Report to the Governor and 79th Legislature

Systems Of Care For Children With Severe Emotional Disturbances And Their Families

Submitted by the
State Texas Integrated Funding Initiative Consortium

In Cooperation with the
Texas Health And Human Services Commission

House Bill 2292, Section 2.166
78th Legislature, Regular Session, 2003

January 2005

Full report in printable Adobe Acrobat (pdf) format.

Table of Contents

Executive Summary

Introduction and Purpose

Background

• System of Care
• Texas Integrated Funding Initiative
• Community Resource Coordination Groups

Services and Supports Needed by Children with Severe Emotional Disturbances and their Families

Implementation of Systems of Care for Children with Severe Emotional Disturbances and their Families in Texas Communities

Barriers to the Effective Provision of Services and Support for Children with Severe Emotional Disturbances and their Families

Recommendations to Overcome Barriers in the Provision of Systems of Care Services and to Improve the Integration of Services For Children with Severe Emotional Disturbance and Their Families

• Recommendations from the local CRCG community assessments
• Recommendations to State Agencies from the State TIFI Consortium with Expected Outcomes
• Recommendations to the Legislature from the State TIFI Consortium

Appendices (*some appendices are available in pdf format only)

• Appendix A: State Texas Integrated Funding Initiative Consortium Members
• Appendix B* : Community Assessment on Systems of Care for Children with Severe Emotional Disturbances and their Families 
  • Assessment Instrument
• Appendix C: Compiled Results of the Community Assessment
• Appendix D: Compiled Results of the Family Focus Forum Results
• Appendix E: Local Site Family Experiences and Cost Comparisons
• Appendix F: Local Texas Integrated Funding Initiative Sites
• Appendix G: System of Care Values and Principles
• Appendix H: Recommendations sent to State Agencies
• Appendix I*: Agency Responses to Recommendations

<<back to top>>

EXECUTIVE SUMMARY

House Bill (H.B.) 2292, Section 2.166, passed by the 78th Texas Legislature, Regular Session, 2003, charged the State Texas Integrated Funding Initiative (TIFI) Consortium with the development of a summary report based on the evaluations submitted to the State Consortium by local Community Resource Coordination Groups (CRCGs). According to this legislative charge, the State Consortium's report must include recommendations for policy and statutory changes at each agency involved in the provision of system of care services for children with severe emotional disturbances and their families, and the outcome(s) expected from the implemention of each recommendation.

The State Consortium which oversees the Texas Integrated Funding Initiative, reflects a unique combination of 50 percent family member representation and 50 percent state agency representation from five child-serving agencies: the Department of State Health Services (DSHS), the Department of Family and Protective Services (DFPS), the Texas Education Agency (TEA), the Texas Juvenile Probation Commission (TJPC), and the Texas Youth Commission (TYC). See Appendix A for the complete list of State Consortium members. The State Consortium developed a community assessment instrument (see Appendix B) that was distributed to the 143 child-serving CRCGs available for all 254 Texas counties. Local CRCG respondents provided their best judgments regarding the type of action needed according to statute, policy/procedure, practice or other. The recommendations ranged from the very general to the very specific, with the majority of recommendations focused on increasing:

• funding
• collaboration/coordination
• family/community-based support
• training

In addition to making recommendations to the state agencies involved with delivering children's mental health services, the State TIFI Consortium recognized there are recommendations beyond the scope of state agencies' authority. The State TIFI Consortium developed ten recommendations to the 79th Legislature which are listed below, with sensitivity to the need to be realistic and fiscally sound within the current environment related to health and human services, education, and juvenile justice areas. The expected outcomes of these recommendations are intended to address the four areas that local CRCGs cited needing attention from state-level stakeholders, including increased funding, collaboration and coordination, family and community-based support, and training.

Recommendations to the Legislature from the State TIFI Consortium

1. Appropriate new funds to create an integrated statewide system for purchasing behavioral health⁽¹⁾ care services that promote the well-being of children, youth and their families, encourage a seamless system of care which is accessible, continuously available, and emphasizes prevention and early intervention, resiliency, recovery and rehabilitation. Place these new appropriations into one fund shared and governed by child-serving state agencies with representation of family and advocacy organizations, to coordinate and ensure access to services in the least restrictive, most effective settings.
     
2. Direct state agencies that provide health and human services, educational services, and juvenile justice services to pair a designated agency staff member with an identified family/youth partner to serve on the State TIFI Consortium. The Consortium shall build upon existing efforts and provide statewide oversight to further develop system of care practices across Texas.
   Functions will include expert consultation relating to:
   1. Interagency agreements and cooperation for integrated service delivery to children and youth with behavioral health needs;
   2. System of care training and technical assistance to state and community partners (including community leaders) in collaboration with the federally designated statewide family network; and
   3. Policy and program issues related to children and youth with behavioral health needs.
        
3. Direct the Regional Councils of Government (COG) to build or enhance existing regional or local collaborative infrastructures to develop a community master plan for children, youth, and families. This master plan should identify barriers to accessing behavioral health services, direct local resources to remove those barriers, and promote positive social-emotional development for all children and youth. Membership of the collaborative shall include leaders from the business and faith-based communities, family advocacy groups, local community leaders, volunteers, local school boards⁽²⁾, service providers, local Public Advisory Committees for local mental health authorities, drug and alcohol abuse councils, and local community resource coordination groups.
     
4. Provide that parent/guardian(s) of a child/youth needing mental health services or treatment who voluntarily relinquish the custody of a child, but retain some partial conservatorship interest in the child, shall have:
   • Notice of any and all treatment (including medical, service coordination, educational, etc.) prior to treatment, or as soon as possible, and
   • The opportunity to participate in the decision-making processes for the child's behavioral health treatment
       
5. Restore the Children's Health Insurance Program (CHIP) behavioral health benefits to fiscal year 2000 service levels, including eligibility, cost sharing, mental health, substance abuse and services for co-occurring disorders. Consider the incorporation of system of care practices into the design of the restored benefits package, including wraparound planning⁽³⁾, flexible funds and other family supports.
     
6. Restore to all health insurance policies regulated by the State mandated benefits that prevent or treat illnesses or disabilities in children and youth that were excluded by:
   • Senate Bill (S.B.) 541, 78th Texas Legislature, Regular Session, 2003, and/or
   • S.B. 10, 78th Texas Legislature, Regular Session, 2003.
       
