Demographic factors in the use of children's mental health services

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.

Are Parents the Key? How Parental Suicide Stigma and Suicide Literacy Affect Help-Seeking Attitudes and Intentions for their Child

Suicide is the leading cause of death among Australian young people, yet rates of help-seeking for suicidal ideation and behaviors in this population are concerningly low. In this study, the relationships between parental suicide stigma, parental suicide literacy, and their attitudes and intentions toward seeking professional help for their child if they were to express thoughts of suicide are investigated. Understanding this influence is critical given parents are key facilitators of their child's access to and engagement with professional mental health services. An online survey was administered to 302 parents of children aged-12-18 (Mage = 45.36, SDage = 6.23; 91.4% female). Parental suicide stigma was significantly associated with more negative help-seeking attitudes and lower help-seeking intentions. Other significant predictors of more positive help-seeking attitudes included parental self-efficacy and having a child with no history of suicidal ideation. Higher help-seeking intentions were associated with female gender, living in an urban area, and positive help-seeking attitudes. Parental suicide literacy was not significantly associated with help-seeking. Practically, outcomes of this study may inform the development and implementation of targeted education programs to increase parental help-seeking for their children.

Treatment Engagement in Adolescents: The Associations of Sociodemographic Characteristics, Caregiver Perceived Barriers, and Clinical Impairment

OBJECTIVE

To examine the associations between sociodemographic characteristics, perceived barriers to treatment, clinical impairment, and youth treatment engagement.

METHOD

Participants included 196 families (youth: ages 12 to 18; 64.3% cis-gender female; 23.5% Black, 60.7% White, and 12.2% Mixed/Other race; 41.3% Hispanic or Latinx ethnicity) recruited as part of a comparative effectiveness trial for adolescent anxiety and depression. Self-report measures of sociodemographic characteristics and caregiver perceived barriers were completed at intake. Youth clinical impairment was assessed at baseline via clinical interview. Measures of engagement were collected throughout treatment, including initiation status, session attendance, and termination status. Relationships were examined using analyses of variances and hierarchal linear and logistic modeling.

RESULTS

Perceived barriers did not differ by sociodemographic characteristics. Greater perceived stressors and obstacles predicted fewer sessions attended and a lower likelihood of successful termination. Youth of caregivers with an advanced degree and those with caregivers who were employed part time attended more sessions and were more likely to initiate and terminate treatment successfully compared to youth with caregivers of a lower education level or student or unemployed status. At higher levels of youth clinical impairment, greater perceived treatment demands and issues predicted reduced likelihood of treatment initiation.

CONCLUSIONS

Perceived barriers, sociodemographic characteristics, and clinical impairment were all associated with levels of engagement in the treatment process. Baseline and continued assessment of perceived and experienced barriers to treatment may promote individualized strategies for families identified as at-risk for reduced engagement.

A cross-sectional examination of service complexity in youths with co-occurring autism spectrum disorder and psychiatric or medical diagnoses across service sectors

Introduction

Autism spectrum disorder (ASD) is a heterogeneous, life-long, and complex condition. Youth diagnosed with ASD require several supports addressing core symptoms associated with the disorder, but also those resulting from co-occurring mental and physical health conditions. As a result, their care is overseen by numerous professionals spanning various service sectors, but communication between sectors is hindered due to the absence of a standardized assessment system to identify and triage youth to services. A paucity of information surrounding this population's service use lingers and a siloed delivery system persists.

Methods

Using archival data collected from 1,020 youth between 12 and 18 years of age, this study explored service complexity among autistic youth with and without psychiatric and medical co-occurring conditions in Ontario, Canada. In doing so, a negative binomial regression was utilized to investigate which predisposing, enabling, and need variables were associated with service complexity.

Results

Results revealed that experiencing financial difficulties was not associated with service complexity. However, age, sex, caregiver distress, comorbidity, intellectual disability, and evaluated health status were significant predictors. More specifically, female youth and youth with distressed caregivers had greater mental health service complexity scores. Additionally, youth diagnosed with two or more conditions in addition to ASD who required longer durations of programming, controlling for other predictors, had greater mental health service complexity scores. Yet, youth with an intellectual disability had lower service complexity scores.

Discussion

Clinical implications of this study are discussed to inform future investments into mental health efforts for autistic youth.

The Child Mental Health Treatment Gap in an Urban Low-Income Setting: Multisectoral Service Use and Correlates

OBJECTIVE

To efficiently target capacity-building efforts for child mental health services in low- and middle-income countries (LMICs), it is critical to define how care is structured across sectors and individual-level factors.

METHODS

In a community-based sample of 1,408 children and adolescents (ages 6-15 years) from Itaboraí, Brazil, the authors assessed need and service use across four care systems (mental health specialty, health, welfare, and informal). Individual-level factors included child gender and age, maternal perception of child mental health need, paternal absence, maternal education, and maternal anxiety and depression.

RESULTS

The mental health treatment gap was 88%, with only 12% of children with psychiatric problems using mental health services. Children with mental health problems were more likely than those without these problems to use health and other sectors of care and to use services in more than one sector of care. Overall, 46% of the children with any clinical mental health problems and 31% of those with only internalizing problems were identified by their mothers as having a mental health need. Among those with clinical mental health problems, factors associated with mental health service use were being a boy and paternal absence but not mental health problem type or maternal awareness.

CONCLUSIONS

Closing the child mental health treatment gap in urban settings in LMICs where resources are scarce will likely require system-level changes, such as engagement of diverse service sectors of care. Interventions need to target increased maternal awareness about mental health problems and encourage provision of mental health services to girls.

