Children and Adolescents with a Serious Emotional Disturbance
Criterion 1: Comprehensive Community Based Mental Health Service Systems
Definition of Children and Adolescents with a Serious Emotional Disorder
Pursuant to Section 1912 of the Public Health Services Act, as amended by Public Law 102-32-
1, "children with a serious emotional disturbance are persons:
• From birth to age 21,
• Who currently, or any time, during the past year
• Have had a diagnosable, mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-IV
• That resulted in a function impairment which substantially interferes with or limits the child's role or functioning in family, school, or community activities."
These disorders include any mental disorder (including those of biological etiology) listed in
DSM-IV or their ICD-9-CM equivalent (and subsequent revisions), with the exception of
DSM-III-R "V codes, substance use, and developmental disorders, which are excluded, unless they co-occur with another diagnosable serious emotional disturbance. All of these disorders have episodic, recurrent, or persistent features and they vary in terms of severity and disabling effects.
Functional impairment is defined as difficulties that substantially interfere with or limit a child or adolescent from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative or adaptive skills. Functional impairments of episodic, recurrent, and continuous duration are included unless they are temporary and expected responses to stressful events in the environment.
Children who have met functional impairment criteria during the referenced year without the benefit of treatment or other support services are included in this definition.
Organizational Structure of the Comprehensive System of Care for Children with SED
Health and Medical
The Iowa Department of Public Health, Division of Family & Community Health, Bureau of
Family Health promotes the health of Iowa families by providing resources for health care services through public and private collaborative efforts. Specific programs offered by the Department of Public Health to serve children with SED are varied and cross the array of needs. Following are some of the highlighted programs that are available through the Iowa Department of Public Health.
Child Health Specialty Clinics
There are 16 community based child health centers covering all 99 Iowa counties. These clinics are charged with developing health programs and designing services that are responsive to the needs of the community through contracts with the Iowa Department of Public Health. The clinics are working with managed care organizations to build partnerships to improve care coordination services, informing families about services available in the community including
Medicaid and Hawk-I (CHIP), and working with the dental community to improve dental care access.

State Children’s Health Insurance Program (SCHIP)
The State Children's Health Insurance Program (SCHIP) was created by the new Title XXI of the
Social Security Act. Title XXI enables states to provide health care coverage to uninsured, targeted low-income children. House File 2517 was enacted in 1998 to initiate the program in
Iowa. Medicaid expansion has been approved to assist in the dissemination of the program.
Mental health and substance abuse treatment is covered under SCHIP. Targeted low-income children are those who are under 19 years of age, who reside in families with income below
200% of the federal poverty level, are not eligible for Medicaid or covered under a group health plan or other health insurance. Iowa's (SCHIP) program provides Medicaid coverage for children below 133% of the federal poverty level (Medicaid Expansion program) and non-
Medicaid coverage for children below 200% of the federal poverty level. The non-Medicaid program is known as the Healthy and Well Kids in Iowa (HAWK-I) program. The HAWK-I program covers mental health and substance abuse but limits may apply.
Mental Health
The Children’s Mental Health System consists of at least two distinct components within the
Department of Human Services: (1) the Iowa Plan and (2) the Child Welfare System. In addition, the Department of Education, the Department of Public Health, and county-based mental health centers provide some mental health services to children.
Iowa Plan for Behavioral Health (Iowa Plan)
Iowa’s Mental Health Medicaid program is called the Iowa Plan and is administered through a managed care contract with MBC of Iowa, an affiliate of Magellan Behavioral Health. Unless specifically excluded, all categories of Medicaid-eligible beneficiaries are covered by the plan.
Under established capitation rates, the contractor is at full risk for providing all Medicaid funded mental health and substance abuse services to enrollees, regardless of pre-existing conditions. The contractor interfaces with the child welfare and juvenile justice system to coordinate mental health and substance abuse needs of children and families in these systems.
The contractor provides administrative services for the Iowa Department of Public Health funded substance abuse delivery system.
The managed care contractor supports local system planning through existing planning entities including the County Central Point of Coordination, County Management Plans,
Decategorization Boards, Empowerment Boards, and holds roundtables involving consumers and the provider community to seek input for planning and implementation of services.
The Iowa Medicaid Program covers both categorically and medically needy persons. The average monthly enrollment during the first year of the managed care contract in 1999 was
175,967. Current monthly enrollment average for FY 2002 is 224,013. In a typical month, unduplicated enrollees who received one or more services are approximately 17,250 persons.
Approximately 55% of the persons receiving services are children.
Although not covered in the fee-for-service Iowa Medicaid Program, the following services are required of the Contractor as appropriate ways to address the mental health needs of enrollees:
• Services for persons with dual diagnoses (substance abuse and mental illness)
• Case consultation by a psychiatrist to a non-psychiatrist physician

• Services of a licensed social worker
• Mobile crisis services
• Mobile counseling services
• Integrated mental health services and supports to assist enrollees remain or return to the community and limit the need for out-of-home placement similar to wraparound services available in the child welfare and juvenile justice system
• Psychiatric rehabilitation services
• Focused care management
• Peer support services
• Supported community living services
• Assessment of functioning level of a child with serious emotional disorder or adult with a serious mental illness; the scale to be repeated by intervals specified by the regimen
• Assertive Community Treatment
• Specified services to persons admitted at the state Mental Health Institutes (MHI)
• Specified inpatient evaluations for mental health conditions

