Predictors for emotionally distressed adolescents to receive mental health care

An Analysis of Six Month Follow-Up Data from a Peer Parent Support Study

The current study examines trajectories of treatment outcomes 6 months after completion of a peer parent program, NAMI Basics. Fifty-two caregivers who were part of a larger trial completed questionnaires prior to, immediately after, and 6 months after completing NAMI Basics. Growth curve models were used to examine trajectories of caregiver ratings of parent activation and engagement, parent help-seeking intentions, child symptoms, outpatient service use, and parent stress at 6 months after completion of the program. Prior improvements to the outcomes of parent activation and engagement (β = 2.31, p < .001, d = 1.35), parent help-seeking intentions (β = 1.94, p = .017, d = 0.69), and child intrapersonal distress (β = - 3.93, p = 0.046, d = 0.58) were maintained at 6 months, while help-seeking intentions was not (β = 1.31, p = .222, d = 0.47). Though no changes were observed immediately post-class, caregivers reported significant increases in outpatient services use (β = - 1.51, p = .030, d = 0.68) and reductions in parenting stress (β = - 4.99, p = 0.009, d = 0.75) and overall child symptoms (β = - 19.67, p = 0.001, d = 0.90) at 6 month follow-up. These results suggest that many of the positive impacts of the NAMI Basics program are sustained 6 months after the intervention. Additionally, these results suggest that some positive outcomes of the program may not emerge until several months after taking the class. Implications and future directions are discussed.

Contextual determinants associated with children's and adolescents' mental health care utilization: a systematic review

Determinants at the contextual level are important for children's and adolescents' mental health care utilization, as this is the level where policy makers and care providers can intervene to improve access to and provision of care. The objective of this review was to summarize the evidence on contextual determinants associated with mental health care utilization in children and adolescents. A systematic literature search in five electronic databases was conducted in August 2021 and retrieved 6439 unique records. Based on eight inclusion criteria, 74 studies were included. Most studies were rated as high quality (79.7%) and adjusted for mental health problems (66.2%). The determinants that were identified were categorized into four levels: organizational, community, public policy or macro-environmental. There was evidence of a positive association between mental health care utilization and having access to a school-based health center, region of residence, living in an urban area, living in an area with high accessibility of mental health care, living in an area with high socio-economic status, having a mental health parity law, a mental health screening program, fee-for-service plan (compared to managed care plan), extension of health insurance coverage and collaboration between organizations providing care. For the other 35 determinants, only limited evidence was available. To conclude, this systematic review identifies ten contextual determinants of children's and adolescents' mental health care utilization, which can be influenced by policymakers and care providers. Implications and future directions for research are discussedPROSPERO ID: CRD42021276033.

Barriers and Facilitators for Mental Health Service Use Among Racial/Ethnic Minority Adolescents: A Systematic Review of Literature

Introduction: Mental disorders represent serious public health concerns in the U.S. Compared with Whites, racial/ethnic minority adolescents are more likely to be affected by mental disorders but less likely to use mental health services. This systematic review aimed to summarize factors related to mental health service use among minority adolescents in the U.S. as identified in previous research.

Methodology: Following the PRISMA guideline, we systematically searched seven databases for peer reviewed articles related to barriers and facilitators of mental health service use among racial/ethnic minority adolescents.

Results: Thirty-two quantitative studies met our inclusion criteria, among which 12 studies (37.5%) sampled mostly Blacks or African Americans, 6 studies (18.7%) focused primarily on Hispanics or Latin/a/x, including Mexican Americans and Puerto Ricans, and 4 studies (12.5%) were mostly Asian Americans (e.g., Chinese, Vietnamese). Based on the socio-ecological framework, 21 studies (65.6%) identified adolescent-related barriers and facilitators of mental health service use, including biological (e.g., age, gender), clinical (e.g., symptom severity), behavioral (e.g., drug/alcohol use), and psychological characteristics (e.g., internal asset) of minority youth. Ten studies (31.3%) identified parents-related factors that influenced minority adolescent mental health service use, including parental perceptions and beliefs, family and parenting issues, and demographic characteristics. Primary factors at the therapist level included ethnic match between patient and practitioner, relationship with healthcare practitioners, and patient-therapist co-endorsement of etiological beliefs. Fifteen studies (46.9%) identified factors influencing minority adolescent mental health service use at the contextual/structural level, including household income, insurance status, and family structure. Lastly, acculturation and school experiences were major factors at the social/cultural level that influence minority adolescent service use.