The Main and Interactive Associations between Demographic Factors and Psychopathology and Treatment Utilization in Youth: A Test of Intersectionality in the ABCD Study

Demographic factors may be associated with youth psychopathology due to social-contextual factors that may also pose barriers to intervention. Further, in line with intersectionality theory, youth with multiple non-dominant identities may be most likely to experience psychopathology and face barriers to care. This study examined rates of parent-reported psychopathology and mental health treatment utilization as a function of several demographic characteristics (in isolation and in concert) in a population-based, demographically diverse sample of 11,875 9- to 10-year-old youth. Results indicated most consistently that lower SES was associated with greater rates of psychopathology and greater likelihood of treatment utilization; that Asian American youth (relative to all other racial groups) and Hispanic/Latinx (relative to non-Hispanic/Latinx) youth were less likely to have a history of psychopathology or to have utilized treatment; and that male youth had greater rates of lifetime Obsessive Compulsive Disorder (OCD) and Oppositional Defiant Disorder (ODD) and were more likely to have utilized treatment. There was more modest support for interactive effects between demographic factors on psychopathology, which are discussed. The present study provides some support for differential rates of parent-reported psychopathology and treatment utilization as a function of demographic identities in youth. Potential explanations for these differences (e.g., cultural differences in symptom presentation; underreporting of symptoms) are discussed.

Mobile Phone Intervention to Reduce Youth Suicide in Rural Communities: Field Test

BACKGROUND

Suicide is a leading cause of death among 10- to 19-year-olds in the United States, with 5% to 8% attempting suicide each year. Suicide risk rises significantly during early adolescence and is higher in rural and underserved communities. School-based universal prevention programs offer a promising way of reducing suicide by providing strategies for emotion regulation and encouraging help-seeking behaviors and youth-adult connectedness. However, such programs frequently run into difficulties in trying to engage a broad range of students. Text messaging is a dominant medium of communication among youths, and studies show both efficacy and uptake in text messaging interventions aimed at adolescents. Text-based interventions may, thus, offer a means for school-based universal prevention programs to engage adolescents who would otherwise be difficult to reach.

OBJECTIVE

We field tested Text4Strength, an automated, interactive text messaging intervention that seeks to reach a broad range of early adolescents in rural communities. Text4Strength extends Sources of Strength, a peer-led school suicide prevention program, by encouraging emotion regulation, help-seeking behaviors, and youth-adult connectedness in adolescents. The study tested the appeal and feasibility of Text4Strength and its potential to extend universal school-based suicide prevention.

METHODS

We field tested Text4Strength with 42 ninth-grade students. Over 9 weeks, students received 28 interactive message sequences across 9 categories (Sources of Strength introduction, positive friend, mentors, family support, healthy activities, generosity, spirituality, medical access, and emotion regulation strategies). The message sequences included games, requests for advice, questions about students' own experiences, and peer testimonial videos. We measured baseline mental health characteristics, frequency of replies, completion of sequences and video viewing, appeal to students, and their perception of having benefited from the program.

RESULTS

Of the 42 participating students, 38 (91%) responded to at least one sequence and 22 (52%) responded to more than a third of the sequences. The proportion of students who completed multistep sequences they had started ranged from 35% (6/17) to 100% (3/3 to 28/28), with responses dropping off when more than 4 replies were needed. With the exception of spirituality and generosity, each of the content areas generated at least a moderate number of student replies from both boys and girls. Students with higher and lower levels of risk and distress interacted with the sequences at similar rates. Contrary to expectations, few students watched videos. Students viewed the intervention as useful-even those who rarely responded to messages. More than 70% found the texts useful (3 items, n range 29-34) and 90% (36) agreed the program should be repeated.

CONCLUSIONS

Text4Strength offers a potentially engaging way to extend school-based interventions that promote protective factors for suicide. Text4Strength is ready to be revised, based on findings and student feedback from this field test, and rigorously tested for efficacy.

A Profile on Emergency Department Utilization in Adolescents and Young Adults with Autism Spectrum Disorders

There has been an increase in utilization of the Emergency Department (ED) in individuals with autism spectrum disorder (ASD) which may reflect a deficit of services (Green et al., Journal of the American Academy of Child and Adolescent Psychiatry 40(3):325-332, 2001; Gurney et al., Archives of Pediatric and Adolescent Medicine 160:825-830, 2006; Leichtman et al., American Journal of Orthopsyhciatry 72(2):227-235, 2001). The current study examined the rates of ED utilization between 2005 and 2013 in ASD youth 12- to 21-years-old. Adolescents with ASD accessed ED services four times as often as adolescents without ASD. Older adolescents and those living in rural areas showed a significant increase in ED visits over time. Post hoc analysis revealed increased ED utilization for females and behavioral health ED services over time. Better access to and greater understanding of services for adolescents with ASD is a critical need.

[The epidemiology of pharmacologically treated attention deficit hyperactivity disorder (ADHD) in the Region of Murcia, Spain: Differences by gender, age and location of residence]

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is the most frequent disorder in childhood and adolescence, and is seen as a public health problem. The recommended treatment includes pharmacological and psychosocial treatment. The aim of this work was to study the changes in the prescribing of the medicines used in ADHD treatment in the Region of Murcia, as well as their socio-demographic variability.

METHOD

A retrospective observational study was conducted using the dispensing of medicines for ADHD treatment by means of prescription in the Region of Murcia from 2010 to 2014. The consumption rates were determined as defined daily doses (DDD) per thousand inhabitants/day (DHD), stratified by gender and age. The reasons for prevalence of treatment by gender were also determined by comparing male and female consumption rates.

RESULTS

The consumption of medicines for ADHD treatment had almost doubled in the period studied, from 5.58 DHD and 3.39 DHD in 2010 to 9.34 DHD and 6.71 DHD in 2014, for the age range of 10-14 and 15-19, respectively. Boys from 10-14 showed the highest consumption rates, showing a high geographical variability with less consumption in rural areas.

CONCLUSION

The results showed a large increase in the use of medicines for ADHD treatment in the Region of Murcia, although the consumption rates are still lower than in other Autonomous Communities or neighbouring countries. A wide geographical variability was found, with a higher consumption in adolescents from urban areas.

