Final Report Of House Joint Resolution 7 Study Group On Child Mental Health Needs In Kent And Sussex County

Submitted to Speaker of the State House of Representatives, President Pro Tem of the State Senate and Governor, March 12, 2012

Legislative Charge to Study Group

This study group was created through the passage of House Joint Resolution 7, which was signed by the Governor on July 25, 2011. Its general charge was to assess child mental health needs in Kent and Sussex County, and it was also specifically charged to focus on the needs of child victims of sexual assault.

Meetings

The study group met on a monthly basis. The study group heard from a number of invited speakers. In addition, although it was not required to do so by its enabling legislation, the study group provided a public comment period at the end of each meeting, which was frequently used by interested members of the public. All of the study group’s meetings were audiotaped, and the audio recordings of each meeting were posted on the state’s web site, as were copies of all written materials examined by study group members.

Summary of Recommendations

  • The study group recommends that the state undertake efforts to recruit two psychiatrists to Sussex County, with an emphasis on (i) psychiatrists who will offer services in western Sussex County, (ii) psychiatrists who can offer services in Spanish, and (iii) psychiatrists who can offer services on nights and/or weekends.
  • In using funds that will be made available by the Delaware Health Care Commission for the recruitment of psychiatrists to Sussex County, the study group recommends that the state concentrate those funds on recruitment of psychiatrists willing to practice in a consultative role, with family doctors and pediatricians, rather than providing all services in a one-on-one fashion.
  • The study group recommends that the Division of Prevention and Behavioral Health Services receive funds necessary to offer Child and Family Traumatic Stress Intervention training to child mental health professionals, ensuring that among those trained will be professionals who can offer this training in Spanish.
  • The study group recommends that the Division continue efforts to work at the school district and individual school level to ensure that appropriate resources to identify and address student needs are in place, including ample resources in Spanish.
  • The study group recommends that the state provide stable funding for the Children’s Advocacy Center’s Family Resource Advocate program, which provides mental health case management services to child trauma victims, and also provide a single Kent/Sussex County case manager through the Division who can provide similar services to children who are not served by the CAC. Case managers should be sensitive to the linguistic and cultural needs of the Spanish-speaking population and actively seek out and connect these families with appropriate services and resources in Spanish.
  • The study group recommends that the Department of Insurance, Office of Management and Budget, and DHSS promptly review the networks of mental health providers available to covered children within the insurance plans they oversee, in order to ensure that said networks are adequate and take remedial steps if they are not.
  • The study group recommends that the Victims Compensation Assistance Program Advisory Council consider the need for a fund to augment existing Victim Compensation Assistance Program funds available to child victims of sexual assault and their families. The purpose of such a fund would be to allow more flexibility in the use of funds for victims of the unique crime of child sexual abuse.
  • The study group recommends continued support for the state’s Stewards of Children program, and encourages the program to continue its efforts to recruit English/Spanish bilingual facilitators and reach more Spanish-speaking participants.
  • The study group recommends that the Child Protection Accountability Commission monitor demands for mental health services in Kent and Sussex County so additional steps can be taken if currently unknown victims of Dr. Earl Bradley create an additional need for mental health services. Monitoring should include Spanish materials and English/Spanish bilingual professionals in these efforts.
  • The study group recommends that the law enforcement, state and community agencies that are customarily called upon to respond to crises which have a social and emotional impact on a community participate in training exercises around communication during times of community crises.

Discussion

The study group’s specific recommendations are focused in five areas: adequacy of direct child mental health services, improved training of child mental health professionals, centralized case management for children needing mental health services, ensuring the adequacy of child mental health coverage under private and public insurance programs, and reviewing the legally permitted use of victim compensation funds for child victims of crime. In each of these areas, the critical importance of increasing professional services to the large and growing Spanish speaking population has been recognized. In addition, the study group strongly believes that adequacy of services in all three of these areas must be closely monitored given the uncertainty regarding the number of children who will need services in Kent and Sussex County as a result of the crimes committed by Dr. Earl Bradley. The study group believes that all of its more general recommendations regarding mental health services for child victims of trauma are applicable to children who have been victims of sexual assault.

1. Availability of Child Mental Health Services

The committee heard evidence regarding child mental health availability in Kent and Sussex County which was both anecdotal and empirical.

Anecdotally, representatives from the Delaware Division of Prevention and Behavioral Health Services, along with representatives of the education and mental health community in Sussex County, told the study group that they experienced delays in attempting to obtain appropriate mental health services for some children in Kent and Sussex County. An informal survey conducted by the Division indicated that the waiting period for non-emergency mental health services could range from two days to eight weeks, with some of that delay caused by a requirement that individuals seeking psychiatric services receive counseling first. Interviews with providers and community representatives also indicated concern about the lack of bilingual (English-Spanish) mental health professionals, and the lack of providers who offered services on nights and/or weekends when working parents could more easily bring their children for treatment.