Conclusion: More empirical studies are needed to understand the mechanism underlying minority adolescents' unmet mental health service needs. Culturally competent interventions are warranted to engage minority adolescents with mental disorders into treatment.

Expectations of barriers to psychosocial care: views of parents and adolescents in the community

Parents with a child suffering from psychosocial problems frequently experience barriers to psychosocial care, which may hinder access. Expectations of barriers may have the same effect, but evidence is lacking. The aim of this study is to examine parents' and adolescents' expectations of barriers regarding psychosocial care for the child, along with associated child and family characteristics. We obtained data on an age-stratified random sample of school children/pupils aged 4-18 via questionnaires (N = 666; response rate 70.3 %). Expectations of barriers to psychosocial care were measured with the "Barriers to Treatment Participation Scale-Expectancies" questionnaire (BTPS-exp). Results showed that 64 % of the parents of children below age 12, 59 % of the parents of adolescents (age 12-18), and 84 % of the adolescents expected one or more barriers. Parents and adolescents expected barriers most frequently with respect to irrelevance of treatment. Mainly parents with low educational level and their adolescents expected barriers regarding treatment, and quite a few characteristics of parents of adolescents were associated with expecting multiple barriers regarding treatment demands and issues, for example, single parents, parents of lower educational level and of adolescent boys, and parents of adolescents with psychosocial problems. We conclude that adolescents especially, but also their parents and parents of younger children, expect major barriers to psychosocial care, which may greatly hinder appropriate care seeking. This evidence may support professionals and policymakers in their attempts to improve access to psychosocial care.

Genetic moderation of child maltreatment effects on depression and internalizing symptoms by serotonin transporter linked polymorphic region (5-HTTLPR), brain-derived neurotrophic factor (BDNF), norepinephrine transporter (NET), and corticotropin releasing hormone receptor 1 (CRHR1) genes in African American children

Genetic moderation of the effects of child maltreatment on depression and internalizing symptoms was investigated in a sample of low-income maltreated and nonmaltreated African American children (N = 1,096). Lifetime child maltreatment experiences were independently coded from Child Protective Services records and maternal report. Child depression and internalizing problems were assessed in the context of a summer research camp by self-report on the Children's Depression Inventory and adult counselor report on the Teacher Report Form. DNA was obtained from buccal cell or saliva samples and genotyped for polymorphisms of the following genes: serotonin transporter linked polymorphic region (5-HTTLPR), brain-derived neurotrophic factor (BDNF), norepinephrine transporter, and corticotropin releasing hormone receptor 1. Analyses of covariance with age and gender as covariates were conducted, with maltreatment status and respective polymorphism as main effects and their Gene × Environment (G × E) interactions. Maltreatment consistently was associated with higher Children's Depression Inventory and Teacher Report Form symptoms. The results for child self-report symptoms indicated a G × E interaction for BDNF and maltreatment. In addition, BDNF and triallelic 5-HTTLPR interacted with child maltreatment in a G × G × E interaction. Analyses for counselor report of child anxiety/depression symptoms on the Teacher Report Form indicated moderation of child maltreatment effects by triallelic 5-HTTLPR. These effects were elaborated based on variation in developmental timing of maltreatment experiences. Norepinephrine transporter was found to further moderate the G × E interaction of 5-HTTLPR and maltreatment status, revealing a G × G × E interaction. This G × G × E was extended by consideration of variation in maltreatment subtype experiences. Finally, G × G × E effects were observed for the co-action of BDNF and the corticotropin releasing hormone receptor 1 haplotype. The findings illustrate the variable influence of specific genotypes in G × E interactions based on variation in maltreatment experiences and the importance of a multigenic approach for understanding influences on depression and internalizing symptoms among African American children.

