Evaluation of state efforts to improve systems of care for children and adolescents with severe emotional disturbances: the CASSP (Child and Adolescent Service System Program) initial cohort study

In 1984, the National Institute of Mental Health (NIMH) began funding its Child and Adolescent Service System Program (CASSP). In this paper, we present findings from a descriptive study of the experiences of the initial cohort of states to receive CASSP grants, conceived and conducted when the projects were approaching the end of their fifth and final year of NIMH funding. Detailed case studies were conducted of each of the 10 initial cohort projects, and the findings analyzed across projects. Data were collected from three major sources: (1) existing documentation about the projects, (2) site visits to each of the projects, and (3) information from relevant secondary sources. Findings suggest that the initial cohort projects utilized a variety of strategies and encountered a variety of barriers and facilitating factors. The projects generally implemented the intended CASSP program and did so by using a variety of strategies. The projects were judged by stakeholders in their states to have influenced the service systems in their states in the intended directions: toward a more comprehensive system of care that emphasizes community-based treatment; toward better integrated, more collaborative efforts among the state agencies involved; toward a more detailed understanding on the part of system stakeholders of the mental health problems of children and adolescents who have severe emotional disturbances, and of the influence of those problems on the lives of the children and their families; and toward increased involvement by parents and other family members in the care of these children and adolescents.

Public sector financing of community-based services for children with serious emotional disabilities and their families: results of a national survey

This article presents the results of a survey of all state directors of mental health programs for children on the agreement with and use of financial policies and practices which promote home- and community-based mental health care for children and adolescents and their families. Whereas only five states reported the implementation of all the financial mechanisms feasible in their states, a majority of states reported the use of mechanisms such as federal funds, state resources and incentives, and flexible funds to encourage the development of community-based care. Results also indicated that states with a local form of government or local district or board that served as the local mental health authority tended to have more of the community-based financial practices in place than did states that contracted directly with providers at the local level.

Rural Youth Disability Prevention Project Survey: results from 169 Iowa farm families

Agriculture is now the most hazardous occupation in the United States and it is the only one in which children not only comprise a significant part of the work force, but also live and play at the work site. Annually, 23,500 pediatric agricultural injuries are reported, with nearly 300 fatalities (Rivara, 1985). The Rural Youth Disability Prevention Project was designed to use innovative, community-oriented methods to address the unique problems of child safety in agriculture. Toward this end, a survey instrument was designed to gather data both to assist in program development and to serve as a pretest for the subsequent evaluation. Analysis of these data indicated several issues to target for intervention efforts. One is lack of supervision--more than 40 percent of children who operate equipment do so unsupervised. Approximately 30 percent of children more than 3 years old play alone in work areas, and 80 percent of these children play near machinery in operation. Another issue is operation of farm machinery by very young children--respondents' children began operating equipment at an average age of 12 years. Coupling this with the finding that the parents believe their children are not capable of operating equipment until age 15 exemplifies the most important issue, the disparity between parents' levels of safety knowledge and safety behavior. Using the survey data to increase local involvement, efforts are being directed toward facilitating an ongoing, community-sponsored intervention program to empower farm families to effect their own solutions.

Mental health services utilization in a children's mental health managed care demonstration

Service delivery under two systems of care--a traditional Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) reimbursement system and an innovative continuum of care--was examined along six dimensions: access, type, mix, volume, timing, and continuity of services received by children and adolescents. It was found that the Demonstration served over three times as many children as the Comparison. In addition to serving more children, the Demonstration also provided more and different types of services to each child treated. Finally, the Demonstration appears to have delivered services in a more timely fashion and made a considerable effort to match children's and families' needs with services.

Developing quality measures for adolescent care: validity of adolescents' self-reported receipt of preventive services

OBJECTIVE

To demonstrate the feasibility of directly surveying adolescents about the content of preventive health services they have received and to assess the validity of adolescent self-reported recall.

