 
provided by the school system. Through our public mental health 
system, he has been placed in residential treatment facilities 
for long-term treatment and has been hospitalized. During his 
hospital stays, he has been drugged to the point where he 
became incoherent. He has been labeled as ``severely 
emotionally disturbed'' as well as ``conduct disordered'' and 
``bipolar.'' I have been told that his future is bleak, and at 
other times that he could have a productive life. I have been 
criticized for being overly involved and for doing too much, as 
well as reproached for being underly involved and not trying 
hard enough. I have been blamed for the ``failures'' at our 
home, school, and community by some and praised for good 
parenting by others. I have been treated with respect, and 
ignored.
    Parents across the country feel that they are their best 
resource for their children. They are the only consistent 
factor in their child's treatment and can provide information 
and insight that can come from no other source. They steel 
themselves against the subtle and not so subtle accusations of 
blame and failure. Parents go from agency to agency, all 
professing to help troubled children. We read books written by 
``experts.'' We receive counseling and attend seminars. We try 
to find a ``cure'' for our children's outbursts, inability to 
learn and socialize like apparent ``normal'' children, and a 
few of us do manage to find help from the mental health system. 
But for the unlucky majority, the feeling of hopelessness 
increases as they see little improvement despite their efforts 
to work cooperatively with professionals that work with their 
children. Many see a future full of heartache and little hope.
    I have not given up on my son and continue to fight for his 
well-being and for the provision of needed services to help him 
overcome his problems. But I demand that our public mental 
health programs not give up on him either. There is much that 
must be done to improve public mental health service delivery. 
I agree that it must be transformed. But the one key element of 
that change, I believe, must be a change in the relationship 
between these programs and the parents of these children.
    Regardless of whether a child is living at home or away 
from home, family members must be viewed as a primary resource 
for their children and must have a voice and a vote as an equal 
partner in the planning and decisionmaking concerning their 
child.
    Mr. Chairman and Members of the Committee, children are not 
little adults. They must be treated by professionals that have 
been trained to work with children and adolescents. Parents in 
every State urge you to make children's mental health a real 
priority and to develop and fund effective Federal programs 
that serve our children's mental health needs. We know that 
there are pockets of expertise, but that is not on a scale that 
bears any relationship to the magnitude of the problems we 
encounter every day. Designing these needed programs may not be 
simple, but they must include a few elements. They must have 
child-centered services that are family-focused, community-
based, multisystem, culturally competent, and least 
restrictive. Such services must be available across the 
country, not just as pilots in a handful of communities. And 
given that our children represent the Nation's future, we must 
approach this with the seriousness, energy, and scope of the 
Manhattan Project.
    Thank you.
    [The prepared statement of Ms. Altenburger follows:]
               Prepared Statement of Barbara Altenburger
    Mr. Chairman and Members of the Subcommittee: My name is Barbara 
Altenburger and I am the parent of Bruce Altenburger who is 15 years 
old. Thank you for the opportunity to speak to you about the serious 
problems I and other parents like me across the country have 
encountered in trying to access services for our children through the 
Public Mental Health System. We struggle to become our child's 
advocate--often learning how to make the system respond by a trial-and-
error process. We become overwhelmed, frustrated, confused, and 
emotionally drained by the process. Many parents give up!
    It is important for you to know that the range of needed mental 
health services is frequently unavailable; that there is very little 
coordination among the systems that are mandated to serve our children 
and there is usually no plan to determine which public agency should be 
responsible for serving a particular child. This evasion of 
responsibility results in long delays in providing children with 
desperately needed mental health and related services. Consequently, 
our children are unserved, underserved or served inappropriately.
    The mental health needs and problems of children are diverse in 
nature and intensity. Some children have disorders that respond to 
intervention, diagnosis, treatment, and services. Others, with more 
complex disorders and needs, often find their tragic plight exacerbated 
by an inadequate public mental health system. Although every parent's 
story is unique, let me outline generally what my experience has been, 
and how it is relevant to the experience of many other parents and 
children with serious emotional disorders.
    My story and that of my son Bruce is a story of the difficulty of 
diagnosing mental disorders in children and adolescents. It is about 
the difficulty of finding qualified specialists to care for a very 
troubled child, and the even greater difficulty of getting access to 
needed care because of health insurance barriers. It is about the 
pressures on parents to give up custody of their children to get needed 
mental health services, finally, for children who are eligible for 
publicly funded care it is about what some call the ``public mental 
health system.'' Parents across the country can tell you there is no 
``system.'' But it is worse than that. It is a maze. My child, and many 
other children, has gotten services through a variety of different, 
uncoordinated programs. The school system has provided certain 
services. Behavioral issues have led to contact with the juvenile 
justice system and its services. We have also gotten services through 
other publicly funded programs. But there has never been any 
coordination between these different agencies and no true system of 
care providing needed wraparound services. As a result, parents must 
become their child's most effective advocate and their case manager. I 
have no reason to think that mental health services in Philadelphia are 
markedly better or worse than they are elsewhere. But my experience is 
that rather than enlisting parents in the children's recovery, too many 
programs lack respect for parents. Parents are seldom given a role in 
planning or even decision-making concerning their children's care. My 
experience is that while public programs are intended to help our 
children, they too often fail them. Yet the philosophy too often is 
that the ``child failed the program'' rather than vice-versa.
    What is it like to have a child with a Bipolar Disorder and 
learning disabilities? What is it like to be perceived as the 
incompetent mother? What is it like to be the parent of a child, who 
from an early age, always seemed to require more? A child who was 
noticed, but often for negative reasons. A child whose school, from 
nursery school on, continually suggested conferences. A child whose 
years in elementary schooled were marked by frequent contact with 
principals, teachers, and counselors. A child who seemed to be almost, 
but never quite, okay.
    At different times my house has been a battleground. My son has 
been severely depressed, angry, out of control, hysterical, and manic. 
At other times he would be full of remorse and expressed great 
bewilderment at his behavior. I felt helpless and pained by his 
apparent distress.
    My family urged me to have my son evaluated by a child 
psychiatrist. It took over 90 days for our first appointment paid for 
by my personal insurance. As a result of the evaluation he was 
diagnosed as having serious emotional problems and possible Bipolar 
Disorder. From that time on Bruce was seen by various psychiatrists and 
each one tried a different approach, different medication and gave a 
different diagnosis. And during this period Bruce was evaluated by the 
school district psychologist because of his various behaviors including 
running out of the school, crying in the classroom, walking the 
hallways while classes were in session and yelling that he wanted to go 
home. It was at this time that I could no longer afford private 
insurance because of the high out-of-pocket cost it required me to bear 
and I then turned to the county mental health system.
    My first experience at a community mental health center was 
devastating as I was told that I was the cause of my son's problems and 
that I needed to be in treatment and that he was perfectly okay! I was 
stunned that a professional could make this statement after meeting 
with me, not my son, for approximately 40 minutes. I was astonished 
when the psychiatrist wanted to give me a prescription for Bruce which 
would calm him down and enable me to then ``handle him''. I went to 
another community mental health center and was put on a long waiting 
list.
    And the process continues across our country, of long waiting 
lists, inexperienced mental health workers, a tremendous lack of public 
mental health system child psychiatrists, and of parents being told 
that their child failed the program.
    What I thought would make the difference never made enough of a 
difference; my child does not stay on an even keel for more than a 
month or two at a time.
    My child has attended many different special education programs for 
children with serious emotional disturbance provided by our school 
system. Through our public mental health system he has also been placed 
in residential treatment facilities for long-term treatment and been 
hospitalized. During his hospital stays he has been so drugged, that he 
became incoherent. He has been labeled ``severely emotionally 
disturbed'' as well as ``conduct disordered'' and ``Bipolar.'' I have 
been told his future is bleak and, at other times, that he can have a 
productive life. I have been criticized for being over-involved and 
doing too much, as well as reproached for being under-involved and not 
trying hard enough. I have been blamed for the ``failures'' at home, 
school, and community by some, and praised for good parenting by 
others. I have been treated with respect, as well as patronized and 
ignored.
    Parents across the country feel they are the best resource for 
their children. They are the only constant factor in their children's 
treatment and can provide information, insight, and continuity that can 
come from no other source. They steel themselves against the subtle and 
not-so-subtle accusations of blame and failure. Parents go from agency 
to agency, all professing to help troubled children. We read books 
written by ``experts.'' We receive counseling and attend seminars. We 
try to find a ``cure'' for our child's outbursts, inability to learn 
and socialize like other apparent ``normal'' children and a few of us 
do manage to find help from the mental health system. For the unlucky 
majority, the feeling of hopelessness increases as they see little 
improvement despite all their efforts to work collaboratively with the 
professionals that work with their children. Many see a future full of 
heartache and little hope!
    I have not given up on my son, and continue to fight for his well-
being and for the provision of needed services to help him overcome his 
problems. But I demand that our public mental health programs not give 
up on him either. There is much that must be done to improve public 
mental health service delivery. I agree that it must be 
``transformed.'' But the one key element of that change, I believe, 
must be a change in the relationship between these programs and the 
parents of these children.
    Regardless of whether a child is living at home or away from home, 
family members must be viewed as a primary resource for the child and 
must have a voice and a vote as an equal partner in planning and 
decision-making concerning their child.
    Mr. Chairman and Members of the Committee--children are not little 
adults and they must be treated by professionals that have been trained 
to work with children and adolescents. Parents in every State urge you 
to make children's mental health a real priority and to develop and 
fund effective Federal programs that serve our children's mental health 
needs. We know that there are pockets of excellence, but not on a scale 
that bears any relationship to the magnitude of the problems we 
encounter every day. Designing these needed programs may not be simple, 
but they must include a few key elements. We must have child-centered 
services that are family-focused, community-based, multi-system, 
culturally competent and least restrictive/least intrusive. Such 
services must be available across the country, not just as pilots in a 
handful of communities. And given that our children represent our 
Nation's future--we must approach this with the seriousness, energy, 
and scope of the Manhattan Project. Thank you.