Racial/ethnic differences in parent-reported barriers to accessing children's health services

The goals of this study were to identify whether barriers that parents perceived to using health care differed by service type (medical vs. mental health care) and whether there were racial/ethnic differences in barriers. Participants were a community sample of 275 parents (34.2% African American, 36.7% Caucasian, and 29.1% Hispanic) of children ages 9-13 years old who rated the extent to which potential barriers in 3 broad domains (stigma-related, logistical, and socioeconomic) would prevent or delay them from obtaining services. They also rated internalizing and externalizing problems exhibited by their child. Overall, parents reported greater socioeconomic and stigma-related barriers to obtaining mental health services than medical services. Hispanic parents reported socioeconomic and stigma-related barriers as more inhibiting than did African-American parents. Findings highlight the importance of strengthening relationships between mental health care providers and the community to reduce the stigma associated with seeking mental health treatment for children and better educating parents about the potential benefits of treatment. Policy focused on educating parents about their insurance options and improving insurance coverage may help to reduce socioeconomic barriers.

Discrepancy between parents and children in reporting of distress and impairment: Association with critical symptoms

BACKGROUND

We examined discrepant parent-child reports of subjective distress and psychosocial impairment.

METHOD

Parent-child pairs (N = 112 pairs) completed the Health Dynamics Inventory at intake for outpatient therapy.

RESULTS

Average parent scores were significantly higher than average child scores on distress, impairment, and externalizing symptoms, but not internalizing symptoms. There were significant associations between parent-child discrepancy (i.e. children who reported greater distress or impairment than parents or vice versa) and child endorsement of several notable symptoms (rapid mood swings, panic, nightmares, and suicidal ideation).

CONCLUSION

Parents tended to report more externalizing symptoms, distress, and impairment than children reported; however, when children report more distress and impairment than parents, this may indicate serious psychological problems.

Why underserved patients do not consult their general practitioner for depression: results of a qualitative and a quantitative survey at a free outpatient clinic in Paris, France

BACKGROUND

The prevalence of depression in the general population is 5 to 10% but can exceed 50% in the most socially vulnerable populations. The perceptions of this disease are widely described in the literature, but no research has been carried out in France to explain the reasons for not consulting a general practitioner during a depressive episode, particularly in people in the most precarious situations. The objective of this study was to describe the reasons for not seeking primary care during a depressive episode in a socially vulnerable population.

METHODS

An exploratory sequential design with a preliminary qualitative study using a phenomenological approach. Subsequently, themes that emerged from the qualitative analysis were used in a questionnaire administered in a cross-sectional observational study at a free outpatient clinic in Paris in 2010. Lastly, a logistic regression analysis was performed.

RESULTS

The qualitative analysis revealed four aspects that explain the non-consulting of a general practitioner during a depressive episode: the negative perception of treatment, the negative perception of the disease, the importance of the social environment, and the doctor-patient relationship. The quantitative analysis showed that close to 60% of the patients who visited the free clinic were depressed and that only half of them had talked with a care provider. The results of the statistical analysis are in line with those of the qualitative analysis, since the most common reasons for not seeing a general practitioner were the negative perception of the disease (especially among the men and foreigners) and its treatments (more often among the men and French nationals).

CONCLUSIONS

Close to 50% of the depressed individuals did not seek primary care during a depressive episode, and close to 80% of them would have liked their mental health to be discussed more often by a health professional. Better information on depression and its treatments, and more-systematic screening by primary care personnel would improve the treatment of depressed patients, especially those in the most precarious situations.

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.

Racial/ethnic disparities in chronic diseases of youths and access to health care in the United States

Racial/ethnic minorities are 1.5 to 2.0 times more likely than whites to have most of the major chronic diseases. Chronic diseases are also more common in the poor than the nonpoor and this association is frequently mediated by race/ethnicity. Specifically, children are disproportionately affected by racial/ethnic health disparities. Between 1960 and 2005 the percentage of children with a chronic disease in the United States almost quadrupled with racial/ethnic minority youth having higher likelihood for these diseases. The most common major chronic diseases of youth in the United States are asthma, diabetes mellitus, obesity, hypertension, dental disease, attention-deficit/hyperactivity disorder, mental illness, cancers, sickle-cell anemia, cystic fibrosis, and a variety of genetic and other birth defects. This review will focus on the psychosocial rather than biological factors that play important roles in the etiology and subsequent solutions to these health disparities because they should be avoidable and they are inherently unjust. Finally, this review examines access to health services by focusing on health insurance and dental insurance coverage and access to school health services.