Although the specific availability of child mental health services has not been measured, it appears likely that Sussex County is experiencing an overall shortage of mental health professionals, in particular in the area of psychiatry. Standard national practice is to measure the sufficiency of mental health services by measuring the ratio of mental health professionals to persons in the population. Kent County’s countywide ratios meet national standards, though there is a shortage of mental health professionals in its northernmost census tract that includes Smyrna. However, Sussex County does not meet minimum federal standards for “areas of unusually high need” with respect to psychiatrists. Sussex County does meet minimum federal standards for areas of unusually high need with respect to other mental health professionals, e.g. nurses, counselors, social workers, and psychologists. Sussex County’s shortage of psychiatrists appears to be concentrated in the western side of the county.

Based upon the anecdotal and statistical evidence regarding provider/patient ratios and waiting periods for mental health services, the study group recommends that the state attempt to create the necessary conditions to recruit an additional two board certified child and adolescent psychiatrists to the Sussex County area, with at least one offering services in western Sussex County. The study group also recommends that an emphasis be placed on the hiring of bilingual (English-Spanish) professionals and that all mental health professionals be encouraged to offer services during hours when working parents can bring their children for services without missing work.

The study group believes it is important that new child and adolescent psychiatrists recruited to Sussex County be amenable to working indirectly, in a consultative role, with family doctors and pediatricians, as opposed to providing all services in a one-on-one fashion. Given the geographic challenges of practicing in a largely rural area, it is unlikely that even the addition of new psychiatrists will alone result in optimum coverage for children in need of mental health services. The Delaware Health Care Commission has made funds available specifically for recruitment of child psychiatrists in Sussex County, and the study group recommends that those funds be targeted at child psychiatrists willing to practice in this consultative fashion.

2. Professional Training

Aside from the numerical adequacy of mental health professionals, the study group also considered the level of training provided for those professionals – especially training specific to the needs of child sex assault victims. The Division made specific recommendations for improving the training of child mental health professionals.

The Division believes that it has adequately trained current providers in Kent and Sussex County for dealing with children suffering from Post Traumatic Stress Disorder. However, training is not yet sufficient for clinicians helping children whose symptoms fall below the threshold for PTSD. The Division believes that widespread training in a separate form of treatment known as Child and Family Traumatic Stress Intervention would allow Kent and Sussex County clinicians to provide a more appropriate range of services to children who have suffered trauma but do not yet suffer from PTSD. The goal of this treatment would be to provide early intervention to children and avoid more severe symptoms. It is recommended that this proposed intervention be provided to all Spanish-speaking mental health professionals working with families, to assure more services to Hispanic children, who, studies indicate, suffer higher than average levels of stress and trauma. The cost of providing this training would be approximately $14,000, most of which would be paid to the University of Pennsylvania. The Division has also proposed paying the University of Delaware $44,000 to have a graduate student intern under faculty supervision analyze the effectiveness of this new training. The study group believes that this is a worthwhile expenditure, but to the extent that the General Assembly must choose between proposals in this report requiring state funds, it believes that other such recommendations should take precedence over this recommended evaluation.

The study group was also encouraged by the creation of the state’s Stewards of Children program, which is designed to train adults to prevent and detect child abuse. The program has received funding from the state’s Criminal Justice Council, and the study group believes it is important that the program continue at a sufficient level to meet community demand for the training. This valuable training should be made more available to Hispanic and Spanish-speaking community members, with an awareness of how cultural differences and concerns create special challenges in the effective provision of this information. Similarly, personnel in primary care provider offices (family doctors and pediatricians), school districts and individual schools should receive this training, given their close daily interaction with children.

3. Centralized Case Management

In addition to achieving numerical adequacy and training of mental health professionals, the study group also heard testimony from advocates and providers about the importance of centralized case management for child victims of trauma. This case management ensures that children receive immediate assessments, and that their families have assistance navigating the mental health system to obtain timely and appropriate treatment.

Centralized case management for child victims of trauma has been provided in two ways in Kent and Sussex County in recent years. First, since 2004, Family Resource Advocates at the Children’s Advocacy Center have provided mental health case management services to child victims of trauma who are seen at the Center, and to those victims’ families. The funding for the Family Resource Advocates in all three counties has been provided by federal funds allocated by the state’s Criminal Justice Council. Unfortunately, these federal funds are diminishing, and are also used to fund a number of other service providers in Kent and Sussex County and are therefore unstable from year to year. Second, the Division temporarily provided a centralized case manager for Kent and Sussex County in order to assist the families who discovered that their children had been victimized by Dr. Earl Bradley. That position was reallocated elsewhere in the Department when the demand for initial case management services from victims of Dr. Bradley sharply diminished after approximately two years. All of these case management positions were focused upon specific child trauma victims – in the case of the Child Advocacy Center, children who were seen at the CAC as part of a law enforcement and/or state investigation, and in the case of the Division, children who were victimized by Dr. Bradley

The study group believes that centralized case management services for children should be provided in Kent and Sussex County on a regular basis, in order to ensure prompt evaluation and treatment of victims. The Children’s Advocacy Center FRA program is a longstanding program that appears to work well for the children it serves; the study group strongly recommends that the state find a more reliable and stable source of funding for this program. In addition, the study group recommends that the Division receive $44,000 annually to hire a single individual capable of providing case management services to children in Kent and Sussex County who are not seen through the Children’s Advocacy Center. Ideally, this person would be bilingual (English-Spanish), but at a minimum would be culturally sensitive to Hispanic (and other) groups, actively cultivating appropriate services for Spanish-speaking Hispanic and other populations. This case manager would also serve as a single point of reference for persons throughout the state seeking assistance with child mental health issues. It is also critical that persons conducting interviews and screening of children who may have been sexually abused be accessible and sensitive to children with disabilities.

