Racial and ethnic disparities in pediatric mental health

Mental Health Service Utilization among Black Youth; Psychosocial Determinants in a National Sample

Racial disparity in mental health service utilization (MHSU) persists, and youths are not an exception to the underutilization of services. Very limited research has been conducted on the determinants of MHSU among Black youth. Using a national sample of American Black youth, the current study investigated the association between demographic factors, socioeconomic status, psychiatric disorders, and self-rated health (SRH) on MHSU. We also tested the heterogeneity of the effects of SRH and psychiatric disorders based on ethnicity, gender, and their intersection. We used data from the National Survey of American Life-Adolescents supplement (NSAL-A), 2003–2004. The study enrolled 1170 Black youth between 13 and 17 years old including 810 African Americans and 360 Caribbean Blacks. Age, gender, ethnicity, socioeconomic status, SRH, 12-month psychiatric disorders (Composite International Diagnostic Interview modified version), and MHSU (last year) were measured. Logistic regressions were used for data analysis. Ethnicity (odds ratio (OR) = 0.33, 95% confidence interval (CI) = 0.17–0.65), subjective socioeconomic status (OR = 1.43, 95% CI = 1.09–1.88), SRH (OR = 2.45, 95% CI = 1.00–6.37), and psychiatric disorders (OR = 2.17, 95% CI = 1.05–4.48) were associated with MHSU. Age, gender, and objective socioeconomic status were not associated with MHSU. Gender and ethnicity did not interact with SRH and psychiatric disorders on MHSU. Actual and perceived need both universally influence Black youths’ likelihood of MHSU, regardless of their ethnicity and gender. Ethnicity and perceived socioeconomic status also play unique roles in MHSU. Future research is needed to understand pathways to MHSU for Black youth who both have and perceive mental health needs. There is also a need to find ways to promote MHSU for those with a need for mental health services.

Neighborhood Safety and Major Depressive Disorder in a National Sample of Black Youth; Gender by Ethnic Differences

Adolescence is a developmental period marked by increased stress, especially among Black youth. In addition to stress related to their developmental transition, social factors such as a perceived unsafe neighborhood impose additional risks. We examined gender and ethnic differences in the association between perceived neighborhood safety and major depressive disorder (MDD) among a national sample of Black youth. We used data from the National Survey of American Life - Adolescents (NSAL-A), 2003-2004. In total, 1170 Black adolescents entered the study. This number was composed of 810 African American and 360 Caribbean Black youth (age 13 to 17). Demographic factors, perceived neighborhood safety, and MDD (Composite International Diagnostic Interview, CIDI) were measured. Logistic regressions were used to test the association between neighborhood safety and MDD in the pooled sample, as well as based on ethnicity by gender groups. In the pooled sample of Black youth, those who perceived their neighborhoods to be unsafe were at higher risk of MDD (Odds Ratio [OR] = 1.25; 95% Confidence Interval [CI] = 1.02-1.51). The perception that one's neighborhood is unsafe was associated with a higher risk of MDD among African American males (OR=1.41; 95% CI = 1.03-1.93) but not African American females or Caribbean Black males and females. In conclusion, perceived neighborhood safety is not a universal psychological determinant of MDD across ethnic by gender groups of Black youth; however, policies and programs that enhance the sense of neighborhood safety may prevent MDD in male African American youth.

Conduct Disorder and Alcohol Use Disorder Trajectories, Predictors, and Outcomes for Indigenous Youth

OBJECTIVE

The aim of this study was to identify separate and joint trajectories of conduct disorder (CD) and alcohol use disorder (AUD) DSM-IV diagnostic symptoms among American Indian and First Nation (Indigenous) youth aged 10 to 18 years, and to characterize baseline profiles and later outcomes associated with joint trajectory group membership.

METHOD

Data were collected between 2002 and 2010 on three indigenous reservations in the northern Midwest and four Canadian reserves (N = 673). CD and substance use disorder (SUD) were measured using the DSM-IV Diagnostic Interview Schedule for Children-Revised (DISC-R), administered at four time points.

RESULTS

Using group-based trajectory modeling, three CD and four AUD trajectories were found. Both had a small group with high symptoms, but the largest groups for both had no symptoms (55% and 73%, respectively). CD symptom trajectories began at age 10 years and peaked at age 14; AUD trajectories began at age 12 years and were highest from age 16 on. Eight joint trajectories were identified. Of the sample, 53% fell into the group with no CD or AUD symptoms. Compared to symptomatic groups, this group had greater caretaker warmth, positive school adjustment, less discrimination, and fewer deviant peers, and were less likely to have a caretaker with major depression at baseline. Symptomatic groups had higher odds of high school dropout, sex under the influence, and arrest at age 17 to 20 years.