DATA SOURCES/SETTING

Audiotaped encounters, telephone interviews, and chart reviews with 14-21 year olds being seen for preventive care visits at 15 pediatric and family medicine private practices, teaching hospital clinics, and health centers.

DESIGN

537 adolescents presenting for well visits were approached, 400 (75 percent) consented, 374 (94 percent) were audiotaped, and 354 (89 percent) completed telephone interviews either two to four weeks or five to seven months after their visits. Audiotapes were coded for screening and counseling across 34 preventive service content areas. Intraobserver reliability (Cohen's kappa) ranged from 0.45 for talking about peers to 0.94 for discussing tobacco. The sensitivity and specificity of the adolescent self-reports were assessed using the audiotape coding as the gold standard.

RESULTS

Almost all adolescents surveyed (94 percent) remembered having had a preventive care visit, 93 percent identified the site of care, and most (84 percent) identified the clinician they had seen. There was wide variation in the prevalence of screening, based on the tape coding. Adolescent self-report was moderately or highly sensitive and specific at two weeks and six months for 24 of 34 screening and counseling items, including having discussed: weight, diet, body image, exercise, seatbelts, bike helmet use, cigarettes/smoking, smokeless tobacco, alcohol, drugs, steroids, sex, sexual orientation, birth control, condoms, HIV, STDs, school, family, future plans, emotions, suicidality, and abuse. Self-report was least accurate for blood pressure/cholesterol screening, immunizations, or for having discussed fighting, violence, weapon carrying, sleep, dental care, friends, or over-the-counter drug use.

CONCLUSION

Adolescents' self-report of the care they have received is a valid method of determining the content of preventive health service delivery. Although recall of screening and counseling is more accurate within two to four weeks after preventive care visits, adolescents can report accurately on the care they had received five to seven months after the preventive health care visits occurred.

Isolated and invisible gay, lesbian and bisexual youth

A 14-year-old boy confides that he feels he does not fit in with the other boys and does not understand why. Would you consider that he might be questioning his sexual orientation? Would you be able to explore these feelings without bias? Do you have an understanding of the developmental process for gays and lesbians? Can you dispel myths and give accurate information?

A clinical study of 100 new admissions to an adolescent psychiatric inpatient unit in Singapore

BACKGROUND

Psychiatric inpatient services for children and adolescents in Singapore began in 1982 when Woodbridge Hospital started the Child and Adolescent Inpatient Unit. To date, this is the only unit with specialised facilities and staff in the management of young patients. Admissions were mainly based on a need for custodial management of acute major behavioural disturbances. Patients were discharged for outpatient treatment once these behaviours subsided.

METHODS

This is a retrospective clinical study of 100 consecutive new patients admitted from April 1993 to August 1994.

RESULTS

Majority of admissions (92%) were adolescents above age 12, who were either attending secondary or vocational school. Most came from nuclear families. Forty-eight percent of referrals were intradepartmental. Ten percent were from general hospitals with 16% as self referrals. Psychoses accounted for the diagnosis in 43%, schizophrenia being the main type. Neurosis and adjustment disorders formed the other main diagnoses. All patients received individual and family treatment. Liaison with schools was required in a third of the cases. Sixty-one percent received pharmacological treatment. Ninety-one percent were discharged home after a stay of less than 3 months. Majority returned to school upon discharge from the hospital.

CONCLUSION

The main criteria for admission in this unit, located in an adult psychiatric hospital, is that of custody of young patients with disturbed and unmanageable behaviour. This provides additional stigma for the admissions of young patients with minor psychiatric problems and interferes with comprehensive care including admission required for some adolescents with psychiatric problems.

Preventive services received by adolescents with cystic fibrosis and sickle cell disease

OBJECTIVE

To determine the proportion of adolescents with cystic fibrosis (CF) or sickle cell disease (SCD) who reported speaking with their physicians about health-promoting and risky behaviors and whether the rate of discussions varied by whether the main physician was a primary care provider or specialist.

