CHILDREN'S MENTAL HEALTH STUDY COMMITTEE

Final Report of the House Study Committee on Children's Mental Health

The Honorable Katie Dempsey Chair State Representative, District 13
The Honorable Joyce Chandler State Representative, District 105

The Honorable Pat Gardner State Representative, District 57
The Honorable Rick Jasperse State Representative, District 11
The Honorable Randy Nix State Representative, District 69

INTRODUCTION
House Resolution 641 created the House Study Committee on Children's Mental Health (the "Committee"} for the purposes of:

examining early intervention and prevention services; identifying available resources for children with mental health issues; and evaluating possible improvements in the delivery of services.

Representative Katie Dempsey, Chairman of the House Human Resources Appropriations subcommittee, served as the Committee's Chairman. Other members were: Representative Joyce Chandler, Representative Pat Gardner, Representative Rick Jasperse, and Representative Randy Nix.

The Committee held public hearings at the Coverdell Legislative Office Building in Atlanta on

four dates: September 10, 2015, October 20, 2015, November 9, 2015, and November 18, 2015.

During these meetings, the Committee heard testimony from various state agencies including:

the Department of Education (DoE}, the Department of Behavioral Health and Developmental

Disabilities (DBHDD}, the Department of Human Services (DHS}, the Department of Community

Health (DCH}, the Department of Juvenile Justice (DJJ}, and the Department of Early Care and

Learning (DECAL}. Additionally, the Committee heard from the three major care management

organizations

in

Georgia:

Amerigroup

Community

Care,

Peach

State

Health

Plan,

and

Wei1Care

1 .

The Committee also heard testimony from health care professionals in the fields of psychiatry

and psychology, and finally, from organizations such as Mental Health America of Georgia,

Georgia Parent Support Network, Voices for Georgia's Children, and Georgia Association of

Community Service Boards (CSB}. (See Appendix A for a full list of presenters.}

The testimony from the above-mentioned organizations led to the identification of the following issues and the formulation of the accompanying recommendations to address the challenges related to the delivery of children's mental health services.

BACKGROUND

Nationally,

one

in

five

children

birth

to

18

has

a

diagnosable

mental

health

problem

2

However,

75-80%

of

children

in

need

to

mental

health

services

do

not

receive

them

3

Children

who

do

not

receive mental health services face significant obstacles when it comes to academic, career and social/emotional development4

1 The Georgia Department of Community Health has since awarded a fourth contract to CareSource Georgia to
provide services to the Georgia Families Care Management Organization. 2 United States Department of Health and Human Services. The National Institute of Mental Health. Disorders
Among Children. Retrieved 2015. 3 Kataoka, S.; Zhang, L.; Wells, K. (2002). Unmet Need for Mental Health Care among U.S. Children: Variation by
Ethnicity and Insurance Status. American Journal of Psychiatry. 4 Froeschle, J., & Moyer, M. (2004). Just cut it out: Legal and ethical challenges in counseling students who self-
mutilate. Professional School Counseling.

CHILDREN'S MENTAL HEALTH SERVICES In Georgia, children's mental health services are administered through a variety of sources: programs administered by state agencies (such as DBHDD, DoE, DECAL, DJJ, and DHS), schools (through school nurses, school counselors, school psychologists, and school social workers), clinical social workers, mental health therapists, psychologists, psychiatrists, and pediatricians.

The Department of Behavioral Health and Developmental Disabilities (DBHDD) provides

services to over 25,000 youth (ages 4-26) in Georgia through community based services such as

mental

health

clubhousess,

psychiatric

residential

treatment

facilities

6 ,

care

management

entities7, mobile crisis response services, crisis stabilization units8, and behavioral health crisis

centers9 DBHDD also created a pilot grant initiative called Georgia Apex Project (GAP). GAP

grants were provided to 24 of DBHDD's Tier 1 Providers, Community Services Boards,

throughout the state to support the hiring of behavioral health staff (i.e. licensed mental health

clinicians, community support individuals, etc.). GAP teams will be school-based, helping ensure

access for students in need of behavioral health intervention.

