January 31, 2013
CHILDREN'S MENTAL HEALTH SERVICES
By: James Orlando, Associate Analyst
You asked several questions concerning how children are identified as needing mental health services and how parents can access such services. The questions and answers appear below.
How are Children Identified as Needing Mental Health Services In Schools and the Community? Are there Follow-Up Procedures?
A child can be identified as in need of mental health services in a variety of ways. The method of identification and type of follow up will vary on a case-by-case basis and depends on several factors, such as:
1. who initiates the referral (e.g., parent, primary care provider, school personnel, probation officer);
2. the child's insurance status and type of insurance;
3. the referral or treatment setting (e.g., private practitioner, emergency department, in-patient hospitalization); and
4. the reason for the referral or treatment (e.g., acute episode, generalized need for assessment).
(See the answer to the next question for more detailed information on ways that schools identify children as needing mental health treatment.)
In 2012, the Department of Public Health's (DPH) Office of Health Care Access (OHCA) issued a Statewide Health Care Facilities and Services Plan. The plan lists several examples of points of access into the behavioral health system (note that not all of these would apply to children):
● general or children's general hospital emergency departments;
● private practitioner's referrals (physicians, therapists, social workers);
● school systems (e.g., school based health centers);
● community health centers or other primary care clinics;
● the departments of mental health and addiction services (DMHAS), children and families (DCF), correction, and developmental services (for autism co-morbidity);
● the courts and the Judicial Branch's Court Support Services Division;
● transfers from other entities/facilities in other states;
● referral by home health providers;
● long-term care providers;
● referral of individuals receiving substance use treatment to mental health providers, or vice versa;
● referral of a teen into adult services when aging out of child/adolescent level services;
● referral from 12-step and other recovery and self-help groups; and
● self-referral or walk-in (OHCA services plan, page 93).
Chapter 8 of OHCA's services plan provides an overview of the range of behavioral health services available in the state. The full plan is available at http://www.ct.gov/dph/lib/dph/ohca/publications/2012/ohcastatewide_facilities_and_services.pdf.
There is no statute establishing general follow-up procedures after a child is identified as needing mental health services. There are specific requirements in some situations (e.g., special education, as discussed below). In some situations, the referring party will regularly follow up on the child's status once he or she starts receiving services. For example, after a primary care provider refers a patient to outpatient therapy, the primary care provider and therapist may remain in contact concerning the child's medication status. In other situations, follow up is less common (e.g., emergency personnel whose role is to stabilize a patient but not to provide ongoing services).
Does the State Require Schools to Conduct Mental Health Screenings for Students?
There is no general requirement for schools to conduct mental health screenings for students.
By law, school boards must require each child to have a health assessment (by a physician or specified other health care providers) prior to public school enrollment and during grades six or seven and nine or ten (CGS § 10-206). While the statute does not list mental health issues as among the required components of the assessment, some of the items on the accompanying health assessment record potentially address mental health issues.
Part I of the health assessment record, to be completed by the child's parent or guardian, includes several specific questions about physical conditions but also a few more general questions that could encompass mental health concerns (e.g., any health concerns, is there anything you want to discuss with the school nurse?).
Part II of the assessment record is to be completed by the health care provider following the medical evaluation and physical exam. While the assessment does not require any specific mental health screening, the provider must indicate whether the student has a developmental, emotional, behavioral, or psychiatric condition that may affect the
student's educational experience. The health assessment form is available at http://www.sde.ct.gov/sde/lib/sde/pdf/deps/student/health/har3_final.pdf.
By law, health assessment records must be included in a student's cumulative health record. Appropriate school health personnel must review the assessment results. If those personnel determine that a student is in need of further testing or treatment, the superintendent must give written notice to the student's parent or guardian and make reasonable efforts to assure that such further testing or treatment is provided (including advising the parent or guardian of how such testing or treatment may be obtained). Any such additional testing or treatment must be recorded in the student's health record and reviewed by school health personnel (CGS § 10-206).