What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies

A minority of children and adolescents with mental health problems access treatment. The reasons for poor rates of treatment access are not well understood. As parents are a key gatekeeper to treatment access, it is important to establish parents' views of barriers/facilitators to accessing treatment. The aims of this study are to synthesise findings from qualitative and quantitative studies that report parents' perceptions of barriers/facilitators to accessing treatment for mental health problems in children/adolescents. A systematic review and narrative synthesis were conducted. Forty-four studies were included in the review and were assessed in detail. Parental perceived barriers/facilitators relating to (1) systemic/structural issues; (2) views and attitudes towards services and treatment; (3) knowledge and understanding of mental health problems and the help-seeking process; and (4) family circumstances were identified. Findings highlight avenues for improving access to child mental health services, including increased provision that is free to service users and flexible to their needs, with opportunities to develop trusting, supportive relationships with professionals. Furthermore, interventions are required to improve parents' identification of mental health problems, reduce stigma for parents, and increase awareness of how to access services.

Rural Trends in Diagnosis and Services for Autism Spectrum Disorder

Rural communities face significant challenges regarding the adequate availability of diagnostic-, treatment-, and support-services for individuals with autism spectrum disorder (ASD). Specifically, a variety of factors, including geographic distance between families and service providers, low reliance on health care professionals, and cultural characteristics, contribute to the diminished availability and utilization of services. Together, these factors lead to risks for delayed ASD screening and diagnosis, yielding lower educational and functional outcomes. The purpose of this review is to outline the specific diagnosis and treatment barriers that affect individuals with ASD and their families in rural settings. Telehealth feasibility and efficacy research is also reviewed, suggesting that telecommunication services may offer an inroad for addressing the specific service barriers faced by rural communities. Together, the current review identifies specific needs for both research and support services that address the specific access barriers characteristic of rural settings.

[Subjective Needs of Support in Families with a Mentally Ill Parent – A Literature Review]

Mentally ill parents are often sceptical about professional help for their children although these children face an increased risk to develop a mental disease themselves. To get a better understanding of needs and help-seeking behaviour in those families a systematic literature review was conducted. Four databases (FIS, PsycINFO, PSYNDEX, PubPsych) were scanned for international and national research literature. Out of 18,057 articles 56 were included which report quantitative or qualitative studies taking the children's and parents' perspectives into account. A thematic synthesis was done to categorize the needs. Results concerning the help-seeking behaviour and the influence of demographic variables were extracted and summarized. Our results were limited by the aspect that no evaluation of study quality had been made and influences on the categorizing process by the authors' subjective perceptions are likely. There were a lot of hints regarding the needs of the families, but little report was found about help-seeking behaviour and demographic variables. The "health literacy" concept was discussed as a basis for further research in this area.

Parent and family factors associated with service use by young people with mental health problems: a systematic review

AIM

To conduct a systematic review of parent and family factors associated with service use for young people with mental health problems, to inform early intervention efforts aimed at increasing service use by young people.

METHODS

A systematic search of academic databases was performed. Articles were included in the review if they had: a sample of young people aged between 5 and 18 years; service use as the outcome measure; one or more parental or family variables as a predictor; and a comparison group of non-service using young people with mental health problems. In order to focus on factors additional to need, the mental health symptoms of the young person also had to be controlled for. Stouffer's method of combining P-values was used to draw conclusions as to whether or not associations between variables were reliable.

RESULTS

Twenty-eight articles were identified investigating 15 parental or family factors, 7 of which were found to be associated with service use for a young person with mental health needs: parental burden, parent problem perception, parent perception of need, parent psychopathology, single-parent household, change in family structure and being from the dominant ethnic group for the United States specifically. Factors not found to be related to service use were: family history of service use, parent-child relationship quality, family functioning, number of children, parent education level, parent employment status, household income and non-urban location of residence.

CONCLUSIONS

A number of family-related factors were identified that can inform effective interventions aimed at early intervention for mental health problems. Areas requiring further research were also identified.

Income gradients within child and adolescent antisocial behaviours

BACKGROUND

Low income is a widely studied risk factor for child and adolescent behavioural difficulties. Previous research on this relationship has produced mixed findings.

AIMS

To investigate the level, shape and homogeneity of income gradients in different types of antisocial behaviour.

METHOD

A representative sample of 7977 British children and adolescents, aged 5-16 years, was analysed. Hypotheses concerning the shapes and homogeneity of the relationships between family socioeconomic status and multiple antisocial behaviour outcomes, including clinical diagnoses of oppositional-defiant disorder, conduct disorder and symptom subscales, such as irritability and hurtfulness, were tested by structural equation models.

RESULTS

Consistent income gradients were demonstrated across all antisocial behaviours studied. Disorder prevalence and mean symptom counts decreased across income quintiles in a non-linear fashion.

CONCLUSIONS

Our findings emphasise that income gradients are similar across different forms of antisocial behaviour and indicate that income may lead to greater behavioural differences in the mid-income range and less variation at low- and high-income extremes.

English Proficiency, Threshold Language Policy and Mental Health Service Utilization among Asian-American Children

This paper explores the role of English proficiency, ethnicity, and California's threshold language policy in the rates of discontinuing mental health services among Asian-American children. We used data from the 2001-2006 Client and Services Information (CSI) System, which contains county-level information about service users in public mental health systems. Our data included 59,218 service users under the age of 18. We used logistic regression to determine the likelihood of discontinuing services, while controlling for sociodemographic and clinical characteristics. English-speaking Asians were 11% more likely than English-speaking Whites to discontinue mental health services. Non-English-speaking Asians were 50% significantly more likely to stay in services. The results also revealed some inter-ethnic variations in the discontinuation patterns; however, the patterns of mental health service utilization appear to be driven by the availability of mental health services in Asian-ethnic languages in county of residence. Further research is needed to understand the intake and referral processes that Asian children go through within the mental health service system.

