INTERAGENCY POLICY AND PRACTICE:

MANDATES AND CONNECTIONS IN

MENTAL HEALTH PROGRAMS

Report on a survey of the

States and Territories

Prepared for

National Association of State

Mental Health Program Directors

by

Ron Haskell

Vermont Department of Mental Health

and

State Mental Health Representatives for

Children and Youth

November 1, 1984

TABLE OF CONTENTS

INTRODUCTION

SURVEY DESIGN

REVIEW OF FINDINGS

 

Data-based Items

Table 1, Organization and Delivery of Children's Mental Health Services

Table 2, Sources of Mandates for Interagency Practices

Table 3, Ranking of Multi-Agency Practices by Average Score and Frequency

Table 4, Outcomes Related to Implementation of Interagency Practices

Document Analysis

Agreements

Executive Orders

Judicial Decisions/Orders

Legislation

Program/Projects

State Plans

Training

Technical Assistance Requests

Education

System and Capacity Building

Money

Leadership Context

Legal Issues

RECOMMENDATIONS

Recommendation 1 and Potential Strategies

Recommendation 2 and Potential Strategies

Recommendation 3 and Potential Strategies

 

 

INTRODUCTION

In late Spring, 1983 the National Institute of Mental Health and the National  Association of State Mental Health Program Directors/State Mental Health  Representatives for Children and Youth agreed to survey the fifty-four states and territories regarding current multi-agency strategies designed to improve  services to young people with severe emotional disturbances. Two purposes are met through the survey. First, the information collected serves as a national  baseline measure of interagency efforts involving mental health authorities.  Second, information on specific strategies is now available to states for developing plans and implementing system-wide approaches to the delivery of  mental health services for severely disturbed young people.

The reader is urged to keep in mind several limitations and assumptions  affecting the scope of information solicited and received. Though care is taken in presenting the essence of an inquiry, respondents undoubtedly interpret the inquiry within the framework of their idiosyncratic knowledge and judgement. This limitation was controlled by reviewing preliminary findings, particularly document summaries, in two consecutive meetings of the State Mental Health Representatives for Children and Youth. Also, in order to standardize  terminology a brief glossary introduced the survey.

Second, the information solicited and collected through this survey focused  only on interagency practices related to young people receiving mental health services. Undoubtedly, other special populations, such as people with chronic  mental illnesses and elderly citizens benefit from interagency practices. A more  encompassing and penetrating review of states' and local communities' multi-agency practices may be useful as a comprehensive information base for technology transfer.

Third, the survey items initially selected represent diverse examples of practices and were not considered comprehensive and complete. However, few responses were provided under "Other" items and may indicate that the items  selected were indeed comprehensive.

In sum, the survey provides a representative picture of interagency practices  in the public mental health arena as reported by state-level child mental health  authorities. Many formal and informal practices occurring at the local level, such as contractual arrangements between schools and community mental health centers, local planning group efforts, and individual case conferences, are  undoubtedly omitted. Nonetheless, the diversity of practices outlined in  Appendix C certainly reflect the state of the interagency art in mental health, even if not to the minutest detail.
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SURVEY DESIGN

The survey design and subsequent analysis focus on four questions:

• What is the current level of interagency practice in states' mental health care systems for young people?
• How well are such practices meeting the needs for which they are implemented?
• What do state mental health representatives identify as obstacles and  facilitators to implementing interagency practices?
• What do state mental health representatives perceive as interagency  research and technical assistance needs?

In August, 1983 a five-page survey (see Appendix B) was mailed to the  fifty-four states and territories. Forty-four surveys (81%) were returned (see  Appendix A) and included in this report. Many states also submitted supporting  documents on current and past practices. Documents were reviewed and  subsequently summarized within seven categories: Agreements, Executive Orders,  Judicial Decisions/Orders, Legislation, Programs/Projects, State Plans, and Training (see Appendix C).

The survey is not designed for rigorous statistical analysis. Therefore, responses to the mailed portion are primarily discussed in a simple aggregate  context. Conclusions are stated where apparent correlation among data items are consonant with practical experience, intuition, and interagency theory.