7. Restore all prevention and early intervention funding including:
   • Monies previously appropriated at fiscal year 2002 levels for Department of Family and Protective Services and the Texas Youth Commission
   • Texas Education Agency's Non-Educational Community-Based Support funding level to the original 2 million dollars
       
8. Increase the quality and availability of a trained public workforce for child and youth services in underserved areas of Texas through mechanisms such as incentives and tuition waivers for continued years of service, identification and use of federal funds for tuition, supported internships/externships, loan forgiveness for mental health professionals willing to work in underserved areas for designated timeframes, and expanded collaborations among state agencies, universities, colleges, and the Texas Higher Education Coordinating Board.
     
9. Direct the Legislative Budget Board (LBB) to incorporate requirements in the guidelines for each child and youth-serving state agency's strategic plan to ensure family/youth involvement in planning and policy development related to behavioral health services needs. The proposal should be cost neutral for the family/youth representatives and reflect the core values and guiding principles of system of care.
     
10. Direct DSHS to review and augment current continuity of care rules related to behavioral health services to ensure children and youth discharged from residentially based treatment will have immediate access to behavioral health services, provided by local mental health authorities, at the level and intensity they require.

Summary

The recommendations to the Legislature from the State TIFI Consortium for policy and statutory changes involved in the provision of system of care services, is a continuation of the work that was completed with the charge under H.B. 2292, Section 2.166, 78th Legislature, Regular Session, 2003. These recommendations reflect the commitment of the State TIFI Consortium in the development of the system of care practices to children and youth and their families who are affected by severe mental health and behavioral health issues. The system of care approach offered through the local TIFI sites, the Substance Abuse and Mental Health Services Administration (SAMHSA)-funded sites and the collaborative work done at local CRCGs have provided a foundation for more effective integrated service delivery. In addition, the transformation of the state health and human services agencies provides the opportunity for multiagency cooperation resulting in improved service delivery. It is the State Consortium's recommendation that the system of care service delivery will be expanded to optimize the resources and strengths of families, state agencies, and communities in providing an individualized and outcome-based plan of service for Texas' children with behavioral health challenges and their families.

<<back to top>>

INTRODUCTION AND PURPOSE

House Bill (H.B.) 2292, Section 2.166, passed by the 78th Texas Legislature, Regular Session, 2003, charged the State Texas Integrated Funding Initiative (TIFI) Consortium with the development of a summary report based on the evaluations submitted to the State Consortium by local Community Resource Coordination Groups (CRCGs). The State Consortium's report is required to include recommendations for policy and statutory changes at each agency involved in the provision of system of care services for children with severe emotional disturbances and their families, and the outcome(s) expected from implementing each recommendation. The State Consortium was also charged with incorporating the recommendations developed under
Senate Bill (S.B.) 491, 78th Legislature, Regular Session, 2003, and the continuum of care developed under S.B. 490, 78th Legislature, Regular Session, 2003 (where appropriate) in the final report.

The State Consortium which oversees the Texas Integrated Funding Initiative, reflects a unique combination of 50 percent family member representation and 50 percent state agency representation from five child-serving agencies (see Appendix A for complete list of State Consortium members). The State Consortium developed a community assessment instrument (see Appendix B) that was distributed between January and March 2004 to the 143 child-serving CRCGs available for all 254 Texas counties. The evaluation responses were received from more than 90 percent of the local CRCGs serving children and youth, representing 234 of Texas' 254 counties (92 percent). The responses:

• Described and prioritized services needed by children with severe emotional disturbances in the community
• Reviewed and assessed the systems of care services that are available in the community to meet those needs
• Assessed the integration of the provision of those services
• Identified any barriers to the effective provision of those services

Additionally, each CRCG included recommendations for overcoming barriers to the provision of systems of care services and for improving the integration of those services (see Appendix C for the compiled results of the community assessments).

Local CRCG participation in the evaluation included:

• Family and Youth Representatives,
• Local state agencies,
• County or city government,
• Public Education,
• Non-profit community organizations,
• For-profit organizations,
• Local businesses, and
• Faith-based community organizations.

Family input was also gathered through the Texas Federation of Families for Children's Mental Health coordination of family focus groups in Harris, Lamb, Lubbock, and Nueces counties to supplement information gathered from CRCG evaluations (see Appendix D for the compiled results of the Family Focus Forum Results).

<<back to top>>

BACKGROUND

One of the primary goals of H.B. 2292, Section 2.166 is to evaluate system of care services in Texas for children with serious emotional disturbances. According to the Texas Department of State Health Services (DSHS) there are an estimated 168,789⁽⁴⁾ youth under the age of 18 in the state of Texas who have serious emotional disturbances. Four Texas TIFI sites have been in operation for the past four years. These four sites are supported through state dollars and utilize a system of care approach to deliver services to children and youth. Each site has proven successful in implementing this service delivery system. (See an example illustrated in the box on this page and throughout the report, and Appendix E for additional family experiences.)

Three communities, federally funded through the Substance Abuse and Mental Health Services Administration (SAMHSA), have strengthened community partnerships and demonstrated cost-effectiveness by including existing interagency programs such as CRCGs, and family and youth representatives as equal players in the design and development of local infrastructures (see Appendix F).

System of Care

A system of care incorporates a broad array of services and supports that is organized into a coordinated network, provides integrated care planning and management across multiple service levels, is culturally and linguistically competent, and builds meaningful partnerships with families and youth at service delivery and policy levels. Systems of care developed as a result of a 1969 study by the Joint Commission on Mental Health of Children, which recognized that children with serious emotional and behavioral needs and their families did not have access to well-organized, community-based mental health services.

In 1984, the National Institute of Mental Health (NIMH) created the Child and Adolescent Service System Program (CASSP). The goal of CASSP was to assist states and communities, through grants, in developing systems of care for children and adolescents with serious emotional disturbances and their families. In 1988-89, the Robert Wood Johnson (RWJ) Foundation created the Mental Health Services Program for Youth (MHSPY), a 20.4 million dollar initiative. This five-year project, in eight states, was the largest funded children's mental health initiative ever to serve children with serious emotional disturbance and their families. Due to the success of the MHSPY initiative, the RWJ Foundation allocated small planning grants in 12 states. The MHSPY Replication Project, as this came to be known, was designed to develop integrated service delivery through a system of care approach for children with serious emotional disturbance and their families.