Mental Health Service Use in Schools and Non-School-Based Outpatient Settings: Comparing Predictors of Service Use

Researchers have consistently documented a gap between the large number of US youth meeting criteria for a mental health disorder with significant associated impairment, and the comparatively few youth receiving services. School-based mental health care may address the need-services gap by offering services more equitably to youth in need, irrespective of family economic resources, availability of transportation, and other factors that can impede access to community clinics. However, diagnoses alone do not fully capture the severity of an individual's mental health status and need for services. Studying service use only in relation to diagnoses may restrict our understanding of the degree to which service use is reflective of service need, and inhibit our ability to compare school and non-school-based outpatient settings on their responsiveness to service need. The present study evaluated predictors of mental health service use in school- and community-based settings for youth who had had an active case in one of two public sectors of care, comparing empirically-derived dimensional measurements of youth mental health service need and impairment ratings against non-need variables (e.g., ethnicity, income). Three dimensions of youth mental health service need were identified. Mental health service need and non-need variables each played a significant predictive role. Parent-rated impairment was the strongest need-based predictor of service use across settings. The impact of non-need variables varied by service setting, with parental income having a particularly noticeable effect on school-based services. Across time, preceding service use and impairment each significantly predicted future service use.

Geographic analysis of the variation in the incidence of ADHD in a country with free access to healthcare: a Danish cohort study

Background

The prevalence of citizens diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) has risen dramatically over the past decades in many countries, however, with large variations. Countries such as Denmark with centrally organized well fare systems, free access to health services and individual tracking based on unique personal identification may in particular contribute to our understanding of the reasons for this increase. Based on Danish registers we aimed to examine the geographical patterns of the distribution of ADHD diagnosis and medication use and explore the association with access to diagnostic services, diagnostic culture, neighbourhood socioeconomic status and municipal spending on health care for children.

Methods

We combined information on registered diagnosis of ICD-10 Hyperkinetic Disorder and ADHD medication use in a Danish register-based cohort of children born between 1990 and 2000. We mapped incidence proportions of diagnoses and medication use within the 98 Danish Municipalities. Global and local clustering of ADHD was identified using spatial analysis. Information on contextual factors in the municipalities was obtained from national registers. The associations between the incidence of ADHD and contextual factors were analysed using Bayesian spatial regression models.

Results

We found a considerable variation in the incidence of ADHD across the municipalities. Significant clustering of both high and low incidence of ADHD was identified and mapped using the local Moran’s I. Clustering of low incidence of diagnosis and medication use was observed in less populated areas with limited diagnostic resources and in contrast clustering of high incidence in densely populated areas and greater diagnostic resources. When considering the spatial autocorrelation between neighbouring municipalities, no significant associations were found between ADHD and access to diagnostic services, different diagnostic culture, socioeconomic status at municipality level or the municipal spending on health care for children.

Conclusions

A large geographical variation of ADHD in the municipalities was observed despite tax-financed and free access to healthcare. Although not statistically significant, results indicate that accessibility to diagnostic resources might explain some of the variation in ADHD incidence. In contrast to US studies the observed variation was not statistically associated to contextual factors in terms of SES, municipal spending on health care for children or differences in diagnostic practices.

Mental health care use among children and adolescents in Germany: results of the longitudinal BELLA study

Data on mental health care use of children and adolescents in Germany is scarce. This study investigates the degree of mental health care use, its trajectories and influencing factors among children and adolescents in Germany, using longitudinal data of the BELLA study. The BELLA study is the mental health module of the representative German National Health Interview and Examination Survey for children and adolescents (KiGGS). Baseline data of N = 2,863 participants aged 7-17 years were collected between 2003 and 2006. The study sample was followed up in three additional measurement points, assessing general mental health problems and impairment, specific mental health problems, and mental health care use. In the current study, we analysed data from the first three measurement points. At baseline, 5.9 % of all participants used mental health care in the past 12 months. Among those with general mental health problems, 29.5 % sought professional help. Only a minority of participants reporting mental health care use at baseline also sought help at the following two measurement points. Analysing a random intercept only model, mental health care use was found to be more likely among participants living in larger communities as well as in the Eastern part of Germany, among those participants with impairment of mental health problems, and signs of externalizing problems. Our results indicate a temporary character of mental health care use. Participants' impairment was identified to be the strongest predictor of mental health care use.

Gender differences in factors associated with perceived need and use of Korean adolescents mental health services

This study investigated the socio-demographic characteristics and emotional and behavioral factors associated with the perceived need and actual use of adolescent mental health services according to genders in Korea. We assessed 1,857 middle school students aged 14-16 years. We administered a self-reported questionnaire including questions on their socio-demographic data, Korean Youth Self Report, and self perceived need and actual use of mental health services. Overall, 11.6 % of the adolescents demonstrated a self perceived need for mental health services regarding their emotional or behavioral problems, while 2.1 % had sought mental health services. There were discrepancies between the perceived need and actual use. Most adolescents (81.6 %) used mental health services without self-perceived need, and only 3.3 % of adolescents with self-perceived need utilized mental health services. The perceived need of mental health services is positively influenced by the adolescent's anxious/depressed problems in both genders. The use of them is negatively influenced by the withdrawn problem in adolescent boys, while positively influenced by the aggressive behavior in adolescent girls. To increase the actual use of mental health services more attention needs to be focused on their internalizing problems, such as anxious/depressed and withdrawn problems, in addition to externalizing problems in both genders.