CONCLUSION

Despite significant risk factors, a large proportion of Indigenous youth had no CD-SUD symptoms over time. CD-SUD symptoms have multiple development trajectories and are related to early developmental risk and later psychosocial outcomes.

The Behavioral and Emotional Screening System Student Form: Is There Evidence of a Global At-Risk Factor in a Sample of Predominantly African American Youth?

School-based universal screening for behavioral and emotional risk can serve as a foundation for effective multi-tiered service delivery systems. The current study examines the measurement and structure of one such universal screener, the Behavioral and Emotional Screening System Student Form (BESS SF). Four models were investigated including a unidimensional model, a multidimensional model, a second-order model, and a bifactor model. This study is the first to use a bifactor model in examining the structure of the BESS SF, and further adds to the literature by using bifactor modeling with a predominantly low-income, urban, African American sample. Results indicate that the bifactor model provided the best fit. Practically, results support interpretation of the global risk score as well as the domain-specific factors.

Ethnic Disparities in School-Based Behavioral Health Service Use for Children With Psychiatric Disorders

BACKGROUND

We examined racial/ethnic disparities in school-based behavioral health service use for children with psychiatric disorders.

METHODS

Medicaid claims data were used to compare the behavioral healthcare service use of 23,601 children aged 5-17 years by psychiatric disorder (autism, attention deficit hyperactivity disorder [ADHD], conduct/oppositional defiant disorder, and "other") and by race/ethnicity (African-American, Hispanic, white, and other). Logistic and generalized linear regression analyses were used.

RESULTS

Differences in service use by racial/ethnic group were identified within and across diagnostic groups, both for in-school service use and out-of-school service use. For all disorders, Hispanic children had significantly lower use of in-school services than white children. Among children with ADHD, African-American children were less likely to receive in-school services than white children; however, there were no differences in adjusted annual mean Medicaid expenditures for in-school services by race/ethnicity or psychiatric disorders. Statistically significant differences by race/ethnicity were found for out-of-school service use for children with ADHD and other psychiatric disorders. There were significant differences by race/ethnicity in out-of-school service use for each diagnostic group.

CONCLUSIONS

Differences in the use of school-based behavioral health services by racial and ethnic groups suggest the need for culturally appropriate outreach and tailoring of services to improve service utilization.

Psychiatric emergencies of minors with and without migration background

Background

The conditions of children and adolescents with migration background receiving emergency psychiatric care in Europe are not well known. Migrants usually attend regular psychiatric care less frequently than the autochthonous population. We therefore speculated that, being undertreated, they would be overrepresented among psychiatric emergency care patients.

Methods

We retrospectively analyzed the records of 1093 minors aged 4‑18 years treated during a period of three years at the psychiatric emergency outpatient clinic of the Department of Child and Adolescent Psychiatry at the Medical University of Vienna.

Results

More minors with migration background than natives consulted our emergency clinic. Most frequent reasons for referral were suicide attempts by Turkish patients, acute stress disorder in Serbian/Croatian/Bosnian and in Austrian patients. Psychiatric diagnoses like eating and personality disorders were mostly diagnosed in natives. We found gender specific differences between the groups.

Conclusions

The reasons for these differences possibly relate to deficits of adequate mental health-care in Austria, to intercultural and intrafamiliar conflicts related to acculturation distress in the migrant population. Prospective longitudinal studies focusing on the utilization of mental health care by the migrant children and the impact of the migration background on their mental health are needed for improving adequate culture-sensitive mental-health care for this population.

Child Health Disparities in the 21st Century

The topic of persistent child health disparities remains a priority for policymakers and a concern for pediatric clinicians. Health disparities are defined as differences in adverse health outcomes for specific health indicators that exist across sub-groups of the population, frequently between minority and majority populations. This review will highlight the gains that have been made since the 1990s as well as describe disparities that have persisted or have worsened into the 21st century. It will also examine the most potent social determinants and their impact on the major disparities in mortality, preventive care, chronic disease, mental health, educational outcomes, and exposure to selected environmental toxins. Each section concludes with a description of interventions and innovations that have been successful in reducing child health disparities.