In 1996, Texas received a replication grant from the RWJ Foundation. This grant was used to implement strategies related to finance, service delivery, governance and administration that were found to be successful in previously funded MHSPY projects in three Texas communities. The lessons learned from this grant complemented the efforts put into action through the Texas Children's Mental Health Plan, which had been funded by the 72nd Legislature. In 1998, the U.S. Department of Health and Human Services provided a 7 million dollar SAMHSA grant to the Texas Health and Human Services Commission (HHSC) to continue work begun by the Travis County Children's Partnership with the RWJ Foundation grant, based upon the "system of care" approach to service delivery. In 1999, the Texas Integrated Funding Initiative was created from S.B. 1234, 76th Legislature, Regular Session, 1999. By 2002, two additional Texas SAMHSA sites were funded in Fort Worth and El Paso.

Interwoven throughout these service delivery programs, methodologies and initiatives,
is the basic cornerstone of the philosophy of system of care: full family partnership. The
system of care should be child centered and family-focused, with the needs of the child and family dictating the types and mix of services and supports provided. (See Appendix G for the System Of Care Values and Principles.)

Texas Integrated Funding Initiative

In 1999, S.B. 1234, 76th Legislature, Regular Session, authorized up to six Texas Integrated Funding Initiative sites and created a State TIFI Consortium (see Table, p. 8). The vision of TIFI is to develop systems of care in local communities for all Texas children with severe emotional disturbances, together with their families, through the integration of federal, state, and local funds, and other resources. TIFI focuses on developing systems of care for children and youth with complex mental health needs, with families as full partners in the planning, implementation and evaluation of individual service programs based on their child's mental health and/or behavioral health⁽⁵⁾ needs.

ACHIEVEMENTS OVER THE LAST TEN YEARS IN TEXAS

• 1987, the 70th Legislature directed child-serving state agencies, in consultation with private sector and advocacy/consumer groups, to develop a community-based approach to coordinate service planning for children/youth who fall through the cracks of service systems, thus creating the CRCG model.
• 1989, the 71st Legislature authorized Texas Education Agency (TEA) and Texas Department of Mental Health & Mental Retardation (TDMHMR) to conduct a study to evaluate the appropriateness and cost effectiveness of mental health residential placements and the creation of community based services. 
• 1991, the 72nd Legislature appropriated the first funds for the Texas Children's Mental Health Plan. Funds were used to build on the federally supported Child and Adolescent Service System Program (CASSP) initiative and build local systems of care for children with mental health needs and their families.
• 1995, the 74th Legislature directed the Texas Department of Mental Health and Mental Retardation, in collaboration with parent representatives and other agencies, to develop a plan addressing the concern that parents of children with serious emotional disturbance are sometimes faced with relinquishment of custody of a child to TDPRS in order to get out-of-home care.
• 1996, HHSC and TDMHMR in a joint request, received Robert Wood Johnson Foundation dollars to develop community-based systems of care for children with serious emotional problems.
• 1997, the 75th Legislature directed TDMHMR to conduct a pilot to study the effectiveness of intensive community-based services options for children and families in decreasing the use of and/or length of stay in residential treatment.
• 1998, HHSC received a $7 million grant from the United States Department of Health and Human Services, SAMHSA to carry on the work begun by Travis County Children's Partnership with the Robert Wood Johnson Foundation grant.
• 1999, based on the promising findings of the study conducted by TDMHMR, the 76th Legislature passed S.B. 1234 that expands the Texas Integrated Funding Initiative to up to six communities in Texas. This legislation also provides for the creation of a Consortium composed of 50 percent child-serving agencies and 50 percent family advocates.
• 2000, four communities were awarded contracts through a request for proposal process to establish systems of care.
• 2001, the 77th Legislature funded TIFI for another biennium to provide technical assistance and training to funded TIFI communities.
• 2002, SAMHSA awarded two more systems of care development grants to two Texas Communities: Fort Worth and El Paso
• 2003, the 78th Legislature passed H.B. 2292, Section 2.166 to further study the feasibility of system of care implementation in the state of Texas.
• 2003, Grant from the Individual with Disabilities Education Act (IDEA) Partnership to identify school-based mental health initiatives and develop plans for expansion.
• 2004, SAMHSA approved continued funding of the Statewide Family Network to operate as a change agent in building a system of care in Texas.

Beginning in fiscal year 2001, TIFI provided state funding ranging from $40,000 to $75,000 annually to two urban communities (Harris County and Tarrant County), and two rural communities (Tri-County which includes Montgomery, Liberty and Walker counties), and one large rural collaborative, (Parmer, Swisher, Castro, Dickens, Briscoe, Bailey, Lamb, Hale, Floyd and Motley counties). Currently, TIFI funding is used to provide training, evaluation, wraparound⁽⁶⁾ facilitation, flexible funds for services, and other activities involved in developing a system of care in the community that meets the needs of children with severe emotional disturbances and their families.

As required by the authorizing legislation, the State Consortium that oversees the Texas Integrated Funding Initiative includes 50 percent family member and youth representation and 50 percent representation from the following state agencies:

• Department of State Health Services with representation from the following service areas:
  •  Alcohol and Drug Abuse Services (formerly Texas Commission on Alcohol and Drug Abuse)
  • Mental Health Services (formerly
    part of TDMHMR)
• Department of Family and Protective Services (DFPS - formerly Department of
  Protective and Regulatory Services)
• Texas Education Agency
• Texas Juvenile Probation Commission (TJPC)
• Texas Youth Commission (TYC)

Additional voluntary representation has included the Texas Council for Developmental Disabilities, the legacy agency of the Texas Department of Health, the State Community Resource Coordination Group Office and the Texas Federation of Families for Children's Mental Health, which is the federally designated Statewide Family Network for the state of Texas. The State Consortium has also partnered and benefited from the expertise and local experiences from the four TIFI sites and the three SAMHSA-funded system of care sites. TIFI has demonstrated an efficient service delivery approach for children/youth with complex mental health needs and their families that is strength-based, child centered, family-focused, has community based management and decision-making responsibility, and has programs and services that are responsive to the cultural, racial and ethnic differences within the communities.

Community Resource Coordination Groups

CRCGs are local interagency groups who serve children and adults with varied disabilities and multiagency needs. They are comprised of representatives from public and private agencies, families, consumers and caregivers. Caregivers and consumers, as recipients of services and as standing representatives, provide a unique perspective not achievable by providers alone. Together, the CRCGs develop individual service plans for adults, youth, and families whose needs can be met only through interagency coordination and cooperation. CRCGs are organized and established on a county-by-county basis.