Schools are a primary venue for children to receive mental health services. There are various ways that school personnel may identify a child as possibly needing mental health services. The referral could be made by a teacher or various other school personnel, such as a school psychologist, counselor, nurse, social worker, resource officer, or administrator. The identification could occur in a variety of ways, such as following discussion with the student, a parent, or other school personnel; as part of the special education process; or following a behavioral incident.
Many students also receive mental health referral or treatment by health care providers at school based health centers (SBHCs). SBHCs are free-standing medical clinics located within or on school grounds, staffed by a multi-disciplinary team of professionals with expertise in pediatric and adolescent health. They provide primary medical and mental health services to students at the school regardless of insurance coverage. According to the Connecticut Association of School Based Health Centers, 80 SBHCs that receive DPH funding are located in 20 communities in the state and they provide over 35,000 students with services annually, including 41,000 visits for mental health concerns.
Below, we provide more information on three issues related to a school's identification of students needing mental health services: (1) special education referral and assessment; (2) required school board policies on (a) communication with mental health personnel and (b) the prohibition on schools recommending psychotropic drugs; and (3) a State Department of Education (SDE) grant program to help detect and prevent emotional, behavioral, and learning problems in young children.
Here are links to additional information about mental health services in Connecticut schools, from SDE's website:
● school psychology: http://www.sde.ct.gov/sde/cwp/view.asp?a=2678&q=320742
● comprehensive school guidance and counseling: http://www.sde.ct.gov/sde/cwp/view.asp?a=2678&q=322288
● Coordinated Approach to School Health (which seeks to align several facets of health, including behavioral health, to improve student health as well as academic achievement): http://www.sde.ct.gov/sde/cwp/view.asp?a=2678&q=320726
Special Education. Both Connecticut and federal law require schools to identify children with disabilities that affect their educational performance and provide them with a “free and appropriate public education” tailored to their individual needs (20 U.S.C. § 1400 et seq.; CGS §§ 10-76a to 10-76i). The list of eligible conditions includes serious emotional disturbance, among various other things (e.g., language impairment or a learning disability) (34 C.F.R. § 300.8(a)).
After a parent, school personnel, or other appropriate person refers a child for a special education evaluation, the district must convene a planning and placement team (PPT) to review the referral and determine whether the child requires special education or needs to be evaluated further. Parents have a right to participate in PPT meetings.
If a child is determined eligible for special education services, the specific special education and related services he or she will receive are documented in the child's individualized educational program (IEP). Such related services can include psychological, social work, and counseling services, among several other things (20 U.S.C. § 1401(26)).
For more information about special education law, such as procedures if a parent disagrees with the PPT's determination, see the website for the SDE's Bureau of Special Education: http://www.sde.ct.gov/sde/cwp/view.asp?Q=320730&a=2678.
School Board Policies on Communication with Health or Mental Health Personnel; Prohibition on Schools Recommending Psychotropic Drugs. By law, local and regional school boards must adopt and implement policies prohibiting school personnel from recommending that a child use psychotropic drugs (e.g., antidepressants or stimulants). These polices must set procedures (1) for school health or mental health personnel and other school personnel to communicate with each other about children who may need to be recommended for a medical evaluation, (2) establishing how school health or mental health personnel should communicate the need for evaluation to a child's parents or guardian, and (3) for obtaining proper consent from parents or guardians for such personnel to talk about a child with outside medical practitioners.
The law specifies that these provisions do not prohibit (1) school health or mental health personnel from recommending appropriate evaluation of a student by a medical practitioner or (2) school personnel from consulting with the medical practitioner with the consent of the child's parents or guardian. These provisions also do not prevent a child's PPT team from recommending a medical evaluation as part of an initial evaluation or reevaluation needed to determine a child's (1) eligibility for special education and related services or (2) educational needs for an IEP.
For these purposes, school health and mental health personnel are (1) nurses; (2) nurse practitioners; (3) medical advisors; (4) school psychologists, social workers, and school counselors; and (5) other school personnel whom a school board identifies in its policy as responsible for communicating with a parent or guardian about a child's need for medical evaluation (CGS § 10-212b).