4. Victim Compensation Assistance Program Funds for Cases Involving Child Sex Abuse

The state’s Victim Compensation Assistance Program allows victims of crimes and “secondary victims” (which includes close family members) to apply for financial assistance from the state to defray “pecuniary losses” incurred as a result of the crime committed. The list of pecuniary losses has been carefully written and limited by legislators and victim advocates over the course of time to properly compensate victims while still maintaining the financial viability of the program. However, the study group believes that the definition of “pecuniary losses” in the Victim Compensation Assistance Program may not permit full or adequate compensation for child sex abuse victims and their families. These cases can result in long-term life changes for both child victims and their caretakers, that the current definition of “pecuniary loss” may not capture. Although the study group does not have sufficient information to determine the scope of this problem, it does recommend that the Victim’s Compensation Assistance Program Advisory Council investigate the precise scope of need in this area, and an appropriate funding mechanism for a separate fund that would address this need. The study group also encourages the Victim Compensation Assistance Program to direct victims at the outset of treatment to providers whose services are covered by the victim’s own insurance carrier, in order to avoid having victims unnecessarily draw down state victim compensation funds (which have a lifetime limit).

5. Insurance Network Adequacy

Some study group members expressed concern regarding the level of reimbursement provided by insurance carriers (private and public) for child mental health providers in Kent and Sussex County, and suggested that the level of reimbursement might discourage provider participation. The result of under-participation by providers could be waiting lists for mental health services or long travel requirements for patients. Each of the three entities that oversee insurance coverage in the State of Delaware – the Department of Insurance with respect to private insurers, the Office of Management and Budget with respect to the state employee health plan, and DHSS with respect to programs such as Medicaid and CHIP – have standards regarding minimum network coverage for insurance carriers participating in their programs. The study group recommends that these three entities promptly review the network of child mental health providers in the networks of their insurance carriers to ensure that those networks meet required standards, and take prompt remedial steps if standards are not being met.

6. Monitoring

Finally, the study group believes it is important to carefully monitor the prevalence of post-traumatic stress disorder and substance abuse in Kent and Sussex County that might result over time from the widespread sexual abuse of children by Dr. Earl Bradley. Because of extraordinary diligence by law enforcement authorities, prosecutors, and health care providers, it appears that currently-known victims of Dr. Bradley are receiving appropriate and timely treatment. However, it is impossible to know precisely how many of Dr. Bradley’s victims have yet to report their abuse, and the Division believes that over time, the number of post-traumatic stress and substance abuse cases arising specifically from Dr. Bradley’s abuse could increase dramatically. For that reason, the study group recommends that the Child Protection Accountability Commission monitor the indicia covered by this report on an ongoing basis, and inform policymakers and professionals promptly if the prevalence of PTSD or substance abuse in Kent or Sussex County appears to be increasing beyond the system’s ability to treat it. Special care should be taken to be on the alert for signs of under-reported post-traumatic stress, substance abuse, and other mental health problems related to past sexual abuse among Hispanic and Spanish-speaking children.

7. Further Study

Just weeks before the study group’s report was due, the state was saddened by a series of juvenile suicides. The issue of juvenile suicide prevention was not part of the study group’s charge, and the group’s reporting deadline does not allow for a thoughtful analysis of the issue. But the study group members believe strongly that a formal review of the state’s efforts in this area is appropriate given recent events. This could occur through the state’s existing Suicide Prevention Coalition or a new group, and either way several members of the study group indicated their willingness to help with such a review.

HJR 7

Study Group to Assess Child Mental Health Needs in Kent & Sussex Counties

Matt Denn, Chair Lt. Governor

Vivian Rapposelli Secretary, DSCYF

Rita Landgraf Secretary, DHSS

Marianne Kenville-Moore Office of the Attorney General

Pat Maichle Developmental Disabilities Council

Terry Wilkinson Cape Henlopen High School

Sharon Collins Milford School Distrct

Randy Williams Children’s Advocacy Center

Debra Reed DE State Police Victim Services

Rep. Ruth Briggs King House of Representatives

Rep.Valerie Longhurst House of Representatives

Lee Dogoloff Public Member

Zaida Guajardo Public Member

Sen. George Bunting Senate

Dr. Karen Chambliss Child Psychiatrist/DE Guidance Services

The ratios cited in this paragraph are drawn from a 2009 study, Mental Health Professionals in Delaware 2009, prepared by the Center for Applied Demography and Survey Research at the University of Delaware.

The training provided by the Division has been in Trauma Focused Cognitive Behavioral Treatment, which is believed to be the best approach to use with children who have been exposed to sexual abuse and other traumas. Forty-seven clinicians in Kent and Sussex County have been trained to use this treatment, and 27 have been formally certified.