Mental Health Diagnostic Considerations in Racial/Ethnic Minority Youth

Misdiagnoses of racial/ethnic minority youth's mental health problems can potentially contribute to inappropriate mental health care. Therefore, we conducted a systematic review that focuses on current theory and empirical research in an attempt to answer the following two questions: 1) What evidence exists that supports or contradicts the idea that racial/ethnic minority youth's mental health problems are misdiagnosed? 2) What are the sources of misdiagnoses? Articles were reviewed from 1967 to 2014 using PsychINFO, PubMed, and GoogleScholar. Search terms included "race", "ethnicity", "minority", "culture", "children", "youth", "adolescents", "mental health", "psychopathology", "diagnosis", "misdiagnosis", "miscategorization", "underdiagnosis", and "overdiagnosis". Seventy-two articles and book chapters met criteria and were included in this review. Overall, evidence was found that supports the possibility of misdiagnosis of ethnic minority youth's emotional and behavioral problems. However, the evidence is limited such that it cannot be determined whether racial/ethnic differences are due to differences in psychopathology, mental health biases, and/or inaccurate diagnoses. Cultural and contextual factors that may influence misdiagnosis as well as recommendations for research and practice are discussed.

Barriers to access and participation in community mental health treatment for anxious children

BACKGROUND

Anxiety disorders are the most common psychiatric disorders among children in the United States; yet many children do not receive treatment due to barriers to treatment access and participation. This study examined common barriers to treatment access and participation among anxious children who participated in computer-assisted cognitive behavioral therapy. Differences in barriers reported by treatment completers/non-completers were examined, as was the association with sociodemographic characteristics, anxiety severity, and impairment. The impact of barriers on treatment response was assessed, as well as the relationship with treatment expectancy and satisfaction.

METHOD

Barriers to access and participation, demographics, anxiety severity/impairment, treatment credibility and satisfaction were assessed among parents and children with anxiety (N=100; ages 7-13) who were enrolled in a community-based randomized clinical trial.

RESULTS

The most common access barrier was parents not knowing where or from whom to seek services (66%). Differences among completers and non-completers were related to stigma, confidentiality, and costs. The most common parent-reported barrier to participating was stress (32.4%) and child-reported barrier to participation was not having enough time to complete homework (22.1%). Of the sociodemographic, clinical and treatment characteristics, minority status, satisfaction, and treatment response were associated with barriers to treatment participation, although these associations varied by barriers related to treatment and external factors.

LIMITATIONS

Cross sectional design and lack of well-established psychometric properties for barriers measures were limitations.

CONCLUSION

Findings suggest that accessible, time-efficient, cost-effective service delivery methods that minimize stigma and maximize engagement when delivering evidence-based treatment for pediatric anxiety are needed.

Computer-Based and Online Therapy for Depression and Anxiety in Children and Adolescents

OBJECTIVE

The purpose of this study was to provide an overview of computer-based and online therapies (e-therapy) to treat children and adolescents with depression and/or anxiety, and to outline programs that are evidence based or currently being researched.

METHODS

We began by defining the topic and highlighting the issues at the forefront of the field. We identified computer and Internet-based interventions designed to prevent or treat depression or anxiety that were tested with children and young people <18 years of age (or inclusive of this age range together with emerging adults). We included randomized controlled trials (RCTs). We summarized available relevant systematic reviews.

RESULTS

There is an increasing body of evidence that supports the use of computers and the Internet in the provision of interventions for depression and anxiety in children and adolescents. A number of programs have been shown to be effective in well-designed RCTs. Replication and long-term follow-up studies are needed to confirm results.

CONCLUSIONS

There are now a range of effective computerized interventions for young people with depression and anxiety. This is likely to impact positively on attempts to make psychological therapies widely available to children and young people. We expect to see increased program sophistication and a proliferation of programs in the coming years. Research efforts, when developing programs, need to align with technological advances to maximize appeal. Implementation research is needed to determine the optimal modes of delivery and effectiveness of e-therapies in clinical practice. Given the large number of unproven program on the Internet, ensuring that there is clear information for patients about evidence for individual programs is likely to present a challenge.

Identifying Targets for Improving Mental Healthcare of Adolescents with Systemic Lupus Erythematosus: Perspectives from Pediatric Rheumatology Clinicians in the United States and Canada

OBJECTIVE

To identify targets for improving mental healthcare of adolescents with systemic lupus erythematosus (SLE) by assessing current practices and perceived barriers for mental health intervention by pediatric rheumatology clinicians.

