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A Reminiscence of the Development of Child Mental Health Policy in New York State

An Opinion by Michael B. Friedman, LMSW
First Published in Mental Health News Summer 2007

The theme of this issue of Mental Health News got me reminiscing about the development of child mental health policy in New York State. A lot has happened over the past 30 years; and even though we have a lot more to do to fully meet the mental health needs of kids—a lot more— the achievements of the past few decades should make us optimistic about the decades to come.

Hard as it is to believe now, 30 years ago children’s mental health was pretty much an afterthought to the Office of Mental Health. Yes, OMH ran a few children’s psychiatric centers—some of which offered outpatient as well as inpatient services. And, yes, some state funding went to local clinics that served kids. But that was generally the result of local decisions that OMH tolerated but did not appreciate. There were a few day treatment programs in those days, but those that weren’t run by the state children’s psychiatric centers were mostly funded by the child welfare system. Residential treatment also was regulated and funded by the child welfare system. Kids were not a priority for the Office of Mental Health. How did it change?

Two Advocates

I think immediately of two people—Jay Goldsmith and Carol Horn, who from the mid-1970’s through the 1980s were relentless advocates for child mental health.

Jay, who was Director of the Jewish Board of Family and Children’s Services, founded the Coalition of Voluntary Mental Health Agencies (now the Coalition of Behavioral Health Agencies) and later founded the Coalition of Residential Treatment Facilities (now The Coalition for Children’s Mental Health Services). In addition to fighting constantly for expansion and better funding for clinics for kids, Jay had a particular interest in residential treatment. His advocacy led to the conversion of about 500 residential treatment beds in the foster care system to a new program category called “residential treatment facilities” (RTFs) licensed by the Office of Mental Health and funded by Medicaid. His advocacy also was the basis of OMH’s recognition of day treatment as a mental health service.

Carol, who was Director of the Mental Health Association of NYC, was one of the most aggressive advocates for children’s mental health that one can ever imagine. She formed the Mental Health Advocacy Group for Children and Youth (MHAGCY). She never stopped pushing for more and better mental health services for kids, all types of services, and she also pioneered the development of working relationships between mental health and child welfare organizations.

Children and the Office of Mental Health

I remember a meeting in 1978 or 79 that Jay and Carol had with Jim Prevost, who was the Commissioner of Mental Health then. They talked about the mental health problems of kids who were not in OMH facilities and about the vast shortage of child mental health services in the community. They pointed out that while kids constituted 25%+ of the population of New York, only 7% of the OMH budget was devoted to them. The Commissioner was clearly stunned by the news. On the spot he pledged to increase it to 10%.

Jim also was the first commissioner to recognize the need for high-level leadership for child mental health in OMH. He was persuaded that moving an agenda required someone who would go to bed every night and wake up every morning thinking about child mental health. He appointed Mike Kalogerakis as the first Associate Commissioner for child mental health.

There was also movement towards the development of intelligent child mental health policy outside of OMH. In 1976, The NYS Council on Family and Children’s Services was established to address the fragmentation of the systems serving children. Fortunately Ilene Margolin was appointed Director. She had previously worked at the Manhattan Children’s Psychiatric Center, so she understood the needs of emotionally disturbed kids and knew that they were scattered in the education system, the child welfare system, the juvenile justice system, and to a much lesser extent in the mental health system. Ilene was, to say the least, an activist Director of the Council, and she pushed hard for NYS to meet the needs of kids with serious emotional disturbance and for inter-agency collaboration.

A Children’s Mental Health System

During this period, the beginnings of a child mental health system emerged in NYS. The first plan for child mental health was cast in 1983. And OMH took important steps in acknowledging its responsibility for kids with serious emotional disturbance with the development of RTFs, the increase of psych beds for kids in general hospitals, the expansion of day treatment programs, and with the expansion of, and increased funding for, clinics.

Later in the 1980s, leadership in OMH began to apply the principles of the federal child and adolescent services systems program (CASSP) to NYS. CASSP was built on the understanding that kids with serious emotional disturbance need more than inpatient and outpatient treatment. They need an array of supports to help them remain in the community. In NYS this included a totally new perspective on the helping role of families and the development of an array of new services such as community residences, family-based treatment, home-based crisis intervention, intensive case management, family support, and more. “Wrap-around services” they were called.

CASSP was also built on the concept of a “system of care,” of collaboration among the mental health, education, child welfare, and juvenile justice systems. Over the years the Federal government awarded a number of systems of care grants in NYS, which resulted in some improvements and some learning experiences.

Several people played important roles in moving the system forward. I think of Mareasa Isaacs and Gloria Logsdon in OMH, Leila Salmon at MHA of NYS, Jane Knitzer and then Gail Nayowith at the Citizen’s Committee for Children, and especially Evelyn Frankford at SCAA, who, working with Davin Robinson, created the Child Mental Health Action Network—the center for child mental health advocacy for a time. Senator Nick Spano gave the effort to build a comprehensive child mental health system a great push by issuing an influential report called “Pay Now or Pay Later.”

The Big Three

During the early 1990s there were three very important developments—the Reinvestment Act, the Coordinated Children’s Services Initiative and the maturation of the family advocacy movement.

