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Inadequate state children's mental health structure hampers chances for improved care

October 11, 2016

State agencies charged with the treatment of children who have mental health and substance abuse conditions are missing out on opportunities to improve care. They are unable to capitalize on chances to advance prevention, care coordination and integration with primary care, according to a national survey of state agency directors.

The 48 children's mental health directors (from 46 states, one territory, and Washington, DC) surveyed offered an uneven picture of poorly organized state agency structures.

The first of its kind, the findings from the "National Survey of Children's Mental Health Directors: Current Status and Future Directions," are published in the latest issue of The Journal of Behavioral Health Services & Research (JBHS&R). JBHS&R is published by the National Council for Behavioral Health, an association of 2,800 mental health and addiction providers, and Springer.

"The directors we surveyed are concerned that children's services are thought of as an 'afterthought' and often driven by adult behavioral health services," said study author Dr. Mario Hernandez, PhD with the University of South Florida (USF) in Tampa.

Survey respondents reported concerns related to three main areas:

Workforce capacity- there is a scarcity of "highly qualified providers, overall workforce shortages and insufficient state supported technical assistance to the workforce." According to the study, "without sufficient financing or opportunities for career advancement it is difficult to keep qualified workers in the public sector."

Accessibility and availability of services- the workforce shortage has resulted in a dearth of services. Interestingly, Medicaid-eligible families "have access to a broader array of children's mental health services and supports than privately insured families." The out-of-pocket costs for people covered by private insurance make obtaining mental health services "prohibitive."

Stigma/lack of public awareness- "stigma of mental illness is still alive and well," and children are affected because the "shame and responsibility felt by parents often prevents early identification and treatment." The directors urged increased public awareness and understanding about mental illnesses as a key factor to increasing access to services.

The state children's mental health directors surveyed by the USF team also cited a lack of data and quality assurance systems, interagency collaboration and coordination as concerns affecting the quality of children's mental health services.

"What's lamentable is that more attention and money is given to adult, than children's, services. As a result, there's scant attention to early intervention when we know that works well for kids," Dr. Hernandez added.

ACA Implementation

Poorly organized state children's mental health offices have created a dichotomy when it comes to implementation of the Affordable Care Act (ACA).

A substantial majority of the directors (81%) perceives significant opportunities to improve accessibility and availability of services through reform in two notable areas: expansion of Medicaid eligibility, and inclusion of mental health services as an Essential Health Benefit on private health insurance plans.

Directors also see opportunities for greater integration of behavioral health and primary care such as the training of pediatricians on how to identify mental health conditions in their young patients, and including behavioral health consultants within pediatric offices.

Yet, for all the promise of not only the ACA, but also the Mental Health Parity and Addiction Equity Act, barriers to progress remain due to political and cultural resistance to reform.

The country is essentially split when it comes to states planning for implementation of the ACA, and those that are not. One hundred percent of directors in the east and 91% of those in the west are planning for implementation. Directors in the midwest and south (42% and 39%, respectively) however, are not making such plans. The result is that only about two-thirds (67%) of directors are planning to leverage the law's benefits.

"The stark reality is that at a time when one half of American youth experience a mental health disorder, 50-70% of which never receive services, children in some states will have a mental health safety net, and many will not," Dr. Hernandez said.


The survey of state children's mental health directors resulted from 17 online, closed and open-ended questions administered by Qualtrics, a web-based survey program. USF utilized The National Association of State Mental Health Program Directors' established regions to identify the mental health directors of all 50 states, 1 U.S. territory, and Washington, D.C. The survey was administered between September 2013 and March 2014.
The Journal of Behavioral Health Services and Research (JBHS&R) is a quarterly, peer-reviewed, multidisciplinary journal that publishes articles on the organization, financing, delivery, and outcomes of behavioral health (including mental health, alcohol, and drug abuse) services. It is the official publication of the National Council for Behavioral Health. To learn more about JBHS&R, visit

The National Council for Behavioral Health is the unifying voice of America's mental health and addictions treatment organizations. Together with 2,800 member organizations, serving 10 million adults, children and families living with mental illnesses and addictions, the National Council is committed to all Americans having access to comprehensive, high-quality care that affords every opportunity for recovery. The National Council was instrumental in bringing Mental Health First Aid to the USA and more than 500,000 individuals have been trained. In 2014, the National Council merged with the State Associations of Addiction Services (SAAS). To learn more about the National Council, visit


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