    Senator DeWine. Thank you very much.
    Senator Reed?
    Senator Reed. Thank you very much, Mr. Chairman, and thank 
you, ladies, for your eloquent and very effective testimony.
    Senator Kennedy and Senator Dodd asked me to raise some 
questions on their behalf, so if I may, Ms. Wong, in our 
schools today children are so often subject to some traumatic 
events--snipers, CNN war stories, and contaminated mail. How 
can schools best help these students when they face these 
unusual traumatic circumstances? And what resources become 
paramount when responding to these types of situations?
    Ms. Wong. In our work also with the Department of Justice 
with Cops in Schools as well as our National Center for Child 
Traumatic Stress, we found that children are exposed to 
violence at a far higher rate than in previous generations and 
if we exclude even the violence that they see on TV. The 
research would suggest, at least the little that we have, after 
the Oklahoma City bombing, show that especially younger 
children are quite traumatized by television viewing of this 
sort. But with older children, we are finding higher rates of 
exposure to community violence, to bullying in schools, to acts 
of violence in the community.
    In Los Angeles, for instance, in certain of our 
communities, especially, I think this can be generalized in 
communities where there are large urban centers, communities 
where there are high rates of crime, gang activity, drug abuse, 
etc, we found up to 90 percent of our students in these 
selected communities had high rates of violence exposure, and 
27 percent of them had posttraumatic stress disorder at 
clinical levels, 16 percent of them had depression at clinical 
levels. We suspect that among special education children as 
well that are integrated into the school district programs that 
there might be high rates of violence exposure.
    I think what we have, we are very lucky in Los Angeles to 
have a school mental health program, but I think the testimony 
you heard today is very true. I think it is quite fragmented. I 
think schools try to piece it together as best they can and 
that there needs to be a system in place where across the 
country--it does not matter whether you live in a rural or 
urban or suburban area--that any parent can access these 
programs for their children, and particularly, as we said, 
programs that respond to trauma and depression and suicide.
    I think these in particular are problems and disorders and 
challenges that can be very well addressed, addressed early, 
and really have a very good outcome, both for the mental health 
of children and success in education.
    Senator Reed. Another question, if I may, and I will 
address it to Ms. Wong and Ms. Osofsky. We screen children for 
vision. We screen children for hearing. We screen children 
routinely for many things. And there is some discussion, at 
least in the literature, about screening children for mental 
health issues. Is that something that you would advocate or 
could comment upon? Ms. Osofsky and then Ms. Wong perhaps.
    Ms. Osofsky. The issue you raise, Senator Reed, is very 
important. The answer is yes, we do need to screen for mental 
health as we screen for medical conditions, physical 
conditions, vision, hearing, those types of issues.
    One of the problems and I think one of the very important 
areas that I would urge the subcommittee to consider as we are 
putting forth these bills is prevention and early intervention 
is very important, but we cannot accomplish prevention and 
early intervention unless we do screening. And there are ways 
to do screening ranging from better education for child-care 
providers, better education for child protection, certainly 
better education for primary care providers and pediatricians 
who see children as part of their well-baby checkups, including 
mental health screening as part of ESDP, the Medicaid screening 
that occurs routinely or is supposed to occur routinely for 
children when they are referred or an evaluation.
    And I think we need to turn to experts in the mental health 
community to develop screenings that are feasible to use. It is 
not feasible during a well-baby checkup to have to spend half 
an hour in-addition to other kinds of things. But what we are 
really interested in are screenings that would alert primary 
care physicians or child-care providers or child protection or 
even parent advocates under certain circumstances, a whole 
variety of people, to what we call red flags. And when they 
recognize some of these red flags, which could be behavior that 
is out of control, aggressive behavior, which could be 
withdrawal on the part of the child, which could be other types 
of things, to then refer them for a more extensive evaluation. 
So we need a variety of levels there.
    But if these things are picked up earlier, we are able to 
do much more in the way of prevention and early intervention.
    Senator Reed. Thank you very much, Dr. Osofsky.
    Dr. Davis, you sketched out a very complex and troubling 
situation where people age out of the system. The story of the 
young woman who was transferred from a pediatric psychiatric 
setting to an adult one sounds like something out of Hollywood 
in the 1930s--horrific.
    Part of the problem is trying to coordinate the system, not 
just the health care system but the housing system, the 
substance abuse system. Any thoughts you have on how we can 
better coordinate that?
    Ms. Davis. You are right. It does all need to be 
coordinated. Quick thoughts are difficult.
    I think one of the things that we have learned in 
children's mental health systems, the system-of-care principle 
where we recognize that children have needs across many 
different agencies certainly holds through this developmental 
stage. And so one of the things that we might think about would 
be the various mechanisms that we have already used to try to 
encourage more system-of-care development where there is a 
recognition that needs go across many different domains of 
functioning and that there is expertise and resources that go 
across our various public agencies.
    And so I think to the extent that we can extend that 
philosophy and those approaches--and basically there are 
various different mechanisms. There are Federal funding 
mechanisms. There are a variety of different mechanisms that 
have developed to try to enhance a wraparound or a system-of-
care approach that would extend through age 25, I think we 
would benefit tremendously.
    I think what we have learned in children's mental health 
would help us tremendously. There is a tremendous strength in 
thinking about individuals developmentally, about thinking 
about the critically important role of families, that when you 
get into the adult mental health system, and other adult 
systems, it does not exist. They tend to think monolithically 
about the adult and not think developmentally, and tend to even 
more so minimize family involvement. So I think that we can 
take that strength from the kid side.
    On the adult side, there is a lot of expertise that the kid 
side does not have in terms of how do you help with vocational 
rehabilitation, the more current models on recovery. Those are 
very important--housing, co-morbid substance abuse.
    Those are all issues that the adult system knows about. 
They just do not know how to apply it to this developmental 
stage. So I think that there is a lot to be done concretely.
    I think at the Federal level there are many different 
things that we can examine and I cannot give you a short answer 
as to exactly what those should be, but clearly an examination 
of the funding mechanisms, as I mentioned, in Medicaid would be 
extremely important to look at in detail about what are some of 
the mechanisms there that are barriers? What are some 
mechanisms that could actually facilitate systems to solve this 
issue?
    I will just tell you quickly, last summer I spoke with one 
member from every State who was in charge of, who was a lead 
administrator for adult mental health systems for every single 
State in the country. And one of the things that they said 
about this population is that this age group, they are just one 
of many populations that they have to worry about. In essence 
it had not received a priority enough for adult systems to turn 
around and handshake with child systems. I think that we have 
many different mechanisms for encouraging that kind of 
prioritization and that is really what needs to happen at this 
time.
    Senator Reed. Thank you.
    Mr. Chairman, I am asking questions for both Senator Dodd 
and Senator Kennedy, so I will not ask for three times the 
time, but----
    Senator DeWine. I was going to say that would give you 
about half an hour.
    [Laughter.]
    Senator Reed  [continuing]. Half an hour, that is right, 
just the warm up time.
    First, Dr. Douce, thank you for your kind words about the 
legislation that the Chairman and I are sponsoring. One of the 
aspects of getting health care is the community's support for 
the individual. However, there is a stigma attached to asking 
for help particularly for a college student asking for help, 
any kind of help. Do you find that as a problem on campus?
    Ms. Douce. Yes, I do, although I think it is lessening, and 
we in fact have a stigma reduction committee as part of our 
counseling center prevention outreach. Next week is Suicide 
Prevention Week and our Stigma Reduction Group has designed a 
number of sort of informational pieces to reduce the stigma of 
accepting help and to demonstrate that it is actually a 
strength to seek help, and it is a strength to seek help 
earlier when the problem is just beginning than to lose your 
whole term by sinking deeper and deeper into a depression of 
anxiety.
    Senator Reed. Thank you very much. Senator Dodd wanted me 
to pose this question, and I recognize that none of the 
panelists are MD's, but the recent controversy surrounding 
antidepressants, and specifically the class of drugs known as 
selective serotonin re-uptake inhibitors, SSRIs, raises real 
questions about the appropriate use of these medicines in 
children. Would anyone like to advance a view as to the use of 
these medicines from your perspective, not as physicians but as 
someone who closely looks at the children's mental health 
system throughout the country? Dr. Osofsky.
    Ms. Osofsky. I work within a medical center and I consult 
frequently with child psychiatrists, and I am not an expert in 
psychopharmacology. However, we see a great deal of use of 
medications for children of all ages. We focus a great deal on 
very young children as well, even children 3-years-old, where 
we find their primary care physicians, often pediatricians, 
will put them on sometimes even more than one medication. Many 
of us are very, very concerned about the fact that instead of 
the issues that you are addressing in terms of screening, 
recognizing the problems, evaluation, early treatment, 
intervention, actually that speaks to the whole age range. 
People are very quick to put children on medication.
    Part of it is I think the reimbursement system because some 
of the reimbursement system is for a very few number of 
sessions, sometimes even just a short consultation, and people 
are looking for quick fixes. They think that the medication 
will change the behavior, and I think it is really not only 
unfortunate, but it does need to be used in a much more 
cautious way.
    What we would urge is to be able to do the things we have 
been talking about in terms of screenings, good evaluations, 
and then sometime medication is very helpful in conjunction 
with treatment, but that better evaluations will probably lead 
to much less medication as well as better reimbursement for 
services.
    Senator Reed. Thank you very much.
    Thank you, Mr. Chairman, you have been most gracious. Thank 
you.
    Senator DeWine. Good questions. Thank you very much.
    Senator Sessions?
    Senator Sessions. Thank you, Mr. Chairman. You have been a 
leader on this issue for so many years, and I am glad I could 
be here. I am sorry I had to be at a conference on health care 
this morning that caused me to be late.
    One of the things we talked about, Dr. Osofsky, at the 
hearing on how to contain health care costs, one of the 
suggestions that I made is, with regard to prescription drugs, 
that we are prescribing drugs that not only do not work, but 
sometimes are harmful. That article that Senator Dodd referred 
to and Senator Reed, indicates that is true on occasion. Do you 
feel like there is enough certainty of efficacy of certain 
drugs, and can we do a better job as a government helping to 
establish which ones are effective and which ones are not, 
therefore helping the psychiatrists and psychologists as they 
treat young people?
    Ms. Osofsky. Training is a very important issue, and 
certainly in our medical schools and our medical centers we 
offer a great deal of training related to psychopharmacology. I 
would agree that if people were better informed about 
medications that may work under certain circumstances and how 
they might be used, that it would be helpful.
    I think that, unfortunately, medications are being 
prescribed, medications that speak to issues of mental illness 
and mental disorders, and these kinds of issues, by people who 
have had less experience with how those medications might 
relate in various ways, but I also think, again, we are very 
quick to think that we can provide some kind of medication to a 
young person, as I say, even as young--we see them as young as 
3-years-old and 4-years-old. Instead of evaluating the problem 
in the context of what is going on with them, what is going on 
with the problem, provide support to the family, a much more 
integrated approach, so that then we might choose medication 
after a period of time, and certainly it is very helpful with 
various disorders, certainly bipolar disorder, other types, 
depression, it can be very effective. But we do need to 
evaluate certainly children within the context of relationships 
and be very careful in terms of the types of treatment. And we 
do need more reimbursement for services.
    Senator Sessions. Any brief comment on that subject?
    Ms. Champion, you are indicating, as did Ms. Altenburger, 
that you did not feel like that some of the professionals or 
health care personnel respected you or understood the 
difficulties you were facing. At one point I think you 
indicated they thought you were indifferent. Why do you think 
that is? Is that a problem in the system?
    Ms. Champion. Yes, it definitely is a problem in the 
system. Parents go through this blame and shame cycle. There is 
something inherent that a parent is to be able to control a 
child, and if you cannot control a child, you are deemed a bad 
parent. So you are not only----
    Senator Sessions. Is that at school too sometimes?
    Ms. Champion  [continuing]. It is at school. I think it is 
throughout the entire community, in school settings, in social 
circles, church circles as well, and it is very difficult. 
Parents usually feel very alone, very alienated. And mental 
health professionals by and large, unless you really get in and 
establish a dialogue and a relationship with the mental health 
professional, it is very difficult to do so. You are 
essentially separated from your child, whether you are entering 
an acute care system or a residential system. Your child is 
taken into the system and you are immediately separated from 
that child, and not much interfacing with them. The systems 
usually are not very family friendly to do so.
    That also bears witness to a lack of coordination among the 
child-serving agencies. There is a lot of finger pointing going 
on, and that of course, boils down to dollars and cents. If 
child-serving agencies can learn to braid and blend Federal and 
State dollars in a different way, I think that you will find a 
much better system overall for children, and a much fuller 
array and richer array of services for children.
    Senator Sessions. You certainly had a number of situations 
in which your child was moved, and you had to make a lot of 
different changes. Is that sort of symptomatic of what you were 
saying, that the system is fragmented and not well organized?
    Ms. Champion. Yes, sir. It certainly is. Mental health 
professionals usually are not aware of a higher level of care 
that is required for your child. They may certainly be able to 
recognize that an outpatient treatment is not suiting the needs 
of their child, that maybe residential treatment is required, 
but oftentimes they cannot point you to a residential treatment 
facility that would meet the needs of your particular child.
    Senator Sessions. Thank you.
    Ms. Altenburger, I thank you for sharing similar comments 
from your background. I think my time has expired.
    Thank you, Mr. Chairman.
    Senator DeWine. Dr. Davis, I am not sure I understand fully 
the barriers you are talking about in regard to this 
transitional period of time. Can you spell that out for me so 
that we can, my staff and I, and Senator Reed and Senator 
Sessions maybe can do something about this?
    Ms. Davis. I would be happy to. I think that the most 
concrete barrier that we see is that we have separate funding 
for child and adult services, and so what typically happens is 
those systems evolve to serve each of their mandated population 
as best they can. So we have various systems just preserving 
children. You have those who are in the child welfare system, 
special education. I do not have to tell you all the various 
systems that we have.
    What surprises me the most is when you get to a system 
where there is no obvious reason why there should not be a 
continuity within the mental health system. We have children, 
adolescents, young adults, adults, older adults, all who have 
mental health needs. We have split our systems into separate 
child and adult systems, and what happens within those systems 
is that the priority populations get defined differently, so in 
the child system we have youth with serious emotional 
disturbance, and adults is typically adults with serious mental 
illness.
    While in fact those disorders do not have to look very 
different, States tend to interpret those as being very 
different definitions. So in the adult system, they will 
typically have a more narrow definition because they feel like 
the adults that they are meant to serve are those with the most 
serious and chronic conditions, and they often then do not take 
into consideration what might be child--typically conditions 
that develop in childhood that could continue into adulthood. 
They say in their list, those are not diagnoses that get you 
entry into the adult system.
    So you have a group of young people, particularly things 
that involve more behavioral kinds of components like conduct 
or disruptive behavior disorder. If a young person is 
identified as primarily suffering from that kind of diagnostic 
criteria, when they go to--somebody has to apply for them to 
get into the adult system even though they are in the State's 
child system. They then have to apply. And at that point the 
eligibility person typically says: this is not one of our 
qualifying diagnoses. You cannot enter. So that is one of the 
major things.
    We just completed a study where we looked at, just in 
policy, the differences for eligibility for child and adult 
mental health systems within a singular State mental health 
agency, and with the exception of one State, every single State 
has some difference and some meaningful difference in their 
eligibility requirements, and they require youth who have just 
been served because they are a child, to meet the new service 
eligibility for adulthood. That is a funnel. In essence there 
is a significant group of young people who do not make it 
through that funnel because of that eligibility difference.
