Factors associated with mental health, general health, and school-based service use for child psychopathology

Factors associated with adolescent utilization of alcohol treatment services

OBJECTIVE

This study examined factors associated with adolescents' use of alcohol treatment services.

METHOD

Data on adolescents (aged 12-17) from the 1994 National Household Survey on Drug Abuse (NHSDA, N = 4,698), a large representative sample of the U.S. population, were used in this study. Information obtained from the survey included adolescent alcohol use, drinking patterns, alcohol abuse/dependent problems, and service use for alcohol-related problems. In addition, socio- demographics, health insurance, mental and behavioral problems, and other drug use were also included in the analysis.

RESULTS

The findings indicate that many adolescents with alcohol problems did not receive treatment. White adolescents were more likely to receive alcohol treatment services than nonwhites. Among alcohol-related problems, alcohol causing problems at home, school, or other settings predicted entry into alcohol treatment. Drug use and poor health status were also associated with receiving alcohol treatment services.

CONCLUSIONS

This study calls for an improved service delivery system to meet service needs of adolescents with alcohol-related problems, especially among minorities, and those with alcohol-related problems but without yet experiencing significant negative social consequences.

Affective disorders in children and adolescents: addressing unmet need in primary care settings

Affective disorders are common among children and adolescents but may often remain untreated. Primary care providers could help fill this gap because most children have primary care. Yet rates of detection and treatment for mental disorders generally are low in general health settings, owing to multiple child and family, clinician, practice, and healthcare system factors. Potential solutions may involve 1) more systematic implementation of programs that offer coverage for uninsured children; 2) tougher parity laws that offer equity in defined benefits and application of managed care strategies across physical and mental disorders; and 3) widespread implementation of quality improvement programs within primary care settings that enhance specialty/primary care collaboration, support use of care managers to coordinate care, and provide clinician training in clinically and developmentally appropriate principles of care for affective disorders. Research is needed to support development of these solutions and evaluation of their impacts.

Organizational context and provider perception as determinants of mental health service use

This study refines and tests an individual client model of service use and contrasts it with a model of service provision based on gateway provider perspectives. Structural equation models demonstrate that provider variables account for more service use variation than client variables. The client model accounts for 24% of the variance in service use, while the provider model accounts for 55% of the variance. Youth self-reported mental health was not positively associated with increased services or with provider perception of youth mental health. The provider model demonstrates the critical role played by provider perceptions, which are influenced more by work environment than by client problems.

The importance of culture in treating abused and neglected children: an empirical review

There is growing evidence that cultural factors may influence symptom development and treatment referral patterns among abused and neglected children. To date, few treatment outcome studies have specifically examined the impact of race, culture, or ethnicity on treatment response among maltreated children. Those that have attempted to include these factors have typically suffered from lack of clarity of the meaning of these terms. This article reviews the available empirical evidence that addresses the influence of culture on symptom formation, treatment-seeking behaviors, treatment preference, and response following child maltreatment. Hypotheses regarding these findings are addressed, and implications for practice, research, and public policy are discussed.

Maximum likelihood analysis of logistic regression models with incomplete covariate data and auxiliary information

This article presents a new method for maximum likelihood estimation of logistic regression models with incomplete covariate data where auxiliary information is available. This auxiliary information is extraneous to the regression model of interest but predictive of the covariate with missing data. Ibrahim (1990, Journal of the American Statistical Association 85, 765-769) provides a general method for estimating generalized linear regression models with missing covariates using the EM algorithm that is easily implemented when there is no auxiliary data. Vach (1997, Statistics in Medicine 16, 57-72) describes how the method can be extended when the outcome and auxiliary data are conditionally independent given the covariates in the model. The method allows the incorporation of auxiliary data without making the conditional independence assumption. We suggest tests of conditional independence and compare the performance of several estimators in an example concerning mental health service utilization in children. Using an artificial dataset, we compare the performance of several estimators when auxiliary data are available.