Prevention and early intervention services
Child Welfare
The Division of Behavioral, Developmental, and Protective Services for Families, Adults and
Children of the Iowa Department of Human Services is responsible for a family-focused, community-based Child Welfare system. Within the Child Welfare system is the second component of the children’s mental health system: Rehabilitative Treatment Services (RTS) and
Psychiatric Medical Institutions for Children (PMIC’s). The Iowa Foundation for Medical Care is the authorizing agent for RTS services
1.
Rehabilitation Treatment Services (RTS) are designed to restore a function or skill that a child lost or never gained as a result of interference in the normal maturation learning process due to individual or parental dysfunction. RTS programs serve children, and in special circumstances, persons up to the age of 21. The goal of RTS services is to maintain the child at home or as close to home and community as possible in the most normalizing and age appropriate setting in order to avoid unnecessarily restrictive or otherwise inappropriate placements. Categories of RTS services include:

Family-Centered Services: Interventions designed to provide treatment services to child and family when the identified child has been determined to have rehabilitative treatment need and is are most often provided within the child’s home. The
Rehabilitative Treatment Services components include therapy and counseling, restorative living, family and social skill development, and psychosocial evaluation.
Family Centered Services focus on preventing out-of-home placement for children identified being at such a risk for various reasons including but not limited to individual child dysfunction, family dysfunction and child protective issues.

Family Preservation: An intensive, time-limited intervention to prevent out-of-home placement of children and stabilize the family. Family Preservation Services consist of therapy and counseling, skill development, psychosocial evaluation, supervision, transportation, family resource building and any other supportive services deemed necessary to stabilize the family. This program is the only program within Iowa which is delivered as a "bundle" of services and has a limited flexible spending

component to meet needs of a child and family for which there is no other funding source.

Family Foster Care: Provides care for children who are unable to live in their own parental or family homes. Placement goals for children include family reunification unless or until such a goal is no longer deemed appropriate at which time the goal is to seek permanency for the child. Therapeutic foster care may be offered to children with a high degree of service and supervision needs, and is often the level of care needed for children with SED’s. Therapeutic foster care includes the availability of a professional with expertise to provide support and assistance to the foster families and the children in therapeutic foster care.

Group Care: Provides highly structured 24-hour treatment services and supervision to children in a licensed group care facility. Children placed in group care cannot be otherwise served in less intensive settings due to the severity of their emotional or behavioral problems. Services are also provided to biological families with the primary goal of reuniting the child with the family.
2.
Psychiatric Medical Institutions for Children (PMIC’s): These facilities have become a primary placement option for adolescents with SED’s who have behaviors and treatment needs that exceed those that can be provided in the parental home and/or are being provided to children with SED’s who require placement for other issues related to family dysfunction or abuse. There are twelve providers that deliver these services to children in
Iowa. Services include diagnostic, psychiatric, nursing care, behavioral health, and services to families, including family therapy and other services aimed toward reunification or aftercare. Children served are those with psychiatric disorders that need
24-hour services and supervision. Diagnoses of attention deficit, oppositional defiant, conduct, adjustment, and other behavioral disorders make up 50% of the admissions.
Major depression, bi-polar, and other mood disorders make up another 33% while post traumatic stress, psychotic, reactive attachment, developmental and anxiety make up 17% of the diagnoses upon admission.
Child Welfare Redesign
The 2003 Iowa General Assembly enacted a provision of state law calling for:
The Department of Human Services [to] initiate a process for improving the outcomes for families in this state who become involved with the state system for child welfare and juvenile delinquency by implementing a system redesign to transition to an outcome-based system for children.
(Senate File #453 – signed by the Governor)
With the adjournment of the 2003 Legislative session, the Iowa Department of Human Services, along with Juvenile Court Services, launched a system design and implementation project, entitled Better Results for Kids in the 21 st
Century.
An extensive “listening phase” has been completed through town meetings, focus groups, and individual interviews involving over 1000 Iowans and covering the broad spectrum of stakeholders for this system. This information gathering process included youth who are currently in the system, biological, adoptive, and foster parents, grandparents, private providers,