CRCGs originated with S.B. 298, 70th Legislature, Regular Session, 1987. The legislative charge directed state agencies serving children to develop a community-based approach to better coordinate services for children and youth who have multiagency needs and require interagency coordination. S.B 1468, 77th Legislature, Regular Session, 2001 codified under Texas Government Code §531.055, authorizes the creation of CRCGs. More recently, communities have begun using this community-based approach to serve adults with complex needs.

In September of 2001, the following agencies signed the most recent Memorandum of Understanding for Coordinated Services to Persons Needing Services from More Than One Agency:

• Texas Health and Human Services Commission and partner agencies:
• Interagency Council on Early Childhood Intervention Services
• Texas Commission on Alcohol and Drug Abuse
• Texas Commission for the Blind
• Texas Department on Aging
• Texas Department of Health
• Texas Department of Human Services
• Texas Department of Mental Health and Mental Retardation
• Texas Department of Protective and Regulatory Services
• Texas Rehabilitation Commission
• Texas Council on Offenders with Mental Impairments
• Texas Department of Criminal Justice
• Texas Department of Housing and Community Affairs
• Texas Education Agency
• Texas Juvenile Probation Commission
• Texas Workforce Commission
• Texas Youth Commission

Health and Human Services Consolidation

H.B. 2292, 78th Legislature, Regular Session, 2003 blended the twelve health and human service agencies into four, with the Health and Human Services Commission as the oversight agency. The goals of this transformation are to improve client services, use every public dollar efficiently, and focus on results and accountability. The HHSC State Offices for the Texas Integrated Funding Initiative and the Community Resource Coordination Groups merged in fiscal year 2004 and later were placed in the Office of Program Coordination for Children and Youth (OPCCY). OPCCY assists executive staff and senior policy analysts by coordinating children's programs and initiatives across the health and human services system. OPCCY also oversees the operations of various children's programs and initiatives, including children's long-term care, family-based alternatives, permanency planning, the Office of Early Childhood Coordination, and staff support of the State TIFI Consortium. Currently DSHS provides oversight to the contract management and technical assistance of the four TIFI demonstration sites.

<<back to top>>

SERVICES AND SUPPORTS NEEDED BY CHILDREN WITH SEVERE EMOTIONAL DISTURBANCES AND THEIR FAMILIES

The following systems of care services and supports were submitted to CRCGs for evaluation for children with severe emotional disturbance and their families receiving services:

• Mental health assessment and evaluation: screening, intake assessment, crisis response, etc.
• Mental health care - Inpatient treatment: refers to hospitalizations for mental health care such as: psychiatric hospitals (public and private), state hospitals, etc.
• Mental health care - Outpatient counseling: individual or family or group counseling to deal with interpersonal issues and/or problem-resolution
• Treatment/Therapeutic foster care: a specialized service for children/youth that are highly disruptive and/or aggressive that includes 24 hour specialized treatment with a specially trained family that works with the natural or permanent family
• Skill development: refers to training in problem solving skills, daily living skills, parenting skills, and techniques of anger management, impulse control, and other areas of development
• Physical health care: includes doctor/dentist care, early childhood screening, medication and/or medication management, special equipment, hospitalization and in-home care, etc.
• Basic needs: includes food (through community providers, food bank, food stamps/TANF, WIC), clothing, utilities, etc.
• Self-sufficiency: includes housing and transportation.
• Substance abuse services: includes prevention, intervention and treatment, etc.
• Sex offender treatment services: specialized programs targeting prevention, intervention, and treatment of juvenile sex offenders that may address motivation, psycho-social education, psychological evaluation for sex offender treatment, and relapse training
• Family support: refers to services such as, respite care, child care, adult day care, access to insurance, etc.
• Family advocacy and mentoring: support groups and family run organizations in the community that support families with information and referral, training, technical assistance, and peer support
• Natural supports and informal community supports: includes opportunities for involvement and social interaction with neighbors, friends, clubs such as boy/girl scouts, places of worship, and other community resources
• Legal assistance: refers to assistance with/ for conservators and guardians, civil and criminal legal needs (including child support), citizenship, benefits counseling, etc.
• Education: could include special equipment, truancy prevention, English as a second language, translators/interpreters, referral to special education, services and educational accommodations, day treatment, adult learning, GED, higher education, etc.
• Employment: may include training/ assistance with job-readiness, on-the-job training, vocational training, and other services related to employment

The compiled results of the community assessments that were completed and returned by local CRCGs are reported below.

Availability of Services and Supports

Services and Supports that were most often rated as "Very Available" were:

• Education,
• Basic Needs, and
• Natural Supports and Informal Community Supports.

Additional comment/details noted that "Basic Needs" such as food, clothing, etc. was often very available; however, utility assistance was frequently noted as an unmet and specific need.

Services and Supports that were most often rated as "Not Available at All" were:

• Treatment/Therapeutic foster care,
• Sex offender treatment services, and
• Mental health care - Inpatient treatment.

Priority Services and Supports

Community assessments most often noted the following five services and supports as areas of highest need/importance for children with severe emotional disturbances and their families:

• Therapeutic Foster Care
• Mental Health - Outpatient
• Mental Health - Inpatient
• Mental Health Assessment
• Family Support services

Although "Sex Offender Treatment services" were often noted as "Not Available at All," they were not identified as a high priority need, perhaps due to the lower incidence/prevalence rate.

<<back to top>>

IMPLEMENTATION OF SYSTEMS OF CARE FOR CHILDREN WITH SEVERE EMOTIONAL DISTURBANCES AND THEIR FAMILIES IN TEXAS COMMUNITIES

A system of care for children with severe emotional disturbances and their families demonstrates the following characteristics:

• Collaboration across agencies
• Partnership with families of children with severe emotional disturbances
• Support for cultural and linguistic competence
• Integrated funding
• Outcomes shared across agencies, reflecting community values
• Interagency/family service planning teams
• Evidence-based service approaches
• Easy access to services and supports
• Comprehensive single plan of care and accountable service coordinator
• Wraparound approach - individualized services and supports
• Links to natural and informal community supports

Community assessments by the local CRCGs indicate that many of these characteristics are not present in their community.