Police reporting and professional help seeking for child crime victims: a review

Most crimes with child victims are not reported to police, nor do child victims access other professional victim services, despite evidence that these yield positive outcomes. This article develops a conceptual framework about the barriers to such access: (a) the reluctance to define the crime episodes or their consequences as serious, criminal, harmful, or warranting intervention; (b) the extra authorities, including parents and schools, who mediate between victims and police or services; (c) developmental issues, such as concerns about autonomy; (d) attitudinal and emotional obstacles; and (e) time and expense factors. This article suggests the need for initiatives to stimulate reporting and help seeking, such as more publicity about the seriousness of juvenile victimization, more justice-system involvement with schools, more child and family friendly police services, and an emphasis on attractive outcomes such as justice and empowerment.

Children in foster care: factors influencing outpatient mental health service use

OBJECTIVE

To determine factors influencing outpatient mental health service use by children in foster care.

METHOD

Detailed survey and administrative data were collected on 480 children who entered long-term foster care in San Diego County from May 1990 through October 1991. These data were linked with claims data from Medicaid and San Diego County Mental Health Services information systems. A Poisson regression model was used to determine whether the following factors influenced outpatient mental health service use: age, race/ethnicity, gender, maltreatment history, placement pattern, and behavioral problems as measured by the Achenbach Child Behavior Checklist (CBCL).

RESULTS

Except for maltreatment history, all independent variables included in the multivariate regression model were statistically significant. The total number of outpatient mental health visits increased with age, male gender, and non-relative foster placements. Relative to Caucasians, visits were lower for Latinos, and Asian/Others, but comparable for African-Americans. Concerning maltreatment history, differences were only found in one category; children experiencing caretaker absence received fewer visits compared to children who did not experience caretaker absence. Children with CBCL Total Problem Scale T-scores of 60 or greater had significantly more visits than those with a score less than 60.

CONCLUSIONS

Both clinical and non-clinical factors influence outpatient mental health service use by foster children. Limitations imposed by gender, race/ethnicity, and placement setting need to be addressed by child welfare policies. These finding suggest that guidelines are needed to systematically link children in foster care with behavioral problems to appropriate services.

Depressive and disruptive disorders and mental health service utilization in children and adolescents

OBJECTIVE

To examine the relationship of depressive and disruptive disorders with patterns of mental health services utilization in a community sample of children and adolescents.

METHOD

Data were from the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The sample consisted of 1,285 child (ages 9-17 years) and parent/guardian pairs. Data included child psychopathology (assessed by the Diagnostic Interview Schedule for Children), impairment, child need and use of mental health services, and family socioeconomic status.

RESULTS

After adjusting for potential confounding factors, disruptive disorder was significantly associated with children's use of mental health services, but depressive disorder was not. For school-based services, no difference was found between the 2 types of disorders. Parents perceived greater need for mental health services for children with disruptive disorders than for those with depression. Conversely, depression was more related to children's perception of mental health service need than was disruptive disorder.

CONCLUSIONS

The findings highlight the need for more effective ways to identify and refer depressed children to mental health professionals, the importance of improving school-based services to meet children's needs, and the necessity to better educate parents and teachers regarding the identification of psychiatric disorders, especially depression.

Maximum likelihood analysis of generalized linear models with missing covariates

Missing data is a common occurrence in most medical research data collection enterprises. There is an extensive literature concerning missing data, much of which has focused on missing outcomes. Covariates in regression models are often missing, particularly if information is being collected from multiple sources. The method of weights is an implementation of the EM algorithm for general maximum-likelihood analysis of regression models, including generalized linear models (GLMs) with incomplete covariates. In this paper, we will describe the method of weights in detail, illustrate its application with several examples, discuss its advantages and limitations, and review extensions and applications of the method.

Goodness-of-fit for GEE: an example with mental health service utilization

Suppose we use generalized estimating equations to estimate a marginal regression model for repeated binary observations. There are no established summary statistics available for assessing the adequacy of the fitted model. In this paper we propose a goodness-of-fit test statistic which has an approximate chi-squared distribution when we have specified the model correctly. The proposed statistic can be viewed as an extension of the Hosmer and Lemeshow goodness-of-fit statistic for ordinary logistic regression to marginal regression models for repeated binary responses. We illustrate the methods using data from a study of mental health service utilization by children. The repeated responses are a set of binary measures of service use. We fit a marginal logistic regression model to the data using generalized estimating equations, and we apply the proposed goodness-of-fit statistic to assess the adequacy of the fitted model.