    What we tend to see as a result of that, the people who 
work with these young people know that they are not going to 
get them into the adult mental health system. They start 
screening them out, in essence.
    There are several States that show a tremendous marked 
decrease in receiving services at age 16, and while not all of 
that can be attributed to the service system, per se, young 
people can decline services. There are a variety of reasons. 
But one of the major ones that we know forces a barrier is that 
if case managers know that they are not going to be entitled, 
they start essentially screening them out of the system at that 
point. So you end up with a very small number who actually 
applies for eligibility to the adult system. That is at the 
State level.
    When we were doing that study we looked at Medicaid 
eligibility entitlements and definitions, and what you see over 
and over is that there are conditions and situations that will 
entitle a child to access Medicaid eligibility. Those 
definitions typically end at age 18. Sometimes States have the 
flexibility to end that at 18, 19, 20 or 21. None of those goes 
beyond age 21. What happens, in essence, is that you had a 
condition that could qualify for a child but now that you are 
now adult, you are no longer eligible for and you can lose 
those Medicaid entitlements at that point or that Medicaid 
service that you needed because you are not qualified any 
longer.
    Those are some of the simple concrete things that get in 
the way of being able to provide continuous services. I think 
the thing that more broadly leads to that is that we haven't 
recognized this as a developmental stage, that we tend to as a 
society say there is some age at which you are an adult, and we 
have legally made that 18. For drinking purposes and those 
kinds of things it is 21. But we do not recognize--we do for 
ourselves and for those of us who have children who are college 
age, most of us would not boot them out the door at 18. We know 
that they continue to need services and we know that there is 
sort of a new developmental stage that is being defined within 
developmental psychology called ``emerging adulthood,'' and 
that is defined as existing up to age 25. We as a society are 
not yet making our service systems accommodate the fact that we 
are not ready at 18 or 21 typically to function as adults, and 
yet these more vulnerable young people who have even fewer 
resources to draw from and forced out without any further 
recognition.
    So I think part of it is that we have made this false 
dichotomy, you are either a child or an adult, and our systems 
follow that and our funding follows that and our entitlements 
follow that, but it is not in fact matching up at all with what 
naturally occurs with a young person's development which 
extends much more toward age 25.
    Does that help clarify?
    Senator DeWine. Sure. I think it is difficult, I think you 
would agree it is difficult to translate that into legislation.
    Ms. Davis. It is, although I think an examination of 
Medicaid and----
    Senator DeWine. I mean your point is very well taken and I 
understand what you are saying, and we have got these 
artificial barriers and they have been erected over the years, 
and the question is how do you begin to try to break that down 
and how do you begin to deal with the reality of the way people 
live their lives, and we do not do that for anybody else, but 
yet we have set this up for this group of people, and we have 
kind of set this artificial barrier, and boom, there it is.
    Ms. Davis  [continuing]. I think one of the things that I 
was impressed with when I looked at the Medicaid eligibility is 
that there are some things that will extend for children who 
have disabilities, certain entitlements from 18 to 21. That is 
the kind of mechanism that may not open up the door for 
everybody, but given that this is a partly vulnerable group who 
has a disability, that kind of thing is possible.
    Senator DeWine. Thank you very much.
    Ms. Davis. You are welcome.
    Senator DeWine. Dr. Douce, let me ask you about--you have 
detailed, particularly in your written statement, what you have 
done at Ohio State. What is your feeling as far as the universe 
of colleges and universities across the country in how well 
they are doing, how well we are doing as a society in regard to 
providing mental health services to students today? How are we 
doing today versus in 1990, 1980, 1970? I mean what have been 
the trend lines here, particularly when we look at the suicide 
problem? Let us just focus on that.
    Ms. Douce. I think services are uneven I think across all 
colleges and universities. Some have extensive, comprehensive 
services available. Some have very limited services available. 
Some have no services available. I think the issue of suicide 
continues to be an issue, and I think the issue of anxiety and 
drivenness feeds that suicidality, that it is actually a 
combination of depression and anxiety that causes someone to 
choose to end their lives, to end the despair.
    The fact that it is uneven, the fact that college 
administrators struggle with the rising costs of college and 
trying to cut costs in any ways they can, some cut mental 
health services out all together. Some provide very limited 
mental health services.
    Senator DeWine. If you do not know the answer to this, just 
tell me, but is there a difference between campuses that are 
residential campuses and campuses that are less residential or 
more commuter campuses?
    Ms. Douce. Absolutely. The reality is when you have 
students on campus and you have a high residential population, 
you have them 24 hours. So you have suicide attempts in the 
dorms. You have drug overdoses. You have assaults. You have 
things that you have to deal with. Those campuses tend to also 
put mental health services in play because they need them for 
the residential students.
    For campuses that are primarily commuter, sometimes those 
campuses, especially if they are regional campuses or draw from 
a variety of different counties, those students are really at 
risk to get the services they need because the local county may 
not choose to serve them if they are not a resident of that 
county. So the commuter services, the regional campuses, the 
campuses that actually are trying to attract more rural 
students, more first generation students, have some of the 
greatest need and some of the fewest services.
    The Act, what I think is important about this Act is it 
applies grants. There will be competitive grants. There will be 
a strong evaluative component to those grants, so that services 
that are needed in unmet areas can be responded to.
    Senator DeWine. You use the term ``availability of 
services.'' It is one thing to be available. It is another 
thing to be accessed. How do you deal with that?
    Ms. Douce. I think there is a real important need to have 
prevention and outreach services to really try to establish a 
wellness culture on your campus. If we are out there doing 
programs at different clubs, in classrooms, in residence halls, 
in a number of places, you present yourself as someone for whom 
you might go seek help. That is how you fight stigma reduction.
    Availability is also about waiting lists and----
    Senator DeWine. About what? I am sorry.
    Ms. Douce [continuing]. Waiting lists, and the reality on 
college campuses, when you talk about a trend from 1975 to 
1995, many, many, many more students are seeking services, and 
most university counseling centers have a hard time meeting 
those services at the time they need to be met. If you spend 
several weeks getting up the courage to go seek counseling, you 
finally go, you get an urgent important or an intake 
appointment, and then you wait another 3 or 4 weeks to get 
service, you have lost your term. That is a problem.
    Senator DeWine. Can you comment at all about the culture on 
a campus? Is there any relationship between, if you know, if 
you have read any studies on this or if there have been any 
studies on this, about the pressure on campus, the academic 
pressure or any other kind of social pressure connected with 
the suicide rate?
    Ms. Douce. I am trying to think of studies in my head. 
Certainly the biggest increase that we have seen in the last 10 
years is anxiety-related disorders, full-blown panic attacks, 
obsessive-compulsive disorders, anxiety disorders in general. 
That anxiety is related to the stress that many people feel 
about needing to be at a certain place, needing to achieve in a 
certain way, where we in our attempt to maximize student 
success, have created a younger generation that is quite 
driven, and driven with a sense of fear of not meeting certain 
expectations, and that fear drives self-destructive behavior, 
suicidal behavior, alcohol abuse behavior, cutting. We are 
seeing more cutting in college students than we ever have.
    Senator DeWine. Seeing more what?
    Ms. Douce. Cutting, which is a self-injurious behavior, 
where you actually cut yourself in a ritualistic way. Twenty 
years ago when I started, if I saw a student who was cutting, I 
could assume that they had had childhood sexual abuse. Today 
that is not the case. It is actually a shared behavior, a very 
self-destructive shared behavior, to relieve the anxiety and 
stress that builds up. That does then relate to suicide. It 
does then relate to serious mental health issues.
    I would like to say that we have covered a whole gamut, and 
more of the students in your system are coming to my system. 
That is an advantage. One of the real advantages of medication 
is we have many, many more people who are able to go to college 
with serious mental disorders than they ever have before. We 
have many, many more people with a variety of disabilities 
going to college than we ever have before. They struggle with 
transition. They struggle with adjustment. They are at higher 
risk and need higher services, but it is to this Nation's 
advantage to have our country continue to be able to compete 
globally, that we graduate a much greater range of students, 
more diverse students, more culturally sensitive.
    Senator DeWine. Sure. I wonder if you could talk in more 
detail about the alcohol and drug abuse focused services that 
you provide. In particular, I am interested in students with 
these co-occurring disorders. I wonder if you find a large 
number of students with clinically diagnosed mental health and 
substance abuse disorders.
    Ms. Douce. Yes, the dual diagnosis is a major issue. In my 
center we have expertise, a full range of expertise, but 
specific expertise in substance and alcohol abuse. We work with 
the Students Wellness Committee to try to do both alcohol 
education and substance abuse education. We have groups that 
focus on success, not excess, which is really not an 
abstinence-based program but a responsibility-based program. We 
accept court mandated DUIs. Part of my dream is actually to 
develop a college student DUI program, because I think when 
college students are sent to the community DUIs, they look at a 
number of people that are older, have more serious addictions 
and distance themselves. Yet, I think that first legal or 
judicial infraction is an absolute educational opportunity to 
require people to look at their own behavior.
    Senator DeWine. Dr. Osofsky, you talked about the need to 
have professionals better trained to identify people who have 
these problems. I wonder if you could talk, for example, about 
pediatricians. Are they getting the professional training today 
in medical schools?
    Ms. Osofsky. Actually, that is one of the groups that we 
need to address very clearly related to training. The focus in 
pediatric training has been, or primary care training as well, 
primarily physical health. They may focus on vision and hearing 
and those types of things, but much more on taking care of 
those types of issues than mental health issues, and, yes, I 
would agree with you very strongly that we need to address, in 
medical school education as well as additional training for 
pediatricians, ways to identify, the red flags to identify 
mental health issues and refer for additional consultation.
    One of the programs that I am involved with, Harris Center 
for Mental Health, where we provide training to mental health 
professionals, we also are actually just starting a program 
where we are going to be consulting with pediatricians and 
pediatric clinics as well to offer mental health consultation, 
but also education and training for pediatricians.
    So many things are missed at that point that that issue is 
very important because often either at a well-baby check, or 
even an emergency room check, that is the only time we are 
going to see some of these people with the kinds of problems 
that we are talking about, and I think that the issues that are 
being raised on the college level with older children are also 
very relevant for the younger children, the issue of 
availability of services, access to services, the stigma around 
services, and I think if we broadened our education related to 
mental health issues for primary care physicians and 
pediatricians, perhaps some of that stigma could be reduced and 
be part of a regular care that they generally achieve.
    Senator DeWine. Senator Sessions.
    Senator Sessions. I do not know whether NIH is investing 
enough in that. To me, some more research in general might be 
helpful in how to diagnose and how to treat these illnesses but 
that is another issue I suppose.
    Dr. Davis, you really raise an interesting point about 
children growing into adulthood. I visited a group home in 
Huntsville, AL. It was basically built by HUD. We provide 
housing for people who have difficulties anyway, and so they 
pooled that money with some other money from other agencies, 
and had a very nice group home for people with mental illness, 
and it helped them, many of whom were working independently. Do 
you think that would be something that might work for a number 
of these children? And what percentage do you think could 
benefit from something like that?
    Ms. Davis. If I understand specifically what that 
represents, this is certainly a group of young people who need 
support around housing as they age out of the children's 
system. Many of them are leaving foster care and foster care 
settings, so they do not have----
    Senator Sessions. A home to live in.
    Ms. Davis. Any homes to go to, yes. So there is a large 
number. I cannot put a precise number, but there are various 
States that have looked at the child welfare population and 
estimated up to 60 and sometimes higher proportions, have a 
serious emotional disturbance, depending on where those studies 
have occurred. So there is a good number of young people who 
have those kinds of conditions exiting foster care with a 
disability. That would clearly be helpful.
    I think that there are many things that are available 
within adult systems for adults with mental illness. I think 
the crux of the difficulty for this age is twofold. You have a 
group that is aging out of the children's system with a 
category that we consider serious emotional disturbance, that 
there is a group of them that will not meet the eligibility for 
adults with serious mental illness because we define that 
slightly differently. So because of that sort of arbitrary 
distinction, some of them will not get into that housing 
because somebody will say, oh, you do not have a mental health 
disability because you do not meet the criteria any longer.
    For those who do meet that criteria, they may have 
developed their mental illness as a young adult, or they may 
have had it since they were younger. The difficulty that we 
have is that a lot of those programs that are currently funded 
that adults can access are largely holding adults that are 30- 
to 50-years-old, and so when we create a group situation in 
particular, it is not very feasible to just make any old adult 
program open to our younger adult population. First of all, 
they will not accept it, they will not stay. For many of them 
if they do stay it can be quite traumatizing for them. For many 
of them essentially they just walk away. So it is a complicated 
issue. It certainly is helpful. I certainly would not want to 
say no, it would not be helpful, but I think we have to look at 
some of these other barriers that are contributing to that not 
being as helpful as it should be.
    Senator Sessions. Thank you very much.
    Ms.  Champion, I know you and I talked one time about the 
school and IDEA Individuals with Disabilities Education Act. 
Most schools are supposed to be able to provide appropriate 
care for children with any disability, and they heroically try 
really. But if you made a decision that there was a private 
center that your child would be particularly benefited by going 
to instead of going to school, and you decided you were 
prepared to fund that yourself, would you get any reimbursement 
from the system at all for that today, even though it would 
relieve a financial burden on the school system if you had sent 
the child to the school?
    Ms. Champion. I would probably need to work very 
aggressively with the school system in accessing services 
through an IEP, and quite frankly, would more than likely 
involve some litigation on the part of trying to do that. I 
think some come full circle in thinking that schools have been 
given quite a bad rap in trying to provide services for 
children that they consider seriously emotionally disturbed, 
and I think more often that advocacy groups and family networks 
need to reach out to school systems and provide a better 
relationship with them, to go in and actually assist them in 
providing a safe environment within the school system or an 
alternate environment that is going to the school system 
instead of parents going in and being very contentious in 
trying to access services for their children.
    I would say that in our State, I think that is beginning to 
happen. Certainly with the school officials that we have had an 
opportunity to talk with recently, they know that they cannot 
handle this age, this population on their own and that it is 
not going away. By just putting them into alternative schools 
or boot camps, they are still coming back into the system with 
the same issues, and they need to look at alternative ways in 
approaching it.
    NAMI has a very wonderful program called Parents and 
Teachers as Allies that certainly needs to be looked at in 
every school system, but I think that particularly in our State 
we are going to try to reach across that bridge to school 
officials and work more effectively with them, and quite 
frankly, it is going to take a culture change.
    Senator Sessions. I know you have been a leader in that, 
and I thank you for it and the advice you have given me on it.
    I think making it easier, Mr. Chairman, that a person could 
use just a small amount of the money the school system would 
have used for care for this child, plus their own. They may 
have an opportunity to make a decision that could provide 
really special care for a child, and it is pretty inflexible as 
it is today. I think we can do better on that.
    Thank you very much, and thank you for your leadership.
    Senator DeWine. Thank you, Senator Sessions.
    This has been a great panel. Thank you very much. We 
appreciate all of you being here, sharing your experiences with 
us. We intend to move forward. This subcommittee has two bills 
that we have introduced. Senator Reed and I have introduced 
one. Senator Dodd and I have introduced another bill. We hope 
to move forward on this legislation. We also have taken from 
you some very specific, several specific recommendations which 
we would hope in the future to be able to move forward on. So 
this has been a very productive meeting. Thank you very much.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

