Behavioral predictors of mental health service utilization in childhood through adolescence

Psychosocial Competencies Among Clinic-Referred and Community-Based Children: Known-Groups Validity of the Psychosocial Strengths Inventory for Children and Adolescents (PSICA)

Child psychosocial competencies protect against the development of psychopathology, ameliorate existing psychosocial problems, and predict positive long-term developmental cascades. Assessment of these competencies can improve identification of children in need of psychosocial services, enrich treatment planning, and improve treatment progress and outcome monitoring. Yet, appropriate measures are limited. One promising option is the Psychosocial Strengths Inventory for Children and Adolescents (PSICA), although its discriminative properties were formerly unknown. The present study evaluated the PSICA's sensitivity, specificity, and optimal cutoff scores with 228 youth (38 clinic-referred and 190 community-based youth with case-control matching) ages 2-10 years (Mage = 5.8, 71% boys, 77% White). Results indicated large, significant discrepancies, with clinic-referred youth rated as having less overall psychosocial competence overall and across domains of compliance, prosociality, and attention. Caregivers also reported significantly less satisfaction with the psychosocial competence of clinic-referred versus community youth. Discriminative accuracy of the PSICA's Frequency and Satisfaction scales, and its subscales, were good-to-excellent. Such discriminative accuracy and empirically derived, if preliminary, cutoff scores further support the PSICA as a pragmatic, psychometrically strong tool to screen children for referral into services, and potentiate future investigations into the PSICA's use in treatment planning and evaluation.

Teacher-reported emotional and behavioural problems and ethnic background associated with children's psychosocial care use: a longitudinal population-based study

Approximately, 15% of children in Western countries suffer from emotional and behavioural problems. However, not all children receive the psychosocial care they need, especially children with a non-Western background experience an unmet need for care. This might be because parents of non-Western children report a lower need for care than parents of Western children, unrelated to the actual need. This study examined the association between teacher-reported problems and psychosocial care use, independent of mother-reported problems. Further, the role of ethnic background in this association was investigated. The study sample of 9-year-old children was retrieved from the Generation R Study (N = 3084), a prospective, population-based cohort of children born in Rotterdam, the Netherlands. Teacher- and mother-reported problems were measured via questionnaire when the children were  6/7 years old. Psychosocial care use was mother-reported at the research centre when children were 9 years old (8.1%). Hierarchical logistic regressions showed significant positive associations between teacher-reported total, externalising and internalising problems and later psychosocial care use. These associations were independent of mother-reported problems. Children with a non-Western background used less care, but ethnic background did not moderate the association between teacher-reported problems and care use. Our findings suggest that teachers might have an important role, next to parents, in the identification of problems and children's access to care. This may be particularly important for non-Western children, as they use less psychosocial care than Western children, despite other research showing that they generally display higher levels of problems. Directions for future research and implications are discussed.

School Disengagement and Mental Health Service Intensity Need Among Clinically Referred Students Utilizing the interRAI Child and Youth Mental Health Assessment Instrument

Although mental health challenges are widespread, impacting 1 in 5 children and youth, only 25% of these young people receive the required mental health supports. Unmet mental health needs are strongly associated with functional impairments including poor self-care, interpersonal challenges, and school difficulties among young people. School disengagement, or a student's lack of involvement in education through interest, curiosity, motivation, and active participation, is associated with a wide array of detrimental outcomes including chronic mental health difficulties, conduct and delinquent behaviors, criminal justice involvement, and unemployment in adolescence and adulthood. Disengagement observed within the school setting may be indicative of underlying mental health challenges and reflective of service intensity need. The current study extends the literature by examining the relationship between school disengagement and mental health service intensity need among 14,750 clinically referred students across elementary and secondary school utilizing the interRAI Child and Youth Mental Health instrument. Findings indicated that more than 25% of clinically referred students were at heighted risk for school disengagement and required high-intensity services. Further, mental health service intensity need was positively associated with risk of school disengagement among students, along with the specific reason for referral (i.e., psychiatric symptoms, harm to self, harm to others, or addiction or dependency), after controlling for sex and age. Implications of the findings are explored within the context of the school setting and future directions are suggested.

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.

Trajectories of Mental Health-Related Service Use Among Adolescents With Histories of Early Externalizing Problems

PURPOSE

To inform efforts to reduce costly service utilization, the present study examined longitudinal trajectories of mental health-related outpatient and residential service use among at-risk youth with a history of early externalizing problems.

