HelpingNot HarmingChildren and Youth with Behavioral Health Needs and their Families: Recommendations to Improve H.R.

3717 (Helping Families in Mental Health Crisis Act of 2013)

H.R.3717 has several important and well-considered components that should be supported, including, as Mental Health America notes, provisions that would reauthorize the Garrett Lee Smith Memorial Act (suicide prevention; S. 116/H.R. 2734), Mental Health First Aid (S. 153/H.R. 274), Children's Recovery from Trauma Act (S. 380), Excellence in Mental Health Act (S. 264/H.R. 1263), Justice and Mental Health Collaboration Act of 2013 (S. 162/H.R. 401) and the Behavioral Health IT Act (S. 1517,S.1685/H.R. 2957). However, much of H.R. 3717 is to the detriment of children with serious behavioral health needs and their families, transition-aged youth with behavioral health challenges, and adults with serious and persistent mental illness and substance use disorders. As outlined in the table below, key elements of the legislation

Will limit the freedom of choice of families, youth, and consumers by prioritizing deemed evidencebased practices instead of promoting the availability and accessibility of evidence-based, evidence/research-informed, and promising practices that have are effective with diverse populations of children and youth and their families; Creates additional, unnecessary levels of bureaucracy that will cost taxpayers more money without any likelihood of improved quality or effectiveness of services; Overreaches into the Executive Branch of the U.S. Government, micromanaging the Secretary of the U.S. Department of Health and Human Services with respect to the programs funded, the individuals hired, and the committees utilized; Unjustifiably favors individuals with medical degrees or individuals with doctoral degrees in psychology for positions on oversight committees and peer review panels, as well as to serve in critical leadership roles, without incorporating family and youth voices or recognizing the particular skill set required by these individuals which may be best represented by an individual with a different educational background or training.

Recommendations in this bill are narrow in focus and are reactionary in their solutionsequating guns and violence with mental illness, promoting a medical model over systems of care, and legislating the daily activities of the Executive Branch. Although the sponsors of the bill are to be commended for their focus on the needs of children, youth and adults with behavioral health disorders and their families, significant revisions are needed to this legislation.
What we canand shoulddo: Support the pieces of the legislation listed above that really help children and families, and remove the parts that are focused on micromanagement of federal government Promote universal prevention and focused early intervention models for children and youth based on what we know about Adverse Childhood Experiences (ACEs) and how adults who experienced multiple ACES are more likely to have significant health problems, even leading to earlier death Support the Presidents Budget that includes Changes to permit community alternatives to psychiatric residential treatment facilities under 1915(c) Waivers and A five-year ACF-CMS competitive demonstration project to encourage states to implement evidencebased psychosocial interventions for youth in the foster care system as an alternative to overreliance on psychotropic medications. Askand listen tofamily members (including at the National Federation of Families for Childrens Mental Health and the Family-Run Executive Directors Leadership Association [FREDLA]) and youth (including Youth M.O.V.E. [Motivating Others through Voices of Experience] National) to find out which services and supports really made a difference for them in their journey, and which challenges they continue to face.

For more information on elements of the legislation that are of concern, but not addressed here, members of Congress are strongly urged to review Dr. Sherns testimony on behalf of Mental Health America to the House Committee on Energy and Commerce (http://energycommerce.house. gov/hearing/helping-familiesmental-health-crisis-act-2013) and the joint statement by NCMHR with the National Disability Rights Network (NDRN) and the Bazelon Center for Mental Health Law (http://www.ncmhr.org/pressreleases/12.12.13.htm).