REVIEW OF FINDINGS

This section consists of three parts. First, data-based items (background  items and questions I and 3) are discussed. Though summary tables of these items  are presented, the discussion focuses on the apparent significance of high and  low responses. Second, documentation is reviewed. The matrices in Appendix C  summarize key features of submitted documents. The discussion in this section focuses on practices which appear innovative or represent an apparent turning  point in a state's commitment to interagency practice. The third part reviews technical assistance requests (survey question 7) and categorizes respondents' comments. The report concludes with a brief discussion of the context for  considering interagency issues in mental health programs and with several recommendations.

Data-based Items

Table 1 summarizes "Background" information collected from respondents.  Thirty-six percent of respondents indicate that children's mental health  services at the state level are administered through a sub-unit of the state  mental health authority. Notably, eight states (18%) claim a single state agency  for all or most children's services. Under the "Other" category, five states  (11%) indicate the absence of a formal staff assignment to children's mental  health services. Four states indicate that children's mental health services are  dispersed among multiple organizations (e.g., Florida, Michigan).

At the local level, thirty-five states (80%) indicate that children's  services are co-located with other mental health and mental retardation services. Although ten states indicate co-location of children's mental health services and other children's services, and fourteen states indicate discrete  children's services, the survey does not extensively probe the nature of  co-located and discrete services.
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Table 1, Organization and Delivery of  Children's Mental Health Services
		Number	Percent
State Organizations
	Single State Agency	8	18
	Mental Health Sub-Unit	16	36
	Program Coordinator Only	10	23
	Other	10	23
Local Organization
	Co-Location/Children's Services	10	23
	Co-Location/Other MH/MR Services	35	80
	Discrete Children's Services	14	32
Delivery of Children's Services
	State Operated Facilities	42	95
	Contracted Agencies	33	75
	County Operated	16	36
	CMHC	42	95
	To Age 18	36	82
	To Age 21	10	23
	To Age 19	1	2
	To Age 20	2	5
Total Sample of 44 States; multiple responses allowed in "Local  organization" and "Delivery of Children's Services"

Almost all states provide some form of children's services through state-operated facilities or community mental health centers. One respondent indicated that only community mental health centers in that state provide  services. Ten respondents indicated two forms of service delivery, and eight of these provide services only through community mental health centers and  state-operated facilities. One state provides services through state- and county-operated facilities, and one provides services through community mental health centers and contracted agencies.

Thirteen states provide children's services through all four mechanisms. Eighteen provide services through all but county-operated programs.

Eight states indicate two age points controlling eligibility for children's  services, For example, Vermont's outpatient programs generally serve adolescents  in the children's program up to age eighteen. However, Medicaid payment for institutional placements and eligibility under a portion of the state's Medicaid waiver are controlled by the 22nd birthday.

Table 2 presents data on the distribution of sources of mandates for interagency policy and practice. Multiple responses were allowed. Nine states  are subject to one type of mandate, ten states are subject to two, eleven states  to three, eight states to four, two states to five, and one state is subject to six types of mandates.

Written agreements are cited as the most frequent form of interagency  mandate. In general, these agreements delineate responsibilities between a  mental health authority and education or social service agency. Some agreements address the relationship between a community mental health agency and  district/state psychiatric hospital. The earliest submitted agreement (Hawaii)  was developed in 1963 and revised in 1977. Most agreements were initiated within  the past five years.
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Table 2, Sources of Mandates for Interagency Practices Number Percent Written Agreements  32 72 Legislative Statute 23 52 State Plan 19 43 Other Mechanisms 16 36 Executive Decree 13 30 Judicial Decisions/Orders 7 16 No Mandate 6 14

Over half the respondent states have legislation which includes language focusing on coordination and cooperation in service planning, delivery, or monitoring. Half of these statutes were enacted in 1983.

The earliest legislation (Maine) was enacted in 1976 as a "resolve to  coordinate services to children and families". Over the next seven years four additional statutes were enacted in Maine as follow-up to this resolution.

Over a third of the respondents indicate that other mechanisms provide a mandate for interagency practices. Several states require agencies to address  coordination with other service organizations as a prerequisite to budget approval (Michigan, Wisconsin), as part of the response to a request for proposals (New Jersey), or through administrative review regulations (Georgia).  Respondents from these states indicated in informal discussions that the  forcefulness (i.e., consistent follow through) of such mandates varied over time  and circumstance.