African American families' expectations and intentions for mental health services

A cross-sectional qualitative descriptive design was used to examine the links among expectations about, experiences with, and intentions toward mental health services. Individual face-to-face interviews were conducted with a purposive sample of 32 African American youth/mothers dyads. Content analysis revealed that positive expectations were linked to positive experiences and intentions, that negative expectations were not consistently linked to negative experiences or intentions, nor were ambivalent expectations linked to ambivalent experiences or intentions. Youth were concerned about privacy breeches and mothers about the harmfulness of psychotropic medication. Addressing these concerns may promote African Americans' engagement in mental health services.

Race/ethnicity, parent-identified emotional difficulties, and mental health visits among California children

Variability in mental health services utilization by race/ethnicity was evaluated with a Behavioral Model approach. Subjects were 17,705 children 5 to 11 years of age in the 2005, 2007, and 2009 California Health Interview Surveys. Parents identified minor emotional difficulties in 18.7% of these children (ranging from 14.8% in Asians to 24.4% in African Americans) and definite or severe difficulties in 7.4% (5.5% in Asians to 9.7% in "other race"). Overall, 7.6% of children had at least one mental health visit in the prior year (2.3% in Asians to 11.2% in African Americans). Parent-identified need was the most salient predictor of mental health visits for all racial/ethnic groups. Beyond need, no consistent patterns could be determined across racial/ethnic groups with regard to the relationship between contextual, predisposing, and enabling measures and mental health service utilization. Different factors operated for each racial/ethnic group, suggesting the need for studies to examine mental health need, mental health service use, and determinants by racial/ethnic subgroup. These findings suggest that a "one-size-fits-all approach" with regard to policies and practices aimed at reducing mental health disparities will not be effective for all racial/ethnic groups.

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.

Are two voices better than one? Predicting permanency in minority youth using multi-informant mental health and strength data

Among youth in child welfare ages 6-17 years, 40 % meet the criteria for one or more DSM diagnoses. For minority youth in child welfare, poor mental health is compounded by limited access to care and racial disparity bias, leading to poorer outcomes. This paper uses data collected and analyzed by an automated behavioral health assessment system for a multiyear study that focused on ways to improve case planning in child welfare. Youth, their caseworkers, and, in some cases, parents completed assessments that measured and monitored the youths' needs and strengths. More than 60 % of youth participating in the study were African-American; permanency rates after six months of case planning were found to be only one third. Predictive factors related to better behavioral health and permanency outcomes are identified and discussed, as well as the implications for improving case planning by incorporating the views of multiple informants, including the youth.

Racial and ethnic disparities in pediatric mental health

Disparities remain in mental health status and care for racial and ethnic minority youth, despite national attention to disparity reduction. This article offers a comprehensive picture of the status of pediatric disparities, by addressing the major areas affecting minority youth mental health, including: prevention of problems, need for services, access to care, mental health treatment types, and treatment outcomes. The authors address relevant factors in the family, community and socioeconomic context, and describe various local and national programs that aim to tackle the obstacles and fill the gaps in high-quality care for racial/ethnic minority youth. The article concludes by offering recommendations for improvement that acknowledge the importance of understanding preferences and attitudes toward treatment, ensuring that screening and diagnosis is appropriate to minority youth, and ensuring that evidence-based programs are available at multiple levels to best service children and succeed in addressing their needs.

Short sleep duration as a risk factor for hypercholesterolemia: analyses of the National Longitudinal Study of Adolescent Health

STUDY OBJECTIVES

To explore the relationship between sleep duration in adolescence and hypercholesterolemia in young adulthood. Experimental sleep restriction has been shown to significantly increase total cholesterol and LDL cholesterol levels in women. Short sleep duration has been found in cross sectional studies to be associated with higher total cholesterol and lower HDL cholesterol levels. Sleep deprivation could increase the risk for hypercholesterolemia by increasing appetite and dietary consumption of saturated fats, decreasing motivation to engage in regular physical activity, and increasing stress and resultant catecholamine induced lipolysis. No previous published population studies have examined the longitudinal relationship between sleep duration and high cholesterol.

DESIGN

Multivariate longitudinal analyses stratified by sex of the ADD Health using logistic regression.

SETTING

United States nationally representative, school-based, probability-based sample.

PARTICIPANTS

Adolescents (n = 14,257) in grades 7 to 12 at baseline (1994-95) and ages 18 to 26 at follow-up (2001-02).