The following table presents some of the aspects of HR3717 that are of greatest concern with regard to children, youth and families. HR 3717 Section Issue Concern Page # 4 Title I Assistant Creates the position of This position creates additional layers of bureaucracy, particularly as the duties Secretary for Mental Assistant Secretary for Mental described are already in place under the responsibility of the Administrator. The Health and Substance Health and Substance Use creation of this new position will cost taxpayer money for no clear benefit. Use Disorders Disorders to directly Additionally, the requirements associated with this position unnecessarily favors supervise the Administrator of the medical profession or those with a doctoral degree in psychology, without SAMHSA regard to individuals who may understand the complexity of policy, statute, financing, and systems design in addition to the clinical needs of the populations it serves. Many of the nations strongest leaders in the behavioral health field are individuals with masters degrees, including in the fields of social work, public administration, and public health. Individuals with clinical training are not inherently better positioned to lead government organizations. The positionas Administrator or as Assistant Secretaryshould be deemed qualified not be the exact nature of the degree but instead by his or her experiences working in and on behalf of the populations of focus, including from an administrative and systems perspective. 14 Sec. 102 Interagency Establishes an interagency The establishment of another committee creates unnecessary bureaucratic layers Serious Mental Illness committee to assist the in the decision-making process. Additionally, the Committee does not include family Coordinating Comm. Assistant Secretary members, youth, social workers, child welfare experts, or Medicaid experts. 100 Title XI-SAMHSA Requires that peer review See notes above regarding overreliance on the medical model and clinically trained Reauthorization and panels be at least 50% psychologists without a balance of individuals who are experts in systems design, Reforms, Subtitle Acomprised of individuals with financing, policy, service array, evidence-based and promising practices, or cultural and Organization and a medical degree or a doctoral linguistic competence. Of particular significance is the absence of a requirement for a General Authorities degree in psychology percentage of the members to be youth, consumers, or family members. 129, 133 Subtitle CChildren Requires the Assistant Service arrays are not comprised entirely of evidence-based practices. Federal With Serious Secretary to consult with the funding to support the rigorous research designs necessary to test evidenceEmotional National Institutes of Health based practices, which comes primarily from NIH, has been very limited in its Disturbances to ensure that grant recipients focus on children and youth with serious behavioral health needs. Research in SEC. 1121. will use evidence-based childrens behavioral health has also demonstrated that utilizing components of Comprehensive practices. evidence-based practices or implementing evidence-informed service delivery models Community Mental can be as effective for children and families as an EBPand often at lower costs. The Health Services for Prohibits SAMHSA from primary focus should be on ensuring that the services and supports that are Children with Serious providing financial assistance available to children, youth and families are effective, not that they have been Emotional for any program relating to deemed an evidence-based practice. The federal government should be Disturbances mental health or substance promoting the availability and accessibility of evidence-based, use diagnosis or treatment, evidence/research-informed, and promising practices that have are effective with Subtitle F-Limitations unless such diagnosis and diverse populations of children and youth and their families. Services and on Authority treatment relies on evidencesupports should be individualized, culturally and linguistically competent and relevant, based practices. and home- and community-based. The entire population of children and youth with serious behavioral health needs do not require evidence-based practices. Instead, they require services that have been found to be effective in maintaining them in their homes 2

HR 3717 Page #

Section

Issue

Concern and communities, improving functioning, and promoting health and well-being. Excerpt from Bernstein, Bae, Daleiden, Southam-Gerow, and Chorpita (2013), published by the American Psychological Association (http://www.apa.org/pi/families/resources/newsletter/2013/04/ebt-programs.aspx):
The evidence-based practice (EBP) movement of the past two decades represents a revolution in the science of psychosocial treatment service quality. Nonetheless, the complexity of leveraging science to optimize or even just improve service has proven substantialaspects of the sciencepractice gap have come into focus more gradually as systems struggle to make use of the bounty of the evidence-based practice movement to serve complex client populations with diverse clinical needs. A principal challenge among those is the growing realization that packaged evidencebased (EBT) products, e.g., programs developed and tested successfully for individual groups, do not and simply cannot exist for every child and context (cf, Kazdin, 2008). [Emphasis added]

134

Section 1152 Elimination of Unauthorized SAMHSA Programs.

Prohibits SAMHSA from establishing & HHS Secretary from delegating responsibility for any program/project not explicitly authorized or required by statute; Requires the termination of any SAMHSA program or project not explicitly authorized or required by statute by end of FY14.

Limiting the service array to evidence-based practices limits the availability of services and reduces the freedom of choice of families and youthparticularly for families and youth of color, who are already over-represented in the public child- and family-serving systems. Additionally, HHS does not need assistance to clarify whether a grantee is utilizing an evidence-based or promising practice as defined by, for example, the Washington State Institute for Public Policy or the California Clearinghouse on Evidence-Based Practices in Child Welfare. A broader focus on evidence-based, evidence/research-informed, and promising practices will strengthen the field of childrens behavioral health services, including diversifying the types of effective interventions that are made available to children and their families. This requirement infringes on the ability of the Executive Branch of the Government to use flexibly those funds within its discretion to meet the needs of families, youth, individuals, and communities. If legislation fails to progressincluding for reasons other than meritHHS is positioned by Congress to fail in meeting the needs of individuals with behavioral health needs. Congress is unable to predict what communities, states, tribes, organizations, and families will need and cannot guarantee that it has fully addressed every possible challenge that may arise and has authorized the appropriate program or funding to address it. The Secretary of HHS is approved by Congress and should be given the latitude appropriate to his or her position to ask the professionals under his or her direction to create or administer programs within the scope of the Administration and budget to address challenges and needs as they arise.

Resources to learn more about the complex service and resource needs of children and youth with behavioral health challenges: To learn more about services and supports that have proven to be effective in terms of cost, quality and outcomesin serving children and youth in their homes and communitiesbut that are not necessarily deemed evidence-based practices: http://medicaid.gov/Federal-PolicyGuidance/Downloads/CIB-05-07-2013.pdf To read a brief on childrens behavioral health expenditures under Medicaid and the implications for public poli cy: Identifying Opportunities to Improve Childrens Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures: http://www.chcs.org/usr_doc/Identifying_Opportunities_to_Improve_Children's_Behavioral_Health_Care.pdf