The Freedom Commission Report
Although the report is now almost nine years old, the goals of The Freedom Commission are still a long way from being completed, no matter what state you live in. With the economy down, and the federal government and states scrambling to cover budget shortfalls, it does seem that “Achieveing the Promise” has been derailed, or is parked at the train station, yet again.
One thing that has changed, since the report was originally written, is the number of children and families affected by an emtional, behavioral, or mental health concern. When the report was written, 1 in 5 kids (20%) dealt with at least one of the listed concerns. Now, nine years later, that rate has gone up, current data suggests that 1 in 4 kids (25%) now have a diagnosis of emotional, behavioral, or mental health concern.
The Freedom Commission Report (The Children’s and Families Report) is just below. For additional information, you may wish to review the following:
February 5, 2003
Mental health problems among children and adolescents constitute a public health crisis for our nation. They affect an increasing number of children and youth, impact children and their families in all spheres of life, and result in costly and often tragic consequences. Yet, our nation has failed to adopt a comprehensive, systematic approach in response. At the first ever Surgeon General’s Conference on Children’s Mental Health in 2000, the Surgeon General reported “growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them.” The National Advisory Mental Health Council’s Workgroup on Child and Adolescent Mental Health, after reviewing data on how mental illnesses affect morbidity, mortality, and disability among children, concluded, “no other illnesses damage so many children so seriously.” The extent, severity, and far-reaching consequences of mental health problems in children and adolescents make it imperative that our nation adopt a comprehensive, systematic, public health approach to improving the mental health status of children.
A Public Health Crisis
The scope of this public health crisis can be characterized by the following:
- The problem of emotional disorders in children is large-25% of all children are affected-and seems to be growing.
- Emotional problems in children often are both serious and long lasting, and can lead to tragic consequences: poor academic achievement, failure to complete high school, substance abuse, involvement with the correctional system, lack of vocational success, inability to live independently, health problems, and suicide.
- Youngsters with emotional problems not only have diagnosable disorders but also show significant impairments in important life domains, such as family, education, peers, work, and community.
- The human and financial costs of emotional problems in children are both broad and deep; they affect the children and their families, schools, communities, employers and the nation as a whole. Expenditures for mental health services in the specialty mental health and general health sectors alone were $11.75 billion in 1998.
- A disproportionate number of low-income children experience emotional problems and a disproportionate number of low-income and racial and ethnic minority children do not access services for their emotional problems.
- Youth with emotional problems are invariably involved with more than one specialized service system, including mental health, special education, child welfare, juvenile justice, substance abuse, and health; but no agency or system is clearly responsible or accountable for them.
In response to this identified need, the Subcommittee seeks to advance a new vision for children’s mental health that will make a real difference in the lives of children and their families. The vision calls for a commitment to promote the emotional wellbeing of children and ensure that children with emotional disorders live, learn, work, and thrive in their communities. The vision for children’s mental health is one in which our communities, states, and nation provide access to comprehensive, home and community-based, family-centered services and supports for children with mental health disorders and their families, while at the same time creating conditions that promote positive mental health and emotional well-being and prevent the onset of emotional problems in all children.
Our vision embraces:
- A comprehensive array of home and community-based services and supports to provide treatment and to support the functioning of children with emotional disorders and their families at home, school, work, and in the community;
- The full participation and partnership of families and other caregivers at all levels;
- The recognition that this is a nation of diverse races, ethnicities, and cultures and that services must be culturally competent and equitable for all children and families; and
- Efforts to promote mental health and prevent emotional disorders among children, as well as to identify disorders and intervene early in order to maximize positive outcomes and minimize disability.
The values underpinning our vision reflect certain “standards of care” for children’s mental health:
- Home and Community-Based Care – Children belong in their homes and in their communities and every effort should be made to keep them there and to return them from institutional to home and community settings.
- Family Partnerships – The family is the most important and life long resource in a child’s life, as well as being legally and morally responsible for a child.
- Comprehensive Services and Supports – A broad array of services and supports should be available to children and their families, responding to issues that are biological, neurological, psychological, and social.
- Cultural Competence – Services and systems should be responsive to the cultural perspectives and racial, ethnic, cultural and linguistic characteristics of the diverse populations served.
- Individualized Care – Services should be individualized to each child and family, guided by a comprehensive, single plan of care for each child and family, that addresses strengths, as well as problems and needs.