System of Care Characteristics "Frequently Present"

The following system of care characteristics were reported by local CRCGs to be frequently present in their communities:

• Cultural and linguistic competence supports through:
  • Translation of key documents, especially all documents that must be signed (including legal and confidentiality documents)
  • Individual child and family culture, traditions, beliefs, religion, race/ethnicity, community, and sexual orientation, are respected and accommodated when planning for services
      
• Sharing outcomes across systems by individual agencies systematically collecting evaluation data.
    
• Using interagency/family services planning teams through:
  • Agencies referring families or providing families with referral information to other systems
  • Staff from different agencies working together on case planning

System of Care Characteristics "Never Present"

The following system of care characteristics were reported by local CRCGs to be never present in their communities:

• Collaboration across agencies through:
  • Sharing staff, joint hiring/recruitment
  • Sharing administrative forms, unified case records, and joint administrative system implementation meetings
      
• Family members are involved in recruiting/hiring of agency staff.
    
• Agency evaluation efforts are linked through common or interactive data management systems.

<<back to top>>

BARRIERS TO THE EFFECTIVE PROVISION OF SERVICES AND SUPPORT FOR CHILDREN WITH SEVERE EMOTIONAL DISTURBANCES AND THEIR FAMILIES

Community assessments identified the most significant barriers to effective service delivery for children with severe emotional disturbances and their families as related to:

Access and Availability:

• Long waiting lists
• Decreased staff and services due to budget constraints
• Restrictive eligibility criteria
• Lack of services in rural communities - cost and availability of transportation
• Cultural differences

Funding:

• Insufficient funding to meet service needs across agencies
• Decreased funding for mental health services
• Inadequate funding for rural or less populated areas of the state
• Lack of flexibility to shift funding where needed
• Inability to integrate or otherwise blend funding to meet needs

Training:

• Limited access to training, especially cross-agency training
• Difficult to access due to time and funding constraints
• Limited knowledge and practice in developing partnerships with families

Economic Issues:

• Low socioeconomic climate in many areas of the state
• Local economic climate - limited employment opportunities and/or low wages, loss of medical insurance coverage with more families working combinations of part time jobs without benefits
• Cost and availability of housing and transportation

Data:

• Lack of standardized and consistent data collection across agencies
• Lack of data-sharing across agencies or centralized location for data

Language Differences:

• Need for more bilingual (Spanish/English) translators and service providers
• Limited funding available for interpreters or translators

<<back to top>>

RECOMMENDATIONS TO OVERCOME BARRIERS IN THE PROVISION OF SYSTEMS OF CARE SERVICES AND TO IMPROVE THE INTEGRATION OF SERVICES FOR CHILDREN WITH SEVERE EMOTIONAL DISTURBANCE AND THEIR FAMILIES

Recommendations from the local CRCG community assessments

Local CRCG respondents provided their best judgments regarding the type of action needed (statute, policy/procedure, practice or other) and the entity responsible for implementing the recommendation(s). Due to the wide variability of the responses for type of action needed and entity responsible for implementation, the analysis primarily focuses on the actual recommendations. Some CRCGs noted difficulty in making specific recommendations at this juncture of the health and human services agencies' consolidation. Recommendation details ranged from very general to very specific. The majority of recommendations focused on increasing:

• funding,
• collaboration/coordination,
• family/community-based support, and
• training.

Recommendations to State Agencies from the State TIFI Consortium with Expected Outcomes

The State TIFI Consortium made the following recommendations (see Appendix H) to state agencies based on the information received from the local CRCG assessments. Note that a summary of the agencies' responses follows each recommendation. The full response from each agency may be found in Appendix I.

Recommendation #1 (Service Provision): DSHS, DFPS, TEA, TJPC, DARS, and TYC will identify and implement mechanisms to promote the availability of qualified translators, including multi-lingual interpreters, interpreters for the deaf, and accommodations for persons with visual impairments or other disabilities.

Response: All agencies indicated an interest to support this recommendation within the parameters of their agency's operation.

Recommendation #2 (Distribution of Services and Rural Issues): DSHS will identify and implement mechanisms to ensure access to, and availability of, an array of mental health/behavioral health/substance abuse services embodying the principles and values of system of care in Rural/Frontier/Colonias areas of Texas.

Response: DSHS supports this recommendation in principle and recognizes the substantial barriers to providing access to services in underserved areas. As with many of the publicly funded service agencies DSHS is, unfortunately, unable to provide access to services for all who are in need. However, DSHS is fully committed to providing access to complete and appropriate packages of services to as many Texans as possible and will continue to focus on identifying the most effective and efficient means to deliver services. DSHS will build on its ongoing initiatives in rural/frontier/Colonias areas to ensure the principles, values, and practices of System of Care are embodied in the services the agency purchases for children and families.

Recommendation #3 (Education and Early Childhood): HHSC, DSHS, DFPS, TEA, TJPC, and TYC will implement the recommendations of S.B. 490, 78th Legislature, Regular Session, 2003, related to coordinating certain agency services and activities involving mental health care for young children, and S.B. 491, 78th Legislature, Regular Session, 2003, related to an assessment of school-based mental health and substance abuse programs. (Reports are due January 2005 and will be available via: http://www.tea.state.tx.us.)

Response: All agencies supported implementation of the recommendations of the final report based upon the scope as it relates to the individual agency's mission and as resources allow.

Recommendation #4 (Insurance): HHSC will identify a dedicated legal position to provide technical assistance to, and advocate for, families in negotiating with insurance companies, in order that families can receive services covered in their policies and help prevent cost shifting to the public sector (e.g., Medicaid, CHIP) by private health insurance carriers.

Response: HHSC will research out-of-state promising practices and meeting with Legal and Third- Party Review staff to explore options for consideration of implementation.

Recommendation #5 (Transportation): HHSC will include representation from the State TIFI Consortium to address transportation needs of children and youth and their families on appropriate interagency workgroups and forums between health and human service agencies, and the Texas Department of Transportation (TxDot).

Response: HHSC is in support of this recommendation.

Recommendation #6 (Therapeutic/Treatment Foster Care): Agencies that provide or fund residential treatment services, including DSHS, DFPS, TEA, TJPC, and TYC, will promote the provision of, or access to, family-based alternatives (such as therapeutic foster care, treatment foster care, or other support-family alternatives) as a least restrictive option to prevent relinquishment of the custody of children and youth in order to receive mental health services.