Table 3 summarizes data collected on general and specific practices. The ranking on the left is based on the average of raw scores across all responding  states (raw scores ranged from zero -- not -at all practiced  -- to three -- practiced formally and informally). The two columns on the right show rankings of items as formal or a combination of formal and informal.

The purpose of these multiple ratings is to provide a clearer sense of the context in which interagency practices are occurring. The following  thought-provoking conclusions are drawn from this table:

• Formal interagency practices are implemented most often by state-level staff from different service organizations.
• Coordinating councils are a principal formal vehicle for co-funding  services to specific individuals.
• Local-level staff operate in a milieu requiring considerable interagency efforts, and these efforts are seldom formally supported by mandates.
• Interagency program planning and development is a secondary activity (to "services to specific clients") of state level staff and occurs most often on an informal basis.

Table 3, Ranking of Multi-Agency Practices by Average Score and Frequency of "Formal" and "Formal plus Informal" Responses
Rank	Item	Raw Score	Formal Only	Informal
1	Among State Level Staff	1.75	3	1
2	Services to Specific Clients	1.75	1	4
3	Among Different Service Providers	1.59	6	1
4	For Program Planning and Development	1.52	5	3
5	For Specific Target Populations	1.52	4	4
6	Among Local Level Staff	1.41	10	1
7	Among Same Service Providers	1.34	8	4
8	Between Divisions within a Department	1.34	9	2
9	For Specific Age Groups	1.27	7	5
10	Coordinating Council	1.20	1	9
11	Co-funding of Services	1.20	2	7
12	To Fulfill Federal Mandates	1.05	6	5
13	To Provide Early Intervention	1.00	10	7
14	Co-sponsoring Training Events	1.00	8	6
15	In Prevention Programs	0.95	11	8
16	Transition Services/Adolescence to Adulthood	0.80	12	8
17	Transition Services/Pre-School to School	0.57	16	8
18	Multi-agency Newsletter	0.30	13	9
19	Transportation Network	0.30	14	9
20	Other	0.14	15	9

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The final question in this section asks: How well is it working? The survey  probed this question by listing potential objective and subjective outcomes of  interagency practice. In hindsight, the majority of items addressing this issue must be considered subjective. Table 4 summarizes the data.

Table 4, Outcomes Related to Implementation of Interagency Practices
		Number	Percent
Objective Outcomes
	Cost Savings	15	34
	Via Redistribution of Resources	12	27
	Via Reduction in Episode Costs	3	7
	Empanel an Interagency Taskforce	20	45
	Budgeted Line Item for Interagency Activity	10	23
	Increased Caseload Capabilities	4	9
	Decreased Central Office "Fire Fighting"	12	27
	More Collaborative Opportunities	29	66
	Increased Coordination	28	64
	Decreased Restrictiveness	11	25
Subjective Outcomes
	Understanding of Obstacles	27	61
	Increased Cooperation	38	86
	Lower Staff Turnover	1	2
	Increased Grassroots/Advocacy Activities	19	43
	Increased Diversity and Innovation	22	50
	Evolving Commitment Evidenced by Executives	19	43
	Other	2	5

 
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Respondents indicated that coordination of services and opportunities for  collaboration are on the increase. Over half of the respondents citing such an  increase also note that their state has empanelled an interagency task force in one form or another.

No state indicating a cost savings from interagency practice provided any  documentation substantiating these savings. However, Florida has set goals for  reduced utilization of child and adolescent inpatient services. In conjunction  with vigorous interagency planning and programs (see Appendix C, Florida, "SEDNET"), Florida appears to be moving toward these targets. Nevertheless, the  respondent indicated that it is "too soon to tell" if actual cost savings are occurring.

Subjective outcomes are encouraging. Eighty-six percent of respondents indicate that cooperation is on the increase while 61% stated that practitioners are better able to understand other organizations' obstacles. As Baker (1) and other investigators have discussed,  understanding obstacles tempers "one's expectations within ongoing  relationships". The assumption of this as a benefit is that participants in the interagency process will feel compassion for their organizational counterparts and maintain a positive feeling tone supporting open communication and problem-solving.