Pharmacological treatment and demographic characteristics of pediatric patients with Attention Deficit Hyperactivity Disorder, Sweden

The aim of this study was to describe the pediatric population with ADHD and their pharmacological treatment. Using the Swedish National Patient Register and the Prescribed Drug Register we identified individuals below 19 years of age who were diagnosed or medically treated for ADHD for the first time 2006-2007. The unique patient identifiers were used to link information from the two registers to describe demographic characteristics, hospital care and drug treatments. Logistic regression model estimated the association between age, sex, frequency of hospitalization, diagnosis or treatment for other mental disorders and risk of gap in the treatment. Totally the study included 7931 patients of whom 74% were males. The mean age at first diagnosis was 12 years. Some 84% were medically treated for ADHD and approximately 90% received methylphenidate as the first substance. Combination therapy was rare and the most common combination was methylphenidate and atomoxetine. More than 55% of the patients, which could be followed up for two years after start of treatment, had at least one treatment gap of six months. Older age at diagnosis, lower number of hospitalizations and comorbidity with other mental disorders increased risks of gaps in medication. Approximately one fifth of the patients recorded in the National Patient Register as diagnosed with ADHD did not receive pharmacological treatment. Medication adherence seems to be low, when measured as gaps in treatment.

Emotion regulation difficulties, youth-adult relationships, and suicide attempts among high school students in underserved communities

To develop and refine interventions to prevent youth suicide, knowledge is needed about specific processes that reduce risk at a population level. Using a cross-sectional design, the present study tested hypotheses regarding associations between self-reported suicide attempts, emotion regulation difficulties, and positive youth-adult relationships among 7,978 high-school students (48.6% male, 49.9% female) in 30 high schools from predominantly rural, low-income communities. 683 students (8.6%) reported a past-year suicide attempt. Emotion regulation difficulties and a lack of trusted adults at home and school were associated with increased risk for making a past-year suicide attempt, above and beyond the effects of depressive symptoms and demographic factors. The association between emotion regulation difficulties and suicide attempts was modestly lower among students who perceived themselves as having higher levels of trusted adults in the family, consistent with a protective effect. Having a trusted adult in the community (outside of school and family) was associated with fewer suicide attempts in models that controlled only for demographic covariates, but not when taking symptoms of depression into account. These findings point to adolescent emotion regulation and relationships with trusted adults as complementary targets for suicide prevention that merit further intervention studies. Reaching these targets in a broad population of adolescents will require new delivery systems and "option rich" (OR) intervention designs.

School mental health resources and adolescent mental health service use

OBJECTIVE

Although schools are identified as critical for detecting youth mental disorders, little is known about whether the number of mental health providers and types of resources that they offer influence student mental health service use. Such information could inform the development and allocation of appropriate school-based resources to increase service use. This article examines associations of school resources with past-year mental health service use among students with 12-month DSM-IV mental disorders.

METHOD

Data come from the U.S. National Comorbidity Survey Adolescent Supplement (NCS-A), a national survey of adolescent mental health that included 4,445 adolescent-parent pairs in 227 schools in which principals and mental health coordinators completed surveys about school resources and policies for addressing student emotional problems. Adolescents and parents completed the Composite International Diagnostic Interview and reported mental health service use across multiple sectors. Multilevel multivariate regression was used to examine associations of school mental health resources and individual-level service use.

RESULTS

Nearly half (45.3%) of adolescents with a 12-month DSM-IV disorder received past-year mental health services. Substantial variation existed in school resources. Increased school engagement in early identification was significantly associated with mental health service use for adolescents with mild/moderate mental and behavior disorders. The ratio of students to mental health providers was not associated with overall service use, but was associated with sector of service use.

CONCLUSIONS

School mental health resources, particularly those related to early identification, may facilitate mental health service use and may influence sector of service use for youths with DSM disorders.

Are we reaching them yet? Service access patterns among attendees at the headspace youth mental health initiative

BACKGROUND

Australian young people have a high prevalence of mental health problems but low rates of service use. This article examines whether the Australian National Youth Mental Health Foundation, headspace, has helped redress this through providing youth-specific services.

METHOD

The article compares headspace service use demographics with population data from the Australian Survey of Mental Health and Wellbeing from 2007.

RESULTS

Headspace has improved access relative to the population, particularly among males and socially and economically excluded young people.

CONCLUSIONS

Despite overall successes, certain ethnic and age groups appear under-represented and in need of more careful targeting by youth mental health services.

Associations between suicidal high school students' help-seeking and their attitudes and perceptions of social environment

Suicide is a leading cause of death among adolescents, many of whom fail to disclose suicide concerns to adults who might help. This study examined patterns and predictors of help-seeking behavior among adolescents who seriously considered suicide in the past year. 2,737 students (50.9 % female, 46.9 % male; racial distribution 79.5 % Caucasian, 11.9 % Hispanic/Latino, and 3.6 % Black/African-American) from 12 high schools in rural/underserviced communities were surveyed to assess serious suicide ideation (SI) in the past year, disclosure of SI to adults and peers, attempts to get help, attitudes about help-seeking, perceptions of school engagement, and coping support. Help-seeking was defined as both disclosing SI to an adult and perceiving oneself as seeking help. The relationship between adolescents' help-seeking disclosure and (1) help-seeking attitudes and (2) perceptions of social resources was examined among suicidal help-seeking youth, suicidal non-help-seeking youth, and non-suicidal youth. Of the 381 (14 %) students reporting SI, only 23 % told an adult, 29 % sought adult help, and 15 % did both. Suicidal help-seekers were similar to non-suicidal peers on all measures of help-seeking attitudes and social environment perceptions. Positive attitudes about help-seeking from adults at school, perceptions that adults would respond to suicide concerns, willingness to overcome peer secrecy requests, and greater coping support and engagement with the school were associated with students' increased disclosure of SI and help-seeking. This study supports prevention strategies that change student norms, attitudes and social environments to promote help-seeking among adolescents with SI. Promising intervention targets include increasing students' perceptions of the availability and capability of adults to help them, and strengthening students' understanding of how existing resources can help them cope.

Seeking professional help for mental health problems, among New Zealand secondary school students

OBJECTIVE

Our aim was to investigate whether secondary school students with mental health problems sought help from general practitioners and to investigate whether mental illness type, socio-demographic variables, family, school and community factors were associated with seeking help.

METHOD

A randomly selected sample of 9699 secondary school students from across New Zealand participated in the Youth2000 Health and Wellbeing Survey. Data analysis included uni-variate and regression analyses.