Response: All agencies indicate support for promoting the delivery of services in the least restrictive environment for children/youth in need of mental health services and their families. DSHS currently requires all centers to develop the capacity to provide treatment foster care through contracting with a child-placing agency. DFPS and TYC cite examples of current efforts, and DFPS includes the need to work with residential treatment centers and families to ensure permanent placements of children/youth returning home in a timely manner. TYC cites family coordination beginning at initial intake and continuing through parole transition. TEA notes that the federal Individuals with Disabilities Education Act (IDEA) requires local school districts to place students in the least restrictive environment. When need for residential placement is not educationally related, the determination of the type of residential placement is not within the scope of TEA or the local school districts.

EXPECTED OUTCOMES FOR RECOMMENDATIONS 1-6

• Increased number and availability of mental health professionals who are multilingual or who can obtain professional translation services so that children, youth and their families can be full participants and partners in the delivery services
• Distribution and availability of services for rural and frontier areas of Texas is geographically balanced
• Increased frequency of involvement of mental health professionals in planning and implementation of services available to students through the public school systems
• Improved integration of mental health professionals in Individual Education Plan (IEP) development process for individual students
• Fewer disruptions to educational objectives for the child receiving services, for faculty, and for other students
• Improved educational achievement/advancement/promotion for the child receiving services
• A standardized benefit structure that enables and improves client access and provider reimbursement
• Creation of a function at the Ombudsman Office at HHSC that provides legal technical assistance to families to empower the families to negotiate competently to maximize their insurance benefits in receiving services covered in their policies, thereby decreasing the need for state dollars (For additional information, reference the procedure currently being utilized in Michigan)
• Transportation needs are addressed for all families requiring health and human services
• Better utilization of community partnerships among traditional and non-traditional providers and families
• Increased knowledge about, and availability of, treatment foster care families

Recommendation #7 (Training): DSHS, DFPS, TEA, TJPC, Texas Correctional Office for Offenders with Medical or Mental Impairments (TCOOMMI), and TYC, in collaboration with family partners, including the federally designated Statewide Family Network, will develop mechanisms to incorporate system of care competencies into agency training for appropriate staff.

Response: All agencies and the federally designated Statewide Family Network indicate support to implement this recommendation with consideration of agency/organization's mandates and as resources allow. The responding agencies recognized existing efforts, the need to address variability of resources across the state, and possible strategies for implementation.

EXPECTED OUTCOMES

• Increased knowledge and awareness of effective services and supports within local systems of care for children with severe emotional disturbances and their families by agencies and communities
• Shared outcomes across agencies/systems by agencies, communities and families
• Increased access to needed services and supports within local systems of care by agencies, communities, and families
• Potential providers receive training in system of care, child and family driven services, and strengths based service delivery including routine continuing education

Recommendation #8 (Supports and Partnerships): The Legislative Budget Board should incorporate requirements into the guidelines for each child/youth- serving agency's strategic plan, a specific proposal to increase family/youth involvement. The proposal should be cost-neutral for the family representatives and reflect the core values and guiding principles of system of care.

Response: The Legislative Budget Board staff reports they will withhold comment on the draft recommendations, as they are independent of the recommendation process.

Recommendation #9 (Supports and Partnerships): DSHS, DFPS, TWC, TEA, TJPC and TYC will sustain and leverage funds for the enhancement and coordination of family/youth support services, such as respite, quality child care for children/youth with disabilities, supported housing, family-to-family supports, peer-led services and training, vocational services, transportation services, and mentoring.

Response: All agencies responded in support of this recommendation with consideration to sustaining existing services at current levels, and the desire to continue to explore ways to provide quality services and supports to youth and their families within the real constraints of extraordinarily tight agency budgets.

Recommendation #10 (Supports and Partnerships): DSHS, DFPS, TEA, TJPC and TYC will identify and implement mechanisms to increase access and availability to family-selected, informal activities, family-to-family supports, and natural supports in the community.

Response: All agencies responded in support of this recommendation and commitment to identifying mechanisms to increase access and availability of family-focused services and the use of ancillary supports in the family's natural environment.

Recommendation #11 (Supports and Partnerships): DSHS will:

1. Build on contracted parent/family care coordination activities (existing parent case management model with legacy agency Texas Department of Health) to include children and youth with behavioral health needs;
2. Consider for inclusion the parent/family care coordination activities (parent case management model) within targeted case management services for children and youth with mental health needs; and
3. Sustain and expand the "family partner" component within Resiliency and Disease Management (refer to: http://www.dshs.state.tx.us/mhprograms/RDMAssess.shtm for additional information).

Response: DSHS supports the use of evidenced-based models of care coordination such as parent/family case management and the use of effective supportive partnerships such as family partners. DSHS is committed to continuing the use of evidence-based supports. The use of family partners is integral to the Department's Resiliency and Disease Management Model. DSHS provides resources to local mental health authorities to provide family partners.

EXPECTED OUTCOMES FOR RECOMMENDATIONS 8-11

• Increased satisfaction with services by children/youth and families as these agencies and services become more responsive to their needs
• Increased informed choices and awareness by families to help their children access the available meaningful supports and services that will positively impact their children's development thus influencing their critical developmental years
• Increased efficient use of public and private funds to reduce the impact of children's mental illness within the family, school, and community
• Improved school performance and decreased utilization of juvenile justice systems in order to access mental health treatment
• Increased responsiveness to match services to the actual needs of children and families. Funding shifts from high cost institutional services toward community-based services sought by families such as respite, quality child-care for children with disabilities, supported housing, family-to-family supports, peer led services, vocational services, and mentoring
• Increased use of evidence-based, family-centered practices by providers in the community
• Increased accountability and cultural competence between agencies and families by involving families at all levels of policy development and implementation
• Increased investment from families in the agencies serving their children and decreased conflict between providers and recipients of services
• Increased respect and understanding between providers and families
• Improved employment opportunities for professional family members to bring their unique experiences and contributions to agencies to enhance a competent and affordable workforce
• Readily available training that is disseminated to providers across systems in skills needed to partner with families. Individualized service planning and delivery increase with families as partners across all levels of the system
• Increased family access for appropriate training to provide them with the knowledge, skills, and abilities to provide excellent services as professional parent liaisons
• Increased access to family-run organizations and promotion of peer-to-peer networks

Recommendation #12 (Utilization of Existing Funds): HHSC will identify and expand strategies and funding sources to provide alternatives to residential treatment and serve children and youth with serious emotional disorders in their communities. Strategies should include consideration of a 1915(c) waiver or other recommendations made from "Community-based Treatment Alternates for Children-Real Choice" grant.