Georgia's Department of Education (DoE) does a number ofthings to combat mental health issues in schools. In 2015, DoE, in collaboration with DBHBB and several experts in the field of suicide prevention, developed, published, and distributed to each school system the State Model Policy for Suicide Awareness, Prevention, Intervention and Postvention. Additionally, DoE received a federal grant to administer Project AWARE (Advancing Well ness and Resilience Education) to exp;md the capacity of state and local educational agencies to increase awareness of mental health and substance abuse issues among school-age youth. DoE is also implementing Positive Behavioral Interventions and Supports (PBIS) in over 350 schools in 50 school systems, and 28 additional school districts have requested PBIS training. PBIS is a proactive approach to establishing the mental health supports and social culture needed for all students to achieve social, emotional, and academic success. It is a framework for changing school climate to be more positive, supportive, safe and secure10.

Of school-age children who receive mental health services, almost 80% receive them at school

through

school

nurses,

school

counselors,

school

psychologists,

and

school

social

workers

11 .

5 Georgia has 6 Mental Health Clubhouses throughout the state: Rabun Clubhouse (Tiger/Avila Community
Services), Connect (Milledgeville/River Edge CSB), The Spot (Atlanta/CHRIS Kids), Aspire (Albany/Albany CSB), Shine
(Statesboro/Pineland CSB), and iCiub (Jackson/Mcintosh Trail). DBHDD is creating 6 additional clubhouses in FY16
located in: Douglas, Bartow, Newton, Thomas, Laurens, and Muscogee counties. 6 Georgia has 7 PRTFs throughout the state: Youth Villages (Douglasville), Devereux (Kennesaw), Hillside (Atlanta),
Laurel Heights (Atlanta), Lake Bridge (Macon), lighthouse (Augusta), and Coastal Harbor (Savannah). 7 ViewPoint Health and Lookout Mountain CSB currently house aCME. 8 Georgia has 4 CSUs: Hopes Corner (Greenville), Lakeside (Bloomingdale), River Edge (Macon), and ViewPoint
Health (Decatur). 9 There are currently five BHCCs in Georgia. 10 Sugai, G. and Horner, R.H. (2008). What we know and need to know about preventing problem behavior in
schools. Exceptionality. 11Atkins, M., Hoagwood, K. E., Kutash, K., & Seidman, E. (2010). Toward the integration of education and mental
health in schools. Administration and Policy in Mental Health.

School riurses collaborate with school personnel, community health care professionals, students and families, in the assessment, identification, intervention, and referral of children in need of mental health services. Georgia has approximately 1,555 licensed school nurses, which is a ratio of 1:1,093. School counselors respond to the need for mental health and behavioral prevention, early intervention and crisis services that promote psychosocial well ness and development for all students. Georgia has approximately 3,400 school counselors, which is a ratio of 1:500. School psychologists screen, evaluate, identify and make referrals for children exhibiting mental health problems. Georgia has approximately 750 school psychologists, which is a ratio of 1:2,475. Finally, school social workers have special expertise in understanding family and community systems and linking students and their families with community services essential to promote student success. Georgia has approximately 620 school social workers, which is a ratio of 1:2,742.
The Department of Juvenile Justice provides mental health services to youth in 26 secure facilities in Georgia. These secure facilities include 7 Youth Detention Campuses (YDCs) and 19 Regional Youth Detention Centers (RYDCs). Every secure facility has a Mental Health Treatment Team consisting of: a Master's level mental health clinician, a psychiatrist, a psychologist, and a registered nurse. In addition to these individuals, the Mental Health Treatment Team at a YDC also includes a substance abuse counselor. Youth are screened for mental health, substance abuse, and suicide risk within two hours of admission by a masters-level clinician. All youth receive services for suicide prevention, crisis intervention, and special management planning. Youth with mental health challenges receive individual therapy, group therapy, treatment planning, and medication, if necessary.
The Department of Human Services (DHS), through the Division of Family and Children Services (DFCS), provide mental health services to children in foster care. These children receive a social/psychological assessment upon entering DFCS custody. If necessary, children receive psychotropic medication. In order to make sure children are not over medicated, DFCS staff participate in psychopharmacology round table meetings to privately discuss a child's medical needs in order to ensure they are receiving the right medication and dosage. Further, as a part of their initial job training, DFCS officers are trained to identify mental health problems through webinars administered by their local DFCS office.
EARLY PERIODIC SCREENING, DIANOSTIC, AND TREATMENT (EPSDT) EPSDT is a five step process: 1) assess and identify problems early; 2) check children's health periodically; 3) provide physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems; 4) perform diagnostic tests to follow up when a health risk is identified; and 5) correct, reduce or control health problems found. The state's Medicaid agency, the Department of Community Health, is required to inform all Medicaid-eligible individuals under age 21 that EPSDT services are available; provide or arrange for the provision of screening services for all children; arrange (directly or through referral) for corrective treatment as determined by child health screenings; and report EPSDT performance information annually. EPSDT is utilized by pediatricians to improve the health of low-income children with special physical, emotional, and developmental health care needs. This benefit