Half of the respondents noted that. interagency practices are increasing in  diversity and innovation. Forty-three percent state that grassroots and advocacy  activities are on the increase and that executive officers are demonstrating an evolving commitment to interagency policy and practice. Sixty-eight percent of respondents indicating the latter (evolving commitment) also cite the former (grassroots/advocacy activities) as present. One conclusion drawn from the data  cited above is that interagency practice is occurring at two historically polarized levels of the service system (executive management and grassroots).  Further, where support for interagency practice is occurring at both levels,  practices tend to be more formal and widespread (2).
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Document Analysis

Respondents were asked to submit documents describing interagency practices  in their states. Documents sorted into seven categories: Agreements, Executive  Orders, Judicial Decisions/Orders, Legislation, Programs/Projects, State Plans, and Training. Appendix C summarizes key features of submitted documents and  relevant information as reported by respondents. Other dimensions of the review are:

• Type of interagency practice
• State where practice is used
• Document reference by name, statutory cite, or similar indicator
• Date initiated
• Initiated by whom (person or agency)
• Scope of practice (purposes, outcomes, budget, implementation  responsibility, timeliness target population, and similar content-related items)
• Current status (extent of implementation, date completed, ongoing nature of practice)
• Reported effectiveness (per respondent, extent to which goals and  anticipated outcomes both explicit and implicit are being/were  met)

The remainder of this section discusses practices or policies which appear exemplary or innovative within each category. Also, certain practices represent  significant turning points (for better or worse) in some states' commitment to  resolving interagency issues, and these are presented. The author acknowledges  that many exemplary practices are occurring in each state when compared against that state's history. Readers who review Appendix C may gain an appreciation of  the spectrum of the states' efforts.
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Agreements

Pennsylvania's "Community Residential Rehabilitation Program" is a collaborative effort between county-level children and youth service providers and the state mental health/mental retardation agency. The program derives from  specific written agreements pertaining to residential services for emotionally  disturbed, adjudicated youth.

Four programs are operational and serve children 5-18 in specialized foster  care or group homes. State officials are developing guidelines to address joint programmatic and fiscal responsibilities. The programs have successfully avoided out-of -state placements for the 150 youngsters served over the past three years. Ninety percent of these youngsters have returned home or entered regular  foster care. Long-term outcome information regarding the stability of these follow-on placements was not provided.

In 1979, Louisiana initiated a state level agreement between the Office of Mental Health and Substance Abuse and the State Department of Education. This  "master agreement" set parameters through which local counterparts could develop  agreements detailing responsibilities and processes for identifying, evaluating,  referring, treating, and exchanging information regarding children suspected of having emotional disturbances.

Local agreements now exist between most local education agencies and mental  health/substance abuse centers in Louisiana. Responsibility for payment of  services remains unresolved. Consequently local education agencies are reluctant  to fully assume obligations specified in the master agreement.
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Executive Orders

Arizona, in 1983 under Governor Babbit, established a cabinet committee and  an interagency advisory council on services to children, youth, and their families. The advisory council consists of 24 members appointed by the Governor  and drawn from various state departments, child care agencies, and the  judiciary.

The cabinet committee (composed of directors from health services, corrections, and economic security departments) is charged with ensuring coordination in development and delivery of services, recommending funding and priorities, and advising and assisting the interagency council. The council is to review programs, policies, budgets, and legislation and to develop and  recommend plans for improved coordination.

Under Governor Hughes in 1982, Maryland was ordered to establish a state coordinating council on services to handicapped children. This initiative  implements the recommendations of a study committee (established under Order  01.01.1978.07 amended by 01.01.1979.17) which looked at policies and procedures affecting children in non-public facilities under purchase of service  arrangements. As a result of these three orders the state is developing local coordinating councils, reviewing and recommending procedures and individual  placements, planning and coordinating provision and monitoring of services, and establishing a multi-agency information system.
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Judicial Decisions/Orders

In January, 1984 the Vermont Departments of Education and Mental Health  stipulated in a class action suit (Mason et al. vs. Kaagan et al.) that class members (people age 17 and under eligible for voluntary admission) would not be  admitted to Vermont State Hospital after July 1, 1984. Several months prior to  this Final Judgement Order, the Vermont State Hospital child clinical staff was eliminated through a reduction in force action. As a result of the court order and the loss of clinical expertise related to children, the Department of Mental Health adopted the policy that no child under age 18 would be admitted to the  state hospital.