METHODS

A cohort of 809 children in the Fast Track Project, a multisite longitudinal study of children at risk for conduct disorder, were followed prospectively from kindergarten through 12th grade. They resided in high-risk areas with high rates of poverty, crime, and violence. Their outpatient and residential service use was assessed annually between sixth and 12th grades through parent report. Growth mixture modeling was applied to model individual differences in trajectories of service use during this period. Teacher, parent, and observer-reported childhood predictors of those trajectories were also examined.

RESULTS

Most youths had minimal service use during preadolescence into adolescence. However, approximately 31% had moderate probability of using outpatient counseling services, and approximately 8% had elevated probability of seeing a family doctor for mental health needs. For residential services, approximately 6% had moderate to high probability of service use that peaked during transition to high school, whereas close to 5% had service use that dramatically increased during high school. Childhood predictors of these trajectories included earlier externalizing, internalizing, and emotion regulation problems.

CONCLUSIONS

This study is the first to use person-centered analytic methods to examine longitudinal trajectories in mental health-related service use among at-risk adolescents. Timely treatment for severe externalizing problems, comorbid internalizing problems, and emotion dysregulation during childhood may be crucial for preventing chronic service use.

How Does the Fast Track Intervention Prevent Adverse Outcomes in Young Adulthood?

Numerous studies have shown that childhood interventions can foster improved outcomes in adulthood. Less well understood is precisely how-that is, through which developmental pathways-these interventions work. This study assesses mechanisms by which the Fast Track project (n = 891), a randomized intervention in the early 1990s for high-risk children in four communities (Durham, NC; Nashville, TN; rural PA; and Seattle, WA), reduced delinquency, arrests, and general and mental health service utilization in adolescence through young adulthood (ages 12-20). A decomposition of treatment effects indicates that about a third of Fast Track's impact on later crime outcomes can be accounted for by improvements in social and self-regulation skills during childhood (ages 6-11), such as prosocial behavior, emotion regulation, and problem solving. These skills proved less valuable for the prevention of general and mental health problems.

Why wait? The effect of wait-times on subsequent help-seeking among families looking for children's mental health services

Placement on a wait-list may increase families' help-seeking efforts, leading them to contact more than one children's mental health (MH) agency/professional. Two issues were examined in the current study: 1) Does time on a wait-list for families impact the time to contact a new agency for children's MH services? 2) What are the effects of predisposing (e.g., child age), need (e.g., child psychopathology), and enabling/system-level factors (e.g., parent treatment history) on the length of time parents wait before they contact a new agency for help with their child's MH problems? A total of 273 families seeking help for their child (64% boys, M = 10.7 years old, SD = 3.3) were asked about their contact with MH agencies/professionals during the previous year. Survival analyses, modeling time from initial wait-list placement to when a new agency was contacted, were conducted separately for families who did (n = 114), and those who did not (n = 159), receive help prior to contacting a new agency. Almost half of wait-listed families contacted a new agency by the end of the study period. Longer wait-time was associated with a greater likelihood of seeking help at a second agency with 25% of families contacting a new agency within the first month of being wait-listed. Parents with previous treatment experience and families living in areas with more agencies contacted a new agency sooner. Subsequent help-seeking behaviour suggests parents' intolerance for lengthy treatment delays may result in disorganized pathways to care. These findings suggest a highly fragmented service delivery system.

Mental Health Utilization Among Diverse Parenting Young Couples

Mental health issues often become apparent as adolescents emerge into young adulthood. The use of mental health services is low among adolescents and young adults, and use is particularly low among minorities. In this study, we examine mental health utilization among diverse young parenting couples. The sample consisted of 296 couples. We used the social-personal framework to examine personal, family, partner relationship, and environmental predictors for using mental health services. We used the Actor-Partner Interdependence Model to assess actor and partner effects on mental health utilization. We also examined moderator effects for gender and internalizing and externalizing behaviors. We found that being female, being White, higher income, more conduct problems, and less anxious romantic attachment predicted mental health utilization. Significant moderator effects included depression × gender, depression × medical insurance, and stress × Latino. Implications for community mental health practice include conducting mental health assessments during medical visits and systematic mental health follow-up for individuals and couples with identified mental health and support needs. Future research should include married couples and the spouse's influence on mental health use and examine relevant parenting factors that may also predict mental health utilization among couples.