DHS staff, juvenile court officers, attorneys, medical professionals, educators, judges, and community members. In addition, the Project Team conducted its own research on systems in other states and contacted national child welfare experts.
Iowa’s redesign effort is building on this work and on Iowa’s recent (May 2003) Child and
Family Service Review; and specifies in detail the parameters that are to guide the design step in this project. A final design will be submitted to the Project Steering Committee for its consideration. The Steering Committee will submit its recommendation(s) to the Director of
DHS. Once the Director accepts the final design, an implementation phase will begin.
The proposed system must be outcome-based and include performance-based purchasing; it must specify the interactions and partnerships among the major participants in the system, for example: the public child welfare agency, the public juvenile justice agency, private child welfare agencies, and the public education system. The design will recognize that the system must operate on an allocation of state resources for FY2004 that has decreased by $10M from
FY2003. Yet this does not assume that total resources invested in the system must decrease. The proposed system must provide for the involvement of children and families in planning and in decisions about their lives.
Educational Services
Success4 is an important initiative in Iowa’s school improvement process designed to address the multitude of challenges for today’s youth. The basic principles of the program are:
1.
Social, emotional, intellectual and behavioral skills are essential to success in school and throughout life.
2.
All children and youth can be successful socially, emotionally, intellectually, and behaviorally.
3.
Families, schools, and the community must work together in partnership to ensure the social, emotional, intellectual, and behavioral well being of children and youth.
4.
Changing the family-school-community relationship is necessary in order to create an environment, which nurtures social, emotional, intellectual and behavioral development for all children and youth.
The Iowa Department of Education is currently undertaking a broad-based effort to redesign its five-year-old Success4 initiative - originally an outgrowth of the Iowa Behavioral Initiative.
Facilitators for this process include researchers, Dr. Howard Adelman and Dr. Linda Taylor from the School Mental Health Project *at UCLA. They will conduct a series of meetings for stakeholders to help the Success4 Design Team create a comprehensive system of learning supports that aligns with the Iowa Collaboration by Youth Development results framework and can be embedded into Iowa's school improvement process. Stakeholder groups include all Iowa state agencies and organizations that serve youth as well as professional educational associations, parent groups, and national experts in the field of positive youth development. (*The School
Mental Health Project is supported in part for the U.S. Department of Health and Human
Services, Public Health Service, Health Resources and Services Administration, Maternal and
Child Health Bureau, Office of Adolescent Health.)

Success4 will be redesigned in the fall of 2003 and implemented in 2004. This redesign will address problem issues that currently exist, build upon lessons learned from the previous initiatives, and infuse the work of promoting healthy social, emotional, intellectual, and behavioral developments into the overall school improvement efforts in Iowa through the development of statewide, regional, and local systems of learning supports.
The Parent Training and Information Center of Iowa, in collaboration with other existing services and programs, provides information and training to families of children with special needs throughout the State of Iowa to ensure that children with disabilities have access to free and appropriate educational services as required by the Individuals with Disabilities Education
Act. About 60% of the requests for services received by PTI involve mental health or behavioral issues. PTI focuses particularly on under-served families and parents of children who may be inappropriately identified for special education or inappropriately excluded from special education. PTI assists parents to better understand their child’s disability, provides information to training on the Individuals with Disabilities Education Act and other disability rights, promotes the development of skills to enable parents to effectively participate in the IEP process and in school reform activities, provides family support information, assists in the development of IEPs, provides one-on-one parent and family support, and offers workshops and technical assistance across the State of Iowa. For the year ending September 30, 2002, the Parent Training and Information Center of Iowa reported the following:

7600 contacts were made to PTI by parents and professionals, through one-on-one problem-solving by telephone, in-person consultations, trainings, meetings, letters, and individualized information packets.

1560 of the individuals served by PTI Iowa were from culturally and racially diverse families.

2286 parents attended training sessions and other presentations offered by PTI Iowa.

1524 professionals serving children with disabilities attended training sessions and other presentations offered by PTI Iowa.

6800 people received the PTI Press newsletter published by PTI Iowa.

71,177 hits were counted on the PTI Iowa web site.
A follow-up telephone survey of parents served by PTI Iowa found:

96% of the parents surveyed reported that the individual assistance they received from
PTI Iowa helped them obtain services they felt their child needed.

87% of the parents surveyed reported they felt more confident about working with school personnel after speaking to PTI Iowa.

80% of the parents surveyed who had attended PTI workshops reported they believed their child received more appropriate services because the parent used the information from the workshop.

88% of the parents surveyed who received one-on-one assistance felt they could not have received this service had PTI Iowa not been available.
The Parent Training and Information Center of Iowa is one of the founding members of the ASK
Family Resource Center, a cooperative of family-friendly organizations that offer a broad range of information and services focused on benefiting children with disabilities and promoting
“Access for Special Kids.”

The Legal Center for Special Education (TLC) is a non-profit corporation created to provide effective, low-cost, and readily available legal and advocacy services for parents of children with disabilities across the State of Iowa. TLC’s focus is on issues concerning the educational rights of children with disabilities, and on issues involving services and supports related to educational development, including residential treatment, medical supports, and psychological services. TLC offers four levels of advocacy services:

Consultation and Self-Advocacy Training

Representation in Pre-Appeal conferences or other alternative methods of conflict resolution

Representation in Due Process Proceedings or similar administrative actions

Representation in court actions to enforce legal rights
In the course of serving families throughout the State of Iowa, TLC is frequently called upon to advocate for students with SED in matters related to their ability to attend school, to benefit from their education, and to access appropriate residential, mental health treatment, and behavioral services.
The Legal Center provides technical assistance and legal back-up to the Parent Training and
Information Center of Iowa which supports the PTI in serving over 7500 families a year and helps assure that they can offer legally sound training on the rights and responsibilities mandated by the IDEA, Section 504 of the Rehabilitation Act, and related statutes and regulations.
For the year ending March 31, 2003, The Legal Center reported the following:

The Legal Center provided direct representation to 191 children with disabilities and their families.

The Legal Center for Special Education represented children and parents in approximately 90 percent of all pre-appeals, mediations, and hearings on special education issues in the State of Iowa.

Of the parents who have contacted our office and requested services for their child, about 81 percent have followed through with our recommendations and
“got what they needed” for their child.