The department created a short-term solution to the inherent difficulty of this policy. This solution--a staff secured, community-based, emergency accessed apartment--provided an interim setting for containing potentially dangerous  individuals, assessing their clinical requirements, and fashioning an appropriate long-term plan for the individual. The department also produced a  memorandum of understanding, principally conceived as a cost-sharing protocol,  with the Department of Social and Rehabilitation Services (a major child-serving  agency) whereby funding decisions for long-term placements could routinely be made.

The departments' long-term solution to meeting the needs of young people eligible for admission to VSH is to establish a small, acute care facility (5  beds) supported by an outreach team and long-term professional family care (see Programs/Projects, Vermont, "Severely Emotionally Disturbed Adolescents Program  Development"). This program development effort began in mid-1982 and is targeted  to begin initial operations in late 1984.
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Legislation

Enactment of legislation, whether specific to an issue or as a sweeping  policy directive, is one of the most widely adopted interagency strategies. States with current or former legislation on a specific issue include California (AB 2315), Florida (Chp. 394, Part III), Maine (HP 232/LD 269), and Vermont  (Title 33, Chp. 14). States with legislation of a more sweeping nature include  Arizona (ARS 15-765), Florida (FS 1981, Chp. 20), Maine (1976 Resolve), New York  (1977, Governor's Council), South Carolina (Code of Law 20-7-20, 1976), and Washington (SHB 433). Two states will be briefly highlighted here.

Through AB 2315 (Chp. 325, statutes of 1984, aka Lockyer Bill), California established a task force to review issues related to voluntary out-of -home  placement of severely disturbed children funded under Aid to Families of  Dependent Children/Foster Care (AFDC/FC). The task force had representatives  from state and local child, youth, and family service agencies, including clinicians, administrators, and advocates. The report issued by the task force after months of study and discussion provides an excellent overview of salient placement issues and yields six recommendations to the legislature.

Washington in 1983 enacted the Children and Family Services Act (SHB 433)  through which the state affirmed "that the family unit is the fundamental resource of American life which should be nurtured" and "that the goal of  serving emotionally disturbed and mentally ill children... in their own homes to  avoid out-of-home placement of the child ... is a high priority of this state." The statute specifies objectives through which the Department of Social and  Health Services must accomplish the law's intent. Staff and an advisory committee were selected in August of 1983. An initial implementation plan has  been prepared and addresses "Action Items," "Blueprint Items," and "Statutory Change Items".
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Program/Projects

Several of the specific programs and projects reviewed in this category are  the products of related legislation. However, most have arisen at the state and local level as initiatives aimed at specific problems of a short- or long-term nature.

In 1983, the Florida Department of Education established "SEDNET: A  Multi-agency Service Network for Severely Emotionally Disturbed Students" in  response to FS 230.2317. SEDNET is designed to provide education, mental health treatment, and residential services to severely disturbed students. In 1983, two projects were funded, one urban and the other rural. By 1986-87, sixteen regions will have operational SEDNET projects.

Fulton County, Georgia created MATCH (Multiple Agency Therapeutic Children's,  Homes) as a response to the needs of emotionally disturbed children in or not in  state custody. MATCH enables several agencies to "piggyback" resources to place or maintain a child in a setting most appropriate to his needs. Seven agencies'  decision-makers participate in monthly meetings to "staff" specific children. Tracking forms have been developed, and issues related to selection criteria of  children, training of staff, and payment have been articulated.

Education and mental health staff in the Independence, Missouri area established a similar program called the "New Direction Program". This initiative arose in response to a community planning committee's efforts to  develop a comprehensive system of care for children with behavior disorders. The  program enables a "cooperative pooling" of mental health and education "talent  and resources".

