Parental Problem Recognition and Child Mental Health Service Use

This study estimates the prevalence and correlates of two components of problem recognition among parents and assesses their relative effects on child mental health service use in several settings. Analyses were based on data from a population-based sample of 1,420 youth-parent pairs. Child psychopathology and impairment were assessed using the Child and Adolescent Psychiatric Assessment. Problem perception was defined as reporting one or more problems or needs; family impact as reporting one or more impacts. Recent use of 30+ types of mental health services was examined. The frequency of problem perception was 13.3% and family impacts 11.2% across all observations. Among parents of children with 1+ DSM-IV psychiatric diagnosis, 39.0% perceived problems and 31.7% perceived impacts. The strongest predictor of problem perception was impact and vice versa. Problem perception (and not impact) was predictive of specialty services after controlling for child illness. Neither problem recognition component predicted general medical or school use. Findings suggest the need for parent education to help them identify serious problems and for universal screening to ensure that access to specialty services is not dependent solely on parents. Problem recognition should be expanded to include perceptions of other adults in models of access mental health care.     

Social competence and emotional/behavioural problems in children of psychiatric inpatients

The social competence and emotional/behavioural problems among 80 5–16-year-old children of 46 inpatients with various psychiatric disorders were assessed by the parents using a Swedish version of the Child Behavior Checklist (CBCL). The ratings of these children were compared to a normative sample of school children, but also whether type of psychiatric disorder among the parents was related to psychosocial functioning in their children. Fifty percent of the parents had a psychotic disorder; other common diagnoses were depressive, neurosis or personality disorders. Overall, children of psychiatric inpatients were perceived by the parents to be less socially competent and to have more emotional/behavioural problems than school children in the same age groups. However, 25% of the children of psychiatric parents were rated as having more severe problems (corresponding to the 90th percentile of the normative sample). About 15% of the children had total problem levels comparable to child psychiatric samples, but only 5% did actually receive ongoing help from the child psychiatric service. Parents with a depressive disorder or a crisis reaction also regarded their children to be more anxious/depressed, and to have more social problems than those of parents with other psychiatric disorders. Four CBCL items were found to be strong predictors of being a child of a psychiatric parent or parent in the normative sample. We suggest that the CBCL might be a valuable clinical tool in the screening and identification of those children of psychiatrically ill parents, who show more extreme problem scores and therefore might need help because of psychological problems. Accepted: 11 November 1999     

Ethnic differences in problem perception and perceived need as determinants of referral in young children with problem behaviour

An underrepresentation of ethnic minority children in mental health care settings is consistently reported. Parents of ethnic minority children are, however, less likely to perceive problem behaviour in their children. Our hypothesis was that, as a result of ethnic differences in problem perception, referral to care by a child health professional (CHP) would be lower for 5- to 6-year-old (high-risk) children from ethnic minority backgrounds than for their peers from the ethnic majority (Dutch origin). For 10,951 children in grade two of elementary school, parents and/or teachers completed the Strengths and Difficulties Questionnaire (SDQ) as well as questions on problem perception (PP) and perceived need for professional care (PN). Referral information was obtained from the Electronic Child Records (ECR) for 1,034 of these children. These children had a high (>90th percentile) SDQ score, and were not receiving mental health care. CHP’s referred 144 children (14 %) during the routine health assessments. A lower problem perception was reported by parents of ethnic minority children (40–72 %) than by parents of the ethnic majority group (80 %; p < 0.001), but there were no ethnic differences in referral (OR range 0.9–1.9-p > 0.05). No ethnic differences were found for parental PN, nor for teacher’s PP or PN. Despite a lower problem perception in ethnic minority parents when compared to ethnic majority parents, no ethnic differences were found in referral of children with problem behaviour in a preventive health care setting.     

Determinants of beliefs about illness: A study of parents of children with diabetes, asthma, epilepsy, and no chronic illness

Social psychological models of health care behaviour frequently take as their starting point perception of the illness. This paper seeks to examine factors that may influence these perceptions. Beliefs about the seriousness of eleven childhood illnesses are compared in four groups of parents. Significant differences were evident between the groups of parents depending upon their experiences with illness. For three conditions (diabetes, asthma and epilepsy) the lowest rating of seriousness was made by parents with a child with that condition. For parents of children with diabetes, having a relative with diabetes in good health was associated with a perception of the illness as significantly less serious than those with a relative in average or poor health, or those with no relatives with diabetes. These results are interpreted within an information processing model. Implications of the findings for social psychological models of health care behaviour are discussed.     