RESULTS

Having symptoms of anxiety (p<0.0001), depression (p<0.0001), and suicidal thoughts (p<0.0001) were associated with help seeking. However, 82%of students who had significant mental health problems had not sought help from a general practitioner. Rates of help seeking increased with age for girls and decreased with age for boys. Seeking help for mental health problems was also associated with living in a single parent family (p<0.0001), living in an over-crowded house (p=0.0006), and being well known by a teacher (p=0.0004).

CONCLUSIONS

The majority of New Zealand secondary school students with mental health problems do not obtain the help they need from general practitioners. Given the prevalence of mental health problems, it is important to find ways of identifying adolescents with difficulties and encouraging them to seek help.

Adoptive parents' suspicion of preadoption abuse of their adopted children and the use of support services

BACKGROUND

Adopted children have a higher risk of developmental, mental, behavioural and social problems compared with non-adopted children, and their use of postadoption support services is of interest. Little attention has been given to the impact of preadoption abuse on the use of these services, and therefore this study examines whether or not adoptive parents' suspicion of preadoption abuse has a significant impact on the use of support services by adopted children.

METHODS

Data from the National Survey of Adoptive Parents, a US nationally representative survey of adopted children, were used to examine parents' suspicion of preadoption abuse and its effects on the use of postadoption support services by children aged 6-17 years (n = 1411). Statistical analyses were used to examine the relationship between suspected abuse and the use of support services while controlling for characteristics of the adopted child and adoptive parents/household.

RESULTS

Seven out of 10 adopted children have used some form of support service, and a larger percentage of 6- to 12-year-old children suspected of experiencing preadoption abuse used a support service compared with children not suspected of experiencing abuse. Significant relationships existed between various types of suspected preadoption abuse and the use of different types of postadoption support services. These relationships may go unaccounted for when only examining if any preadoption abuse occurred, or if any support service was used.

CONCLUSIONS

The type of preadoption abuse suspected appears to play a modest role in predicting the type of postadoption support services used by an adopted child. Giving further attention to understanding the relationship between different types of preadoption abuse and types of postadoption support services may help better understand the problems and difficulties experienced by adopted children.

Prevalence and correlates of psychotropic medication use in adolescents with an autism spectrum disorder with and without caregiver-reported attention-deficit/hyperactivity disorder

BACKGROUND

Many youths with an autism spectrum disorder (ASD) benefit from psychotropic medication treatment of co-morbid symptom patterns consistent with attention-deficit/hyperactivity disorder (ADHD). The lack of clear indications and algorithms to direct clinical practice has led to a very poor understanding of overall medication use for these youths. The present study examined the prevalence of psychotropic medication use compared across individuals with an ASD without a caregiver-reported ADHD diagnosis (ASD-only), ADHD without ASD (ADHD-only), and an ASD with co-morbid ADHD (ASD+ADHD). Correlates of medication use were also examined.

METHODS

Data on psychotropic medication from the first wave of the National Longitudinal Transition Study 2, a nationally representative study of adolescents ages 13-17 in special education, were used to compare the prevalence of medication use across the three groups, overall and by class. Separate logistic regression models were constructed for each group to examine the correlates of psychotropic medication use. Poisson regression models were used to examine correlates of the number of medications.

RESULTS

Youths with ASD+ADHD had the highest rates of use (58.2%), followed by youths with ADHD-only (49.0%) and youths with ASD-only (34.3%). Youths with an ASD, both ASD-only and ASD+ADHD, used medications across a variety of medication classes, whereas stimulants were dominant among youths with ADHD-only. African American youths with ASD-only and with ASD+ADHD were less likely to receive medication than white youths, whereas race was not associated with medication use in the ADHD-only group.

CONCLUSIONS

Clearer practice parameters for ADHD have likely contributed to more consistency in treatment, whereas treatment for ASD reflects a trial and error approach based on associated symptom patterns. Additional studies examining the treatment of core and associated ASD symptoms are needed to guide pharmacologic treatment of these youths. Interventions targeting African American youths with ASD and the physicians who serve them are also warranted.

Health care supply and county-level variation in attention-deficit hyperactivity disorder prescription medications

PURPOSE

Although much literature reports small-area variation in medication prescriptions used to treat attention-deficit hyperactivity disorder (ADHD), scant research has examined factors that may drive this variation. We examine, across counties in the USA, whether the use of prescription medications to treat ADHD varies positively with supply-side healthcare characteristics.

METHODS

We retrieved annual prescription data for ADHD medications in 2734 US counties from a nationally representative sample of 35 000 pharmacies in 2001-2003. We used a county-level, multivariable fixed effects analysis to estimate the relation between annual changes in healthcare supply and ADHD medication prescriptions. Methods controlled for time-invariant factors unique to each county as well as ADHD prevalence.

RESULTS

From 2001 to 2003, retail prescription purchases for ADHD medications increased 33.2%. In the multivariable analysis, ADHD medication prescriptions move positively with an increase in the concentration of total physicians. In addition, ADHD medication prescriptions move inversely with changes in the percentage of non-Hispanic Black population.

CONCLUSIONS

Supply-side healthcare factors may contribute to the rise from 2001 to 2003 in ADHD medication prescriptions. This finding warrants attention because it implies that the relative capacity of the healthcare system may influence population prescription rates. We encourage further exploration of the contribution of the supply-side of the healthcare market to secular changes in ADHD medication prescriptions.

Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A)

OBJECTIVE

Mental health policy for youth has been constrained by a paucity of nationally representative data concerning patterns and correlates of mental health service utilization in this segment of the population. The objectives of this investigation were to examine the rates and sociodemographic correlates of lifetime mental health service use by severity, type, and number of DSM-IV disorders in the National Comorbidity Survey-Adolescent Supplement.

METHOD

Face-to-face survey of mental disorders from 2002 to 2004 using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview in a nationally representative sample of 6,483 adolescents 13 to 18 years old for whom information on service use was available from an adolescent and a parent report. Total and sector-specific mental health service use was also assessed.