HYPOTHESIS

Adolescents reporting a primary care provider as their main physician would be more likely to have received risk behavior counseling and other preventive services.

DESIGN

Survey.

SETTING

Comprehensive CF and SCD centers in 5 North Carolina referral hospitals.

PARTICIPANTS

Three hundred twenty-one (74%) of 437 adolescents aged 12 through 19 years (mean age, 15.6 years; 51% male) with CF or SCD identified through center registries.

MAIN OUTCOME MEASURES

Sources of health care, main physician, and recall of discussions with physicians regarding sexual issues, substance use, weight or dieting, safety issues, depression, and violence.

RESULTS

Adolescents with CF (53%) or SCD (46%) most commonly reported a specialist as their main physician. For those (83%) who saw their main physician in the past year, adolescents with SCD reported counseling rates ranging from 43% for sexuality to 15% for weapon carrying or fighting. For adolescents with CF, rates ranged from 65% for weight and dieting to 30% for sexuality and 6% for weapon carrying or fighting. Adolescents whose main physician was a primary care provider were no more or less likely to report counseling for any topic (all P>.05).

CONCLUSIONS

Physicians, regardless of specialty, infrequently discussed common behavioral issues with these adolescents with CF or SCD. A coordinated effort between primary care physicians and specialists may be helpful in delivering optimal preventive services to this population.

Alternative medicine use by homeless youth

BACKGROUND

Mainstream health care for homeless youth is often fragmented or unavailable.

OBJECTIVE

To evaluate the use of complementary and alternative medicine (CAM) by homeless youth who use our free clinic.

DESIGN

Self-administered cross-sectional survey.

SUBJECTS AND METHODS

Subjects included homeless youth between the ages of 14 and 21 years receiving care at the 45th Street Clinic Youth Program in Seattle, Wash, between January 29,1998, and March 5, 1998. The self-administered survey included items on demographics, health issues, use frequency of different therapists or therapies, referral sources, and perceived effectiveness of treatment.

RESULTS

The response rate by patients was 96.3% (157/163) with an average respondent age of 18.5 years (range, 14-21 years). Complementary and alternative medicine was used by 70.1% of the subjects. Referrals most often came from friends (52.7%). The most common reason for using CAM was because it was "natural" (43.9%). Most of those who used alternative therapies (87.3%) believed they had been helped "some" or "a lot." Given a choice of providers to visit when they were ill, 51.7% would seek care from a physician, 36.9% from a CAM provider, and 11.4% would treat themselves.

CONCLUSIONS

Care with CAM is frequently used and accepted by homeless youth. Cost-effectiveness and contributions to overall health care require additional evaluation. Integrating CAM into allopathic health centers may serve as an incentive to entice youth into mainstream health care.

[Child and adolescent psychiatric services in the canton of Zurich: a comparison of outpatients, day clinic, and inpatient referral populations]

Findings in intervention research are an important basis for the discussion of issues pertaining to quality control. In Switzerland such findings have been rare. The present study of the entire 1988-1995 referred child and adolescent population of the Child and Adolescent Psychiatric Service of the Canton of Zurich (N = 7538 treated patients) concentrated on the demographic, diagnostic, and therapeutic attributes of the outpatient, day clinic, and inpatient populations that comprised the referred population. Marked differences are found in comparable studies from Germany with regard to patients treated in an inpatient setting. For example, the mean age of the patients in the Zurich sample is lower and patients with conduct disorders are more frequently represented. On the other hand, patients with psychotic illness are missing and, on the average, the duration of treatment is considerably longer. The reasons for these differences are to be found in the various structural attributes of the cantonal services that are provided in Zurich. In the area of inpatient care, where in comparison to outpatient settings and also day care settings patients with severe disorders are treated, there is a lack of places for the short-term care of acutely ill patients--for example, psychotic patients. This is especially true for adolescent patients. The limitations of traditional outpatient settings are frequently marked by unsatisfactory treatment results in outpatients with conduct disorders, developmental disorders, and a high impact of abnormal psychosocial circumstances.