Trends in mental health care among children and adolescents

BACKGROUND

Increasing mental health treatment of young people and broadening conceptualizations of psychopathology have triggered concerns about a disproportionate increase in the treatment of youths with low levels of mental health impairment.

METHODS

We analyzed the 1996-1998, 2003-2005, and 2010-2012 Medical Expenditure Panel Surveys, which were nationally representative surveys of U.S. households, for trends in outpatient use of mental health services by persons 6 to 17 years of age; 53,622 persons were included in the analysis. Mental health impairment was measured with the use of the Columbia Impairment Scale (range, 0 to 52, with higher scores indicating more severe impairment); we classified youths with scores of 16 or higher as having more severe impairment and those with scores of less than 16 as having less severe impairment.

RESULTS

The percentage of youths receiving any outpatient mental health service increased from 9.2% in 1996-1998 to 13.3% in 2010-2012 (odds ratio, 1.52; 95% confidence interval, 1.35 to 1.72). The proportionate increase in the use of mental health services among youths with more severe impairment (from 26.2% to 43.9%) was larger than that among youths with less severe or no impairment (from 6.7% to 9.6%). However, the absolute increase in annual service use was larger among youths with less severe or no impairment (from 2.74 million to 4.19 million) than among those with more severe impairment (from 1.56 million to 2.28 million). Significant overall increases occurred in the use of psychotherapy (from 4.2% to 6.0%) and psychotropic medications (from 5.5% to 8.9%), including stimulants and related medications (from 4.0% to 6.6%), antidepressants (from 1.5% to 2.6%), and antipsychotic drugs (from 0.2% to 1.2%).

CONCLUSIONS

Outpatient mental health treatment and psychotropic-medication use in children and adolescents increased in the United States between 1996-1998 and 2010-2012. Although youths with less severe or no impairment accounted for most of the absolute increase in service use, youths with more severe impairment had the greatest relative increase in use, yet fewer than half accessed services in 2010-2012. (Funded by the Agency for Healthcare Research and Quality and the New York State Psychiatric Institute.).

Social discomfort in preadolescence: predictors of discrepancies between preadolescents and their parents and teachers

The present study investigated whether salient preadolescent behaviors and experiences predicted parents' and teachers' underestimation of preadolescents' shyness. Participants included a community sample of 129 fifth and sixth graders, along with one parent and teacher per preadolescent. Preadolescents, parents, and teachers provided reports about preadolescents' shyness, and parents and teachers rated preadolescents' prosocial and aggressive behaviors, peer victimization experiences, and academic performance. Results indicated that parent- and teacher-reported prosocial behavior, teacher-reported aggressive behavior, and parent-reported peer victimization were associated with lower parent and teacher reports of preadolescent shyness, relative to preadolescent reports, controlling for demographic variables and parent stress. Additionally, higher parent-reported academic performance was associated with lower teacher reports of preadolescent shyness, compared to preadolescent reports. These findings suggest that preadolescents with higher levels of relatively conspicuous behaviors and experiences feel more shyness than their parents and teachers report.

Serial pediatric symptom checklist screening in children with prenatal drug exposure

OBJECTIVE

To examine screening results obtained by serial annual behavioral assessment of children with prenatal drug exposure.

METHOD

The Maternal Lifestyle Study enrolled children with prenatal cocaine exposure (PCE) at birth for longitudinal assessments of developmental, behavioral, and health outcomes. At 8, 9, 10, 11, and 12 years of age, caregivers rated participants on the Pediatric Symptom Checklist (PSC). Serial PSC results were compared with an established broad-based behavioral measure at 9, 11, and 13 years. PSC results were analyzed for 1081 children who had at least 2 annual screens during the 5-year time span. Most subjects (87%) had 4 or more annual screens rated by the same caregiver (80%). PSC scores (and Positive screens) over time were compared at different time points for those with and without PCE. Covariates, including demographic factors and exposures to certain other substances, were controlled.

RESULTS

Children with PCE had significantly higher scores overall, with more Positive screens for behavior problems than children without PCE. Children with PCE had more externalizing behavior problems. Children exposed to tobacco prenatally and postnatally also showed higher PSC scores. Over time, PSC scores differed slightly from the 8-year scores, without clear directional trend. Earlier PSC results predicted later behavioral outcomes.

CONCLUSION

Findings of increased total PSC scores and Positive PSC screens for behavioral concerns in this group of children with prenatal substance exposure support the growing body of evidence that additional attention to identification of mental health problems may be warranted in this high-risk group.