Response: HHSC responded that they would consider all recommendations upon completion of the final report of the feasibility study in December, 2004.

Recommendation #13 (Utilization of Existing Funds): HHSC, DSHS, DFPS, TEA, TJPC, and TYC will incorporate System of Care core values into relevant grants awarded by the State that pertain to the delivery of services to children and youth with mental health needs.

Response: HHSC, DSHS, and TEA support this recommendation when appropriate. DFPS and TJPC note existing contracts that reflect implementation of this recommendation. TYC notes that they do not award grants that pertain to the service delivery to children and youth with mental health needs.

Recommendation #14 (New Non-General Revenue Funding Sources): HHSC, in collaboration with family partners and resource procurement experts (including the Office of the Governor's State Grants Team and Texas A&M University Agricultural Extension Services-Community Grant Support Initiative), will develop formal linkages, structures and agreements in order to increase local communities' abilities to identify and procure grant funds which will enhance and sustain core elements of local systems of care.

Response: HHSC responded they would look at existing opportunities within the health and human service system to address this recommendation to build from existing efforts and work toward increasing information and accessibility to funding opportunities in partnership with families and resource procurement experts as resources allow.

Recommendation #15 (New Non-General Revenue Funding Sources): DSHS, DFPS, TEA, TJPC, TCOOMMI, and TYC will continue to enhance funding sources through alternate or additional funding strategies (e.g., IV-E, 1915-C, 1915-B, 1915-G, etc.) for procurement and implementation of community-based services for children's mental health.

Response: DSHS, DFPS and TEA support implementation of this recommendation. TJPC, TYC, and TCOOMMI note current activities, programs, and strategies that illustrate their commitment to implementing this recommendation.

EXPECTED OUTCOMES FOR RECOMMENDATIONS 12-15

• Increased funding through Title IV-E and additional grants that will enable improved access to, and expansion of, services which are alternatives to residential treatment, including treatment/therapeutic foster care
• Establishment of formal relationships, which increase local and state expertise related to systems of care development and effective grant writing
  

Recommendation #16 (Integrated Planning): HHSC will use the Office of Program Coordination for Children and Youth to incorporate the following:

1. Staff with expertise in services to children and youth who have special needs such as the need for mental health services, special health care services, substance abuse intervention services, and/or services provided through the child welfare and juvenile justice systems;
2. Collaboration with DSHS, DFPS, DARS, and Department of Aging and Disability Services (DADS) and their designated family partners to ensure ongoing coordination of activities related to children and youth issues across health and human service agencies; and
3. Collaboration with child and youth experts at non-health and human services agencies serving children and youth including TEA, TJPC, TYC, TWC and the federally designated Statewide Family Network to ensure ongoing coordination of activities related to children and youth issues.

Response: HHSC, DADS, DSHS, DFPS, TYC and TEA support this recommendation. DARS supports collaboration among health and human service agencies and family partners, but notes that implementing "staff with expertise in services to children and youth who have special needs…" is outside the scope of DARS. TWC cites current collaborative efforts to serve children and youth in need.

Recommendation #17 (Integrated Planning): DSHS, DFPS, DADS, and DARS will ensure that each agency's Center for Policy and Innovation and/or Center in Program Coordination include dedicated staff, which, in collaboration with identified family partners, will:

1. Coordinate policy and services implementation across programs for children and youth;
2. Ensure expertise in providing services to children at the programs implementation and oversight levels;
3. Ensure coordination with the HHSC Office of Program Coordination for Children and Youth; and
4. Ensure agency participation with local community groups such as Community Resource Coordination Groups, systems of care, and family-run organizations.
   1. Ensure innovations and best practices are identified and incorporated into program policy and services for children and youth;
   2. Ensure coordination with the HHSC Office of Program Coordination for Children and Youth; and
   3. Ensure that agency policy supports participation with local community groups such as Community Resource Coordination Groups, systems of care, and family-run organizations.

Response: DARS indicates support and will ensure that staff with the necessary background/awareness are available. DADS notes their support to implement the recommendation, including hiring a program specialist within the center to ensure this collaboration. DFPS notes that some of the specific responsibilities noted in the recommendation are under the responsibility of the assistant commissioner rather than the centers.

Note: The State TIFI Consortium accepts the suggested changes in the recommendations as offered by DFPS:
  
DSHS, DFPS, DADS, and DARS will ensure that each agency's Center for Policy and Innovation and/or Center in Program Coordination in collaboration with identified family partners, will:

1. Coordinate policy and services across programs for children and youth;
2. Ensure innovations and best practices are identified and incorporated into program policy and services for children and youth;
3. Ensure coordination with the HHSC Office of Program Coordination for Children and Youth; and
4. Ensure that agency policy supports participation with local community groups such as Community Resource Coordination Groups, systems of care, and family-run organizations.

Recommendation #18 (Systems of Care Expansion): HHSC, DSHS, DFPS, TEA, TWC, TJPC, and TYC will pair a designated agency staff member with an identified family partner to serve on the State TIFI Consortium to provide statewide oversight to build on existing efforts to further develop system of care practices. Functions will include expert consultation relating to:

1. Interagency agreements and cooperation of integrated service delivery for children and youth with behavioral health needs;
2. System of care training and technical assistance to state and community partners, in collaboration with the federally designated Statewide Family Network; and
3. Policy and program issues related to children and youth behavioral health.

Response: All agencies responded to this recommendation with recognition of the value of family partners. The Statewide Family Network supports and commits to assisting with the implementation of this recommendation. DSHS supports this recommendation as stated and agrees to provide technical assistance and training on integrated service delivery, system of care, and policy and program issues related to children and youth with severe emotional disturbances. HHSC indicates support to provide consultation for system of care training and technical assistance as resources allow, and supports collaboration with the inclusion of HHSC Advisory Councils to address policy and program issues related to children and youth with behavioral health needs. TWC stated it will continue its commitment to serving families with complex needs through ongoing involvement with CRCGs, thereby deferring to serve on the State TIFI Consortium.

EXPECTED OUTCOMES FOR RECOMMENDATIONS 16-18

• Enhanced coordination and collaboration among service delivery providers with the inclusion of building on family's expertise as involved partners in policy planning and development, implementation, and evaluation
• Existing collaborative structures such as local CRCGs and other interagency groups have readily available broad-scale technical assistance needed to implement key components of system of care

Recommendations to the Legislature from the State TIFI Consortium

1. Appropriate new funds to create an integrated statewide system for purchasing behavioral health care services that promote the well-being of children, youth and their families, encourage a seamless system of care which is accessible, continuously available, and emphasizes prevention and early intervention, resiliency, recovery and rehabilitation. Place these new appropriations into one fund shared and governed by child-serving state agencies with representation of family and advocacy organizations, to coordinate and ensure access to services in the least restrictive, most effective settings.
     