Of the parents who entered into formal attorney-client agreements with The
Legal Center, about 97 percent “got what they needed” for their child.
 The Legal Center’s overall record of successfully resolving disputes between families and schools is about 90 percent.

In about 98 percent of all cases, The Legal Center has been able to successfully resolve disputes between families and schools through conflict resolution efforts without resort to due process hearings.
The Legal Center is also one of the founding members of the ASK Family Resource Center.
Iowa Behavioral Alliance
The Department of Education awarded this five-year, $2.3 million grant in November 2002. It has three key elements: 1) development and implementation of multi-system school-based services for students with significant and complex mental/behavioral problems; 2) Drop-out

Prevention; and 3) Positive Behavioral Supports. Furtherance of the goals established in the
Children’s Mental Health Initiative was one of the stated objectives in the RFP released by the
Department of Education for this grant. The grant was awarded to Drake University and Iowa
State University. Some important components of the project will include partnering with the
Child Health Specialty Clinics, the use of telemedicine, the use of person-centered planning, wraparound services, and the development of systems change philosophy for whole school environments.
Early ACCESS is a partnership between families with young children, birth to age three, and providers from the Departments of Education, Human Services, and Public Health, the Child
Health Specialty Clinics and Iowa’s Area Education Agencies. The program is federally funded under IDEA Part C funds. The purpose of the program is for families and staff to work together to identify, coordinate, and provide needed services and resources that will help the family assist their toddler to grow and develop. All services to the child are provided in the child’s natural environment including the home and other community settings where children of the same age without disabilities participate. Service coordination and a host of other services are provided including psychology, screenings, evaluations, assessments, social work, health and medical evaluations. Eligibility requirements, other than age, include that the child has a condition or disability that is known to have a high probability of later delays if early intervention services are not provided or the child is already experiencing a 25% delay in one or more areas of growth or development.
Substance Abuse Services
The Iowa Plan has data on how many children come to the attention of the child welfare system via court ordered Medicaid funded evaluations for substance abuse. In the last quarter of State
FY2002, the Iowa Plan served 17 such children. Of those, 20% went to inpatient hospitalization and 80% went to various residential programs. This suggests that the vast majority of children served by Iowa’s child welfare system do not initially present through the publicly funded substance abuse evaluation.
We do not know of any data available to illustrate how many children are funded by private insurance.
Services for Adolescents with Co-Occurring (Substance Abuse/Mental Health) Disorders:
Two of the 12 PMIC facilities in Iowa provide services to adolescents diagnosed with cooccurring substance abuse and mental health disorders. The program located in Glenwood, Iowa has a capacity of 15 and the program in Sioux City, IA has a capacity to serve up to 41 children at any given time. Both programs serve children aged 12 to 18. In SFY20003, a total of 141 children were served in these two programs.
Education and Support Services:
NAMI Family Education Course The course consists of a series of workshops for caregivers of children with brain disorders. Caregivers may be parents, extended family, or foster parents.

Visions for Tomorrow is a family member-to-family member course. Teachers of the program will be trained family members who have experienced firsthand the rewards and challenges of raising children with brain disorders. The course offers caregivers an opportunity to share mutual experiences and learn valuable lessons from one another. Visions for Tomorrow covers educational material and provides the basics for day-to-day caregiving skills.
Statewide Parent Specialists and Support Networks
1) ASK (Access for Special Kids) Family Resource Center www.askresource.org
This statewide resource center is a “one-stop-shop” for children and their families. Through its member organizations, the ASK Family Resource Center provides a broad range of information, advocacy, support, training, and direct services. The cross-disability, collaborative, blending of resources approach strengthens their effectiveness across the state by eliminating duplication and providing families with a clear simple and direct source of information.
Parent Training and Information Center (PTI)
Family Voices of Iowa (FVI)
The Legal Center for Special Education (TLC)
Iowa Family Support Initiative (IFSI)
Child Health Specialty Clinics (CHSC)
2) Parent Coordinators have children with special educational needs and provide free peer support to other parents. There are 34 Parent Coordinators across the state that identify local needs, develop support groups, provide appropriate resource material and conduct appropriate workshops. They are paid through the Department of Education.
3). Parent Consultants have children with special health care needs and provide free peer support to other parents. There are 16 Parent Consultants across the state. They are paid through Iowa’s
Title V Program and are located in the Child Health Specialty Clinics.
4). Parent Liaisons have foster and/or adoptive children and provide free peer support to other parents. There are 15 Parent Liaisons across the state who identify the needs of foster and adoptive parents, develop local support groups and communicate concerns to local DHS workers.
They are contracted by the Department of Human Services.
Home & Community Based Service Waivers
Families receive support services, such as respite, supported community living, and home health care, when their child qualifies for one of the Medicaid HCSB Waivers. (Mental Retardation, Ill
& Handicapped, Brain Injury, AIDS, etc.)
Child Care Services: Supplement parental care by providing care and protection to children in or outside their family homes for part of the day. Services include supervision, food, transportation, comprehensive child development and care, including services to children with special needs.
Case Management Services
Children receiving child welfare services to address their mental health needs receive case management from the Department of Human Services. Children within the juvenile justice system receive case management services from a juvenile court officer.