Methodological Challenges in Assessing Children's Mental Health Services Utilization

This paper describes the reliability and validity of the service assessment for children and adolescents (SACA) for use among Spanish-speaking respondents. The test-retest reliability of the instrument was assessed in a randomly selected clinical sample of 146 Puerto Rican children and adolescents aged 4–17. Both parents and children were administered the SACA twice by independent interviewers over an average 12-day follow-up period. The accuracy of parental and youth self-reports was assessed by comparing these reports to information obtained from medical records. The results showed that parents and children (aged 11–17) were able to report with fair to moderate reliability any last year use of mental health services, any outpatient mental health services, and school services. Residential and hospitalization services were reported by both informants with substantial test-retest reliability. Slight or no test-retest reliability was obtained for parent and child on the use of the specific type of mental health professionals, as well as parental reports of several treatment modalities. Substantial sensitivity of the SACA was obtained when comparing medical records to parental and child reports to lifetime use of any service and outpatient mental health service. Moderate sensitivity was obtained for last year use of mental health services for both parent and child informants.     

Parent–Teacher Disagreement on Ratings of Behavior Problems in Children with ASD: Associations with Parental School Involvement Over Time

ASD symptomology and behavioral problems pose challenges for children with ASD in school. Disagreement between parents and teachers in ratings of children’s behavior problems may provide clinically relevant information. We examined parent–teacher disagreement on ratings of behavior problems among children with ASD during the fall and spring of the school year. When child, teacher, and class characteristics were considered simultaneously, only ASD symptom severity predicted informant disagreement on internalizing and externalizing behavior problems. We also examined associations between informant disagreement and parent school involvement. Cross-lagged panel analyses revealed that higher informant disagreement on children’s behavior problems in the fall predicted lower parent school involvement in the spring, suggesting that greater informant agreement may foster parental school involvement over time.

     

Parent ratings of school behaviour in children at risk of attention deficit/hyperactivity disorder

OBJECTIVE: To investigate whether parents are accurate informants of child hyperactivity symptoms and impairment at school. METHOD: Parents of a community sample of 93 children with pervasive hyperactivity completed rating scales about their child's behaviour at home and school. These were compared with teacher ratings. RESULTS: Parent ratings about school correlate more closely with parent (home) than teacher ratings. Such ratings systematically under-estimate teacher ratings and are influenced by the child's behaviour at both home and school as well as parental mental health. However, a parental report of impairment for the child at school is likely to be accurate. CONCLUSION: There are limitations in relying on parental accounts of school behaviour if teacher ratings are unavailable. As such ratings may under-identify children with ADHD and discrepancies between parent and teacher ratings may reflect actual differences in behaviour, this suggests that ratings are required from both sets of informants.     

Cross-informant correlations on social competence and behavioral problems in Sami and Norwegian preadolescents

In a community-based birth cohort from Arctic Norway, correlations between parents and teachers on child competence and behavioral problems were determined for Sami and Norwegian 11–12 year-olds, using as instruments the child behavior checklist (CBCL), teacher report form (TRF), and the impact supplement of the extended strength and difficulties questionnaire (SDQ). Parent–teacher correlations on child behavioral problems were generally high in the Norwegian group, but low in the Sami group. Cross-cultural differences in cross-informant correlations were highest regarding externalizing and attention problems. Parent–teacher correlations on total impact of child difficulties also differed between the ethnic groups. Once again, a lower correlation was found for the Sami children. The discrepancy between parents’ and teachers’ perception of problems that needed attention was highest for the Sami, and lowest for the Norwegians. The Sami parents reported fewer perceived difficulties and less impact of problems than did the Norwegian parents. In contrast, no ethnic differences emerged for teachers’ ratings. The paper discusses how cultural norms might influence the reports of child problems. It demonstrates the importance of combining parent and teacher reports of child behavior problems in minority and indigenous children, who often live under different cultural norms in home and school contexts.     

Egocentrism in children of parents with a history of psychotic disorders.