METHODS

Members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) completed a Web-based survey assessing current mental health practices, beliefs, and barriers. We examined associations between provider characteristics and the frequency of barriers to mental health screening and treatment using multivariable linear regression.

RESULTS

Of the 375 eligible CARRA members, 130 responded (35%) and 119 completed the survey. Fifty-two percent described identification of depression/anxiety in adolescents with SLE at their practice as inadequate, and 45% described treatment as inadequate. Seventy-seven percent stated that routine screening for depression/anxiety in pediatric rheumatology should be conducted, but only 2% routinely used a standardized instrument. Limited staff resources and time were the most frequent barriers to screening. Respondents with formal postgraduate mental health training, experience treating young adults, and practicing at sites with very accessible mental health staff, in urban locations, and in Canada reported fewer barriers to screening. Long waitlists and limited availability of mental health providers were the most frequent barriers to treatment. Male clinicians and those practicing in the Midwest and Canada reported fewer barriers to treatment.

CONCLUSION

Pediatric rheumatology clinicians perceive a need for improved mental healthcare of adolescents with SLE. Potential strategies to overcome barriers include enhanced mental health training for pediatric rheumatologists, standardized rheumatology-based mental health practices, and better integration of medical and mental health services.

Reducing the Risk of Internalizing Symptoms among High-risk Hispanic Youth through a Family Intervention: A Randomized Controlled Trial

Familias Unidas is an intervention that has been found to be efficacious in preventing and reducing substance use, sexual risk, and problem behaviors among Hispanic youth. While it does not specifically target youth internalizing symptoms, the intervention works to strengthen parenting and family factors associated with reduced risk of internalizing symptoms (i.e., depression, anxiety symptoms). This study examines the effects of Familias Unidas on internalizing symptoms among high-risk youth, as well as the role of family level factors in the intervention's effects. A total of 242 12-17-year-old Hispanic youth with a history of delinquency and their primary caregivers were recruited from the school and juvenile justice systems, and randomly assigned to the Familias Unidas intervention or community practice control. A linear latent growth model was used to examine intervention effects on the trajectory of adolescent internalizing symptoms from baseline to 6 and 12 months post-baseline. Results show that the Familias Unidas intervention was more efficacious than control in reducing youth internalizing symptoms. Baseline youth externalizing and internalizing symptoms did not moderate the intervention's effects on the trajectory of youth internalizing symptoms. While parent-adolescent communication did not significantly moderate the intervention's effects, changes in parent-adolescent communication mediated the intervention's effects on internalizing symptoms, showing stronger intervention effects for youth starting with poorer communication. Findings indicate that the Familias Unidas intervention can reduce internalizing symptoms among high-risk Hispanic youth, and that improving parent-youth communication, a protective family factor, may be one of the mechanisms by which the intervention influences youth internalizing symptoms.

Identifying Differences in Risk Factors for Depression and Anxiety in Pediatric Chronic Disease: A Matched Cross-Sectional Study of Youth with Lupus/Mixed Connective Tissue Disease and Their Peers with Diabetes

OBJECTIVE

To investigate differences in risk factors for depression and anxiety, such as central nervous system involvement in systemic lupus erythematosus (SLE)/mixed connective tissue disease (MCTD), by comparing youth with SLE/MCTD to peers with type 1 diabetes mellitus (T1D).

STUDY DESIGN

We conducted a cross-sectional study of 50 outpatient pairs, ages 8 years and above, matching subjects with SLE/MCTD and T1D by sex and age group. We screened for depression, suicidal ideation, and anxiety using the Patient Health Questionnaire-9 and the Screen for Childhood Anxiety Related Emotional Disorders, respectively. We collected parent-reported mental health treatment data. We compared prevalence and treatment rates between subjects with SLE/MCTD and T1D, and identified disease-specific risk factors using logistic regression.

RESULTS

Depression symptoms were present in 23%, suicidal ideation in 15%, and anxiety in 27% of participants. Compared with subjects with T1D, subjects with SLE/MCTD had lower adjusted rates of depression and suicidal ideation, yet poorer rates of mental health treatment (24% vs 53%). Non-White race/ethnicity and longer disease duration were independent risk factors for depression and suicidal ideation. Depression was associated with poor disease control in both groups, and anxiety with insulin pump use in subjects with T1D.