MEASUREMENTS AND RESULTS

Among females, each additional hour of sleep was associated with a significantly decreased odds of being diagnosed with high cholesterol in young adulthood (OR = 0.85, 95% CI 0.75-0.96) after controlling for covariates. Additional sleep was associated with decreased, yet not statistically significant, odds ratios for hypercholesterolemia in males (OR = 0.91, 95% CI 0.79-1.05).

CONCLUSIONS

Short sleep durations in adolescent women could be a significant risk factor for high cholesterol. Interventions that lengthen sleep could potentially serve as treatments and as primary preventative measures for hypercholesterolemia.

Social determinants of mental health treatment among Haitian, African American, and White youth in community health centers

We examine adequate mental health treatment, emergency room (ER) use, and early treatment dropout for Haitian, African American and White youth with a psychiatric diagnosis treated in community health centers in the United States. We present associations with possible socioeconomic determinants of care. Adequate treatment was less likely among Haitian youth from areas with greater poverty and among all youth from areas with more female-headed households. Medicaid-insured youth had more ER visits, especially African Americans. The relative impact of poverty on adequate care was higher for Haitians than Whites, and the relative impact of Medicaid coverage on ER use was higher for African Americans than for Whites. Early dropout was more likely among youth who were uninsured or from areas with more female-headed households. Socioeconomic factors and insurance status were significant determinants of care. Haitians living in poverty in the U.S. may face barriers to mental health services relative to other racial/ethnic groups.

Assessing racial/ethnic differences in the social consequences of early-onset psychiatric disorder

Individuals with early onset of psychiatric disorder have worse social outcomes than individuals with adult onset. It is unknown whether this association varies by racial/ ethnic group. Identifying groups at risk for poor social outcomes is important for improving clinical and policy interventions. We compared unemployment, high school dropout, arrest, and welfare participation by race/ethnicity and time of onset using a nationally representative sample of Whites, Blacks, Asians, and Latinos with lifetime psychiatric disorder. Early onset was associated with worse social outcomes than adult onset. Significant Black-White and Latino-White differences in social outcomes were identified. The association between early onset and negative social outcomes was similar across Whites, Latinos, and Blacks. For Asians, the association between unemployment and early onset was opposite that of Whites. Increasing early detection and treatment of psychiatric illness should be prioritized. Further study will clarify the association between onset and social outcomes among sub-ethnic populations.

Behavioral predictors of mental health service utilization in childhood through adolescence

OBJECTIVES

This study investigated predictors of mental health service utilization from age 5 through age 16.

METHODS

Data were collected on a community sample of 399 children, including 338 European Americans and 61 African Americans. Internalizing and externalizing behaviors were assessed by maternal and teacher reports in kindergarten. History of mental health service utilization was assessed by maternal reports when participants were 16 years old.

RESULTS

On average, the probability of first-time mental health service utilization increased in early to middle childhood, stabilized, and then increased in early adolescence. Mother reports of internalizing behaviors (independent of teacher reports of externalizing behaviors) predicted an increased likelihood of service use among European American children but a decreased likelihood of service use among African American children. Externalizing behaviors (independent of internalizing behaviors) predicted a higher likelihood of first-time service use in middle childhood. The combination of elevated internalizing and externalizing behaviors predicted a higher likelihood of first-time service use in adolescence, mainly among European American children.

CONCLUSIONS

This study provides evidence that elevated mother-reported internalizing behaviors are less likely to forecast mental health service utilization among African American children compared with European American children. To meet the mental health service needs of all children, it is critical to further examine reasons for service utilization and underutilization among children with internalizing problems.

Association between bullying victimization and physical fighting among Filipino adolescents: results from the Global School-Based Health Survey

OBJECTIVE

Interpersonal violence is an important, but neglected public health issue in low and middle-income countries. Adolescent physical fighting not only results in injury, disability and death, but is also associated with other potentially harmful behaviors such substance use and premarital sex. The study aims at dose-response association to prevent adolescent problem behaviors.

METHODS

We used data from the 2003-2004 Global School-Based Health Survey conducted among school adolescents in the Philippines. We estimated the prevalence of bullying victimization and physical fighting. We also conducted logistic regression analysis to assess the association between a selected list of explanatory variables and physical fighting. We hypothesized that there would be a dose-response relationship between physical fighting and number of times the adolescent reported being bullied in the past 30 days.