Use of health services by children and young people according to ethnicity and social class: secondary analysis of a national survey

OBJECTIVE

To assess whether equity is achieved in use of general practitioner, outpatient, and inpatient services by children and young people according to their ethnic group and socioeconomic background.

DESIGN

Secondary analysis of the British general household survey, 1991-94.

SUBJECTS

20 473 children and young people aged between 0 and 19 years.

MAIN OUTCOME MEASURES

Consultations with a general practitioner within a two week period, outpatient attendances within a three month period, and inpatient stays during the past year.

RESULTS

There were no significant class differences in the use of health services by children and young people, and there was little evidence of variation in use of health services according to housing tenure and parental work status. South Asian children and young people used general practitioner services more than any other ethnic group after controlling for socioeconomic background and perceived health status, but the use of hospital outpatient and inpatient services was significantly lower for children and young people from all minority ethnic groups compared with the white population.

CONCLUSIONS

Our results differ from previous studies, which have reported significant class differences in use of health services for other age groups. We found no evidence that children and young people's use of health services varied according to their socioeconomic status, suggesting that equity has been achieved. A child or young person's ethnic origin, however, was clearly associated with use of general practitioner and hospital services, which could imply that children and young people from minority ethnic groups receive a poorer quality of health care than other children and young people.

Evaluation of a linked service model of care for HIV-positive, homeless, and at-risk youths

Two instruments were used to evaluate an agency's type and availability of services for HIV-positive and at-risk adolescents, and to assess opinions concerning healthcare referral patterns. These instruments were administered to representatives of 22 agencies from 10 categories of healthcare services. Nonmetric multidimensional scaling was used to model ratings of interagency knowledge, referral patterns, and general satisfaction with services. We found that no agencies offered youth services for inpatient adolescent-specific mental health treatment or short-term residential drug treatment; however, few offered long-term residential substance abuse detoxification services (5%), outpatient drug maintenance (5%), HIV-specific inpatient services (9%), intensive day treatment for substance abusers (9%), HIV home care (14%), HIV hospice care (14%), inpatient medical services (14%), short-term shelters (14%), long-term housing (18%), HIV-specific clinical trials (18%), and dental services (23%). Barriers to expanding care included lack of funding, transportation, and lack of awareness among youths about services. A multidimensional scaling analysis identified a tight service cluster of two community health centers and the largest public hospital serving poor communities of color, as well as a relatively tight cluster of three service agencies located on the Boston Common serving homeless youths. A third service cluster consisted of two university-affiliated medical centers and one community health center. In conclusion, we found that many critical services for HIV-positive youths are relatively scarce. Multidimensional scaling provides a visual presentation of the relationships of network sites. This evaluation of services indicates a need for increased, accessible youth-oriented HIV services and suggests that linkages across the three distinct clusters of service providers should be solidified. These methodologies can be used to develop a generic model describing the stages of linkage formation in HIV care service networks.

Child mental health services. Side by side

The appointment of a primary care mental health worker can relieve pressure on child and adolescent mental health services. In one health authority, GP practices with access to a liaison clinic run by a primary care mental health worker referred a third fewer cases to child and adolescent mental health services than practices without such access. Referrals by these practices were more likely to be assessed as appropriate and as high priority.

[A successful attempt with a consulting service for boys]

As adolescence is a critical period of development, and as boys are less inclined than girls to approach the school facility for adolescent counselling, segregated consulting hours were introduced for boys to attract those with problems. The frequency of consultations by boys increased by 25 per cent, and 70 per cent of the boys reported a preference for the segregated consulting hours; 75 per cent appreciated the absence of girls from the waiting room; and of the 42 per cent with special preferences regarding the gender of the staff encountered, half reported preferring a man. Most of the boys presented with defined problems, though many revealed other problems, often relating to sexuality, in the course of consultation. The availability of segregated consulting hours for boys with adolescent problems is important, and often the only way to reach young boys who need help.