It is known that children of schizophrenic parents have an increased risk for becoming schizophrenic, but it has been extremely difficult to determine what features may exist in such children before they become manifestly ill that might provide a key for identifying vulnerability to subsequent disorder. This study was carried out to determine whether certain types of egocentric perception exist in the children of psychotic parents that might represent a clue to vulnerability. Sixty parent-child pairs were investigated as part of the University of Rochester (NY) Child and Family Study, using standardized diagnostic assessment procedures in the parents and several methods for evaluating egocentric perception in their offspring. Results showed that severity of psychotic symptoms in a parent related significantly to the degree of persistent age-inappropriate spatial egocentrism in his or her child. All of several diagnostic approaches used for parent classification were about equally valid in this regard, except for hospital diagnosis of schizophrenia, which did not correlate significantly with offspring egocentricity.     

Parental perception of problems and mental health service use for hyperactivity

OBJECTIVE: To examine predictors of parental perception of hyperactivity as a serious problem and its role in determining the use of specialist mental health services. METHOD: A community sample of 5- to 11-year-old children with pervasive hyperactivity (n = 93) was identified. Children whose parents perceived the hyperactivity as a serious problem were compared with those whose parents did not. Predictors of parental perception of problem and the roles of this and child and parent clinical factors in predicting service use were examined. RESULTS: Controlling for child and parental mental health, the strongest predictor of parental perception of problems was the financial impact of the child's behavior on either parent's work (odds ratio [OR] = 17.43; 95% confidence interval [CI] 3.52-86.40). Other effects on the parent's working ability were also important. Parental perception of problems was the strongest predictor of service use (OR = 9.85; 95% CI 1.42-68.50). CONCLUSIONS: The effects of child behavior difficulties on perceptions of caregivers are multidimensional. The impact of hyperactivity on parents' work and family finances is substantial. Mental health service use is increased if these impacts reach the threshold for the parent to perceive the child's behavior as a problem.     

Understanding transference in parent guidance

Much has been written about parent guidance in the treatment of young children. However, a neglected area of study is the parents' transference relationship with the child clinician and the extent to which the clinician uses that transference in the treatment of the parents and the child. A second type of transference altogether is that between parent and child: the issues that the parents transfer onto their relationship with the child, which the clinician may observe in the parent work. Although it is widely accepted that such transference issues are an unavoidable aspect of parent guidance work, it is also generally understood that exploring the parents' transference may hinder the treatment of the child and, in certain instances, may even lead to premature termination. A supportive approach that facilitates a working alliance using a combination of information gathering, parent education, guidance, and advice giving is usually recommended to be the most helpful. The author suggests that although support is essential for effective parent guidance, that supportive interventions alone may actually limit therapeutic progress. At those times when a parent's emotional conflicts have contributed to or continue to exacerbate the child's ongoing difficulties, transference interpretations can facilitate changes in both the parent-child relationship and the child's individual treatment. The author proposes that working with the transference in parent. guidance and working supportively need not be understood as mutually exclusive approaches but should instead be viewed as complementary. Two cases are presented to demonstrate this approach to parent guidance.     

Education rights and the special needs child

A child with a disability has a federally protected right to special education and related services when he or she needs them to benefit from education. The term "disability" is not limited to physical disability but rather includes mental disability, including mental retardation, serious emotional disturbance, autism, traumatic brain injury, specific learning disabilities, and other health impairments. A parent may request that a child be evaluated by the school district for special education and related services. The law sets forth specific guidelines for the evaluation, assessment, and eligibility determination. Unique to each child, the IEP is the written plan that documents the child's special education and related services. The initial IEP is developed at a meeting among parents, various school personnel, and others whom the parents may wish to invite. Parents are an integral part of the team and are involved in all decisions by the team. The IEP must be reviewed annually, with attention given to whether educational objectives have been met. For a child with mental health issues, the IEP likely contains "related services," such as counseling, and measurable goals to improve behaviors in the school setting. When a child's condition is such that he or she cannot benefit from education in the regular school setting, other placements are considered. The school district maintains the ultimate responsibility of the cost of all such education placements, including residential care. A child with behaviors that result in frequent suspensions should have a functional analysis assessment by the school psychologist. The results of the assessment can be used to create a behavioral intervention plan. (If the school refuses to perform an assessment or develop a plan, the usual remedy of a due process hearing is available to the parents.) This plan should address problem behaviors and include strategies for redirecting the child's behavior. Even if a special education child is "expelled" from school, the district maintains the responsibility of providing FAPE. For this reason, districts--even in their own interests--should be proactive in dealing with these children, which often has not been the case. The Supreme Court has said that a child with services under IDEA (a child with an IEP) must receive some benefit from his or her education [31]. The issue of "how much benefit is enough benefit" is still troubling to parents and schools alike. The court also has ruled that related services, even costly ones such as a one-to-one nursing aide, must be provided if a qualifying child needs such services to access education [29]. Children with disabilities were long excluded from the public education system in this country. Obvious exclusion rarely occurs in the current education system, although exclusion through isolation does. Children with disabilities, especially mental disabilities, need and deserve the same educational benefit offered to children without those differences.     