supports children and youth with special health care needs by ensuring they receive individualized health care when they need it.

CHALLENGES 1. Workforce Shortages A key aspect of EPSDT is the step between diagnosis and treatment. Pediatricians are often the first to diagnose mental health illnesses in children. Typically, the pediatrician will refer that child to a psychiatrist or psychologist for treatment. However, due to a workforce shortage of child psychiatrists and child psychologists, children often go untreated. An April 2009 Health Affairs study reported that pediatricians were more likely than other primary care physicians to be unable to refer their patients to outpatient mental health services. In Georgia, the shortage is compounded by the fact that there are only six graduating child psychiatrists per year. Georgia has approximately 1,050 psychiatrists, which is a ratio of 1:2,38012 Additionally, Georgia has approximately 3,200 psychologists, which is a ratio of 1:781. Further, the number of students in psychiatry training programs has declined from 1.35 per 100,000 citizens to 1.1813. The majority of child psychiatrists and psychologists do not devote all of their clinical hours to children and adolescents, rather they see a mixture of adult and child and adolescent patients. In fact, over 50% of Georgia's psychiatry patients are over the age of 5514 The chart below, prepared and presented to the Committee by Voices for Georgia's Children, shows the workforce shortage mental health specialists in Georgia.

::.. ~t~A_ - ---

J Counties without licensed psychologist
I I Counties without licensed social worker

Counties without licensed psychologist or licensed social worker
County with parent and peer support specialists
0 County with child parent
psychotherapy

0

Project Apex (DBHDD): Community Service Board (CSB) providing school-based services

iill DBHDD Mental Health Resiliency Club House Locations
A Counties with behavioral health/CSB ser-
vices provided through

12 McDonald, W. (2013). Psychiatric workforce in Georgia. Presentation to the Georgia House Study Committee on
Mental Health. 13 1bid. 14 1bid.

2. Fragmentation State agencies oversee a vast array of programs that are geared toward improving outcomes for children with mental health issues. Although there are several programs where multiple agencies collaborate, the Committee believes that the collaboration between agencies can be enhanced to ensure that children in Georgia with mental health challenges are served efficiently and effectively.
RECOMMENDATIONS Based on the challenges addressed in the preceding section, along with the information gathered from the Committee hearings, the Children's Mental Health Study Committee recommends the development of a Children's Mental Health State Strategic Plan to provide comprehensive, accessible and coordinated mental health prevention, early and timely interventions, and appropriate treatment services for children. Many of these recommendations do not require additional funding because they leverage existing resources. Further, the Committee recommends implementing these recommendations as soon as possible.
The Children's Mental Health State Strategic Plan includes the following elements: 1. Annual recommendations from an advisory committee for the State budget for children's access to mental health prevention, early intervention and timely interventions, and treatment across State agencies, based on assessment of mental health services and resources and needed resources (including plans to integrate local, . State, and federal funding sources) 2. Develop a State mental health workforce plan across State agencies with a managed and budgeted scale-up plan that includes as a combined mental health service group: a. Psychiatrists b. Psychologists c. Clinical social workers d. Mental health counselors/therapists e. School nurses f. School counselors g. School psychologists h. School social workers 3. For mental health workforce development incentives, offer students studying psychiatry or psychology loan forgiveness in exchange for committed time of a minimum ofthree years to work solely serving Georgia's children 4. Develop a community psychiatry fellowship program (public/private partnerships with universities (i.e., 70 percent grant fellowship grants; 30 percent DBHDD) [See New York/Columbia University model; Connecticut/Yale University model; Texas/University of Texas Southwestern model15]
15 McDonald, W. (2013). Psychiatric workforce in Georgia. Presentation to the Georgia House Study Committee on Mental Health.