              The Keeping Families Together Act (S. 1704)
    Each year, thousands of parents are forced to relinquish their 
custody rights to the State in order to obtain mental health care for 
their seriously ill children. Services to treat severe mental disorders 
in children can be extremely expensive and private insurance tends to 
run out after a few months, leaving even middle class parents unable to 
afford the cost. Yet affected children often remain ineligible for 
Medicaid because their parents' income and assets keep them from 
qualifying for assistance. With no other way to get their treatment for 
their children, parents are forced to choose between custody or care. 
The GAO reported in April that, in 2001, parents in 19 States placed 
12,700 children in State welfare or juvenile justice agencies in order 
to obtain mental health services for them. Moreover, that estimate is 
considered low, because 31 States did not respond to the survey.
    The Keeping Families Together Act seeks to keep these children with 
their families and includes three main components:
                    family support grants to states
    Authorizes $55 million in competitive grants to States that would 
be payable over 6 years to create an infrastructure to support and 
sustain statewide systems of care to serve children who are in custody 
or at risk of entering custody of the State for the purpose of 
receiving mental health services. These grants are intended to help 
States serve these children more effectively and efficiently, while 
keeping them at home with their families.
    The Family Support Grants could be used to:
     Foster inter agency cooperation and cross-system financing 
among the various State agencies with responsibilities for serving 
children with mental health needs. This will help to eliminate 
fragmentation of services and will increase the capacity of agencies to 
share public resources. States already dedicate significant dollars to 
serving children in State custody, and this will enable them to use 
those resources more effectively, while still allowing children to 
remain with their families;
     Provide a comprehensive array of community-based mental 
health and family support services for eligible children and their 
families that will be sustainable after the grant has expired;
     Facilitate the design of a State plan through a 
collaborative process involving State child-serving agencies, parents, 
providers, and other stakeholders;
     Provide outreach and public education programs to increase 
awareness about the services that are available to eligible children 
and their families;
     Carry out administrative functions related to the programs 
and activities carried out under the grant, including the development 
and maintenance of data systems.
    Requires States to provide matching funds over the 6-year period of 
the program, ultimately equaling not less than $2 for each $1 of 
Federal funds provided under the grant. States would also be required 
to report annually, beginning with the second fiscal year in which a 
State receives funding under a grant, on the progress and success of 
the programs and activities carried out by the State under the grant. 
Not later than 3 years after the date of enactment, and after the full 
6 years of the grant, a report to Congress is required evaluating the 
success of States in using the grants to eliminate the problem of 
custody relinquishment.
                     Federal Interagency Task Force
    Requires the Administrator of the Substance Abuse and Mental Health 
Services Administration, acting in conjunction with the Director of the 
Office of Juvenile Justice and Delinquency Prevention, the 
Administrator of the Administration for Children and Families, the 
Administrator of the Centers for Medicare&Medicaid Services, and the 
Assistant Secretary of Education for Special Education, to establish a 
Federal interagency task force to examine mental health issues in the 
child welfare and juvenile justice systems and the role of their 
agencies in promoting access by children and youth to needed mental 
health services. The task force would also be charged with monitoring 
the family support grants, making recommendations to Congress on how to 
improve mental health services, and fostering interagency cooperation 
and removing interagency barriers that contribute to the problem of 
custody relinquishment.
 allows states to use the medicaid home- and community-based waiver to 
    treat children with mental illness in less restrictive settings
    Modernizes a critical Medicaid State waiver program by making 
children and adolescents in residential treatment facilities, like 
those in hospitals, eligible for home- or community-based services 
under Medicaid, providing that the cost is no higher than that of 
institutional care.
   Prepared Statment of the American Academy of Child and Adolescent 
                               Psychiatry