Reinvestment was designed so that the money would follow state hospital patients into the community as more and more beds for adults were closed in state hospitals. Most of the savings went to local governments, which determined how to spend the new funds. They chose to put about 25% towards new kids’ services—a very big boost for kids with serious emotional disturbance not only because of the new services but because it made it clear how important child mental health is. Much credit is owed to Ernie Townsend, Commissioner of Mental Health in Ulster County who, at the time, led the fight to get agreement that localities should have the option to spend Reinvestment funds on kids.

During this period (roughly 1993-2000), OMH and other state agencies together started the Coordinated Children’s Services Initiative, which established local interagency groups to work together to resolve difficult cases one-by-one, established a second level of local groups to identify needed changes in systems, and established an interagency group in Albany to identify and press for policy changes. CCSIs now exist throughout NYS. Lots of people worked on getting this to happen, but I think particularly of Myra Alfreds in Westchester County, whose early efforts to develop local “networks” to resolve difficult cases were a model of what could happen. I also think of Jim Purcell, who then headed child welfare in the NYS Department of Social Services. He really understood the overlap of child welfare and mental health and pressed for integration. Doug Bailey, from the Department of Education, also provided important leadership.

This was also the period of the maturation of the family advocacy movement. Through mutual support programs, participation in systems planning, and hard-driving advocacy, family members of kids with serious emotional disturbance became a force for improved care. Ginny Wood at MHA of NYS got the movement started. Later, Page Pierce—head of Families Together, a statewide group—emerged as a respected spokesperson for parents like herself. Giselle Stolper, head of MHA of NYC, and a person with first hand experience with mental illness in her family, led the development of parent resource centers in NYC, championed the participation of family members in the system, and has continuously insisted that mental health services can and must be of higher quality in NYS.

One of the important offshoots of the family movement and efforts to integrate care was youth self-advocacy, which has brought young people into the process of program and system design in several parts of the state.

Medicaid

Over time child mental health became more and more important to the leadership of OMH. A Medicaid waiver known as the “home and community based waiver” allowed OMH to use Medicaid funds to pay for wraparound services for kids with serious emotional disturbance who are at risk of placement in hospitals or residential treatment. Jim Stone, Commissioner at the time, Sharon Carpinello, then Executive Deputy, and Linda Rosenberg, then the Senior Deputy, believed that kids services were so important that they steered over $40 million of the funding provided when NYS established involuntary outpatient commitment to child mental health services. They also encouraged providers to break out of the molds of traditional services and offer more intensive and flexible services particularly in times of crisis. Most providers felt constrained by regulation and by financing. Eventually, rates for clinic services were increased. Philip Saperia, head of The Coalition pressed hard for these rate changes and deserves considerable credit for OMH’s growing recognition of the realities of funding mental health services for kids.

Quality of Mental Health

During this same period of time, OMH focused a great deal of attention on improving the quality of mental health services for kids through the dissemination of evidence-based practices with help from several leading researchers such as Peter Jensen and Kimberly Hoagwood.

In 2006-7 Sharon Carpinello, by now Commissioner, and her Executive Deputy, Barbara Cohn, created Child and Family Clinics Plus, a program that involves screening kids for emotional disturbance, providing professional assessment of those who screen positive, and making treatment available for those kids who have diagnosable disorders. This initiative involves not only a new structure of service, but also a new public health perspective that extends the responsibility of OMH beyond kids with serious emotional disturbance to the 20% of all kids who have mental disorders. They also won an increase of $62 million for child mental health in their last year at OMH, mostly split between home and community based waivers and Clinics Plus. Advocacy behind the scenes played no small part in this achievement.

Most recently, NYS has enacted Timothy’s Law, which essentially establishes the responsibility of the private sector to pay for mental health services for kids whose parents have health insurance. Credit Tom O’Clair, Timothy’s father, whose persistent and charismatic leadership along with the determined support of virtually the entire mental health advocacy community made that possible. I think that Richard Gallo deserves special recognition as the person in on the push for parity from the very beginning. Special credit also to Assemblymembers Peter Rivera and Paul Tonka and Senators Thomas Morahan and Thomas Libous.

Magnitude of Change

I know that this account of the past 30 years in child mental health policy is selective in the extreme, both with regard to developments and with regard to the people who were important to the process. I apologize for all my omissions.

But I find that remembering the magnitude of change that has taken place in my professional lifetime and remembering just some of the many people who made these changes happen, stirs my optimism about the future. Yes, we have a very long way to go but the current child mental health advocates—people like Gail Nayowith, Paige Pierce, Davin Robinson, Philip Saperia, Karen Schimke, Ray Schimmer, and Giselle Stolper —working with new governmental leaders will—I am confident—continue the pace of change. And new leaders will emerge and—I am also confident—will bring about as much change in the next three decades as I have had the great good fortune to witness over the past three.

(Michael B. Friedman is the Director of the Center for Policy and Advocacy of The Mental Health Associations of NYC and Westchester and The Chairman of the Geriatric Mental Health Alliance of New York. The opinions expressed in this column are his own and do not necessarily reflect the positions of the MHAs. Mr. Friedman can be reached at center@mhaofnyc.org.)

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