In South Carolina, the Developmental Disabilities Council in conjunction with  the University of South Carolina created the Handicapped Services Information System. The system provides immediate access by local offices via telephone  (modem) to a centralized computer storing county-by-county service listings.  Instantaneous updating of listings is possible.
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State Plans

Nineteen respondents indicated that their state plans addressed coordination of services in some measure. Maryland's plan is one of the more notable of these documents. The Maryland "Comprehensive Mental Health Plan for Children and Adolescents" was published in 1983 and served to incorporate provisions of Executive Order 01.01.1982.09. Prepared for the legislature, the plan addresses  the current system of care within the context of service coordination among multiple public and private providers. The plan focuses on residential and inpatient services. Objectives are established for pooling state agencies' resources, creating state and local coordinating mechanisms (to include  placement approval, case management, and advocacy activities), and facilitating linkages among agencies providing child, adolescent, and adult services.

Louisiana has prepared several partial or complete plans for children's  services since 1980. A "Special Report on Mental Health Services for Children"  was intended to call attention to programmatic needs of young people and is presently used as a resource directory. The State Department of Health and Human Services prepared a "Plan for Community Alternatives" complete with five-year  objectives to better meet the needs of individuals handicapped by specific  conditions. Though the document was used in conjunction with other materials to develop community support program alternatives for adults, available data  related to children and youth was limited, hence a definitive plan for young  people never emerged.
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Training

Initiatives in this area scored "informal" when taken in aggregate. However, sixteen states (36%) reported formal training activities. In 1983, Arizona established a "Child Protective Services Training Governing Board" to advise the Director of Economic Security. The fifteen board members identify training programs, materials, and special projects related to the needs of child  protective service providers and recipients. Georgia held three multi-agency  training conferences in 1983. "Raising a New Generation of Georgians" is a  prevention-focused initiative on which the Department of Human Resources based a  conference in April, 1983. The conference sought to establish executive level commitment, define a philosophy and values framework, derive goals and outcomes, and establish activity, communication, and public education processes.

Conference participants recommended expanding the base of invited individuals  and preparing an agenda for a follow-up conference. The Vermont Interagency Inservice Network sponsored several conferences since 1980 around the broad  topic of "interagency". The activities of the network are guided by a steering  committee composed of representatives from educational institutions and public  administrative and provider organizations. Through a combination of "how-to" and  theory-based workshops, the network sought to increase the interagency awareness  and expertise of staff and management at both state and local levels. In 1983, a  landmark conference was held where commissioners from seven state agencies  participated in a panel presentation on their agencies' past, present, and  future involvement with each other.
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Technical Assistance Requests

This section examines responses to the question: What type of technical  assistance would be most useful in developing interagency policy and practice in  your state? Thirty-seven respondents provide comments to this question. Comments  group readily into five categories: education, system or capacity building, money, leadership context, and legal issues.

Education

Sixteen states provide comments judged educational in nature. Describing these comments as educational is somewhat of a misnomer since the majority of  responses focus on sharing information. Several states are quite specific in  topics and methods. However, most are rather

vague. States' responses are listed below:

• Share information and strategies with other states which have "resolved" the issues
• Share information regarding effective interagency practices
• Bring in consultants to share non-exploitative interagency agreements  and practices
• What have others done--for "interagency" and for creating comprehensive  systems?
• Review other states' practices and study how to implement them elsewhere
• How have other states provided needed services despite decreasing  funding?
• Exchange relevant information on state models through various  presentations by state experts
• Models of collaboration for local coordinating groups
• In-service training, public relations materials, and liaison with  successful providers
• Comprehensive service delivery models based on interagency cooperation
• Consultation from other state administrators regarding what works, and at what costs, within an interagency framework
• Models for developing successful interagency policy, practice, and responsibility
• Identify effective models for a child mental health commission
• Educational technical assistance
• Successful models of interagency policies and practices
• Communication with other states and access to interagency resource materials
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System and Capacity  Building

This category overlaps with education to a considerable degree. The  distinction made between the two categories is based on the level of  participation and external support necessary to meet the technical assistance request. For example, this report fulfills many of the states' education and information requests particularly through the document analysis in Appendix C. System and capacity building however require a substantive investment of on-site consultation, information processing, and decision-making. Twelve states have  requests in this category:

• Build systems and programs for individuals involved with juvenile  justice
• Assess needs of young people with severe emotional disturbances, design  a service continuum, clarify organizational roles, and organize/structure a children's service commission
• Assistance in interagency planning and strategizing
• Assistance as received through human resource development grants
• Support from NIMH with specific recommendations
• Coordinated funding of comprehensive day treatment programs (inclusive of education and treatment)
• Develop an appropriate child mental health program within the (state's)  mental health department
• Needs assessment, long- and short-term payoffs to various service  arrays, practical cost/benefit assessment of interagency policy and practice
• Programs designed to increase competence and facilitate technology transfer between state and local jurisdictions
• Local-level implementation of interagency policies and practices
• Removal of obstacles to interagency policy and practice
• Development of effective service delivery models
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Money

Financing issues are of major concern to eight states. Though most states  would welcome technical assistance in the form of non-categorical funding,  respondents generally did not make such requests. On the contrary, requests tend  to focus on particular applications or finance issues. Responses include:

• Financing for a child and adolescent unit within the state to initiate and maintain interagency policies and practices
• Effective delivery of services despite decreased funding
• Identification of funding (federal, state, and local) for coordination and collaboration and for innovative interagency programs
• Seed match money to create demonstration projects
• Money (non-categorical)
• Federal financing and policy trends information
• Funding for field staff to implement interagency policies
• Funding for demonstration projects such as the Child and Adolescent  Service System Program

Leadership Context

Initiating and maintaining effective interagency policies and practices rely on many factors--information and communication systems, rules and procedures,  technology, ideology, history, power and resources, and organization overlaps (3). The least changeable and perhaps most critical of these factors is the power and resources element. This element relates to personal, informal, organizational control and decision-making. Both  individuals and institutional entities granted authority and discretion in  decision-making control the context within which agencies participate in  interorganizational transactions.

States' requests in this category overlap with education as well as system and capacity building categories. However, the category is held distinct due to  the emotional issues (e.g., frustration, "burn-out", anger) fostered in staff operating within environments which may not support, or may in fact obstruct,  interagency practice. Seven respondents request technical assistance or offer comments focusing on the power base including:

• Conduct forums on interagency policy and practice for chief executive  officers
• No request. Issues relate to internal administration and turf guarding
• Desensitize agency chief executive officer
• Work with the state legislature
• Overcome state government lethargy and lassitude
• Assist chief executive officer in recognizing the value of boundary  spanning
• Develop chief executive officers' leadership for interagency practice
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Legal Issues

Four states request assistance related to legal issues. Although two of these  requests are for information, the author perceives legal issues as a specialized  category appropriate for highlighting. The requests are as follows:

• Assistance in disentangling federal and state mandates
• Sample legislation
• Information from states which have overcome mandate difficulties
• Federal intervention at the regulatory level

RECOMMENDATIONS

This study focused on the sources, nature, and outcome of interagency  strategies including mental health services for children and youth. The fact  that 44 states and territories responded to this survey suggests that a national  interest in and perhaps need for information related to interagency practices exists.

Professionals involved with mental health services are aware that effective  intervention with severely disturbed children often requires coordination of  services across multiple agencies. Anecdotal evidence from field-based  clinicians reveals that the information and support offered to the family by  each agency are all too often at cross-purposes.

One remedy to this phenomenon is to open communication among staff involved  with the family. Unfettered by regulations, policies, and fiscal imperatives, staff may more readily identify clear, common sense approaches in support of the young person and his family. However, significant impediments exist and serve to complicate service delivery.

Regulatory, policy, and fiscal decisions do not spring from a vacuum. Rather,  these decisions are made and implemented by individuals with varying talents and  information. The following recommendations and potential strategies may serve as  a foundation upon which to build a more widely comprehensible multi-agency  system for effectively serving and fully supporting children, youth, and their  families.
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Recommendation 1

Create and strengthen linkages among specialized child, adolescent, and adult  programs within public mental health organizations and with other public and  private child-serving programs (e.g., education agencies, inpatient programs, juvenile justice organizations, health departments).

Potential Strategies

Promote the transfer of appropriate interagency technology and information among federal, state, and local child- and family-oriented human resource  entities and training institutions.

Potential Strategies

Identify effective, operational responses to interagency dilemmas  particularly as removal of such dilemmas promote more productive services to  young people and their families.

Potential Strategies

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