Introduction

    The American Academy of Child and Adolescent Psychiatry (AACAP) is 
a medical membership association established by child and adolescent 
psychiatrists in 1953. Now over 6,900 members strong, the AACAP is the 
leading national medical association dedicated to treating and 
improving the quality of life for the estimated 7-12 million American 
youth under 18 years of age who are affected by emotional, behavioral, 
developmental and mental disorders. AACAP supports research, continuing 
medical education and access to quality care. Child and adolescent 
psychiatrists are the only medical specialty fully trained in the 
treatment of mental illness in children and adolescence.
    The AACAP thanks Substance and Mental Health Services Subcommittee 
chairman, Sen. Mike DeWine (R-OH) for holding this important hearing, 
and we applaud his continued commitment to increasing access to 
treatment for children and adolescents with mental illnesses.
    The Surgeon General's 2000 report on children's mental health 
estimated that 20 percent of American children and adolescents have a 
diagnosable mental or emotional illness. Of this number, fewer than one 
in five receive treatment. Barriers to treatment include a lack of 
affordability, lack of availability of specialists, including child and 
adolescent psychiatrists, and stigma. Anxiety disorders, ADHD, and 
depression are the most common mental illnesses occurring in children 
and adolescents.

Early Intervention

    The barriers to early identification and treatment are the critical 
areas of focus for children and adolescents with mental illnesses. Five 
studies funded by NIMH have consistently identified under-recognition 
of mental illnesses as a major problem. Missed opportunities, because 
of under-identification or no opportunity for identification, 
translates into losing the option of early intervention. For children 
and adolescents, an early diagnosis and adequate treatment may limit 
the severity of a life-time disorder or minimize a less severe 
disorder. After the option of early intervention is lost, the chain of 
life-time devastation from mental illness looms ahead: school failure, 
family crises, substance abuse, entrance into the juvenile justice 
system, more and more costly interventions, and on into adulthood. The 
President's New Freedom Commission on Mental Health listed the 
expansion of early intervention services for children and adolescents 
with mental illnesses as one of its main recommendations in its final 
report, Achieving the Promise: Transforming Mental Health Care in 
America. In the report, the Commission states, `` If the system does 
not appropriately screen and treat them early, these childhood 
disorders may persist and lead to a downward spiral of school failure, 
poor employment opportunities, and poverty in adulthood. No other 
illnesses damage so many children so seriously.'' The increased 
availability and affordability of treatment will enable earlier 
identification and interventions for children and adolescents with 
mental illnesses.

Coverage

    Today, approximately 85 percent of all privately insured families, 
and a growing number of those covered by Medicaid, are in a managed 
health care plan. Children are being enrolled in managed care plans at 
a higher rate than adults and represent a disproportionately larger 
number of managed care members. The current efforts to contain costs 
increase the risk of compromises in the quality of care for a 
population that is still growing.
    One of the key barriers to treatment for children and adolescents 
with mental illness is a lack of parity in insurance coverage for 
mental illness. Discriminatory coverage, including limiting the number 
of inpatient and outpatient visits, and higher copays and deductibles 
for children and adolescents, is uniquely counterproductive. Reducing 
treatment options contributes to missed school days, involvement with 
the juvenile justice system or even suicide attempts. Too often, a 
misperception of the cost of mental health coverage prevents access to 
care, but the Congressional Budget Office (CBO) estimates that managed 
nondiscriminatory mental health benefits will increase average premiums 
by less than 1 percent the cost of the average benefit. The cost offset 
of not treating a child with a mental illness will prove to be much 
more expensive in the future.
    Due to the risk-adjustment strategies to protect the financial 
interests of managed care organizations, there is little incentive in a 
managed care system to offer parity for services for children with the 
most serious disorders. These children tend to be high service 
utilizers and are often involved in multiple agencies. They pose a 
challenge to managed care systems because they require services at 
various levels of intensity for extended periods of time. These 
children are then left underserved, resulting in shifting the 
responsibilities for care to other systems such as special education, 
child welfare or juvenile justice. Co-pays for children and adolescents 
should not only reflect parity but should be set so moderately that 
families seek early intervention, evaluation and treatment for mental 
and physical illnesses without the fear of financial disaster. With 
early intervention and treatment, children will live healthier, 
productive lives into adulthood. When managed care systems deny 
coverage to children and adolescents, an expedited appeals process 
should be in place to resolve denials.

Coverage that Meets Developmental Needs

    Children and adolescents are too often treated according to adult 
standards. They are not little adults and need age-appropriate 
treatment coverage that respects developmental needs. Accurate 
comprehensive evaluations are more time consuming for children and 
adolescents. This is recognized in the CPT manuals for interactive 
psychotherapy. Health care plans should not limit the assessment of all 
levels of neurological and behavioral development. There are current 
pressures for child and adolescent psychiatrists to prescribe 
medication without a full evaluation, which is not good medicine or an 
efficient use of resources.
    Most managed care systems for behavioral health have been designed 
without input from a child and adolescent psychiatrist or family 
members of children with serious emotional disorders. Most do not 
understand the importance of strong links among the treatment, home, 
and community environment. Services that support a system of care for a 
child's treatment plan should not be denied automatically if they fall 
outside the inpatient or outpatient benefit or be discriminated against 
because the benefit is for a mental illness. Children and adolescents 
with serious emotional disorders and their families need many kinds of 
services from a variety of sources, such as schools, community mental 
health centers, and social service organizations. Many managed care 
systems are not yet coordinating these services that children with 
serious emotional disorders and their families need, and, too often, 
when the services are implemented, the coverage for their use is denied 
and only partially covered.
    Coverage, with parity, should include a full continuum of 
treatment--including, but not limited to, preventive interventions, 
early identification, assessment and diagnosis, case management, 
outpatient treatment, partial hospitalization, home-based services, 
detoxification and inpatient treatment. Treatment for children and 
adolescents requires that services involve the child or adolescent and 
family as well as appropriate collaboration with other significant 
caregivers, teachers, physicians or providers of other needed services.

Access

    The health system's denial of access to specialists, such as child 
and adolescent psychiatrists for mental illnesses is a major concern. 
Children and adolescents should have access to all providers in the 
plan, with direct access to specialists with training in treating the 
disorders of childhood and adolescence. Child and adolescent 
psychiatrists are physicians specifically trained to treat children and 
adolescents with mental illnesses. The denial of access to such 
specialists can result in inadequate diagnosis and treatment of the 
illness and delayed treatment.
    Often children and adolescents are faced with discriminatory 
coverage combined with their physicians being eliminated from the 
provider networks. Continuity of care between a child and adolescent 
psychiatrist and his/her patient is crucial to the well being of the 
child. Trust between a doctor and patient is critical, and the 
relationship between a child or adolescent and his/her psychiatrist 
must not be compromised. When a child or adolescent is suddenly 
required to change therapists, the trust and confidence that child 
depends on is undermined, damaging the outcome of the treatment and of 
future treatments.

Systems of Care

    Currently, most State mental health, education, juvenile justice, 
social service and child welfare agencies do not provide coordinated 
treatment for children and adolescents with mental illnesses; although, 
a number of federal laws and programs, including Medicaid and the 
Individuals with Disabilities Education Act (IDEA) mandate 
comprehensive coverage for low-income children, children in the child 
welfare system and children with disabilities, including children with 
serious emotional disorders. Differing eligibility criteria for 
services and a lack of State mandates or funding streams contribute to 
fragmentation of State service systems. This lack of coordination 
across State service systems, coupled with the lack of parity in the 
insurance system, has forced many families to consider the 
unthinkable--giving up custody of their children to State child welfare 
or juvenile justice agencies in order to access treatment for their 
children.
    No services should be denied that support a system of care for a 
child's treatment plan. Children and adolescents should have direct 
access to the services that support them and their families. A serious 
emotional disturbance touches every part of a child's life. Therefore, 
children and adolescents with serious emotional disturbances and their 
families need many kinds of services from a variety of sources, such as 
schools, community mental health centers, and social service 
organizations.
    Studies suggest that effective systems of care:
     reduce the need for hospital and out-of-home residential 
treatment placements;
     improve how children behave and function emotionally;
     improve school performance;
     reduce juvenile involvement with the justice system; and
     provide services to more children and families who need 
them.

Model Systems of Care Program

    The Substance Abuse and Mental Health Administration's (SAMHSA) 
Comprehensive Community Mental Health Services for Children and Their 
Families program is a model systems of care program for States. The 
program is a discretionary grant and contract program that supports the 
development of intensive community-based services for children and 
their families based on a multi-agency, multi-disciplinary approach 
involving the public and private sectors. Recent evaluation data found 
notable improvements for children after 1 year of services in the 
following areas: reduced law enforcement contact, improved school 
attendance and academic performance, and improved emotional and 
behavioral problems. The program currently funds 67 programs in 43 
States and services a total of 46, 633 children and adolescents with 
serious emotional disorders. The AACAP recommends an increased 
appropriation for the SAMHSA's Children's Mental Health Services 
Program so that it may be expanded to serve all States.

Medicaid Access

    The Medicaid program provides low-income families with 
comprehensive health care. Medicaid's Early, Periodic, Screening, 
Diagnosis and Treatment (EPSDT) program mandates that all children 
eligible for Medicaid receive comprehensive mental health treatment. 
Despite this mandate, full implementation in all States has not 
occurred, leaving many eligible children without access to the 
comprehensive care they are entitled to by law. This is due to a lack 
of parity for mental illnesses in State Medicaid systems, differing 
State eligibility criteria and regulations, and a lack of coordination 
between service systems. Allowing middle-income families of children 
with mental illnesses to buy-in to the Medicaid program, for example 
through the Katie Becket waiver currently available in the States of 
Kansas, New York and Vermont, provides access to intensive treatment 
services such as residential treatment centers for these families that 
they would otherwise not be able to afford. Increased access to 
Medicaid coverage for middle-income families and low-income families 
who are ineligible for Medicaid because of family assets such as 
ownership of a home, would remove one of the barriers to treatment for 
these children and their families. The AACAP recommends passage of the 
Dylan Lee James Act, S. 622 and H.R. 1822, to allow families of 
children with serious emotional disorders to buy into the Medicaid 
program.

Shortage of Children's Mental Health Professionals

    A final barrier to treatment for children and adolescents with 
mental illnesses is the lack of available specialists trained in the 
diagnosis and treatment of these disorders. In particular, there is a 
critical national shortage of child and adolescent psychiatrists. There 
are about 7,000 child and adolescent psychiatrists nationwide while the 
prevalence rate for children and adolescents with mental illnesses is 
between 10 and 15 million. Data on this professional shortage comes 
from several sources including the Surgeon General, the President's New 
Freedom Commission on Mental Health, the Council on Graduate Medical 
Education (COGME), a committee of the Department of Health and Human 
Services and the Bureau of Health Professions. The Abt Associates 
report for COGME concluded that by 1990, the Nation should have over 
33,000 child and adolescent psychiatrists. The Bureau of Health 
Professions projected that between 1995 and 2020, the use of child and 
adolescent psychiatrists will increase by 100 percent, with general 
psychiatry's increase at 19 percent. An increase in the numbers of all 
children's mental health professionals can help reduce one of the 
barriers to treatment for the families of children with mental 
illnesses. The AACAP recommends congressional action in this effort, 
including passage of the Child Healthcare Crisis Relief Act, S. 1223 
and H.R. 1359, which would encourage individuals to enter all 
children's mental health professions through the creation of education 
incentives.