SDE Primary Mental Health Program. The SDE Primary Mental Health Program provides discretionary grants to school districts to support students, primarily in grades K-3, who are having difficulty adjusting to school and may benefit from an early intervention program for the detection and prevention of emotional, behavioral, and learning problems (CGS §§ 10-76t to 10-76x). Twenty-three districts currently receive funding under the program.
School districts use the grants to screen students and hire and train paraprofessionals, called child associates. The associates deliver services during regular individual and group expressive play sessions outside the classroom through which the child develops the trust and acceptance that enable him or her to integrate better into the school setting.
More information is available on the program's website:
How can Parents Access Mental Health Services for their Children?
Parents' access to mental health services for their children depends on their insurance status and what services they are seeking. According to testimony by the DMHAS commissioner and Healthcare Advocate at the January 29, 2013 informational forum, private insurers do not generally cover as wide a range of behavioral health services as public plans.
Private Insurance. Connecticut requires individual and group health insurance plans to cover the diagnosis and treatment of all mental health disorders included in the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.
Insurers must cover mental health conditions in such a way that there is no greater financial burden on the insured than for physical health conditions. This is referred to as “mental health parity.” (State insurance mandates do not apply to self-insured plans, but there is a federal mental health parity law that applies to large group plans whether or not they are self-insured.) For more information on the mental health parity law, including differences between state and federal requirements, see OLR Report 2013-R-0086.
Parents with private insurance seeking mental health services for their children must follow the requirements in their insurance plan. Specific requirements will vary by insurer and by service. For example, many insurance plans require preauthorization for specified mental health services to determine that they are medically necessary. Similarly, some plans (e.g., “gatekeeper” plans) require participants to get a referral from their primary care provider to access such services. Private insurers also typically require plan participants to choose in-network providers in most circumstances or provide reduced reimbursement for out-of-network providers.
If a person thinks an insurance company improperly denied a claim, he or she can file an appeal with the company, and if necessary, subsequently file a complaint with the Insurance Department's Consumer Affairs Division.
If a service is not covered by the insurer, the parent would have to pay out of pocket for the service. Of course, parents with the financial resources to do so may choose to pay for their children's mental health services directly rather than submit the claim to an insurer. See below for information regarding uninsured persons.
Public Insurance. The Connecticut Behavioral Health Partnership (BHP), operated by DCF, DMHAS, and the Department of Social Services, provides a range of behavioral health services to people with public insurance, such as children enrolled in HUSKY A (Medicaid) or HUSKY B (the State Children's Health Insurance Program). ValueOptions, a national managed behavioral health care company, serves as the BHP's administrative services organization. Providers must be Medicaid certified to be included within BHP's provider network.
As with many private insurers, BHP requires prior authorization from ValueOptions for many services, particularly higher levels of care, to ensure that the services are medically necessary and appropriate. Parents who are denied services can appeal the decision with ValueOptions, and then with the Insurance Department or other appropriate state agency, depending on the program providing coverage.
For more information about the BHP, including its history, covered services, membership statistics, appeals process, and governance, see OLR Report 2013-R-0045. The BHP's website is http://www.ctbhp.com/.
Emergency Services Regardless of Insurance Status. If children are not covered by a private or public insurance plan, their parents would typically have to pay for most non-emergency mental health services out-of-pocket. However, in a mental health emergency or crisis, there are options for parents to receive certain emergency services regardless of insurance status or ability to pay.
For example, parents can call 911 or bring their child to an emergency room for stabilization. The federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires all Medicare-participating hospitals that offer emergency services to provide a medical screening examination related to emergency medical conditions, regardless of ability to pay. The hospital must then stabilize any emergency condition it detects before discharging the patient. If the hospital cannot stabilize the patient, it can transfer him or her under specified conditions.
More information on EMTALA is available on the federal Centers for Medicare and Medicaid Services website: http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html.