5. Add psychiatry training, with a focus on child psychiatry, in medical school rotations 6. Expand mental health training of pediatric primary care physicians to provide mental
health services for children 7. Develop a clearinghouse of children's mental health research and best practices (within
the comprehensive plan) to disseminate to schools, practitioners, and others through training, technical assistance, and educational materials 8. Expand PBIS to provide full-time School Climate Specialists at each RESA to augment efforts to improve school climate and to improve the conditions for learning 9. Expand implementation of PBIS to early learning centers to support social, emotional, intellectual, and behavioral development and link to K-3 grades to create continuity of positive learning climates 10. Expand language nutrition awareness and training to parents/guardians, nurses, school nurses, caregivers, early learning centers, and kindergarten teachers 11. Create grants to expand social and emotional learning training to more school systems and include Pre-K 12. Support the development of a State sustainability plan for Project AWARE (Mental Health First Aid Training and coordination of community mental health services for students) and expand Mental Health First Aid training to include more teachers and school administrators 13. Support the development of a State sustainability plan for Georgia Apex Project (Community Service Boards working to provide mental health services to students in the school setting) as a framework of mental health services, training, and collaboration 14. Create grants for schools to expand and augment substance use and abuse education 15. Broaden access to healthcare and mental health services by expanding telemedicine and tele-mental health services and include coordination with Care Management Organizations (Medicaid) 16. Develop partnerships of facility usage for cross-functioning training opportunities, dissemination of information, and technical assistance between and among:
a. Community Service Boards Centers b. Region Public Health Centers c. Regional Educational Service Agencies d. Workforce Development Centers e. Juvenile Courts f. University System of Georgia g. Technical College System of Georgia h. Community schools (high schools) i. Public libraries j. DFCS offices

Mr. Speaker, these are the findings and recommendations of your Study Committee on Children's Mental Health. Respectfully Submitted,
~L;~.~~Vl
\ j The Honorable Katie Dempsey
Chair State Representative, District 13
State Representative, District 105
:Pat:~~
The Honorable Pat Gardner State Representative, District 57
1ck Jasperse sentative, District 11

APPENDIX A
Below is a list of speakers for each of the four public hearings of the Study Committee on Children's Mental Health.
September 10. 2015 1. Garry W. McGiboney, Ph.D. Deputy Superintendent, External Affairs Georgia Department of Education 2. Matt Yancey Director, Office of Children, Young Adults, and Families Georgia Department of Behavioral Health and Developmental Disabilities 3. Ellyn Jeager Director, Public Policy & Advocacy Mental Health America of Georgia 4. Talley Wells Director, Disability Integration Project Atlanta Legal Aid Society, Inc.
October 20. 2015 1. Sue Smith Georgia Parent Support Network 2. Marcey Alter Assistant Chief, Medicaid Department of Community Health 3. Earlie Rockette Regional Vice President and Georgia Families 360 Executive Director Amerigroup Georgia 4. Jeff Luce Clinical Director for Behavioral Health Peach State 5. Dauda Griffin, MD and Reme Rodriguez, Sr. WeiiCare of Georgia 6. Kathy Colbenson Chief Executive Officer CHRIS Kids
November 9. 2015 1. Dianne Kelly and Dr. Debora Johnson Division of Family and Children Services Department of Human Services 2. Dr. Sarah Vinson Child Psychiatrist 3. Miguel Fernandez, LCSW, CADC Deputy Commissioner, Division of Support Services Department of Juvenile Justice Dr. Christine Doyle Director, Office of Behavioral Health Department of Juvenile Justice

November 18, 2015 1. Gerald Clark, M.D. Georgia Chapter of the American Academy of Pediatricians 2. Susan Adams, Assistant Commissioner for Pre-K and Instructional Supports Jennie Couture, Director of Instructional Supports Department of Early Care and Learning 3. Erica Fener Sitkoff, Ph.D. Policy & Outreach Director Voices for Georgia's Children 4. Gwen Skinner Executive Director Devereux 5. Robyn Garrett-Gunnoe, Director, Georgia Association of Community Service Boards Heather Stanley, CME Director, Lookout Mountain Community Services Cindy Levi, CEO, Avita Community Partners