- Evidence-Based Practices – When state-of-the-art, evidence-based interventions are available, families should be informed of them, and these interventions should be made available to children and families.
- Coordination – Services and systems should be coordinated at the service delivery level, and the agencies and programs that serve children should be linked with those serving adults.
- Early Identification and Intervention – Services and supports should emphasize early identification and intervention, as well as prevention of mental health problems, to maximize the likelihood of positive outcomes.
- Accountability – There should be a clear point of responsibility and accountability for children’s mental health care at all levels.
Expanding on the Commission’s Interim Report, the Subcommittee delineates nine problem areas that hinder the vision for children’s mental health and its underlying values from becoming reality:
- Fragmentation in responsibility and funding
- Lack of family partnerships and family support
- Unmet need and disparities in access
- Gaps in services
- Gap between what we know and what we do
- Lack of prepared workforce
- Lack of focus on prevention and early intervention
- Lack of accountability and quality improvement
- Lack of understanding of mental health problems in children and stigma
Policy Options to Achieve the Vision
The Subcommittee highlights ten policy options as essential strategies to begin building a better system to address the mental health needs of the nation’s children. These ten, followed by implementation options, are the first steps toward achieving the Subcommittee’s vision. In its final report, the Subcommittee offers a more extensive blueprint for building the system.
1. Implement a Comprehensive Approach to Children’s Mental Health at Federal and State Levels
The federal government and each state government should plan and implement a comprehensive, cross-agency, public health approach for promoting, preserving, and restoring children’s mental health. The approach should focus on both strengthening services and supports for children with serious emotional disorders and their families, and on prevention and early intervention strategies for all children.
- Plan and Implement a Cross-Agency, Comprehensive, Public Health Approach for Children’s Mental Health at Federal and State Levels
- Strengthen Children’s Mental Health Focus in State Governments
- Establish a Federal Interagency Entity for Children’s Mental Health
- Re-Institute White House Conferences on Children
2. Finance a Broad Array of Services and Support
Federal and state agencies and commercial insurers should realign funding policies related to children’s mental health to support a comprehensive array of services and supports, including home and community based services and supports that are individualized, family focused, coordinated, and culturally competent.
- Develop a Plan for Medicaid to Support Home and Community-Based Services and Supports and Individualized Care
- Allow Families to Buy Into Medicaid in Order to Access Intensive Rehabilitative Community Services and Supports only Available Through Publicly-funded Systems
- Develop Strategies to Better Align Children’s Mental Health Funding Streams Across Systems
- Maximize Strategies to Provide Coverage and Mental Health Care to Uninsured Children
- Develop Strategies to Increase Coverage of Home and Community-Based Services, Preventive Interventions, and Screening in Private Insurance and Managed Care Systems
- Demonstrate Home and Community-Based Alternatives to Medicaid-Funded Psychiatric Residential Treatment
- Provide Technical Assistance Related to More Efficient and Effective Implementation of (EPSDT) Early and Periodic Screening, Diagnosis, and Treatment
3. Strengthen Family and Youth Partnerships and Family Support
Federal, state, and local governments should ensure that families, substitute families, and other caregivers, as well as youth, are full partners and have substantial involvement in all aspects of service planning and decision making for their children at federal, state, and local levels.
- Implement Strategies to Prevent the Unnecessary Transfer of Custody in Order to Provide Care
- Review and Strengthen Federal and State Requirements for Family Participation
- Expand Support for Family Organizations to Provide Information and Training
- Provide Coverage for Family Support Services in Public and Private Insurance
4. Individualize Care: A Single Plan of Care for a Child and Family
States should ensure that each child with a serious emotional disorder has an individualized, single plan of care (Individualized Service and Support Plan – ISSP) that addresses the child and family’s needs across life domains and incorporates services and supports from all needed agencies and systems.
- Develop and Implement an Individualized Service and Support Plan (ISSP) for Each Child with a Serious Emotional Disorder
- Provide Technical Assistance on Individualized Service Planning (Developing a Single Plan of Care) and Providing Individualized Care
5. Broaden the Range of Services and Supports and Build Capacity
Federal and state governments should promote a broader concept of “mental health” services for children and adolescents with emotional disorders and their families. This concept should include the comprehensive array of treatment services and supports needed to enable these youngsters to reach and maintain their optimal level of functioning within their homes, schools, and communities.