Within the redesign of child welfare/juvenile justice services currently being done, the case management services will be reviewed.
Dental Services
The Bureau of Oral Health promotes and advances health behaviors to reduce the risk of oral diseases and improve the oral health status of all Iowans. Programs are in place targeting pregnant women, children, and youth for the prevention, early identification, referral, and treatment of oral disease. These programs have been implemented in schools, maternal and child health agencies, public dental health clinics, and other community-based settings. Children with
SED access these services in the same manner as other children.
Iowa Access to Baby and Child Dentistry (ABCD) is a program to improve access to dental care for low-income children. Iowa has had four ABCD programs implemented through Title V Child
Health Agencies: 1) Dubuque Visiting Nurse Association; 2) North Iowa Community Action
Organization; 3) Mid-Iowa Community Action, Inc.; and 4) Washington County Public Health and Home Care. The focus of the ABCD program is to identify and ease barriers to early preventive dental care through infrastructure-building and care coordination services, allowing communities to strengthen oral health services for children and work with local dentists to provide a dental home to low-income children through age 21.
Employment Services
Iowa is responding to a federal mandate to provide transition services to children in the care of the DHS when the child reaches the age of sixteen. This mandate included the provision of services related to assessment of skills, education related to work readiness, and preparing the youth to enter the world of work as an adult. A portion of the Performance Partnership Grant is used for provision of transition services to children with SED.
Services provided through the Iowa Aftercare Services Network (IASN) include: pre-exit planning (up to 3 months prior to youth “aging out”), for youth deemed to be at high risk for unsuccessful transition into adulthood; aftercare services for youth, ages 18 through 20, for youth who have “aged out” of foster care or a PMIC – services include a case management component, assisting youth with acquiring needed life skills and linking youth to appropriate community resources to assist them in their transition into self-sufficiency; a vendor payment component, of up to $1000 per youth, to assist with housing, clothing, transportation, medical needs, food, day care, etc. Services are available to youth in each of Iowa’s 99 counties.
Housing Services
The Department of Human Services (MHA) does not offer any services specifically designated as housing services for children. However, on a regular basis many families with significant housing issues, including inadequate housing and homelessness, come to the attention of the child welfare and juvenile justice systems, as well as the attention of other community based programs and schools. It is quite common for families being served within these systems to have housing related needs and individualized goals within their treatment plans to address these needs. The services may take many forms, some examples include: referrals for

homemaker/home health aide programs to assist with home maintenance and cleanliness issues; referrals to local Section 8 Leased Housing programs; referrals and coordination with local housing inspection departments; coordination with Community Action Programs which are in several communities across the state and provide housing services utilizing federal HUD and
HOME funds; Community Development Block Grant funds and other services; referrals to programs that can assist with budgeting and money management skills that are so closely tied to the ability to obtain and maintain housing; and others.
Having knowledge of this kind of array of available community services and how to facilitate families involvement with such services is expected of those who provide treatment and case management services to children and families who come to the attention of DHS and the juvenile justice systems.
When children come to the attention of the child welfare system and are determined to need
Rehabilitative Treatment Services, (RTS), information is gathered about the child’s living arrangement at the time of authorization. The following table represents the living arrangements of these children across the past three state fiscal years. Fifty-eight percent of children lived with a parent while 17% lived in foster family homes and 8% lived with relatives.
The following chart identifies placement of children at the time of an RTS authorization request.
Children may receive more than one authorization in a year resulting in duplication of children and their living arrangements.
RTS Living
Arrangement
Detention
Foster home
Group care
Hospital
Other
Parent home
Relative
PMIC
Shelter
Subacute
FY 2000-2001
15
4,474
2,992
41
614
15,245
2,196
63
780
0
FY 2001-2002
80
4,019
3,203
14
461*
12,256
1,881
58
611
0
FY 2002-2003
60
3,577
2,865
31
329
10,701
1,940
47
746
0
Total 26,420 22,583 20,296
*The FY 01-02 RTS Characteristic Report included the number of children in detention as part of the “other” category. Detention has been pulled out as a separate category for this report.

Social Services
Protective Services
These services begin when a referral of possible child abuse and/or neglect is received by
DHS regarding a child and/or family.
When such a referral is received, a Child Protective Worker (CPW) will conduct a child protective assessment which includes not only information regarding the specific allegations but an assessment of child and family strengths, needs, recommended services, and necessary court action to remedy the protective concerns and promote safety for the child.
A child protective treatment worker is assigned to work with the child and family to develop an appropriate individualized treatment plan, which may include mental health services for the children or parents identified, in order to address any identified protective and family concerns.
Shelter Care
Short-term placement and emergency services provide crisis intervention, daily supervision, medical and mental health care and protection.
Mental Health Issues in Detention/Shelter
A workgroup to address mental health issues in detention/shelter care has been formed at the request of the Iowa Juvenile Justice Advisory Committee and is administratively housed within the Iowa Criminal and Juvenile Justice Planning Division (CJJP). This work group is focused on the issue of increased admissions of youth with mental health issues to Iowa’s detention and shelter facilities. At the work group’s recommendation,
CJJP contracted with the University of Iowa Hospitals and Clinics to review the increase in admissions through facility visits and interviews and to develop a variety of informational/training products for the staff.
Supervised Community Treatment
Comprehensive, multidisciplinary treatment services within a school or community setting. Youths participate in the program 4-6 hours a day, 5-6 days a week for an average of ten months. Services are targeted for youth 9 through 17 who are experiencing severe behavioral or emotional problems, and are adjudicated delinquents or who are atrisk of delinquency. These programs are frequently referred to as day treatment and have the desired outcome of providing treatment services to a child within the community while not having to transfer custody and be placed out-of-home.
Activities Leading to Reduction of Hospitalization
The complete list of services described within the narrative in this section could be described as having the potential to reduce the need for hospitalization of children with
SED’s.