CONCLUSION

Depression and anxiety are high and undertreated in youth with SLE/MCTD and T1D. Focusing on risk factors such as race/ethnicity and disease duration may improve their mental health care. Further study of central nervous system and other disease-related factors may identify targets for intervention.

Emotional and behavior problems in an urban pediatric primary care setting

We sought to identify needs for behavioral health care in a large, urban pediatric primary care (PPC) clinic serving a population covered by Medicaid. Specifically, children (N = 197; 120 girls; 91 % African American) ages 8-17 years and their caregivers completed measures of internalizing and externalizing symptoms (RCADS, RCADS-P, MASC, and SDQ). Clinical elevations on all but one domain of the SDQ were significantly higher than expected. However, self-reported anxiety and depression symptoms were consistent with expectations. These findings suggest urban, low-income, primarily African American youth presenting at a PPC clinic demonstrate significant levels of behavioral and emotional symptoms. Implications of the findings include the need to ask both parents and children about child behavioral health problems and the possible influence of screening tool selection on detection.

DISC Predictive Scales (DPS): Factor structure and uniform differential item functioning across gender and three racial/ethnic groups for ADHD, conduct disorder, and oppositional defiant disorder symptoms

The factor structure and potential uniform differential item functioning (DIF) among gender and three racial/ethnic groups of adolescents (African American, Latino, White) were evaluated for attention deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD) symptom scores of the DISC Predictive Scales (DPS; Leung et al., 2005; Lucas et al., 2001). Primary caregivers reported on DSM-IV ADHD, CD, and ODD symptoms for a probability sample of 4,491 children from three geographical regions who took part in the Healthy Passages study (mean age = 12.60 years, SD = 0.66). Confirmatory factor analysis indicated that the expected 3-factor structure was tenable for the data. Multiple indicators multiple causes (MIMIC) modeling revealed uniform DIF for three ADHD and 9 ODD item scores, but not for any of the CD item scores. Uniform DIF was observed predominantly as a function of child race/ethnicity, but minimally as a function of child gender. On the positive side, uniform DIF had little impact on latent mean differences of ADHD, CD, and ODD symptomatology among gender and racial/ethnic groups. Implications of the findings for researchers and practitioners are discussed.

Parent Reports of Mental Health Concerns and Functional Impairment on Routine Screening With the Strengths and Difficulties Questionnaire

OBJECTIVE

This study used the Strengths and Difficulties Questionnaire (SDQ) to describe the prevalence of parent-reported mental health (MH) concerns in youth presenting for primary care appointments and to examine relationships between children's MH issues and functional impairment. We hypothesized that increased MH symptomology would be associated with increased impairment and family burden.

METHODS

Parents of 4- to 17-year-old children were approached at routine visits in 13 primary care sites. Chi-square tests, independent sample t tests, and a 1-way analysis of variance (ANOVA) were used to make comparisons between demographic groups. Age-, sex-, and race-adjusted ordered logistic regression models and ANOVAs examined relationships between impact and SDQ scales.

RESULTS

Boys had higher total Hyperactivity and Peer Problems. Adolescents showed higher Emotional Symptoms, while younger children showed more Hyperactivity. Latinos reported more Conduct Problems, Hyperactivity, and Peer Problems. Latinos also indicated less distress on the child, impairment at home and school, and family burden. Regression analyses indicated increased odds of impairment with higher scale scores. MH symptoms identified with the SDQ in pediatric primary care settings were associated with parent-reported impairment affecting youth and their families.

CONCLUSIONS

The presence of significant impairment suggests that parents' concerns identified by screening are likely to be clinically important and worthy of practice strategies designed to promote assessment, treatment, and referral for these common problems. Identifying and exploring parents' concerns with strategic use of screening tools may allow primary care providers to directly engage families around the MH issues that affect them most.

Behavioral health services following implementation of screening in Massachusetts Medicaid children

OBJECTIVES

To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children.

METHODS

After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007-June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services.

RESULTS

Of 261,160 children in the cohort, 45% (118,464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22-11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53-4.06).

CONCLUSIONS

Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services.