Relationship of parent and child informants to prevalence of mania symptoms in children with a prepubertal and early adolescent bipolar disorder phenotype

OBJECTIVE: A controversy regarding pediatric bipolar disorder is whether to use child in addition to parent informants. To investigate this issue, the authors conducted a study comparing separate child and parent interview data for child bipolar disorder. METHOD: Responses on the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia from 93 child and 93 parent informants were compared by using kappa statistics. Research nurses, blind to subject information, separately interviewed parents about their children and children about themselves. Different nurses were used for the parent and child in each family to avoid bias from the same research nurse interviewing a child after interviewing that child's parent. Mania was defined by DSM-IV criteria, with at least one of the two cardinal symptoms of mania (elated mood and/or grandiosity), to avoid diagnosing mania by symptoms that overlapped with those for attention deficit hyperactivity disorder (ADHD). RESULTS: Parent-child concordance was poor to fair for all cardinal and noncardinal mania symptoms. Kappas were not significantly different by age within the 7-14-year-old age range. CONCLUSIONS: Symptoms endorsed by just the child included substantial proportions of bipolar symptoms that have been shown to best differentiate mania from ADHD (i.e., elation, grandiosity, flight of ideas, racing thoughts, decreased need for sleep). These findings support the need for child informants in research on prepubertal and early adolescent bipolar disorder in children ages 7-14. Differences in mania symptom profiles between investigative groups may be, in part, due to whether child informants were assessed.     

Changes in psychiatric problems and service use among 8-year-old children: a 16-year population-based time-trend study

OBJECTIVE: To study differences in children's psychiatric symptoms and child mental health service use at three time points: 1989, 1999, and 2005. MethoD: Three cross-sectional representative samples of 8-year-old children were compared from southern Finland. The sampling, procedure, and methods were similar at all three time points. Information was gathered from parents and teachers using Rutter questionnaires and other related determinants of service use and from children using the Children's Depression Inventory. The participation rate at the three time points was 96% in 1989, 86% in 1999, and 84% in 2005. RESULTS: Overall, parent and teacher reports of children's problems did not show a significant increase during the 16-year period. Parent reports of boys' conduct symptoms decreased from 1989 to 1999. However, self-reported depressive symptoms among girls increased from 1989 to 2005. Low parental education level, broken family, and negative life events were associated with depressive symptoms among girls. Although 4% of boys and 1% of girls had used child mental health services in 1989, the respective figures in 2005 were 12% and 4%. The majority of children who were screen positive on either parent or teacher ratings of emotional and behavioral problems using Rutter scales had received some educational support from school in 2005. CONCLUSIONS: Reports of depressive symptoms increased among girls, and this finding merits further studies. Use of services has continuously increased. School services play an important role in providing support and early detection of children who need to be referred to child mental health services.     

All God's children: religion, divorce, and child custody

Many young Americans, married and marriageable, are turning to more traditional or fundamentalist religions. Religiosity and ultra-strict morality often leads to attitudes that alter decision-making in marriage, divorce, and the disposition of the children of divorce. Judgmental pastoral counseling may affect these decisions even more. This paper discusses these issues, emphasizing the need for forensic psychiatrists involved in the custody arena to be aware of the religious, spiritual, irreligious, or even anti-religious feelings of the battling partners. It also presents detailed information about the four major American religions (Roman Catholicism, traditional Judaism, Mormonism, and Islam) that have specific doctrine, protocols, or customs affecting decisions in marriage, divorce, and child custody and visitation. This information is presented from the viewpoint of a child advocate. Mental health experts consulting in child custody must understand the backgrounds of the battling parents, including the religious pressures that well may adversely affect their interspousal disputes, particularly those over child custody. The experts must also recognize the attitudes of the religious communities in which the custodial parent may reside after divorce. Those attitudes may be rejecting of the children as well as of the divorced parent(s). Mental health experts may have a better chance to reach agreement between the battling parents if the experts reverse the historic reluctance of psychiatrists to evaluate and discuss the religious feelings and beliefs of their forensic evaluatees.     