Conclusion

    Children and adolescents in America, regardless of their family 
income level, should have access to psychiatric treatment, which should 
be provided on a nondiscriminatory basis integrated with other 
necessary medical services. Services should include a full continuum of 
treatment--including, but not limited to, preventive interventions, 
early identification, assessment and diagnosis, case management, 
outpatient treatment, partial hospitalization, home-based services, 
detoxification and inpatient treatment. Treatment for children requires 
that services involve both the child or adolescent, and family as well 
as appropriate collaboration with other significant caregivers, 
teachers, physicians or providers of other needed services.
    Summary of Legislative Recommendations:
     Enactment of the Paul Wellstone Mental Health Parity Act, 
S. 486 and H.R. 953, sponsored by Sen. Domenici (R-NM) and Kennedy (D-
MA), and Reps. Kennedy (D-RI) and Ramstad (R-MN).
     An appropriation of $140 million for SAMHSA's 
Comprehensive Community Mental Health Services for Children and Their 
Families program.
     Enactment of the Keeping Families Together Act, H.R. 3309 
and S. 1704.
     Enactment of the Dylan Lee James Act, S. 622 and H.R. 
1822, sponsored by Sens. Grassley (R-IA) and Kennedy (D-MA), and Reps. 
Sessions (R-TX) and Waxman (D-CA).
     Enactment of the Child Healthcare Crisis Relief Act, S. 
1223 and H.R. 1359, sponsored by Sens. Bingaman (D-NM) and Collins (R-
ME) and Reps. Kennedy (D-RI) and Ros-Lehtinen (R-FL).
    The AACAP appreciates this opportunity to submit a statement for 
the record on issues throughout the developmental process for children 
and adolescents with mental illnesses.
    Attachment: Health Care System Leaves Mentally Ill Children Behind. 
Boston Globe, March 26, 2004.http://www.boston.com/news/globe/health	
science/articles/2004/04/27/health	care	ststem	leaves	mentally	ill	
children	behind/




                  Prepared Statement of Michael Faenza
    Mr. Chairman and Members of the Subcommittee: The National Mental 
Health Association (NMHA) is the country's oldest and largest nonprofit 
organization addressing all aspects of mental health and mental 
illness. In partnership with our network of 340 State and local Mental 
Health Association affiliates nationwide, NMHA works to improve 
policies, understanding, and services for individuals with mental 
illness and substance abuse disorders, as well as for all Americans. 
Established in 1909 by a mental health consumer, NMHA's philosophy has 
consistently been that the needs of consumers and communities must be 
at the center of all policy and practice concerns in the mental health 
field.
    We applaud the careful work this committee is undertaking in 
studying the many facets of mental health in this country. The subject 
of your hearing today is critically important because children are 
falling through the cracks of our ``mental health system,'' and those 
cracks are widening. We welcome your focus.
    As a society, we attach a high value to children's well-being. Yet 
our country is failing children and adolescents by not addressing or 
treating their mental and emotional health. We are failing because we 
are not addressing the issues that keep children and adolescents from 
receiving appropriate care: these include the limited access to 
treatment and services; the fragmentation of services; the lack of 
investment in prevention; the shortage of providers with sufficient 
expertise; stigma of mental illness; and the failure to engage families 
and children in mental health and substance abuse prevention and 
treatment efforts. Sadly, even the limited research information we 
possess about children's mental health is not being translated into 
clinical practice. If we do not change this trajectory, we will 
continue to foster a cycle of emotional and behavioral problems for our 
children resulting in school failure, substance abuse, violence, 
imprisonment, and most tragically, wasted lives that could have been 
changed.