- Develop a Model Benefit Design for Children’s Mental Health Services for public and private insurers
- States and Foundations Initiate Demonstration Programs of Services and Supports Considered to be High Priority Service Gaps
- Implement a Demonstration of Respite Services for Caregivers of Children with Serious Emotional Disorders
- Provide Support for Research in the Area of Psychopharmacology for Children
- Provide Incentives to State Governments to Invest in Building Service Capacity
- Increase Development of Services for Youth with Co-Occurring Substance Abuse and Mental Health Disorders
- Develop State Plans to Improve Access to High Quality, Culturally Appropriate Mental Health Services for Racial and Ethnic Minority Youth with Emotional Disorders
6. Strengthen Mental Health Services to Children Within Schools
Recognizing that children receive more services through schools than any other public system, federal, state, and local agencies should more fully recognize and address the mental health needs of youth in the education system. Likewise, these agencies should work collaboratively with families and develop, evaluate, and disseminate effective approaches for providing mental health services and supports to youth in schools.
- Strengthen Mental Health Services in Schools and Schools’ Role in Promoting Social and Emotional Well Being
- Expand Prevention/Early Intervention Approaches and Positive Behavioral Supports in Schools
- Train Teachers and School Personnel to Recognize Signs of Emotional Problems in Children and to Make Appropriate Referrals for Assessment and Services
- Create a State-Level Infrastructure for School-Based Mental Health Services
- Ensure State Special Education and Related Services for Children with Emotional Disorders Under IDEA
7. Screen High-Risk Populations (Juvenile Justice and Child Welfare Populations) and Link Them with Services
Systematic screening procedures to identify mental health and substance abuse problems and treatment needs should be implemented in specific settings in which youngsters are at high risk for emotional disorders or where there is known to be a high prevalence of these or co-occurring mental health and substance abuse disorders. Screening should be implemented upon entry into, and periodically thereafter in, the juvenile justice and child welfare systems, as well as in other settings and populations with known high risk, such as the Medicaid population. When mental health problems are identified, youth should be linked with appropriate services and supports.
- Analyze Existing Tools for Screening and Identifying Mental Health Problems and Support Research to Develop New Tools Where Needed
- Incorporate Developmentally and Culturally Appropriate Behavioral Health Screening into EPSDT Screens
- Improve training for professionals in Schools, Child Care and Primary Health Systems to Recognize Signs of Mental Health Problems and Take Appropriate Action
- Screen High Risk Children in Settings with High Prevalence (Juvenile Justice and Child Welfare Systems) and Link to Services
8. Strengthen Early Childhood Mental Health Interventions
A national effort focusing on the mental health needs of young children and their families should be implemented. Grounded in emerging neuroscience research highlighting the ability of environmental factors to shape brain development and subsequent behavior, this effort should include educating parents, the public, and professionals about the importance of the first years of a child’s life for developing a foundation for healthy social and emotional development.
- Develop a Collaborative State Plan for Early Childhood Mental Health
- Provide Technical Assistance to States to Implement a Comprehensive Approach to Early Childhood Mental Health Services
- Explore Feasibility of Coverage for Early Childhood Mental Health Services in Public and Private Insurance and Eliminate Barriers to Coverage
- Train Mental Health Practitioners to Diagnose and Treat Mental Health Problems in Young Children and Families
9. Prevent Mental Health Disorders
The federal government should develop and implement a comprehensive approach for enhancing the well being of children and adolescents, based on a bio-psychosocial model, through preventive interventions prior to the onset of mental and behavioral disorders.
- Screen All Children Ages 0 to 5 for Social and Emotional Development as Part of Primary Health Care Visits
- Provide Mental Health Screening in Community Health Centers
- Address Barriers to Coverage of Preventive Intervention Services in Health Insurance
10. Build an Adequate Workforce
The federal government should work in partnership with state governments, national accrediting organizations, professional disciplines and organizations, licensure entities, family organizations, and universities to ensure an adequate workforce for the delivery of children’s mental health services.
- Develop and Implement a Strategic Plan to Develop the Children’s Mental Health Workforce
- Develop and Implement a Strategic Plan to Address the Workforce Crisis in Mental Health Services and Research for Racial and Ethnic Minority Youth and their Families
Like I mentioned above, you may wish to review the following: