1. Setting the Stage: The Current Landscape of Children’s Mental Illness in North Carolina E. Jane Costello, Ph.D. Duke University

2. Examples from Great Smoky Mountains Study N=1,420 youth Aged 9 – 13 in 1993 Evaluated up to 10 times since Most recently at age 21 Psychiatric disorders Medical illness Physical development Family, school, and neighborhood risk

4. What is child mental illness? Mental illnesses are disorders of the brain that cause Emotional and behavioral symptoms oExamples: suicidal behavior, uncontrollable compulsive rituals Impairment of normal functioning oExamples: falling grades, disrupted relations with parents, friends SED is defined as a mental illness that causes significant functional impairment

5. Why does child mental illness matter?  These disorders cause great suffering to children and their families  Children fail to achieve what they could at school and work  Children have reduced options later in life  They place a heavy burden on all public agencies that serve children - education, juvenile justice, child welfare, pediatrics and mental health agencies

6. Example: The legacy of depression Unplanned teen pregnancy following depression 1 girl in 10 with a past history of depression had an unplanned pregnancy by age 16 Among girls with no history of depression, only 1 in 100 became pregnant by age 16 Percent

7. Example: The legacy of depression Criminal conviction following depression  1 in 8 boys with a history of depression were convicted of a crime or juvenile offense by age 16  Compared with 1 in 50 non-depressed boys Percent

8. Example: The legacy of depression Dropped out of school following depression  Girls with a history of depression were 12 times more likely to drop out of school by age 16  Youth with a history of depression were 4 to 5 times more likely to drop out before graduating Percent By age 16 By age 18

9. Example: The legacy of depression Expelled from school by age 16 following depression For boys, a history of depression tripled the risk of being expelled by age 16 Percent

10. The legacy of depression: Summary  1 in 8 depressed youth had been expelled, dropped out, become pregnant, or been convicted of a crime by age 16  Compared with 1 in 50 youth with no history of depression

11. Map of LMEs

12. North Carolina Child Mental Health Plan (March, 2004), Services to be provided by LMEs: Assessment and diagnosis Community inpatient services Inpatient alternatives Community living services School-based services Vocational services

13. North Carolina State Plan: Blueprint for Change (2005), LMEs expected to: Ensure access to services on a 24/7/365 basis Create systems that ensure greater consumer input on management of service delivery systems Coordinate with public and private organizations to assess consumer needs and fill service gaps Recruit and contract with service providers Approve person-centered plans for individual consumers

14. Results so far The shift from Area programs that provided services to LMEs that manage and oversee services -has vastly increased privatization of mental health services in North Carolina

15. North Carolina’s target population for children’s mental health services  Children with an early childhood disorder  Children with SED who require out-of- home placement  Children with SED who do not require out-of-home placement  Children who are deaf or hard of hearing  Children who are homeless

16. Children served by the NC public mental health system in FY 2005: Total served: 68,704 58% 12-17 years old39,848 33% 6-11 years old22,672 9% younger than 6556 50% White34,352 43% African American29,542 500+ homeless

17. Who pays for NC’s Public Mental Health Services for Children? Medicaid, state appropriations, county general funds, other FY 2005: North Carolina Division of MH/DD/DAS spent $504 million for children’s mental health services: Medicaid: $451 million (89%) State appropriations: $53 million (11%)

18. NC Division of MH/DD/SAS Expenditures on Children’s Mental Health Services Services (Top Five) Number of Children Served (FY05) Percent of Children Served Expenditures (FY05) Percent of Expenditures (FY05) Residential~60009%$217 million43% Community- based ~10,00015%$127 million25% Case Management ~25,00037%$49 million10% Outpatient Therapy ~49,00072%$44 million9% Inpatient Hospital ~4,0006%$41 million8%

19. But other agencies also incur costs from children with mental disorders Schools Juvenile justice Child welfare Primary medical care

20. Example: Total annual service costs for youth aged 13-16 based on GSMS data Services3-month Utilization Rate (% of population) Annual average per user $ Annual NC $ Inpatient hospital0.57,97655,687,195 Residential1.211,313119,261,521 Outpatient3.01,28718,152,123 Primary care2.63148,124,645 School8.358947,130,978 Juvenile justice2.62,24457,078,182 Informal services1.266703,750 Medications3.92858,703,831 Total16.22,968327,092,586

21. Sources of services for SED children (units of service provided) Education---- Juvenile justice----- Outpatient MH----- ----Primary care ----Residential Informal ----Inpatient

22. Distribution of costs for SED children ----Education Juvenile justice Outpatient MH----- ----Primary care Residential---- Informal Inpatient----

23. Discussion points about costs  Of SED children who receive any care, specialty mental health services serve only a small proportion  Most of the cost of serving SED children falls on non-MH agencies

24. Health insurance and MH services for SED children  What effect does the family’s health insurance status have on access to needed care?

25. GSMS: Non-Indian population (9-16) by type of health insurance, 1993-2000

26. Proportion with need for mental health services (SED) Need for services is highest in those with public insurance or no insurance Percent

27. Proportion with need for mental health care (SED) who received any services in past 3 months Percent Specialty mental health:  Children with Medicaid were most likely to receive specialty MH care  Children with private insurance were no more likely than those with no insurance to receive services in the MH system

28. Proportion with need for mental health care (SED) who received any services in past 3 months Percent Education:  No significant difference in access to care in schools

29. Are children’s mental health care needs being met? Fewer than half of children with SED (44.7%) receive any services from any agency within a 3 month period Fewer than 1 in 5 (17.9%) receive any specialty mental health care in a 3 month period Fewer than 2 in 5 report ever receiving any specialty MH services

30. Reflections, Questions, and Considerations for North Carolina Policymakers  Children with serious mental illness are unlikely to receive services  When they do, it is most likely to be through agencies not specially designed to serve MH needs  Most of the costs associated with children with mental illness are borne by juvenile justice and education agencies

31. Reflections, Questions, and Considerations for North Carolina Policymakers  The need to document: - the need for children’s mental health services - the provision and use of children’s mental health services - the cost of children’s mental health services - the effectiveness of children’s mental health services  How can policymakers support efforts to provide appropriate, community-based mental health services for children? - Support a System of Care approach to children’s mental health services