``Symptoms'' Compromising Quality of Care

    While there are many serious problems in the mental health system 
that cross the age span, a unique set of ``symptoms'' too often 
compromise the quality of children's mental heath care. They include:
     Requiring diagnosis prior to treatment. As noted by the 
U.S. Surgeon General, due to the ongoing physical, emotional, and 
cognitive development of children, it can be difficult to accurately 
diagnose mental disorders. Premature or inaccurate diagnosis can result 
in inappropriate treatment and labeling. In addition, a key aim of 
children's mental health should be to address mental health problems 
before they progress into conditions that meet the diagnostic criteria 
for a mental disorder. Unfortunately, both public and private financing 
mechanisms tend to require that a child be diagnosed prior to receiving 
treatment.
     Treating only ``ED children.'' Many public systems require 
not only that a child have a diagnosis, but that the child meet the 
diagnostic, durational, and functional requirements set by the State/
county for a ``serious emotional disturbance.'' In other words, systems 
purposely avoid treating children until their condition reaches a point 
where functioning is severely impaired.
     Lack of child- and family-centered services. When 
children's mental health needs are addressed at all, the system for 
serving them is often treated as an extension of the adult system, and 
as a result truly child- and family-focused service planning and 
delivery is in short supply. In many cases, children with mental 
disorders are not served at all by the mental health system, but end up 
instead in other systems, such as juvenile justice.
     Shortage of practitioners specifically trained in 
children's mental health.
     Too many children inappropriately placed in the juvenile 
justice and child welfare systems due to lack of MH services for 
children and families. Some families are even forced to relinquish 
custody to these systems just to get MH services for their children. 
Increasing numbers of children with emotional or behavioral disorders 
are entering the juvenile justice system. Researchers estimate that 
between 50-75 percent of youth in the juvenile justice system have 
diagnosable mental health disorders; one in five has a serious 
emotional disorder (ED). Correctional systems are simply not designed 
to provide mental health services and are ill equipped to meet and 
often even recognize the mental health needs of children.
     Lack of prevention and early intervention.
    This committee, in its oversight capacity and as an architect of 
SAMHSA reauthorization legislation, has an opportunity to address these 
problems, and make children's mental health and well-being the priority 
it must be. We urge the Committee to make the needs of America's 
children and youth with, or at risk of, mental disorders a major focus 
of SAMHSA's authorizing legislation. We recommend that you develop 
legislation that places major emphasis on high-quality community-based 
mental health treatment services and prevention (to include screening, 
preventive services and early intervention) of mental disorders in 
children and youth.
    Core Principles:
    We believe the following core principles should shape the 
development of that needed policy direction:
    (1.) The promotion of good mental health, prevention and treatment 
for children and youth with mental disorders is the responsibility of 
every family, school, social service agency including child welfare, 
law enforcement, and juvenile justice system.
    (2.) Effective mental health services for young people are based 
and administered in the communities where children and families live.
    (3.) Parents, siblings and other caretakers are central to the 
treatment of children with mental disorders, and should be seen as 
critical partners and participants in every child or youth receiving 
treatment.
    (4.) In addition to specific centers or agencies that need to be 
developed and funded to deliver community-based services for children 
and youth with mental health needs, organizations that serve children 
and families--including child welfare, juvenile justice and schools--
need adequate resources to screen and identify children and youth at 
risk of increased mental health challenges.
    (5.) Schools, child welfare agencies, and juvenile justice systems 
need to provide preventive mental health services, identify and provide 
basic services for children and youth who are screened and known to 
have mental disorders, and work collaboratively with other community 
organizations to ensure good outcomes for each child.
    (6.) Many youth with mental disorders also have substance abuse 
problems, and substance abuse prevention and treatment should work in 
an integrated fashion with children and youth, not separately, for good 
outcomes for children.
    (7.) Children and youth are often the most adversely affected 
individuals regarding the experience of living through any disaster, 
witnessing or being exposed to violence, loss of family members, living 
in poverty, having poorly met physical health care needs, and 
experiencing acute medical problems. Community organizations that 
address these issues need the resources to identify the mental health 
needs of children and youth and ensure that appropriate treatment is 
accessed.
    Policy recommendations:
    Building on those principles, we urge that a SAMHSA reauthorization 
bill, and this committee's oversight of SAMHSA, address the following:
    (1.) SAMHSA leadership must address the reality that mental health 
services and preventive programs for children and adolescents are 
scarce in number and poor in quality; given the magnitude of the need, 
the situation could aptly be termed a national crisis.
    (2.) Mental health services and prevention programs targeting the 
needs of vulnerable children and families should be near the top of 
SAMHSA's goals and investments in community.
    (3.) Federal agencies including the Department of Education, Office 
of Juvenile Justice and Delinquency Prevention, Maternal and Child 
Health and other URSA programs, CDC, NIGH and Homeland Security should 
all be linked formally and with clear charges to SAMHSA. SAMHSA needs 
support and direction to move much more vigorously towards 
collaborative planning and pooled resources with other Federal agencies 
to meet the challenges to the mental health of children across the 
United States.
    (4.) Prevention resources within CMHS need to be greatly expanded, 
and should be a public health cornerstone of the agency.
    (5.) A fourth SAMHSA center that focuses on the promotion of mental 
health and the prevention of mental disorders in children and youth, as 
well as the risks and solutions for adults, is needed.
    (6.) The Children's Mental Health Services Grant program 
(hereinafter the ``Systems of Care'' program) within the Center for 
Mental Health Services should have greater flexibility to meet the 
needs of youth. We urge that you revisit eligibility rules that limit 
program access to youth who meet the criterion of having a ``serious 
emotional disturbance,'' and, as a result, too-frequently deny needed 
services until a youngster's condition deteriorates.
    (7.) The needs of children in communities who are at risk because 
of traumatic events or disaster argue for a robust new Grant program 
within SAMHSA.
    (8.) A new Grant program to support community-based planning would 
help move many more communities toward developing needed systems of 
care.
    The National Mental Health Association looks forward to working 
with this Committee to make its vision for meeting the special needs of 
children a reality for tomorrow.
             Statement of Susan Mikolic, Parent & Advocate
    Chairman DeWine and members of the Committee, I am Susan Mikolic of 
Lake County, Ohio. I have two children with mental illness. My oldest 
son, now 16, has been ill since age 5. His challenges include Bipolar 
Disorder, Attention Deficit Disorder, Oppositional Defiance Disorder, 
Post-Traumatic Stress Disorder, multiple medical problems, and several 
learning disabilities. My youngest son, now 14, has been ill since age 
6. His challenges include Bipolar Disorder, Attention Deficit Disorder, 
Anxiety Disorder, multiple medical problems, and several learning 
disabilities.
    I am a registered nurse by education and experience. I have, 
however, out of necessity, devoted the last 6 years to mental health 
advocacy. Today I present to you as a very concerned parent and 
citizen. It wasn't long after my children were diagnosed and I 
attempted to access services that it became clear to me that a large 
portion of the services my children needed didn't exist, or if they did 
exist, were either of poor quality, ineffective, inaccessible, or cost 
prohibitive. I rolled up my sleeves and got involved in an attempt to 
make the system better for my children and all others to walk in their 
footsteps. I served as President of National Alliance for the Mentally 
III (NAMI) Lake County, member of the NAMI Ohio Board of Directors, Co-
chair of the NAMI Ohio Children's Committee, co-chair of the Ohio 
Department of Mental Health Children's Division Strategic School 
Success Committee, co-chair of the Professional Development work group 
of the ``Mental Health, Schools, and Families Working Together Toward a 
Shared Agenda'' Initiative, and countless other task forces, 
committees, work groups, panels, and advisory groups. Due to the extent 
of my involvement, visibility, and expertise I have become an 
established advocate for childhood mental health issues, assisting 
families around the entire State as they attempt to secure needed 
services for their children.
    I mention all this to provide a framework for your interpretation 
of my testimony as I will not only relate my personal family 
experience, but will also reflect those of struggling families all 
around the State of Ohio. I will focus my comments primarily in the 
area of middle-income families as this is my area of expertise and 
experience.
    I stated earlier that it became clear that the services my children 
needed were either non-existent, poor quality, ineffective, 
inaccessible, or cost prohibitive. I will expand.
    1. High quality, effective, accessible, and affordable psychiatric 
care--My children, and all these children, need high quality, 
effective, accessible, and affordable psychiatric care for our 
children.
    As you know, there is a critical shortage of Child Psychiatrists. I 
am blessed to live in Cleveland, a medical hub in the State of Ohio. We 
have a large number of Child Psychiatrists, yet waiting lists remain at 
3 months for an initial appointment, with many practices closed to new 
patients. We are blessed. There are areas around the State and nation 
that have few, if any, Child Psychiatrists. I see the initiative to 
stem this gap with use of Pediatricians. This practice concerns me. As 
a healthcare professional, it is clear to me that in this information 
age one cannot know all there is to know in multiple specialties. Many 
pediatricians have a special interest in Attention Deficit 
(Hyperactivity) Disorder (ADD/ADHD), for example, and diagnose and 
treat the child for ADHD with stimulants. Because they rarely are well 
versed in the entire field of Child Psychiatry, they often miss co-
morbidities, as well as exacerbate other undiagnosed illness by 
medication management. Specifically, I refer to the use of stimulants 
and antidepressants, the use of which can unmask an underlying Bipolar 
Disorder. Children are given stimulants for ADHD, and antidepressants 
for Depression, Anxiety Disorder, and Obsessive-Compulsive Disorder, 
and often no one is watching for a potentially emerging mania. Both of 
my children were originally treated with antidepressants and mood 
stabilizers for depression, anxiety, and ADHD, and both were triggered 
into mania. Had they not been under the care of a Child Psychiatrist I 
believe the mania would have been identified as the ``impulsiveness'' 
of ADHD and they would not have been appropriately diagnosed and 
treated until some time later when untold health and social damage 
would have taken place.
    I will relate a personal experience where such a thing happened 
even with the oversight of a Child Psychiatrist. My youngest son was 
diagnosed with Bipolar Disorder. His Psychiatrist eliminated pediatrics 
from her practice. It was too time-consuming. It was better for her 
economically to only treat adults who didn't need interaction with 
school systems, etc. We changed care to another local Child 
Psychiatrist. He did not concur with the Bipolar Diagnosis and promptly 
took my son off his mood stabilizer, remaining on antidepressants and a 
stimulant. My son went into a manic mood swing shortly thereafter. He 
was walking on the roof on one foot, was extremely activated, etc. When 
notified that my son was walking on the roof the Psychiatrist 
responded, ``Is that dangerous?'', saying my son was getting more 
impulsive and increased his stimulant dose. Eventually he ended up on 
triple the recommended dosage when I sought a 2nd opinion, where the 
Psychiatrist looked at his mood charts and promptly concurred that he 
indeed had Bipolar Disorder. If I did not know what mania looked like, 
from having experienced with my other child, the mania would have 
continued unchecked, indeed, exacerbated, by his medication management.
    I hear stories like this all around the State. It is my personal 
opinion that these children's illnesses need to be managed by a 
psychiatric specialist.
    Now, one decides their child needs to see a Child Psychiatrist. 
They must next determine if that Psychiatrist is a provider on their 
insurance panel. Most are not on all panels and now the family finds 
that the pool of Child Psychiatrists available shrinks by perhaps 50 
percent or more. Then the family calls to make an appointment with the 
Psychiatrist only to BE scheduled 3 months out even though their child 
is in crisis. One is then guided in the meantime to go to the Emergency 
Room for any crisis situations. This is not a helpful option. The staff 
in most Emergency Rooms are not adequately trained to assist with this 
population. If indeed the child is admitted to a psychiatric hospital 
based on the Emergency Room visit, which only occurs if the child is 
actively homicidal or suicidal, the child only stays 3-5 days and is 
discharged with poor follow-up care. Essentially hospitalizations are 
non-productive in terms of helping stabilize a child.
    In this area of discussion I will relate two personal experiences 
to highlight some of today's realities.
    We have a family history of 5 suicides. I took my son to the 
Emergency Room hoping to have him hospitalized for his safety. He was 
not admitted because he was not suicidal ``enough'' I ask you, if you 
had a significant family history of suicide, your child has a personal 
10 year history of profound depression and suicidality, and is now 
actively suicidal, would you feel that suicidality is so measurable 
that one's suicide risk could be nonchalantly dismissed?
    I now relate another example of how Emergency Room care may be 
used. My son's illness was increasingly unstable. At one point he 
refused an appointment with his Psychiatrist due to this instability 
and limited energy to make the trip to the physician's office. His 
illness continued to escalate. I called his attending Child 
Psychiatrist asking for an urgent appointment, a med change over the 
phone, or some guidance. His Psychiatrist told me to take him to the 
Emergency Room. I said that would do no good as he was not suicidal or 
homicidal. She said, ``Yes, I know, but maybe if he waits in the 
Emergency Room for 4 or 6 hours he will think twice about canceling an 
appointment with me.'' My, what a cost-effective, compassionate, and 
humane approach to a cry for help. We changed Psychiatrists.
    Now, in the area of changing Psychiatrists I would like to address 
an increasingly common complication. The parent who carries the family 
health insurance changes jobs or the employer changes carriers, and, 
the child's established Child Psychiatrist is not a provider on the new 
insurance panel. One must then choose if they will self-pay or put 
their child through the distress and care lag inherent in relaying 
history and trying treatments already attempted, once again. In 
addition, changing Psychiatrists is not equivalent to changing 
orthopedists or pulmonologists. One has to build a relationship with 
the Psychiatrist to trust them enough to share troubling symptoms. 
Changes in the treatment team create excessive and unnecessary distress 
as well as treatment delays as the new physician learns the patient.
    2. Financial Burdens--Let's talk cost. If you stay with the child's 
current Psychiatrist on a self-pay basis, you will pay $65-$150/hour. 
Also, virtually all insurance plans limit the number of appointments 
per year that are covered for psychiatric care. If your child has a 
typical care schedule they will see the Psychiatrist once per month, 
and their therapist once per week. This totals 64 appointments per 
year, of which greater than 2/3 will be self-paid by the family. And if 
they self-pay for an out of network psychiatrist that cost increases. 
At one time our family paid $500/week out of pocket for psychiatric 
care. Historically, for the last 11 years, our family has spent 
$20,000-$25,000/year out of pocket on medical expenses. My husband and 
I are college educated, professional people, earning good wages, but a 
family cannot sustain bills like this on an ongoing basis. We took 3 
home equity loans against our home and eventually could no longer 
afford all the loan payments. Last fall we sold our home.
    If my child had leukemia, we would not have lost our home, we would 
not be broke. The lack of insurance parity creates an unconscionable, 
unnecessary burden on families. It is truly a present day 
discrimination as clear as lack of voting rights for women or the 
historical discriminatory practices against minority populations. I 
read somewhere a great analogy regarding this practice. I do not recall 
where I read it and therefore cannot credit the author, but the author 
noted that the illness of Parkinson's Disease is thought to be related 
to a deficit in the neurotransmitter Dopamine and that Schizophrenia is 
associated with abnormally high levels of dopamine. Yet Parkinson's 
Disease is well covered under insurance plans and Schizophrenia is not. 
The author suggests that this practice is as ludicrous as insuring the 
right leg but not the left. This practice is plain and simple, 
unadulterated discrimination and this country should be outraged at the 
discriminatory nature of this practice.
    But they aren't . . . and why not? I believe insurance parity has 
not been achieved yet, in large part, due to misunderstandings and 
stigma about mental illness. In our old neighborhood the children were 
forbidden to play with my children because of their illness. This was a 
professional, educated community. But they were afraid, out of a lack 
of knowledge. They assumed mentally ill children were violent children. 
For 10 years my children had no friends. The families would not even 
acknowledge us if we said hello. We have to do better than this for our 
children. We recently moved when we had to sell our home. My son is 
trying to make friends in his new environment, which has truly been a 
blessing in this one sense. He said to me last night, ``Mom, I can't be 
myself. I want friends and if I act myself I won't make any friends. Do 
you have any idea what it was like to not have any friends for 10 
years. I don't want that again . . . so I pretend to be someone else 
with them.''
    The need for friends and to fit and to be accepted is at it's 
strongest in the school environment. The children use what little 
coping energy they have to try to fit in and be accepted. This leaves 
little reserves to devote to education.
    3. Educational Issues--School related issues are the number one 
reason families call me for assistance. They are in tears, desperate to 
find help. The biggest common denominator in this struggle has been the 
lack of knowledge about mental illness among the school staff 
interacting with our children as well as ingrained judgments about 
children with mental illness. We, as most all parents of mentally ill 
children, have been told that our child was just being lazy, refusing 
to do work. Yes, on the most surface level this would be the 
observation. But our children's struggles are much more complex than 
that superficial assessment. My children are coping with extreme 
emotion swings, concentration problems, attention problems, medication 
side effects, poor sleep, and the list goes on. We need to ask, ``What 
are the child's behaviors telling us? What do they need?'' and work to 
meet those needs so that our children can involve themselves in 
learning. One cannot learn when they are falling asleep from powerful 
medication, when their thoughts are racing in a mania, when they have 
entirely lost initiative from a depression. When children are in 
exacerbations of their mental illness, they cannot access the general 
education curriculum. Instead of providing accommodations to help our 
children, we are repeatedly told by school staff that we are enabling 
our children as they push our children beyond their limits and 
sacrifice their health. I have repeatedly heard this scenario over and 
over again in my advocacy work with families. And I have experienced it 
first-hand throughout my children's school careers.
    We have had to pay a Psychiatrist to come to a school meeting to 
explain, in her words, ``that we are dealing with a situation where my 
son is making a choice between `should I kill myself today' and 
algebra.'' We had to bring the doctor because we, as parents, are not 
believed when we inform the school of our children's challenges. We 
have been offered a ``choice'' of home instruction Mon./Wed. and Tues./
Thurs. at 2:45 or 3. What if a parent's work schedule necessitated them 
never being home from work prior to 5 p.m.? When I pointed out to the 
school that this hardly reflected true choice, I was told again, ``You 
have a choice. You may CHOOSE between Tues./Thurs. and Mon./Wed. And 
you can choose either 2:45 or 3 p.m.'' That's hardly a variety of 
choices. My son at one point could only handle 1 hour of home 
instruction per day, but the district couldn't secure a tutor who would 
tutor 1 hour/day 5 days a week. So his services were reduced to 1/hour 
day twice a week.
    As a more complete example of what our children are up against, I 
will briefly describe the challenges our family fought when my oldest 
son was in 7th grade. In the spring we met to plan his 7th grade 
Individual Education Plan (IEP) with services in an Serious Emotional 
Disturbance (SED) inclusion setting. Yes, plan for what 7th grade would 
bring. However, none of the 15+ school personnel at that meeting 
informed us how very different the structure of 7th grade would be, 
requiring him to change classes for every class, 11 different 
personalities to adjust to, 11 different sets of expectations, chaos in 
the halls, gym and hall lockers. These things may seem insignificant to 
a healthy adult, or even a healthy child, but for my child and most 
children with mental illness, these are huge barriers. Again, I imagine 
out of lack of knowledge, those at the IEP meeting felt these things 
weren't worthy of mention. They were, however, to prove to be the 
antecedent of my son's decompensation into suicidality and catatonia. 
Fall classes began and within 2 weeks my son was identifying how 
stressed and pressured he was feeling. I began to communicate with the 
school about the need to reduce his stress and the need to access the 
accommodations planned for in his IEP. At 1 month into school his Child 
Psychiatrist was alarmed at the decompensation that had occurred in 
just 1 month. She cautioned we must reduce his stress immediately. I 
sent letters, notes, made calls, and had meetings with school personnel 
as we tried to implement his IEP plan that allowed for him to return to 
his SED class if he was feeling stressed or having a bad day. I asked 
that the school use my son as his own barometer of what he could handle 
for the day. He knows best how he is feeling. This suggestion was met 
with disdain. I was ``called to the principal's office'' and told I was 
enabling my son. I was actually supporting my son's survival strategy. 
During exacerbations of his illness he cannot handle large groups of 
people, sometimes any people at all. He was feeling very volatile and 
was asking to accommodate his need for less chaos and stress. As I said 
in a recent letter to our Special Education Director, ``If my child had 
leukemia and was asking to go to the nurses office because he was 
feeling nauseated, he would be escorted there--no questions asked--and, 
with much empathy.'' At a minimum, my child should be able to state his 
needs and have them honored. Instead, they labeled him and pushed him 
relentlessly to go to inclusion classes. Eventually he became so 
unstable, depressed, and suicidal that we had to remove him from 
school. He was hospitalized twice that fall and was so severely 
depressed he was unable to dress, talk, or leave the house. He slowly 
emerged from the depression with the stress of school eliminated. He 
returned to school the following spring to a self-contained SED class, 
attending 3 periods of school a day. It took him 1/1/2/ years to return 
to a full school day. He lost nearly 2 years of education because the 
staff refused to believe that his disability was getting in the way of 
his education and reduce his stress. Had his stress been reduced via 
strategies agreed to in his legal IEP, it is likely this exacerbation 
and 2 year recovery would have been avoided.
    Another major challenge once there is agreement to provide 
services, is that the type of services our children need are, for the 
most part, unavailable. Our children need a therapeutic approach. Some 
also need a behavioral approach, but that's just a portion of the 
affected children. Most programs available to our children are 
behavior-oriented programs. They are missing the mark. Our children 
need therapy in their day. My son did transfer into a behavior-oriented 
SED class. We placed him there because he needed a small group setting. 
He does not need to be with SED kids all day, but that is the only way 
to get him into a small group setting with the present menu of program 
options. We do not design services for kids . . . we place kids into 
existing programs. We as parents must pick the ``least of the evils'' 
among the ``programs'' offered. My son might just make it in a self-
contained SED class, but what he will achieve will not be ``school 
success'' he will survive school.
    Not only are our children not learning, but the stressors place on 
the child by an uninformed educational system exacerbate their 
illnesses even further. As the stressors continue their health 
continues to decompensate . . . their illness becomes unstable. And 
with every exacerbation the possibility of them returning to their 
previous functioning level declines. So if they were operating at a 90 
percent functioning level, then decompensated into another episode, 
they may only return to a functioning level of 86 percent next time, 
and so on the spiral goes, until 1 day we reach the current outcomes 
detailed in the National Longitudinal Transition Study of Special 
Education Students commissioned by Congress. The study was initiated in 
1987 and completed in 1994. The study showed the following outcomes for 
students with Serious Emotional Disturbance (SED).
     41.7 percent of students with SED graduate from high 
school
     They earn a grade point average between 1.7-2.1
     They earn an average of 2.1-3.0 credits per year.
    In Ohio a child needs to earn 21.5 credits to graduate from high 
school. At this credit rate it would take a typical SED child 7-10 
years to complete high school. And we wonder why they don't graduate 
from high school?
    Post-graduation statistics showed that at 3-5 years post-
graduation:
     Less than half were competitively employed (47.4 percent)
     A little less than half were already mothers (48.4 
percent)
     More than half were already arrested (57.6 percent)
     Nearly half were living with their parents (45.4. percent)
    4. Recommendations--Clearly, our nation needs to do better for this 
vulnerable population than this. I implore you to search your souls. Be 
afraid of mental illness if you need to. But do the right thing. I 
think a great deal of stigma is related to fear that these tragic 
illnesses might strike one's own family. And indeed they often do. One 
in 4 families are affected by mental illness. It will strike someone 
you know and love and all of this could happen to them. PLEASE stop 
this atrocity today. Search your souls and roll up your sleeves. Make 
changes to this horribly broken system that is as much a tragedy as the 
children's and families struggles themselves. Make a difference for 
future generations. In the ``The Report of the Surgeon General's 
Conference on the Children's Mental Health: A National Action Agenda'' 
released January 3, 2001 David Satcher states, quoting The World Health 
Organization, that ``by the year 2020, childhood neuropsychiatric 
disorders will rise proportionately by over 50 percent to become one of 
the five most common causes of morbidity, mortality, and disability 
among children.'' The time is now. If we don't change this, who will?
    So, what do we need to do? First and foremost, what is critically 
needed, yesterday, is a national educational media blitz. Every mental 
health board, mental health agency, advocacy group, etc. knows this 
needs to be done, but it is expensive. No groups budget can handle the 
cost of this initiative alone. It is done for AIDS. It is done for drug 
abuse. It is time to do this for mental illness. Once people understand 
that mental illness is like any other illness, other changes will fall 
into place naturally. Many of this countries citizens are wealthy. 
Every day they donate millions of dollars to museums, parks, and other 
assorted groups. The money is out there. It's just that mental illness 
is not yet identified as a worthy recipient for a variety of reasons. 
But information, education, splashed everywhere, will open eyes. We 
know that. It happens time and time again. If you do nothing else, help 
this country establish an anti-stigma campaign. A lot of the rest will 
fall into place then. Parity will occur because people will understand 
that is the only right and decent thing to do. College students will 
see the need and the rewards of pursing a career in Psychiatry. 
Teachers will approach children with compassion. The tasks to improve 
the system will all be easier.
    Goal 1 of the President's New Freedom Commission Report clearly 
states this recommendation as follows: Recommendations 1.1: Advance and 
implement a national campaign to reduce the stigma of seeking care and 
national strategy for suicide prevention.
    Recommendations 1.2: Address mental health with the same urgency as 
physical health.
    Secondly, school issues for children with mental illness need to be 
addressed immediately. Changes will only be made through collaboration. 
These are complex inter-system issues. Collaborative projects need to 
be supported. In the Ohio ``Mental Health, Schools, and Families 
Working Together Toward a Shared Agenda'' initiative, the mental 
health, educational, and family/advocacy communities are uniting to 
make a difference. We can only make this very complex system effective 
if we unite. Education about childhood mental illness for all teachers, 
on an preservice and in-service basis, is essential. The education 
community cannot know how to help our children unless they are educated 
on how to do this. Mandatory education on how to support academic 
success for children with mental illness is crucial.
    The President's New Freedom Commission was charged to ``make 
recommendations that would enable adults with serious mental illnesses 
and children with serious emotional disturbance to live, work, learn, 
and participate fully in their communities.'' \1\ Please help to assure 
that the recommendations in that report are enacted. Our children, your 
children, will thank you.
---------------------------------------------------------------------------
    \1\ Report of The President's New Freedom Commission on Mental 
Health, July 22, 2003
---------------------------------------------------------------------------
    5. Conclusion--Chairman DeWine and Members of the Committee, I 
thank you for the opportunity to share my views on this important 
issue. And I stand ready to serve and work with you as you move forward 
on your work.
    In closing I would also like to add that I have attached an 
addendum to this testimony. It is a newspaper article that appeared in 
the Cincinnati Enquirer on Sunday, March 21, 2004. The Enquirer ran a 
special report on Childhood Mental Illness. My family and it's story 
was one of the families highlighted in that report.