Under What Conditions Does Caseworker-Caregiver Racial/Ethnic Similarity Matter for Housing Service Provision? An Application of Representative Bureaucracy Theory

In this article, we examine child welfare caseworkers' housing-related service strategies when they serve culturally similar versus culturally dissimilar clients. Testing hypotheses drawn from representative bureaucracy theory and using data from the second cohort of the National Survey of Child and Adolescent Well-Being, we find that when non-Caucasian caseworkers share the same racial/ethnic background as caregivers, caseworkers use more active strategies to connect caregivers to needed housing services. The relationship between racial/ethnic matching and frontline workers' repertoire of service strategies is most pronounced when the need for housing has been registered formally via referrals and case plans and thus legitimated institutionally. These results reinforce basic tenets of representative bureaucracy theory and provide evidence of the benefits of racial and ethnic diversity in the human service workforce. Our findings also highlight the need for research identifying institutional and frontline organizational factors that enhance the quality of service provision.

The relationship between substance use and sexual health among African-American female adolescents with a history of seeking mental health services

BACKGROUND

This study examined relationships between substance use patterns and problems and sexual health outcomes among low-income, urban, African-American female adolescents with a history of seeking mental health services.

METHODS

Participants were recruited from outpatient mental health clinics serving urban, primarily low-income youth and families in Chicago, Illinois, as part of a 2-year, longitudinal investigation of HIV risk behavior during which they completed interviews every 6 months (five time points). Girls who completed at least one follow-up interview were invited to participate in a sixth wave of assessment to assess trauma exposure, substance use problems, and sexual risk. The current study (n = 177) examined the association between sexual risk behavior and substance use problems reported at the most recent interview (ages 14-22) and substance use patterns and sexually transmitted infections (STI) reported at all six times points. Multiple regression examined the combined and unique effects of different patterns of substance use and substance use problems as correlates of sexual risk behavior and STIs.

FINDINGS

Substance use problems were associated with increased sexual risk behavior and increased likelihood of experiencing STIs. Substance use patterns were associated with sexual risk behavior.

CONCLUSIONS

Results suggest that specific patterns of substance use and substance use problems are important to address in sexual health promotion among low-income, urban, African-American girls with a history of seeking mental health services. Understanding the nuances of these relationships is important in informing how to best serve this vulnerable group of adolescents who experience significant sexual risk and mental health care disparities.

Microaggressions and the Enduring Mental Health Disparity

Despite federal focus on reducing mental health disparities for Black Americans, mental health disparities persist, resulting in reduced access to and benefit from mental health care. Amid calls for deeper examination of etiology, the current literature review introduces discrimination in the form of microaggressions at the institutional level as one changeable systemic cause for mental health disparities. In combining the mental health disparity and microaggression literatures, I first review the evidence regarding prevalence and contributing factors for current mental health disparities and microaggressions. Next, I examine the potential contributing role that microaggressions as a form of institutional betrayal within mental health care may play in perpetuating these disparities. Finally, I review implications regarding the particular role of mental health care systems, the field of psychology in general, and Black American psychologists specifically in systematically reducing mental health disparities for Black Americans.

Use of mental health services in transition age youth with bipolar disorder

OBJECTIVES

There is concern that treatment of serious mental illness in the United States declines precipitously following legal emancipation at age 18 years and transition from specialty youth clinical settings. We examined age transition effects on treatment utilization in a sample of youth with bipolar disorder.

METHODS

Youth with bipolar disorder (N=413) 7-18 years of age were assessed approximately twice per year (mean interval 8.2 months) for at least 4 years. Annual use of any individual, group, and family therapy, psychopharmacology visits, and hospitalization at each year of age, and monthly use from ages 17 through 19 years, were examined. The effect of age transition to 18 years on monthly visit probability was tested in the subsample with observed transitions (n=204). Putative sociodemographic moderators and the influence of clinical course were assessed.

RESULTS

Visit probabilities for the most common modalities-psychopharmacology, individual psychotherapy, and home-based care- generally fell from childhood to young adulthood. For example, the annual probability of at least one psychopharmacology visit was 97% at age 8, 75% at age 17, 60% at age 19, and 46% by age 22. Treatment probabilities fell in transitionage youth from age 17 through 19, but a specific transition effect at age 18 was not found. Declines did not vary based on sociodemographic characteristics and were not explained by changing severity of the bipolar illness or functioning.

CONCLUSIONS

Mental health treatment declined with age in this sample of youth with bipolar disorder, but reductions were not concentrated during or after the transition to age 18 years. Declines were unrelated to symptom severity or impairment.