The Role of Parental Language Acculturation in the Formation of Social Capital: Differential Effects on High-risk Children

This person-centered study examines the extent to which parents’ language dominance influences the effects of an after school, multi-family group intervention, FAST, on low-income children’s emotional and behavioral outcomes via parents’ relations with other parents and with school staff. Social capital resides in relationships of trust and shared expectations, which are highly dependent on whether parents share the language of other parents and teachers. This study is based on a community epidemiologically-defined sample of Latino families (N = 3,091) in San Antonio, Texas and Phoenix, Arizona. Latent profile analyses revealed three language profiles of parents across the two cities: English-dominant, Spanish-dominant, and bilingual. Path models revealed that FAST did not have a direct or indirect effect on children’s emotional and behavior functioning, although FAST increased parent–parent and parent-school social capital among Spanish-dominant parents in Arizona and these parent–parent relations were associated with better child outcomes. Implications for interventions are discussed.     

Mental health of Bosnian refugee children: a comparison of clinician appraisal with parent, child and teacher reports

This study compares clinician appraisal of Bosnian refugee children with independent parent, child and teacher reports. From whom and by what means can children "at risk" be reasonably identified? Forty-eight Bosnian refugee children (aged 7-20), resettled in Sweden 1994-95, were assessed clinically by means of a semi-structured interview. Thereafter, standardized mental health questionnaires were administered to parents (Achenbach's Child Behavior Checklist), children (Achenbach's Youth Self-Report and Macksoud's Posttraumatic Stress Reaction Checklist) and teachers (clinician designed School Competence Scale and Achenbach's Teacher's Report Form). On clinician interview, nearly half of the children (48%) were identified with one or more mental health problem "demanding further attention". Depressiveness was the single most prevalent symptom (31%); followed by post-traumatic stress (23%), and anxiety-regressiveness (15%). At the same time, 75% of the children were rated by teachers as "quite competent" in school. Parent, child and clinician appraisals of primary school children showed broad similarities. Teachers reported a similar prevalence of child distress, but identified different symptoms and different children demanding attention. Evaluation of teenage youths showed greater disparity: teenagers labeled their own symptoms more often as post-traumatic stress reactions and teachers identified few youths in need of attention. Inter-relatedness among parent, child and clinician appraisals supports the robustness of our semi-structured interview. At the same time, apartness of teacher report underscores the need to incorporate an outside-world vantage point in the process of risk assessment. Also, a more concrete presentation of post-traumatic stress reactions and a higher "further attention" threshold for inward emotional problems seem called for.     

Children of a cohort of depressed patients 25 years on: identifying those at risk

OBJECTIVE: Factors associated with psychological outcome in children of patients with depression have been examined piecemeal, with emphasis on young rather than adult children. We hypothesized that psychological morbidity in adult children of patients with depression would be associated with characteristics of the children, their parents and their family relationships. METHOD: Factors predicting psychopathology in children (n = 94) of a cohort of patients with depression, admitted to a teaching hospital 25 years earlier, were examined using logistic regression. RESULTS: Psychological morbidity in children was predicted by their being younger at parent's admission, their perception of the depressed parent as more controlling and chronicity of the parent's depression. Correlations between child characteristics, parent illness and family relationship variables showed systemic interactions between parental illness, child psychopathology and family relationships. CONCLUSION: Chronicity (though neither recurrence nor severity) of parent depression and younger children's age at the time of parental admission for depression were associated with psychological morbidity in the children in adulthood. The interaction between child psychopathology, parental illness and family relationships emphasizes the need for a systemic, family focus in the treatment of depression.     

School-Based Open Access Parenting Programmes: Factors Relating to Uptake

Background:  Many parents of children with conduct problems do not seek professional help.
Method:  A new questionnaire examining the beliefs about the problem behaviour, together with the Strengths and Difficulties Questionnaire, was administered to all parents of five reception year classes. They were then invited to attend school based group parent training.
Results:  Attendance was associated with the beliefs that there was potential for change and the child's behaviour adversely affecting the parent, but not with the child's behaviour adversely affecting the child.
Conclusions:  These findings may be of use when devising promotion for parent training.