Depot medroxyprogesterone acetate (Depo-Provera) and levonorgestrel (Norplant) use in adolescents among clinicians in Northern Europe and the United States

PURPOSE

To compare attitudes and practices related to clinicians' use of depot medroxyprogesterone acetate [Depo-Provera (DMPA)] and levonorgestrel implants in adolescents in three northern European countries and the United States.

METHODS

Between the fall of 1993 and the winter of 1995, surveys eliciting clinician attitudes and practices with the two contraceptive methods were collected from practitioners who provide contraceptive care to teens in Sweden (n = 282), The Netherlands (n = 197), Great Britain (n = 108), and the United States (n = 548).

RESULTS

Clinicians in Great Britain and the United States reported prescribing of DMPA, selected DMPA in their top three choices for contraception in teens, and had patients ask about DMPA more frequently than clinicians in Sweden or The Netherlands (p < 0.0001). U.S. clinicians were more likely to report prescribing of the implants, list them as a top choice, and have patients ask for it more frequently than were providers in the other three countries (p < 0.0001). Noncompliance with previous contraceptives was the most common indication for use of either method in this age group. "Worst fears" with DMPA use included infertility, particularly among Swedish clinicians (p < 0.0001), as was pregnancy and loss to follow-up, particularly among British clinicians (p < 0.0001). Condom nonuse was a concern associated with both methods. Breakthrough uterine bleeding was a concern related to implant use, particularly among Swedish practitioners (p < 0.0001).

CONCLUSION

Clinicians in the United States and Great Britain display more enthusiasm toward the use of the long-term progestins in adolescents than do clinicians in Sweden or The Netherlands. Continuing education programs could be designed to educate clinicians to allay their concerns about these contraceptives in countries where teen pregnancy is considered a problem.

Suicidal behaviours in vulnerable adolescents. Time trends and their correlates

BACKGROUND

Suicide rates have increased over the past three decades, especially in young men. Depression, conduct disorder, crime and substance misuse have also increased. This study tested hypotheses on the possible links between the secular increase in the rates of these behaviours.

METHOD

A data set on 6091 subjects aged 8-18 years (58.4% boys) referred to psychiatric services over a 21-year period (1970-1990) was used. A detailed analysis of a random sample of 80 case notes was conducted.

RESULTS

Suicidal behaviours increased significantly among pubertal male adolescents only (n = 1313). In this sub-sample, substance misuse accounted for the increase over time. The rates of both suicidal behaviours and of substance misuse almost doubled between 1979 and 1990 in this patient group. The case note analysis showed that solvent and alcohol misuse had also increased over the study period. Moreover, among the subjects misusing substances, alcohol was the only substance with a strong and positive association with suicidal behaviours. Substance misuse pre-dated suicidal behaviours in most patients.

CONCLUSIONS

A link has been found between the increase over time of suicidal behaviors in adolescent boys and a contemporaneous increase in substance misuse. The strength and direction of the association suggests that alcohol misuse is the causal factor.

Influence of referral source on return compliance of adolescents

PURPOSE

To determine the effect of the source of referral on appointment compliance of adolescents to referring doctors or to consultants at tertiary medical centers.

METHODS

This analysis included 421 adolescent patients aged 10-18 years who were referred to the tertiary teaching hospital in Taiwan by 75 primary care doctors, including 56 pediatricians and 19 general practitioners in 1987-1996. Medical records were abstracted to determine clinical severity and demography. Data of compliance with return appointments were collected by an independently trained interviewer.

RESULTS

A total of 18.07% of referrals were initiated by patients or families and 81.93% were initiated by primary care doctors. More severe illness was found in patient-initiated referrals than in doctor-initiated referrals. After controlling for demographic, family features, medical payment, and doctor specialty, this study showed that if the referral were initiated by patients or families, adolescent patients were less likely to return to either the primary care doctors or tertiary teaching hospitals.