Local projects in children’s mental health have begun as collaborative efforts to achieve not only a reduction is hospitalization for children with SED but to assure that children and their families receive the needed services in a timely, unduplicated manner.
The Integrated Pediatric Behavioral Health (IPBH) program at the Creston Regional
Center began taking referrals the first part of 2003. The IPBH provides integrated and comprehensive mental and behavioral health services. Referrals originate from communities, schools, families, and individuals and will involve screenings at the
Integrated Evaluation and Planning Clinics (IEPC’s). These clinics provide multidisciplinary evaluation and diagnostic services for children with behavioral, developmental, and medical concerns. The staff includes a pediatrician, psychologist, social worker, dietician, and nurse practitioner. Children identified by the IEPC as being in need of expanded services are referred to the IPBH where staff works closely with the families to coordinate mental health care for their child. The clinic provides greater access to mental health services through extensive care coordination, sub-specialty consults and educational in-services to assist professionals in serving children with a mental and behavioral health diagnosis. The educational component of the program will provide in-services for school and AEA staff. Tele-health services will be utilized as needed to bring appropriate additional expertise for the care of any specific child via the
Iowa Communications Network (ICN). MBC of Iowa is supporting this innovative and collaborative process through the provision of technical and clinical assistance with the hope of enhancing the coordination of care and reducing and/or preventing hospitalization. This program is attempting to do evaluation of outcome achievement by comparing the services received through this program with a similar number of children identified in a demographically comparable area without such a program.

Criterion 1: Comprehensive Community-Based Mental Health System
Goal: Create and implement an organized community-based system of care that meets the needs of children with serious emotional disorders and their families.
Objective 1: Maintain or increase enrollment of children in public health insurance plans.
Population: Children with SED
Brief Name: Community-Based Mental Health System of Care
Indicator: Enrollment of children in public health insurance plans.
Measure : Numerator: Number of children enrolled in Hawk-I and Iowa Plan
Denominator: Estimated Number of children in the state eligible for
Hawk-I and Iowa Plan
State Fiscal Year
SFY2002 SFY2003 Numerator
Number of children enrolled in Iowa Plan*
Number of children enrolled in Hawk-I**
Denominator***
129,600
13,672
85,000
144,000
15,169
88,400
SFY2004 estimated
145,000
18,000
88,400
Sources of Information:
* These figures reflect the number of children enrolled in the Iowa Plan, which is
approximately 60% of the total number of enrollees.
** Based on the estimates shown on the Iowa Department of Public Health website.
www.idph.state.ia.us/fch/cover/insured_map1102.pdf
*** Prevalence estimate for children with a SED per NIMH Epidemiological study. This
denominator has been brought forward from previous years and may be outdated.
Significance : Since July 1998, Iowa continues to provide health care coverage to uninsured, targeted low-income children less than 19 years of age. In Iowa, the
Children's Health Insurance Program (SCHIP) required under Title XXI of the Social
Security Act is called Hawk-I.

Objective 2: Increase the number of Local Education Agencies (LEA's in school districts) and Area Education Agencies (AEA's) accessing federal Medicaid funding to assist in the provision of mental health services to eligible children.
Population: Children with SED
Brief Name: Community-Based Mental Health System of Care
Indicator: Enrollment of AEA's and LEA's enrolled as Medicaid providers.
Measure : Numerator: Number of LEA's and AEA's enrolled as Medicaid providers
Denominator: Number of LEA’s and AEA's eligible to become enrolled as Medicaid providers
State Fiscal Year
Numerator SFY2002
(actual)
4
SFY2003
(actual)
95
SFY2004
(projected)
150
Number of LEA’s enrolled
Number of AEA’s
Enrolled
Denominator:
Eligible AEAs
Eligible LEAs
15
15
370
11
15
370
12
12
370
Sources of Information: Iowa Dept. of Education, Dann Stevens, Suana Wessendorf
(MHPC
State agency representative)
Special Issues : AEAs are mandated by Iowa Code to participate in being enrolled as
Medicaid providers. Due to legislative action in 2003, the number of
AEAs has been reduced by merging AEAs from 15 to 12. While it is projected that approximately 200 LEAs will be enrolled as providers, it is projected that approximately 125-150 will actively submit claims.
Significance : Area Education Agencies (AEAs) have been able to seek Medicaid reimbursement for special education services since 1988. Local Education
Agencies (LEAs) have been able to claim for their services since March 0f
2001. Criteria for Medicaid reimbursement requires the child be Medicaid enrolled and have an IEP (ages 3 to 21) or IFSP (ages birth to 2) that defines the services.
Additional information: The statistical data reflects claims paid in the State fiscal year for Behavioral, Psychological, or Social Work services that would be appropriate for a child with SED. Generally, LEAs provide behavioral

