Children deserve to live and be nurtured in families and communities, and to have access to the culturally responsive supports and services that they need to be healthy, well, and thrive. Without timely access to necessary supports and services, children with behavioral health conditions suffer and their needs often intensify. In too many instances, appropriate, available, and accessible community-based services do not exist for children with behavioral health needs, and as a result, parents and caregivers are left with no choice but to place a child into a restrictive residential facility – away from their family, home, and community – in order to receive the care they need.
What happens when community-based behavioral health supports are unavailable
Placement in residential facilities disrupts relationships and connections that are central to a child’s development and well-being. Children who are placed in a residential facility are deprived of the norms and support of home environments and day-to-day life, have restricted access to in-person or other communication with their families and loved ones, and are in most instances unable to continue school and activities in their community. These disruptions happen not just for older youth but also for very young children – children as young as five-years-old. These disruptions can be devastating for the development of all children, impacting a child’s ability to form healthy relationships and connect with their peers.
Compounding the harms of separating children from their families and communities is clear evidence that children routinely suffer harms in residential facilities, including physical, sexual, and emotional abuse; overused and improper physical and chemical restraints; isolation and seclusion; and inadequate treatment and supervision. Experiences in these facilities can present acute safety concerns and have long-term negative effects on children rather than facilitating healing or treatment for behavioral health needs.
Opportunities to promote healing
There are opportunities to do better. Children belong in their communities and with families. We must invest in communities to ensure they have the resources and supports they need to support all children and families. Public systems play an important role in ensuring that community is a place of healing and have an obligation to provide community-based services to children.
Federal and state policymakers have affirmed what research tells us children need by advancing policy that supports and legally requires a shift away from segregated residential facilities. Specifically, recent guidance from the Centers for Medicare & Medicaid Services (CMS) reinforces children’s rights under Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) to a comprehensive array of services including behavioral health services that are provided within children’s homes and communities. Some services cited within CMS’s guidance are crisis services, including Mobile Crisis Intervention services, that can be provided in the home or other settings where a crisis occurs; Certified Community Behavioral Health Clinic (CCBHC) services which are designed to ensure access to coordinated, comprehensive, 24/7 behavioral health care and include staff with expertise in addressing trauma and supporting children with serious emotional disturbances; and other intensive home-based services which may include therapy, care coordination, parent and/or youth peer services, and behavioral interventions.
Additional best practices highlighted in the guidance include:
- Avoid requiring a child to have a specific behavioral health diagnosis for the provision of services, as screenings may identify symptoms that necessitate services but do not meet diagnostic criteria.
- As with a physical health condition, ensure that behavioral health symptoms that are identified through screening are addressed in a timely way.
- Ensure services covered under EPSDT are provided in the most integrated setting appropriate for the child – including clinics, educational settings, or within their homes – and avoid unnecessary placements in segregated treatment settings. Inpatient and residential settings must not be the default treatment setting, either explicitly or because of a lack of capacity of services offered in integrated settings.
Implementation of the practices within the above referenced guidance along with actions to ensure children and families have access to culturally responsive programs and affirming services and supports including gender- and identity-affirming care, are critical to advancing change.
This is not a controversial issue. We must do more to ensure children and their families can access community-based behavioral health services that are appropriate, available, and accessible – this means ensuring quality services that are culturally responsive and affirming, providing a range of supports including those that are focused on promoting wellness and healing, and ensuring supports are available when and where children and families need them.