RESULTS

Approximately one third of adolescents with mental disorders received services for their illness (36.2%). Although disorder severity was significantly associated with an increased likelihood of receiving treatment, half of adolescents with severely impairing mental disorders had never received mental health treatment for their symptoms. Service rates were highest in those with attention-deficit/hyperactivity disorder (59.8%) and behavior disorders (45.4%), but fewer than one in five affected adolescents received services for anxiety, eating, or substance use disorders. Comorbidity and severe impairment were strongly associated with service utilization, particularly in youth with behavior disorders. Hispanic and non-Hispanic Black adolescents were less likely than their White counterparts to receive services for mood and anxiety disorders, even when such disorders were associated with severe impairment.

CONCLUSIONS

Despite advances in public awareness of mental disorders in youth, a substantial proportion of young people with severe mental disorders have never received specialty mental health care. Marked racial disparities in lifetime rates of mental health treatment highlight the urgent need to identify and combat barriers to the recognition and treatment of these conditions.

Disparities in treatment for substance use disorders and co-occurring disorders for ethnic/racial minority youth

OBJECTIVE

To review the literature on racial and ethnic disparities in behavioral health services and present recent data, focusing on services for substance use disorders (SUD) and comorbid mental health disorders for children and adolescents.

METHOD

A literature review was conducted of behavioral health services for minority youth. Articles were included if specific comparisons in receipt of SUD services for youth were made by race or ethnicity. The review was organized according to a sociocultural framework.

RESULTS

Compared with non-Latino Whites with SUD, Black adolescents with SUD reported receiving less specialty and informal care, and Latinos with SUD reported less informal services. Potential mechanisms of racial and ethnic disparities were identified in federal and economic health care policies and regulations, the operation of the health care system and provider organization, provider level factors, the environmental context, the operation of the community system, and patient level factors. Significant disparity decreases could be achieved by adoption of certain state policies and regulations that increase eligibility in public insurance. There is also a need to study how the organization of treatment services might lead to service disparities, particularly problems in treatment completion. Institutional and family characteristics linked to better quality of care should be explored. Because treatments appear to work well independent of race/ethnicity, translational research to bring evidence-based care in diverse communities can bolster their effectiveness.

CONCLUSIONS

This review suggests promising venues to decrease ethnic and racial disparities in behavioral health services for ethnic and racial minority youth.

Prevalence of methylphenidate prescription among school-aged children in a Swiss population: increase in the number of prescriptions in the Swiss Canton of Vaud, from 2002 to 2005, and changes in patient demographics

OBJECTIVE

Methylphenidate is prescribed for children and adolescents to treat ADHD. As in many Western countries, the increase in methylphenidate consumption is a public concern in Switzerland. The article discusses the authors' assessment of prescription prevalence in 2002 and 2005 for school-aged children in the canton of Vaud.

METHOD

Pharmacy prescription information is available from the regional public health authority. Descriptive analyses are conducted on an anonymized database of the years 2002 and 2005. Data for each year are compared to assess trends in methylphenidate prescription prevalence.

RESULTS

The findings show an increase from 0.74% to 1.02% in the number of prescriptions for 5- to 14-year-old children, particularly in prescriptions for girls. Data also show important geographical differences in prescription.

CONCLUSION

The prevalence of methylphenidate prescription is lower in Switzerland than other Western countries, particularly the United States. However, some aspects of prevalence are similar, including the increase per year, demographics, and geographic characteristics.

Engaging families into child mental health treatment: updates and special considerations

OBJECTIVE

The current paper reviews recent findings regarding how to conceptualize engagement and factors influencing engagement, treatment attendance rates, and interventions that work.

METHOD

Research related to the definition of engagement, predictors of engagement and treatment termination, attendance rates, and engaging interventions are summarized as an update to the McKay and Bannon (2004) review.

RESULTS

Despite ongoing advances in evidence-based treatments and dissemination strategies, engaging families into mental health treatment remains a serious challenge. Within the last several years, a number of technological advances and interventions have emerged to address this problem. Families with children who present disruptive behavior challenges and symptoms of trauma are considered in terms of the unique barriers they experience regarding engagement in treatment.

CONCLUSIONS

Potential solutions to increase treatment utilization and further research in this area are discussed.

Service use among Mexico City adolescents with suicidality

BACKGROUND

We report the lifetime and 12-month prevalence and associations of mental health treatment among Mexican adolescents with suicide-related outcomes (SROs; including ideation, plans, gestures and attempts).

METHODS

A representative multistage probability household survey of 3005 adolescents aged 12 to 17 years residing in the Mexico City Metropolitan Area was carried out in 2005. Discrete-time survival analyses were used to assess the relationships between SROs and receiving treatment for emotional, alcohol, or drug problems.

RESULTS

The prevalence of lifetime service use among respondents with SROs was 35% for those with ideation only, 44% for those with ideation and plan, 49% for those with gesture and 50% for those with attempt; the prevalence of 12-month service use was 10%, 24%, 6% and 21%, respectively. Timing between onset of SRO and receiving treatment for emotional, alcohol, or drug problems showed that about 50% of adolescents will have contact with a service provider before developing any SRO. Healthcare professionals were the most likely to be consulted, followed by school-based programs.

LIMITATIONS

This survey was limited to adolescents living in one of the largest metropolitan areas in the world and the analyses used data on retrospectively reported ages of onset that are subject to recall errors.

CONCLUSIONS

Most suicidal adolescents do not receive treatment, and many adolescents develop their suicidality in spite of prior contacts with service providers. Interventions to increase treatment, prevention, and monitoring are sorely needed for this vulnerable population.