Also, a parent may obtain crisis intervention services through DCF's Emergency Mobile Psychiatric Services (EMPS) program. EMPS provides a range of crisis and stabilization services, such as mobile assessment, medication consultation, and behavioral management services. The program is accessed by calling the state's 2-1-1 information line. It is available 24 hours per day, seven days per week to all children up to age 18, regardless of insurance status. Children and families may receive stabilization follow-up sessions with EMPS providers for up to 45 days, after which the child must be discharged from the program.
For more information on the program, see OLR Report 2013-R-0082.
Are Parents Guided Through the Mental Health Care System? What Resources are there to Support Children with Mental Health Needs and their Parents?
There are several resources to help parents navigate mental health services and to provide support for both parents and their children. Following are some examples.
DCF. DCF is the primary state agency for children's mental health issues. For children requiring institutional care, the department operates the Albert J. Solnit Children's Center, with campuses in East Windsor (North) and Middletown (South) (formerly the Connecticut Children's Place and Riverview Hospital for Children and Youth, respectively). The North campus provides brief treatment, residential care, and educational instruction to children and youth ages 10-18. The South campus is the only state-administered psychiatric hospital for children.
Through Connecticut Community KidCare, DCF also provides funding for a broad array of clinical and other services in the community, such as outpatient clinics, therapeutic group homes, extended day treatment programs, EMPS (see above), respite care, family advocacy, and intensive case management.
DCF's behavioral health website has information and links to help parents learn about these programs and the behavioral health system. The website is available at http://www.ct.gov/dcf/cwp/view.asp?a=2558&q=314348.
Insurance Department. The Insurance Department's Consumer Affairs division assists consumers with complaints regarding insurance policies issued in Connecticut: http://www.ct.gov/cid/cwp/view.asp?Q=254350.
The department's website also has a frequently asked questions page for consumers regarding mental health benefits:
OHA. The Office of the Healthcare Advocate assists health insurance consumers to understand their rights and responsibilities under managed care plans, including providing assistance with filing complaints and appeals. OHA's website is http://www.ct.gov/oha/site/default.asp.
BHP and Private Insurers. BHP's member handbook contains information on several topics to help guide parents of children who receive services through BHP. The handbook is available at http://www.ctbhp.com/members/info/Member_Handbook-English.pdf.
BHP also has resource guides tailored to specific geographic areas. For example, the guide for the Greater New Haven area is available at http://www.ctbhp.com/docs/DCF_Greater_New_Haven.pdf.
Many private insurers also provide information, either online or in other forms, about accessing mental health services.
Other Agencies or Websites. Various other organizations have websites or resources with helpful information for parents or others trying to navigate the behavioral health system. Here are some examples.
● Child Health and Development Institute of Connecticut: http://www.chdi.org/ and http://www.kidsmentalhealthinfo.com/
● Connecticut Clearinghouse: https://www.ctclearinghouse.org
● Mental Health Association of Connecticut: http://www.mhact.org/
● National Alliance on Mental Illness-Connecticut: http://www.namict.org/
For more information about various state programs for children with special needs (including programs for children with mental health issues), see OLR Report 2012-R-0344.
OHCA's facilities plan includes a table listing several government and private agencies and programs with information about the state's mental health and substance abuse treatment environment: http://www.ct.gov/dph/lib/dph/ohca/publications/2012/ohcastatewide_facilities_and_services.pdf (see section 8.6).
What are the Standards for Screening Children for Mental Health Issues?
There are no universal standards for mental health screening for children. The Administration for Children and Families (ACF), within the U.S. Department of Health and Human Services (HHS), maintains a website with links to several resources related to screening and assessing children's mental health. These resources include various mental health screening tools as well as articles describing best practices or assessing screening methods, among other things. The website is available here:
In 2012, the Substance Abuse and Mental Health Services Administration within HHS produced a comprehensive report titled Identifying Mental Health and Substance Use Problems of Children and Adolescents: A Guide for Child-Serving Organizations. The report discusses in detail the process of screening and identifying children for mental health issues. Appendix B provides overviews of 15 screening tools for child or adolescent behavioral health issues. The report is available at http://www.samhsa.gov/children/508compliant_Identifying_MH_and_SU_Problems_1-30-2012.pdf.