Practice parameter for cultural competence in child and adolescent psychiatric practice

The United States faces a rapidly changing demographic and cultural landscape, with its population becoming increasingly multiracial and multicultural. In consequence, cultural and racial factors relating to mental illness and emotional disturbances deserve closer attention and consideration. This Practice Parameter outlines clinical applications of the principle of cultural competence that will enable child and adolescent mental health clinicians to better serve diverse children, adolescents, and their families.

Prevalence of mental health disorders among low-income African American adolescents

PURPOSE

Data on the prevalence of mental health disorders for low-income, urban African American adolescents are scarce. This study presents data about the burden of mental disorders for this understudied population.

METHODS

Mental disorders were assessed using the Diagnostic Interview Schedule for Children (C-DISC), Youth Self-Report (YSR), and Child Behavior Checklist (CBCL) among a sample of adolescents and their caregivers from very impoverished neighborhoods in a Southern city.

RESULTS

Based on the C-DISC, 3.8, 5.1 and 7.7% of adolescents met diagnostic criteria for major depression, post-traumatic stress disorder, and conduct disorder, respectively. There were significant differences among some of the mental health disorders based on adolescent and caregiver characteristics such as sex, school status, caregiver work status, and income level. We found a low prevalence of alcohol, marijuana, and substance abuse and dependence disorders.

CONCLUSIONS

Information about the prevalence of mental health disorders in specific communities and populations can assist in addressing unmet needs, planning for services and treatment, and reducing health disparities.

Genetic testing and genetic counseling among Medicaid-enrolled children with autism spectrum disorder in 2001 and 2007

The rise in the prevalence of autism spectrum disorder (ASD) has resulted in increased efforts to understand the causes of this complex set of disorders that emerge early in childhood. Although research in this area is underway and yielding useful, but complex information about ASD, guidelines for the use of genetic testing and counseling among children with ASD conflict. The purpose of this study was to determine the frequency of use of genetic testing and counseling before the widespread implementation of clinical chromosomal microarray (CMA) to establish a baseline for the use of both services and to investigate potential disparities in the use of both services among children with ASD. We found that about two-thirds of children with ASD received genetic testing or counseling and the use of both services is increasing with time, even in the pre-CMA era. Being female and having a comorbid intellectual disability diagnosis both increased the likelihood of receiving genetic testing and genetic counseling. Initial discrepancies in the use of both services based on race/ethnicity suggest that troubling disparities observed in other services delivered to children with ASD and other mental health disorders persist in genetic testing and counseling as well. These results should incentivize further investigation of the impact of genetic testing and counseling on children with ASD and their families, and should drive efforts to explore and confront disparities in the delivery of these services, particularly with the advancing scientific research on this topic.

Cross-Sectional Study of Unmet Mental Health Need in 5- to 7-Year Old Latino Children in the United States: Do Teachers and Parents Make a Difference in Service Utilization?

The aim of the study is to examine the rates of mental health service utilization in young Latino children of immigrants in relation to maternal and teacher reports of child mental health need. Specific knowledge is lacking about gaps in service utilization among young Latino children, the fastest growing and possibly the most underserved segment of the US child population. The associations of mental health service utilization (Service Assessment for Children and Adolescents) and mental health need (clinical levels of internalizing, externalizing, or total problems reported by mothers [Child Behavior Checklist] and teachers [Teacher's Report Form]) were examined in a community sample of young Latino children of immigrants (n = 228; mean age = 6) and compared across mothers' and teachers' responses. Mother-teacher agreement was also studied. Sixty-five children (28.5 %) had a mental health need; most (76.9 %) of these received no services. For all types of mental health need, service utilization was more likely when need was reported by mothers rather than teachers (p = .03). Teachers' reports were not associated with service utilization. Mother-teacher agreement was low for externalizing (r = .23; p ≤ 0.01) and total problems (r = .21; p ≤ 0.05), and nonsignificant for internalizing problems. This study is the first in the United States to document, in such a young Latino group, high rates of unmet need comparable to those among older Latino youth; low or no mother-teacher agreement on which children had a mental health need; low utilization of school-based services; and a lack of association between service utilization and teacher-reported mental health need-both for externalizing and internalizing problems. These findings suggest that schools are not effectively leveraging mental health services for young Latino children. Potential factors responsible for the findings are discussed.

Predictors of adequate depression treatment among Medicaid-enrolled youth

PURPOSE

To determine if Medicaid-enrolled youth with depressive symptoms receive adequate acute treatment, and to identify the characteristics of those receiving inadequate treatment.