2. Direct state agencies that provide health and human services, educational services, and juvenile justice services to pair a designated agency staff member with an identified family/youth partner to serve on the State TIFI Consortium. The Consortium shall build upon existing efforts and provide statewide oversight to further develop system of care practices across Texas.
   Functions will include expert consultation relating to:
   1. Interagency agreements and cooperation for integrated service delivery to children and youth with behavioral health needs;
   2. System of care training and technical assistance to state and community partners (including community leaders) in collaboration with the federally designated statewide family network; and
   3. Policy and program issues related to children and youth with behavioral health needs.
        
3. Direct the Regional Councils of Government (COG) to build or enhance existing regional or local collaborative infrastructures to develop a community master plan for children, youth, and families. This master plan should identify barriers to accessing behavioral health services, direct local resources to remove those barriers, and promote positive social-emotional development for all children and youth. Membership of the collaborative shall include leaders from the business and faith-based communities, family advocacy groups, local community leaders, volunteers, local school boards⁽⁷⁾, service providers, local Public Advisory Committees for local mental health authorities, drug and alcohol abuse councils, and local community resource coordination groups.
   
4. Provide that parent/guardian(s) of a child/youth needing mental health services or treatment who voluntarily relinquish the custody of their child, but retain some (partial?) conservatorship interest in the child, shall have:
   • Notice of any and all treatment (including medical, service coordination, educational, etc.) prior to treatment, or as soon as possible, and
   • Opportunity to participate in the decision-making processes for the child's mental health treatment.
       
5. Restore the Children's Health Insurance Program (CHIP) behavioral health benefits to fiscal year 2000 service levels, including eligibility, cost sharing, mental health, substance abuse and services for co-occurring disorders. Consider the incorporation of system of care practices into the design of the restored benefits package, including wraparound planning, flexible funds and other family supports.
     
6. Restore to all health insurance policies regulated by the State those mandated benefits that prevent or treat illnesses or disabilities in children and youth that were excluded by:
   • Senate Bill (S.B.) 541, 78th Texas Legislature, Regular Session, 2003 and/or
   • S.B. 10, 78th Texas Legislature, Regular Session, 2003.
       
7. Restore all prevention and early intervention funding including:
   • monies previously appropriated at fiscal year 2002 levels for
     • Department of Family and Protective Services and
     • Texas Youth Commission.
   • Texas Education Agency's Non-Educational Community-Based Support funding level to the original 2million.
       
8. Increase the quality and availability of a trained public workforce for child and youth services in underserved areas of Texas through mechanisms such as incentives and tuition waivers for continued years of service, identification and use of federal funds for tuition, supported internships/externships, and expanded collaborations among state agencies, universities, colleges, and the Texas Higher Education Coordinating Board.
     
9. Direct the Legislative Budget Board (LBB) to incorporate requirements in the guidelines for each child and youth-serving state agency's strategic plan to ensure family/youth involvement in planning and policy development related to behavioral health services needs. The proposal should be cost neutral for the family/youth representatives and reflect the core values and guiding principles of system of care.
     
10. Direct DSHS to review and augment current continuity of care rules related to behavioral health services to ensure children and youth discharged from residentially based treatment will have immediate access to behavioral health services, provided by local mental health authorities, at the level and intensity they require.

Summary

The recommendations to the Legislature from the State TIFI Consortium for policy and statutory changes involved in the provision of system of care services, is a continuation of the work that was completed with the charge under H.B. 2292, Section 2.166, 78th Legislature, Regular Session, 2003. These recommendations reflect the commitment of the State TIFI Consortium in the development of the system of care practices to children and youth and their families who are affected by severe mental health and behavioral health issues. The system of care approach offered through the local TIFI sites, the Substance Abuse and Mental Health Services Administration (SAMHSA)-funded sites and the collaborative work done at local CRCGs have provided a foundation for more effective integrated service delivery. In addition, the transformation of the state health and human services agencies provides the opportunity for multiagency cooperation resulting in improved service delivery. It is the State Consortium's recommendation that the system of care service delivery will be expanded to optimize the resources and strengths of families, state agencies, and communities in providing an individualized and outcome-based plan of service for Texas' children with behavioral health challenges and their families.

<<back to top>>

FOOTNOTES

1. Mental health, substance abuse or co-occurring mental disorders
2. Schools offer a primary opportunity for success for children with emotional, behavioral or mental disorders and represent a primary, non-stigmatizing role within childhood. School achievement must be successfully mastered in order for children and their families to flourish. Supportive environments are created by a strong partnership between schools and community involvement, and because best practices in children's mental health involve local communities.
3. Per Department of State Health Services, Children and Disease Management Initiative - Wraparound Planning: A collaborative team-based process for service and support planning. The process focuses on the strengths of the child and family as the basis for a service and support plan to meet the unmet needs specified by the child and family to improve the lives of the child and family. The plan is individualized for each child and family and tailored to the strengths, needs, values, culture and preferences as defined by the child and family. Treatment services and supports are included in the plan as well as informal supports to sustain the child and family when professional services and supports are completed or at a minimum.
4. Texas Department of State Health Services, Child/Adolescent Mental Health Prevalence/Priority Population Data. Revised in 2005.
5. Mental health, substance abuse or co-occurring mental disorders
6. Per Department of State Health Services, Children and Disease Management Initiative - Wraparound Planning: A collaborative team-based process for service and support planning. The process focuses on the strengths of the child and family as the basis for a service and support plan to meet the unmet needs specified by the child and family to improve the lives of the child and family. The plan is individualized for each child and family and tailored to the strengths, needs, values, culture and preferences as defined by the child and family. Treatment services and supports are included in the plan as well as informal supports to sustain the child and family when professional services and supports are completed or at a minimum.
7. Schools offer a primary opportunity for success for children with emotional, behavioral or mental disorders and represent a primary, non-stigmatizing role within childhood. School achievement must be successfully mastered in order for children and their families to flourish. Supportive environments are created by a strong partnership between schools and community involvement, and because best practices in children's mental health involve local communities.

<<back to top>>