CONCLUSIONS

Although in a competitive environment, follow-up care is more likely to occur for both primary care doctors and consultants at tertiary teaching hospitals when the referral was initiated by primary care doctors.

School-based health center utilization: a survey of users and nonusers

BACKGROUND

As school-based health centers (SBHCs) continue to grow, it remains important to study use of the centers. The extent to which mental health problems exist in the students with access to the centers, whether those students are using the available services, if they are satisfied with the services, and the reasons for nonuse by those students who do not enroll are all meaningful questions.

METHODS

The above issues were studied in an urban high school with a 2-year-old SBHC by administering questions during physical education classes on health center use and mental health concerns. The 630 respondents were 45% male, 55% female, 61% black, 29% Hispanic, 54% in grades 9 or 10, 46% in grades 11 or 12.

RESULTS

Sixty percent of the students were registered in the SBHC; 40% were not registered. Seventy-five percent of registered students reported average use (< or =3 visits); females were more likely than males (P=.017) to be frequent (>3 visits) users of SBHC services. Mental health problems among all participants included depression in 31%, use of alcohol 1 time or more per month in 21%, use of alcohol daily in 5%, suicidal ideation in 16%, history of a suicide attempt in 10%, knowing someone who had been murdered in 50%, and being in at least 1 fight at school in 26%. Frequent users, average users, and nonusers did not differ by age, grade, race, or any of the measured mental health problems. Among the 472 students who completed the survey section on SBHC perceptions, 305 described health center use: 92% were satisfied with health center services, 79% were comfortable being seen in the SBHC, 74% believed visits were kept confidential, 61% told their parents about each visit, and 51% considered the SBHC their regular health care source. The health center was used for mental health services by 34% and sexuality-related care by 15%. The 167 students who described reasons for not using the SBHC most frequently reported that they already had a physician (60%), did not need it (50%), prefer continuing previous health care (45%), did not get around to it (30%), parents were opposed (20%), were not comfortable (19%), did not know about the service (19%), and did not want problems known (19%).

CONCLUSIONS

We conclude that, in this urban high school, (1) average users, frequent users, and nonusers did not differ in the mental health problems measured in this study; (2) those who used the SBHC indicated strong satisfaction with the care received; and (3) those who did not use the SBHC chose to stay away for a variety of reasons, most commonly the availability of other care or the perception of lack of need.

The school-linked health center: a promising model of community-based care for adolescents

PURPOSE

To examine the nature of the linkages between school-linked health centers (SLHCs) and schools; the centers' services, staffing, financing, and other operational details; and the advantages of this model of care.

METHOD

Twenty-one SLHCs completed a written survey on a range of operational issues, including types of services provided, staffing patterns, budgets, and populations served in 1995. The researchers conducted on-site interviews with six centers and telephone interviews with 14 centers to obtain more detailed information.

RESULTS

Although each SLHC has a unique program design, the study identified characteristics common to all sites. In general, SLHCs provide comprehensive medical, reproductive health, mental health, and health education services designed for adolescents. Staffed with a minimum of an administrator, a primary care provider, a nurse, and an administrative assistant, SLHCs serve students from more than one school as well as out-of-school youth. SLHCs develop formal and/or informal linkages with schools to improve outreach and follow-up services.

CONCLUSIONS

The report describes a community-based model of care that is designed to provide affordable, age-appropriate, confidential, convenient care to adolescents, a population that traditionally has been very hard to reach. The SLHCs ability to provide reproductive health care makes it an attractive option for communities trying to prevent pregnancy and sexually transmitted diseases among adolescents. To firmly conclude that the SLHC is an effective model for improving adolescent access to services, more research is needed on adolescents' use and nonuse of SLHCs and other models of care; the cost of SLHCs compared to other models of care; and how SLHCs can sustain themselves financially, particularly in a managed care environment.