METHODS

We used administrative claims data from a Medicaid-enrolled population in a large urban community to identify youth aged 6-24 years who started a new episode of treatment for a depressive disorder between August 2006 and February 2010. We examined rates and predictors of minimally adequate psychotherapy (four visits in first 12 weeks) and pharmacotherapy (filled antidepressant prescription for 84 of the first 144 days) among youth with a new treatment episode during the study period (n = 930).

RESULTS

Fifty-nine percent of depressed youth received minimally adequate psychotherapy, but 13 % received minimally adequate pharmacotherapy. Youth who began their treatment episode with an inpatient psychiatric stay for depression and racial minorities were significantly less likely to receive minimally adequate pharmacotherapy and significantly more likely to receive inadequate overall treatment.

CONCLUSIONS

While the majority of youth appear to be receiving minimally adequate acute care for depression, a substantial number are not. Given current child mental health workforce constraints, efforts to substantially improve the provision of adequate care to depressed youth are likely to require both quality improvement and system redesign efforts.

Role of referrals in mental health service disparities for racial and ethnic minority youth

OBJECTIVE

To investigate racial/ethnic differences in teachers' and other adults' identification and/or encouragement of parents to seek treatment for psychiatric problems in their children and to evaluate if and whether identification/encouragement is associated with service use.

METHOD

Data on identification/encouragement to seek treatment for externalizing disorders (i.e., attention-deficit/hyperactivity disorder, oppositional-defiant disorder, and/or conduct disorder) and internalizing disorders (i.e., major depressive episode/dysthymia and/or separation anxiety disorder) and services used were obtained for 6,112 adolescents (13-17 years of age) in the National Comorbidity Survey Adolescent Supplement. Racial/ethnic differences were examined for Latinos, non-Latino blacks, and non-Latino whites.

RESULTS

There were few racial/ethnic differences in rates of youth identification/encouragement and how identification/encouragement related to service use. Only non-Latino black youth with low severity internalizing disorders were less likely to be identified/encouraged to seek services compared with non-Latino white youth with the same characteristics (odds ratio [OR] = 0.4, 95% confidence interval [CI] = [0.2-0.7]). Identification/encouragement increased the likelihood of seeking services for externalizing and internalizing disorders for all youth. However, compared with their non-Latino white counterparts, non-Latino black youth who met criteria for internalizing disorders appeared less likely to have used any services (OR = 0.4, 95%, CI = 0.2-0.7), after adjusting for identification/encouragement, clinical, and sociodemographic characteristics. Non-Latino black youth with internalizing disorders and without identification/encouragement were less likely to use the specialty care sector than their non-Latino white counterparts.

CONCLUSIONS

In this study of a nationally representative sample of adolescents, almost no ethnic/racial differences in identification/encouragement were found. However, identification/encouragement may increase service use for all youth.

School-based health centers in an era of health care reform: building on history

School-based health centers (SBHCs) provide a variety of health care services to youth in a convenient and accessible environment. Over the past 40 years, the growth of SBHCs evolved from various public health needs to the development of a specific collaborative model of care that is sensitive to the unique needs of children and youth, as well as to vulnerable populations facing significant barriers to access. The SBHC model of health care comprises of on-school site health care delivery by an interdisciplinary team of health professionals, which can include primary care and mental health clinicians. Research has demonstrated the SBHCs' impacts on delivering preventive care, such as immunizations; managing chronic illnesses, such as asthma, obesity, and mental health conditions; providing reproductive health services for adolescents; and even improving youths' academic performance. Although evaluation of the SBHC model of care has been complicated, results have thus far demonstrated increased access to care, improved health and education outcomes, and high levels of satisfaction. Despite their proven success, SBHCs have consistently faced challenges in securing adequate funding for operations and developing effective financial systems for billing and reimbursement. Implementation of health care reform (The Patient Protection and Affordable Care Act [P.L. 111-148]) will profoundly affect the health care access and outcomes of children and youth, particularly vulnerable populations. The inclusion of funding for SBHCs in this legislation is momentous, as there continues to be increased demand and limited funding for affordable services. To better understand how this model of care has and could further help promote the health of our nation's youth, a review is presented of the history and growth of SBHCs and the literature demonstrating their impacts. It may not be feasible for SBHCs to be established in every school campus in the country. However, the lessons learned from the synergy of the health and school settings have major implications for the delivery of care for all providers concerned with improving the health and well-being of children and adolescents.