services and the AEAs provide psychological and social work services, as well as all of the birth to age 2 services.
Criterion 2 : Mental Health System Data Epidemiology
Goal: Maintain or improve the treated prevalence of mental health services to children with SED’s
Objective: Treated prevalence of serious emotional disorders among children with
SED
Population: Children and Adolescents with a Serious Emotional Disorder
Brief Name: Treated prevalence of mental health services to children with SED
Indicator : Children and Adolescents with a Serious Emotional Disorder who received mental health services during the fiscal year
Measure : Numerator: Number of children with SED who received mental health
services
Denominator: Number of children estimated to have a serious emotional
Disturbance
State Fiscal Year
Numerator
Children receiving
Medicaid managed behavioral health services* (Iowa Plan)
Children with SED
receiving Child
Welfare treatment
services**
SFY2001
(actual)
19,580
NA
SFY2002
(actual)
22,216
4,502
SFY2003
(projected)
22,216
4,500
Denominator*** 85,000 88,400 88,400
Sources of Information :
* unduplicated children receiving services funded by MBC of Iowa per average month.
** 20% of all children receiving Rehabilitative Treatment Services through the Child
Welfare system have an SED. Iowa Foundation for Medical Care, annual report,
September
2002
*** NIMH Epidemiological Study. The estimate of children and adolescents between ages 0 to
18 who need mental health intervention of some sort are based on NIMH
Epidemiological Studies. According to this estimate, the prevalence rate among 0-18

age group is 11.8 percent. This prevalence rate, when applied to 718,000 children and adolescents in this age group, yields 88,400 children who need mental health services in the state.
Special Issues : Due to the design of the current data collection systems, it is challenging to track unduplicated children with SED who may receive mental health services from more than one delivery system (i.e. Medicaid, SCHIP, and
Child Welfare).

Criterion 3 :
Children’s Services
Goal: Improve identification of children in out-of-home placements who have need for mental health services.
Objective: Number of children in out-of-home placements receiving mental health services.
Population: Children with a Serious Emotional Disorder
Brief Name : Mental health services to children living out of home.
Indicator: Percentage of children with SED who are placed out-of-home (e.g., foster
care, residential home)
Measure: Numerator: Children placed out-of-home
Denominator: Children with SED
State Fiscal Year
SFY2001
(actual)
SFY2002
(actual)
SFY2003
(projected)
Out of home placements
Family foster care
Group foster care
Relative home
Shelter
4474
2992
2196
780
4019
3203
1881
611
4000
3000
2000
600
PMIC
Detention
Children with SED
63
15
88,400
58
80
88,400
Sources of Information: Numerator: Iowa Foundation of Medical Care
Denominator: NIMH Epidemiological Study
The numbers in the table represent places where the children who received Rehabilitative
Treatment Services were residing at the point they were that discharged from RTS.
Special Issues : Approximately 35% of all children receiving RTS in state fiscal year
2003 had an SED. Approximately twelve percent of Iowa’s children receiving Rehabilitative Treatment Services (RTS) are living out-ofhome. This includes children remaining in the parental home as well as those placed out-of-home. The percentage of children with SED, receiving RTS and placed out of home has not been accurately tracked to date.
Narrative
While the children’s mental health system in Iowa is centralized in that most funding is federal or state and most services are planned and administered at the state level, planning, regulation and administration of children's services is not vested in a single
60
60
88,400

state entity. Rather, these responsibilities are diffused in a variety of agencies including the state mental health authority and child welfare agency (the Iowa Division of
Behavioral, Developmental, and Protective Services for Families, Adults, and Children of the Iowa Department of Human Services), the Iowa Department of Human Services regional and local offices, the juvenile justice system, the Iowa Department of Education, the Iowa Department of Public Health and the Iowa Department of Inspections and
Appeals.

Criterion 4: Targeted Services to Homeless and Rural Populations
Goal: Improve identification of homeless school age children with an SED.
Objective: Identify number of homeless school age children
Population: Homeless C hildren
Brief Name : Mental health services for homeless school age children
Indicator: Percentage of homeless children with SED receiving mental health services
Measure: Numerator: Homeless school age children needing mental health services
Denominator: Homeless school age children
State Fiscal Year
SFY2002
(actual)
4709
SFY2003
(actual)
5886
SFY2004
(projected)
5886 Homeless school age children needing MH services*
Homeless school age 18,111 22,639 22,639 children in Iowa**
*26% of the school age children identified mental health services as their most prevalent need.
** Of Iowa’s 22,639 homeless children 80% are school age. The other 20% are preschool age.
Sources of Information : Drake University reports of Homeless Children and Families in
Iowa
Special Issues : SFY 2003 reflects the children living in court-placed shelter care programs who were not included in the Drake University report the previous year.
Narrative
Iowa’s Adult Mental Health Specialist and PATH Coordinator, Lila Starr, participates in the state’s Interagency Taskforce on Homelessness. This organization has been working to restructure it’s roles and responsibilities, reorganize it’s membership, increase linkages to the Governor’s office, which established the taskforce, and to clarify it’s role in housing and homelessness as well as continuum of care issues. The primary focus of the last two meetings has been around a new study on homelessness conducted by the
Department of Education, in conjunction with all of the 364 school districts across the state. This study, expected to be released in December of 2002, undertook an ambitious