Differences in mental health service sector utilization among African American and Caucasian youth entering systems of care programs

Differences in unmet need and access to services between African American and Caucasian youth have been established; less is known about differences in specific mental health service sectors. This study examined differences in past year outpatient, school-based, day treatment and residential/inpatient service utilization among African American and Caucasian youth (n = 3,649) entering a federally funded system of care program. Random effect logistic regression models were implemented to examine the relationship between race and past year service utilization. Analyses revealed that African American youth were less likely than Caucasian youth to have utilized school-based and residential/inpatient mental health services in the past year. Findings suggest that racial disparities exist in service use for certain types of service sectors and highlight the importance of understanding and identifying individual, family, and community factors that contribute to disparities in service utilization.

Perceived need and use of child mental health services in Korea

This study examined the degree of perceived need and use of child mental health services in Korea, as well as the factors associated therewith. The sample consisted of 3,477 children aged 8-13 years. Overall, 10.4% of the parents demonstrated a perceived need for mental health services regarding their children's emotional or behavioral problems, while 1.9% used mental health services. Although the perceived need for mental health services is high, only a small proportion of children receive them. Whether a child receives mental health care is influenced by the child's psychopathology, especially when social and/or thought problems exist.

Children's and Adolescents' Use of Mental Health Care Is a Family Matter

This article discusses the influence of family structure on children's use of mental health services and explores whether a family's dependency on government assistance compensates for the effect of family income on children's use of services. Children in nontraditional families are at greater risk of using mental health services and have more mental health visits. Family participation in government subsidies programs offsets the influence of family income on the use of mental health services.

Treatment of mental disorders for adolescents in Mexico City

OBJECTIVE

This study describes the prevalence, adequacy and correlates of 12-month mental health service use among participants in the Mexican Adolescent Mental Health Survey.

METHODS

The authors conducted face-to-face household surveys of a probability sample of 3005 adolescents aged 12-17 years residing in the Mexico City metropolitan area during 2005. The prevalence of mental health disorders and the use of services were assessed with the computer-assisted adolescent version of the World Mental Health Composite International Diagnostic Interview. Correlates of service use and adequate treatment were identified in logistic regression analyses that took into account the complex sample design and weighting process.

FINDINGS

Less than one in seven respondents with psychiatric disorders used any mental health services during the previous year. Respondents with substance-use disorders reported the highest prevalence of service use and those with anxiety disorders the lowest. Approximately one in every two respondents receiving any services obtained treatment that could be considered minimally adequate.

CONCLUSION

We found large unmet needs for mental health services among adolescents with psychiatric disorders in Mexico City. Improvements in the mental health care of Mexican youth are urgently needed.

Practitioner review: How can epidemiology help us plan and deliver effective child and adolescent mental health services?

This review focuses on ways in which epidemiological research can inform mental health service development and clinical practice. Data from epidemiological studies can provide cross-sectional and secular estimates of the prevalence of psychopathology to support rational service development. Epidemiological surveys have difficulties in finding large enough samples of children with rare disorders, although these disorders are often severely debilitating and require extensive service input. Systematic surveillance provides a rigorous method for studying rare disorders and events. Only a minority of children with impairing psychopathology reach mental health services, although a larger proportion have mental health related contacts with other services. The gap in provision is such that an expansion of mental health services is unlikely to reach all children who could benefit, suggesting that mental health professionals need to develop innovative strategies to increase the number of children seen and the effectiveness of interventions that they receive. Training and supervision of non-mental-health professionals working with children in the identification and management of mental health problems is also extremely important. Most studies suggest that the children with the severest problems are getting to specialist mental health services, and service contact is more likely if important adults can perceive the child's difficulty or find it to be burdensome. The latter suggests that education of key adults would improve detection if services had the capacity to cope. Studies consistently suggest that the region in which the child lives affects the likelihood of service contact, but studies of other characteristics predicting service contact are so contradictory that studies should only be (cautiously) applied to similar populations to assess which types of children may currently be falling through gaps in service provision. Academics are beginning to explore the use of structured measures developed for epidemiological studies in clinical assessment and outcome monitoring.

Longitudinal mental health service and medication use for ADHD among Puerto Rican youth in two contexts

OBJECTIVE

The study describes prevalence and rates of services and medication use and associated factors over time among Puerto Rican youths with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Longitudinal data are obtained on Puerto Rican children ages 5 through 13 years in the south Bronx in New York (n = 1,138) and two metropolitan areas in Puerto Rico (n = 1,353). The Diagnostic Interview Schedule for Children-IV is the diagnostic tool. Five composite measures of risk factors: negative family influences, ineffective structuring, environmental risks, child risks, and maternal acceptance are constructed to relate services and medication use to risk variables.

RESULTS

ADHD prevalence is similar in Puerto Rico and the south Bronx. Overall mental health services, medication, and psychostimulant use is lower in Puerto Rico across three time points. Most participants never received treatment at any time point. More environmental risks, negative child traits, and low maternal warmth are associated with more services, even after adjusting for comorbidity. When risk variables are controlled, the effects of ADHD on services use decrease. Previous treatment is a strong predictor of subsequent treatment.

CONCLUSIONS

Rates of services and medication use are lower in Puerto Rico. Context seems to be more important than ethnicity in predicting mental health services and medication use among Puerto Rican children with ADHD. Other psychiatric diagnoses and general risk variables are important correlates of services and medication use.

Predicting improvement of transitioning young people in the partnerships for youth transition initiative: findings from a multisite demonstration

Prior research has indicated that young people with serious mental health conditions show poorer progress and greater challenges in the transition to adulthood, as reflected by lower rates of employment and postsecondary education, higher rates of criminal justice involvement, and greater interference in daily activities from mental health and substance use disorders. Little knowledge exists, however, regarding improvement on these indicators among young people enrolled in community-based transition support programs and individual characteristics that might moderate this improvement. This study describes rates of improvement on indicators of transition progress and challenges among young people enrolled in a multisite demonstration of transition support programs. Young people in the study showed increased rates of progress and decreased rates of challenges over four quarters of enrollment. Moderation of these changes by individual characteristics including demographic, historical, and diagnostic variables suggested ways of improving transition support programs and avenues for future research.