RESULTS

Of the 7,338 respondents, 35.5% (34.7% males and 36.1% females) were bullied and 50.0% (51.6% males and 48.8% females) reported having been in a physical fight in the past 12 months. There was a dose-response relationship between bullying victimization and physical fighting (p-trend <0.001). Compared to subjects who were not bullied, those who reported being bullied were more likely to engage in physical fighting after controlling for age, gender, substance use (smoking, alcohol drinking or drug use), and parental supervision (OR=2.38; 95% CI [1.99, 2.86] for 1-2 days of bullying victimization per month, OR=3.55; 95% CI [2.61, 4.83]) for 3-5 days/month per month, OR=4.45; 95% CI [2.61, 7.60]) for 6-9 days/ month, OR=1.91; 95% CI [1.17, 3.13]) for 10-30 days/month.)

CONCLUSION

The dose-response relationship between physical fighting and the number of times an adolescent had been a victim of bullying deserves further study. If causal relationship exists, preventing bullying, even if not totally eliminated, may have significant results in preventing physical fighting.

Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern

PURPOSE

To examine risk characteristics associated with citing confidentiality concern as a reason for forgone health care, among a sample of U.S. adolescents who reported having forgone health care they believed was necessary in the past year.

METHODS

The study used data from Wave I home interviews of the National Longitudinal Study of Adolescent Health. The generalized estimating equations method was used to account for the clustered nature of the data.

RESULTS

Prevalence of several risk characteristics was significantly higher among boys and girls who reported confidentiality concern, as compared with those who did not report this concern. Regression analyses for boys (n = 1123), which adjusted for age, race/ethnicity, parental education and insurance type showed that high depressive symptoms, suicidal ideation, and suicide attempt were each associated with increased odds of reporting confidentiality concern as a reason for forgone health care. In multivariate analyses for girls (n = 1315), having ever had sexual intercourse, birth control nonuse at last sex, prior sexually transmitted infection, past-year alcohol use, high and moderate depressive symptoms, suicidal ideation, suicide attempt, and unsatisfactory parental communication were each associated with increased odds of citing confidentiality concern as a reason for forgone care.

CONCLUSION

The population of U.S. adolescents who forgo health care due to confidentiality concern is particularly vulnerable and in need of health care services. Adolescents who report health risk behaviors, psychological distress and/or unsatisfactory communication with parents have an increased likelihood of citing confidentiality concern as a reason for forgone health care, as compared with adolescents who do not report these factors. Findings of this study suggest that if restrictions to confidentiality are increased, health care use may decrease among adolescents at high risk of adverse health outcomes.

Factors Associated with Mental Health Service Need and Utilization among Unaccompanied Refugee Adolescents

This study is the first to address the need for mental health Care (MHC) and the patterns of utilization of MHC services among Unaccompanied Refugee Minors (URM). Information concerning the well being, mental health need, and utilization of services of URM was collected from three informants, the minors themselves (n = 920), their legal guardians (n = 557), and their teachers (n = 496). The well-being, need and utilization of MHC services of URM was compared with those of a representative Dutch adolescent sample (n = 1059). The findings of this study indicated that URM that report a mental health care need (57.8%) also report higher levels of emotional distress than Dutch adolescents who report a similar need for MHC (8.2%). In addition, guardians and teachers detect emotional distress and mental health care needs in only a small percentage (30%) of URM. The referral of URM to mental health care services does not appear to be driven by the reported needs of the URM, but by the need and emotional distress as observed and perceived by guardians. This resulted in the fact that 48.7% of the URM total sample reported that their need for mental health care was unmet.

The premature demise of public child and adolescent inpatient psychiatric beds : Part II: challenges and implications

Psychiatric disorders are the leading reason for hospitalization among 5-19 year olds. Current data, however, suggest there are fewer than necessary available services for children and adolescents requiring intensive, inpatient psychiatric care. Children and adolescents with behavioral health problems, the majority of whom do not receive appropriate treatment, have increased risk of school failure, family disruption, out-of-home placements, poor employment opportunities, and poverty in adulthood. This paper will examine the challenges inherent in serving children and adolescents with serious emotional disturbances, avenues of financing for treatment and services, and various loci of intervention for high-risk children, including inpatient settings and systems of care. The goals of this paper are to illustrate the complexities of working with children and adolescents most in need of intensive psychiatric services, to explore how inpatient services "fit" into existing treatment approaches, and to discuss the efficacy of downsizing or closing inpatient psychiatric units for this population.