March 7, 2005

Dear Senator:

I am writing on behalf of the American Psychological Association (APA) to reiterate our recommendations for the reauthorization of the Temporary Assistance for Needy Families (TANF) program in advance of the upcoming mark-up of the legislation.

APA is the largest scientific and professional organization representing psychology in the United States. APA's membership includes 150,000 researchers, educators, clinicians, consultants, and students. Our mission is to advance psychology as a science, as a profession, and as a means of promoting health, education, and human welfare. Through our divisions, governance structure, and affiliated state psychological associations, APA members work to prevent and treat mental health and substance abuse problems that serve as barriers to gainful employment. In so doing, our members help to enable families to achieve and maintain self-sufficiency, lead productive lives, and contribute to their communities.

1. Provide screening and treatment for mental health and substance abuse problems.

Rationale: Mental health and substance abuse problems represent significant barriers to employment and economic self-sufficiency for women receiving TANF benefits. TANF clients with mental health problems, if not identified and treated, are more likely to continue to require public assistance over a long period of time. A 1998 Department of Health and Human Services (DHHS) study reports national estimates of up to 28% of TANF clients with mental health problems, and state and local estimates of up to 39%. Major depression is the most common mental health problem among TANF clients, followed by posttraumatic stress disorder (PTSD) and generalized anxiety. Mental health and substance abuse problems can affect employment directly through absenteeism, illness, injury, reduced capacity, and lost productivity, or indirectly through lowered self-esteem and self-concept. TANF recipients may be especially reluctant to disclose mental health and substance abuse problems for fear they will lose their children, their TANF benefits, or both.

Recommendation: States should develop a plan to ensure that standards and procedures are in place to address the needs of individuals who face barriers to work, such as, but not limited to, a mental health problem (including learning disabilities), substance abuse problem, physical impairment, and/or have been subjected to domestic or sexual violence. The state plan must ensure that:

• Trained caseworkers or qualified professionals conduct a preliminary screening and assessment of each TANF client. If the client is identified as experiencing a barrier to work, the caseworker or professional must refer, at the client's option, the client and her family for appropriate mental health or substance abuse treatment, counseling, vocational rehabilitation, and/or job training. Such services must be individualized and appropriate for families, gender#45;specific, and culturally competent. Support services, such as childcare and transportation, must also be offered to help ensure accessibility to the other services.

• For those clients for whom treatment or services are unavailable, the five-year benefits clock must stop until the treatment or services are available.

• The caseworker or qualified professional assigned to the client's case must collaborate with employment case managers, with the client's consent, to ensure that the client receives integrated, comprehensive services.

2. Provide comprehensive health insurance coverage that meets the mental health needs of low-income children.

Rationale: Research indicates that low-income children have a significantly higher prevalence of mental health problems than their counterparts. For instance, low-income children often do not have access to quality nutritional services and have fewer educational opportunities, greater exposure to environmental hazards, and inadequate housing. All of these disadvantages have a detrimental effect on children's health status.

In addition, the Medicaid program is a critical source of support for people with mental health problems, particularly children. In fact, Medicaid is the single largest source of financing for mental health care and encompasses more than half of state and local spending on mental health services. While nearly 30 million children receive health care through Medicaid and the Children's Health Insurance Program (CHIP), more than nine million children under the age of 19 remain uninsured.

The highest prevalence of mental health problems among children and youth between the ages of 6 and 17 is observed among Medicaid and CHIP recipient children, a rate significantly higher than for other insured children or uninsured children. Given Medicaid's and CHIP's relatively comprehensive coverage of mental health benefits, the two programs can clearly help reduce disparities in use of mental health services between higher- and lower-income children.

Recommendation: Increase funds for children's mental health services under the CHIP and Medicaid programs.

3. Include mandatory state and federal data collection, evaluation, and reporting provisions of referrals and services, especially those regarding mental health and/or substance abuse.

Rationale: Although there have been studies of how individual states have addressed the needs of TANF clients with substance abuse and/or mental health problems, states do not routinely report this information. Therefore, it is difficult to determine whether or not TANF clients are receiving the necessary services to overcome barriers to economic self-sufficiency.

Recommendation: The reauthorization of TANF should include state and federal mandatory data collection, evaluation, and reporting provisions for referrals and services, especially those regarding mental health and substance abuse. The DHHS Secretary should:

• Review programs receiving funding from the TANF block grant or funded with maintenance of efforts funds to determine the amount of funds spent on services, including, but not limited to, mental health services, substance abuse treatment, domestic violence counseling, and rehabilitation for people with physical disabilities; and

• Evaluate the process of referral, such as, but not limited to, whether recipients received referrals and services, and how such services affected their economic status.

Thank you for your consideration of these recommendations. We look forward to working with you in the process of reauthorizing the TANF program. Please do not hesitate to contact Lori Valencia Greene of the APA Public Policy Office at (202) 336-6062, if we can be of any further assistance.
Sincerely,

L. Michael Honaker, Ph.D.
Deputy Chief Executive Officer
And Chief Operating Officer

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