                     everything spent, and no help
                 mother fights to save her bipolar sons
       by debra jasper and spencer hunt enquirer columbus bureau
    After 14-year-old Matthew Mikolic chased his younger brother with a 
knife, his mother asked Lake County officials to pay to send him to a 
psychiatric center. They refused.
    ``They said he wasn't violent enough, that he had only tried to 
kill his brother once,'' Susan Mikolic says.
    Now, the Eastlake, Ohio, mom lives in fear that next time, Matthew, 
who is now a 220-pound, mentally ill 16-year-old, will succeed. She 
hides tools and poisonous household cleaners in a locked fishing tackle 
box in the garage. She started locking up kitchen knives after Matthew 
tried to stab Brian, then 12.
    ``Brian locked himself in the bathroom, called me and said, `Get 
home, Matthew's got a knife and he's trying to kill me,'' Mikolic, 44, 
recalls.
    ``I called the police, and a whole SWAT team came. By the time I 
got there, Brian was crying in the driveway, and Matthew had his hands 
in the air.''
    Mikolic sought help from the county because she had no money left 
for more care. When her insurance ran out, she sold her $287,000 
suburban home to cover treatment for both of her sons, who have bipolar 
disorders that cause them to swing from overly hyper to depressed or 
violent.
    At first, the boys needed weekly counseling, but insurance only 
covered half the cost of 20 sessions with a psychiatrist a year at $125 
each per child. Eventually, Mikolic and her husband were shelling out 
more than $20,000 a year for family therapy. They took out three home 
equity lines of credit to pay for treatments, including lightbox 
therapy, music therapy, and anti-psychotic drugs.
    For Mikolic, the pressures finished off her marriage and forced the 
couple to sell their home to pay off their loans. In the end, she was 
left with just enough to put a small downpayment on a modest white 
house that needs a $3,000 roof.
    She also developed diabetes and such deep depression that she could 
no longer work as a nurse.
    ``It was a process of letting go, selling the house, the furniture, 
everything,'' she says. ``I've had relatives look at me and say, `How 
could you lose your home, your husband, your job?' And I say, `Where 
would you have stopped? What would you do to save your kids?' ''
    Mikolic says what happened to her shows just what families with 
mentally ill children are up against. She and other advocates are 
pushing Ohio lawmakers to pass a bill that would force insurance 
companies to cover a mental illness in the same way they cover a 
physical illness.
    If her sons had leukemia, Mikolic reasons, she wouldn't have had to 
sell her home. ``Why should it be different for us because they are 
bipolar?'' she asks.
    Roberta Barb, an administrator of child protection services in Lake 
County, says her agency opted not to send Matthew to a treatment center 
because, ``As a group, we decided he was not in need of placement. We 
can't make everybody happy, and we're not placing a kid in treatment 
just because a parent believes he needs to go.''
    The teen has tried everything to get his emotions under control, 
even shock treatments that applied electric jolts to his brain. So far, 
nothing's worked. He refused more shock treatments after he was given 
two drugs during a procedure--one to paralyze him and one to put him to 
sleep. The drug to paralyze him took effect first.
    ``I could hear the machine start, but I couldn't tell them I was 
awake,'' Matthew says. ``I kept thinking, I should put my hand up, but 
I couldn't. It was scary. Once they started the procedure, I didn't 
know if I'd feel it.''
    He's frustrated, but grateful for his mom for refusing to give up 
on him. ``If it weren't for her, I'd be dead. If she didn't support me, 
I would have killed myself.''
    He pauses and lowers his voice.
    ``The illness puts that in your head,'' he says. ``People say you 
can control it, but I don't think so. I know I can't control it.''




























    [Whereupon, at 11:48 a.m., the subcommittee was adjourned.]