Advocates call for new cabinet-level state agency to oversee children’s behavioral health

Seven different agencies spread across Rhode Island state government offer children's behavioral health services. The Rhode Island Coalition for Children and Families wants children's behavioral health to be overseen by one cabinet-level department. (Getty image)

A coalition of social and health service providers wants to remap the labyrinth of seven different agencies spread across state government that offer children's behavioral health services.

that make up the Rhode Island Coalition for Children and Families called for a new cabinet-level state department to oversee children's behavioral health in a report released Thursday at an event in Providence.

"Kids' behavioral health is not akin to adult behavioral health," Benedict F. Lessing Jr., the CEO of Community Care Alliance, said of the findings in the coalition's 22-page report titled "Children in Crisis Can't Wait: The Case for System Transformation."

"We know that kids suffer in terms of behavioral health concerns from infancy through adolescence."

The proposed cabinet would be similar to the Office of Healthy Aging , said Tanja Kubas-Meyer, the coalition's executive director. Technically a division within a department, the aging office reports directly to the governor like a cabinet position — a model preferable to what the new report calls "too-often disjointed access to care for children and their families."

This hypothetical division would be charged with coordinating the services of existing state agencies who serve kids with behavioral health needs, which would mean being responsible for things like licensing and contracting providers.

One example: While the Department of Behavioral Healthcare, Developmental Disabilities & Hospitals (BHDDH) handles both substance use and mental health treatments for adults, the agency is only responsible for youth who use substances. The Department of Children, Youth and Families (DCYF) is responsible for youth who experience what the state calls "serious emotional disturbance" — whether they are or aren't in state custody or foster care, which DCYF also provides via contracted providers.

"This is not simply a matter the state will wrap up by itself, and it will be all unicorns and rainbows," Kubas-Meyer said, adding the recommendations were made in the "spirit of collaboration, as opposed to a criticism."

The report gives no estimate for what the creation of the new office would cost nor does it calculate the savings that could come from consolidating children's services. Determining the cost would be difficult anyway.

"Another challenge is that there is not a state-wide unified Children's Behavioral Health budget that clearly articulates how much money is being spent on these services, and which funding is available to children in general versus only for children with targeted needs," the report states.

This is not simply a matter the state will wrap up by itself, and it will be all unicorns and rainbows.

– Tanja Kubas-Meyer, executive director of the Rhode Island Coalition for Children and Families

The executive-level Rhode Island Children's Cabinet has reported a "children's budget" annually since 2018, which is included in the governor's executive summary . For fiscal 2025, it rose 4.6% to over $2 billion.

But, "there is no clear breakdown of what this funding includes, without which the public is not able to understand what relevant investments were recommended or funded," the coalition report states.

"The system is really fragmented," said Sen. Bridget Valverde, a North Kingstown Democrat, one of two state legislators who attended the report release, in an interview after the event. "I think where there are a lot of duplicated efforts, that's an opportunity where children fall through the cracks."

Democratic Rep. Tina Spears of Charlestown, who is the executive director of the Community Provider Network of Rhode Island, a nonprofit that supports people with disabilities, also attended.

A new cabinet would have to be achieved through legislation, said Valverde, calling the recommendation "a good suggestion that should absolutely be explored."

"Efficiency in government — I think that's something that everybody wants, in all of our sectors, so let's do it for our kids," Valverde said.

Other recommendations from the report include establishing a working group of public and private stakeholders to shape the cabinet's goals, as well as a shared state data hub with more reliable information for understanding children's behavioral health.

"We worked with Brown University earlier this year, thinking that we were going to put together a data dashboard, and found that neither the coalition nor Brown could access the data that they needed within any kind of reasonable time," Kubas-Meyer said.

An out-of-office reply for kids' mental health

Rhode Island's health system is "deeply frustrating" and it can be confusing for families to access the services they need for their children, the report states.

"You need to invest not just federal dollars, but also state dollars in children's medical services," Kubas-Meyer said. "Not every component of services for children are medically eligible, and we need alternate financing. The state must have financing mechanisms that make it possible for both large and small organizations to continue to provide services."

Lessing pointed to an erosion of diverse outpatient services as one reason he sees behavioral health care having declined in the Ocean State the past two decades. An emphasis on residential treatments or hospitalization in the absence of alternative models has led to situations wherein kids may be staying in psychiatric hospitals — an allegation made by federal and state attorneys against DCYF back in May , who reported the agency was "warehousing" kids at Bradley Hospital for longer than needed.

"There has not been a concerted effort in terms of what are the outpatient needs for kids and families," Lessing said. "These have been generally left to individual organizations to kind of figure out, and that has become more and more problematic over the years...I think what happened 20 years ago, when the state basically gave these programs to managed care, was that it got off track."

The state lost control over programming, Lessing said, and assumed that managed care organizations would figure out the rest.

"We began to see kids being boarded in emergency departments. That never happened 20 years ago...There were just not enough services in the community."

Margaret Holland McDuff leads the coalition's public policy committee and is also CEO of Family Service Rhode Island, which hosted the event. She started her career as a home-based clinician — an example of the community-based care often referenced in calls to reform behavioral health care for children. It's a holistic approach that means "having a clinician, a case manager, whatever support that you need, within the setting that you need," McDuff said.

The system is really fragmented. I think where there are a lot of duplicated efforts, that's an opportunity where children fall through the cracks.

– Sen. Bridget Valverde, a North Kingstown Democrat

A community-based clinician can observe more deeply a child's routine, life experiences and formative traumas, McDuff said. The community-based care model allows for collaborations with schools to intervene and offer support when needed.

"Whether it's a coach or an art teacher or whatever, to say, 'You know, we know that you've been having challenges. Let's all work together as a team, wrap around this child to be able to get the supports that they need,'" McDuff said, "It's about being out of the office and being in the community with family."

McDuff arrived at that perspective after working in residential treatment, which she found lacked the perspective of family life.

"I really felt like I wanted to work with the whole family and not just the child while they were an inpatient, and then send them home, and then see them come back," she said.

But McDuff noted that organizations like Family Service can't compete with the wages offered by managed care organizations.

"People have to make a living," McDuff acknowledged. "And so the two tracks that really became available were institutions or outpatient."

Similar statewide or cabinet initiatives for kids' behavioral health already exist in states like New Jersey . McDuff said the state has seen a reduction in hospitalization rates.

"The biggest predictor of if a child is going to be in a psychiatric hospital is if they were in a psychiatric hospital before," McDuff said.