agenda of capturing information about homelessness for children and their families, as well as data regarding the primary needs and obstacles to housing for these children and families. The primary purposes of “Iowa’s Homeless Children/Youth and Their
Families,” are listed below:
1) Estimate the number of homeless children and youth in Iowa
2) Estimate the number of children not living with adults
3) Provide a demographic profile regarding homeless children and youth and their families
4) Identify the causes of homelessness for homeless children and youth and their families
5) Identify the educational and personal needs of homeless children and youth and programs provided to meet these needs
6) Identify barriers that interfere with the enrollment, attendance, and success of homeless children and youth in school
7) Estimate the number of homeless adults in families with children
8) Estimate the number of homeless adults not living with children
Mental health was identified as one of the greatest needs for the children and/or family members in this study. The information contained in this report will be reviewed with the
Mental Health Planning Council and perhaps presented in more detail by appropriate persons from the Department of Education. We will attempt to learn how this study may be useful in targeting Block grant funds and/or addressing any of the priorities of the
Council.
Psychiatric services are lacking particularly in rural areas and fewer psychiatrists are accepting Title XIX. Due to the rural nature of Iowa, it has proven to be extremely difficult to attract psychiatrists as well as other mental health service providers to the state. There are several counties that have psychiatric services for a few hours a week while other counties have none, which poses yet another barrier. Transportation has been and continues to be a huge barrier for persons who lack their own transportation.

Criterion 5: Management Systems
Goal : Maintain or increase public expenditures for community-based mental health services for children diagnosed with a serious emotional disturbance.
Population: Children with Serious Emotional Disturbance
Criterion: Management Systems
Brief Name : Expenditures for Community-Based Services
Indicator: Allocation of financial resources necessary to implement the plan
Measure : Numerator: Total State Expenditures for Children with Serious Emotional
Disturbance (SED)
Denominator: Total State Expenditures for Mental Health Services
Expenditures for Children with SED by State Fiscal Year
SFY2002 SFY2003
(actual)
14,630,038
(actual)
15,434,442 Medicaid Behavioral
Health/Iowa Plan –(kids only)*
SFY2004
(projected)
16,669,197
12,193,668 9,088,424 8,726,918 Rehabilitative treatment services**
Psychiatric Medical Institutes for Children (PMICS)***
8,432,744 8,725,154 8,523,194
MH Block Grant
(children’s services)
Medicaid spending for children MH services
1,539,765
Not available
1,530,575
78,580
1,545,880
78,580
Numerator 36,796,216 34,857,175 35,543,769
Denominator 129,367,004 131,859,564 130,346,533
Sources of Information:
*Iowa Plan and Medicaid Spending: Iowa Dept. of Human Services, Medical Division
**RTS expenditures Sources:
FY02 family centered and family preservation dollars based on percentage of cases in which child's behavior was primary reason for service on April 2003 reports from child welfare data. FY03 and FY04 dollars are calculated using data from the same source for
July 2003.
FY 02 adoption services based on percentage of cases in which child's behavior was primary reason for service in April 03. FY03 and FY04 dollars are calculated using data from the same source for July 2003.

FY 02 family foster care and group care based on percentage of cases in which child's behavior was the primary reason for removal on the April 03 child welfare data report.
FY03 and FY04 dollars are calculated using data from the same source for July 2003.
***PMIC Spending: Iowa Dept. of Human Services, Finance Division
Denominator:
Gross expenditures for mental health for children and adults (see Maintenance of Effort, page 9)
Special Issues : The Iowa Plan has projected an 8% increase in eligible children for
SFY2004 which is reflected in the increase of spending.
The total funding for PMIC's in SFY2004 is increased from FY2003, however the state funding impact is decreasing because of the enhanced federal participation rate (FFP) designated for Iowa at the federal level from April 2003 to June 30, 2003. The federal FFP rate was 62.86% from July - Sept., 2002; 63.50% from July - Sept., 2003; and 65.88% from Oct., 2003 to June 30, 2004, or a SFY state match of 33.23%.
Significance : Many children with SED are served through the child welfare system.
The child welfare system experienced a budget cut of approximately
$10 million in SFY2004. While the Department of Human Services is making an effort to find this money in other places, this cut may indeed impact the service level for children.
Narrative
Typically, approximately half of the block grant ($1.8 million) is distributed among 40
Community Mental Health Centers (CMHCs) and other community mental health providers. The size of the allocation is based on a formula which is largely governed by local population. The allocations for SFY2003 ranged from $21,000 to $94,000 across
CMHC’s. Approximately half of all funds are directly targeted to children’s programming. There are separate allocations to each CMHC for children and adult programming (the numbers shown reflect total funds). This funding stream of “last resort” has become an increasingly vital source of funding for many CMHCs.
Recipients of block grant funds are required to generate and submit work plans that describe the services and programming that they intend to provide with the funds, as well as the unmet needs that are being addressed. The work plans typically include a projected estimate of the number of individuals to be served by these funds.
A table illustrating the breakdown of allocations for the SFY03 block grant funds can be found at the end of Adult Criterion 5, Management Systems, page 81.