Patterns of medical, educational, and mental health service use in a national sample of US children.

BACKGROUND: Special services are provided to children by the medical, educational, and mental health service systems, but it is unknown whether the same group of children receives different types of services or whether discrete subgroups predominantly receive these services. OBJECTIVE: To determine the proportions of children who receive special medical, educational, and mental health services, individually and in combination. DESIGN/METHODS: Using data from the 1994 National Health Interview Survey (NHIS) and its concurrent Disability Supplement (NHIS-D), we determined the proportions of children under age 18 (N = 30 032) who received each of 3 types of special services (medical, educational, mental health). We also examined the proportions of children who used combinations of these services. Finally, we determined whether the patterns of service use differed across age, sex, socioeconomic, or racial/ethnic groups. RESULTS: Overall, 9.6% of children used some type of special services. Somewhat greater proportions of children used specialized health services (5.5%) or educational services (5%) than mental health services (1.5%). About one third of children receiving services in each of the special medical and educational sectors are users of another type of services as well, but among children receiving mental health services, the majority also are recipients of another type of services. Highest rates of overall service use and of use in all 3 sectors were found among subgroups of children who were elementary school-aged or adolescents, male, of white non-Hispanic race/ethnicity, and living below the federal poverty level. This pattern is consistent with the literature on service utilization within the 3 systems of care and with the greater prevalence of children with chronic conditions in these same subgroups. CONCLUSION: These findings underscore the importance of communication in the planning of services for children across the medical, educational, and mental health sectors. Further research is needed to assess the actual degree of overlap among the various systems providing this care and the degree to which children and their families would benefit from more integrated systems.     

Medical,legal, and mental health service utilization by physically abused children and their caregivers

The use of medical, legal, and mental health services was examined among 37 Medicaid-eligible, physically abused children and their caregivers. Fewer than half of the children received a medical examination related to the physical abuse, but the majority had received basic wellness care, including immunizations. Roughly half of the cases were heard in family court. Fewer than half of the children were receiving mental health services. Children were more likely to receive services if the maltreating caregiver was not in the home. More maltreating caregivers received mental health services than did their children, but this still only accounted for half of the parents. Caregivers were more likely to receive treatment if they acknowledged the abuse. Children who participated in treatment showed reductions in parent-reported problem behaviors but showed increases in anxiety in comparison to children who did not participate in treatment.     

Do adolescents know where to find help for mental health problems? A brief report

Objective: Few previous studies have investigated adolescents' knowledge of the services available to provide help with mental health problems. This is an important omission as knowledge about the availability of mental health services may significantly influence the extent to which adolescents with mental health problems receive appropriate help for their difficulties. The purpose of this study was to investigate knowledge of mental health services among socio-economically disadvantaged adolescents.
Methodology: Students attending the participating high school completed a questionnaire describing mental health services in South Australia.
Results: The results suggest that the adolescents had little knowledge of mental health services and they primarily discussed their problems with other family members or friends. The results also suggest that the adolescents prefer to obtain information about mental health problems from education programmes in schools or on television.
Conclusions: There is a need to make adolescents and their families more aware of the services available to provide help for mental health problems.     

The adolescent and young adult with Klinefelter syndrome:ensuring successful transitions to adulthood

As many adolescent and young adult males with Klinefelter syndrome move into young adulthood, they will require long-term medical and mental health care for their complex and specific health care needs. Adult general medical providers and endocrinologists may feel ill-prepared to meet the medical needs of this population. In turn, many pediatric primary care and subspecialty providers may find themselves struggling to determine how best to transition the older adolescent to adult-oriented services. Working with families and their teens to consider and address current and future medical, mental health, educational and vocational needs will enhance that young adult's independence and functioning. This chapter addresses general transition issues and those that are specific to adolescents with Klinefelter syndrome. The prognosis for these young patients is good, and can be further enhanced by supportive families and a medical team that is informed about how best to facilitate the transition to adult-oriented services.     

Expanding the reach of preventive interventions: development of an Internet-based training for parents of infants

There are major obstacles to the effective delivery of mental health services to poor families, particularly for those families in rural areas. The rise of Internet use, however, has created potentially new avenues for service delivery, which, when paired with the many recent advances in computer networking and multimedia technology, is fueling a demand for Internet delivery of mental health services. The authors report on the adaptation of a parenting program for delivery via the Internet, enhanced with participant-created videos of parent-infant interactions and weekly staff contact, which enable distal treatment providers to give feedback and make decisions informed by direct behavioral assessment. This Internet-based, parent-education intervention has the potential to promote healthy and protective parent-infant interactions in families who might not otherwise receive needed mental health services.     

Patienten/-innen am Rande des Gesundheitswesens

Patient groups without lobbies are those that experience most problems related to ill-balanced distribution policies concerning public health services. This particularly applies to children and adolescents with mental health problems, often living (with their families) under rather precarious conditions. This article attempts to shed some light on the scope of health care services for this group in Austria. Given the Austrian situation, which is characterised by a major lack of adequate services for mentally impaired children and adolescents, international health care standards for this young patient group have not been met by far. Hence, families with children and adolescents with special (mental) needs often face situations they cannot deal with or which they cannot afford. Against this backdrop, current distribution policies in the context of health care services need to be re-designed and politicians called to take concerted action in favour of deprived patient groups.     

Health care of young children in foster care

Greater numbers of infants and young children with increasingly complicated and serious physical, mental health, and developmental problems are being placed in foster care. All children in foster care need to receive initial health screenings and comprehensive assessments of their medical, mental, dental health, and developmental status. Results of these assessments must be included in the court-approved social services plan and should be linked to the provision of individualized comprehensive care that is continuous and part of a medical home. Pediatricians have an important role in all aspects of the foster care system.     

Foster children and the foster care system, Part II: Impact on the child

These three programs represent efforts to solve some of the common clinical problems encountered in the care of foster children. Building on existing community resources, they create new services tailored to the specific needs of the individuals. Together, they form a continuum of services for foster and natural families; as children are identified in the Foster Care Clinic, they are referred for help to community service providers. Supporting visitation through the FRP can smooth the child's adjustment to placement and facilitate eventual return home or another permanent plan. The information from each program complements the other, and a rich and very valuable picture of the children which emerges can assist the agency and the court to make decisions based on assessments of the individual strengths and needs of the children and their families. The medical passport provides a critical link between the agency and physicians to ensure that the children receive the highest standard of health care possible.     

Aging adult children with developmental disabilities and their families: challenges for occupational therapists and physical therapists

The purpose of this article was to review the literature about families of adult children with developmental disabilities, the impact of culture on access to health care services, and community-based health care services for adults with developmental disabilities to answer the following questions: (1) How do parents of adult children with mental retardation and other developmental disabilities describe their caregiving experiences?, (2) What are frequently identified unmet service needs by the parents/families?, (3) Does the family's culture or ethnic background influence how they view their caregiving experiences?, and (4) What are the unique challenges facing families when attempting to access health care services? Currently little information exists about the needs of parents and other family members who live with adults with developmental disabilities. Longitudinal studies and studies to assess the influence of culture on care giving are especially needed. Therapists need to use approaches that will empower children and their families so they can better meet their current challenges and provide a foundation for the skills they will need to meet future challenges as adults.     

Family-based services in children's mental health: a research review and synthesis

A systematic review was undertaken of scientifically rigorous studies of family-based services in children's health and mental health. From a pool of over 4000 articles since 1980 in health and mental health that examined either specific family-based interventions for families of children or the processes of involvement, 41 studies were identified that met the methodological criteria for inclusion. These 41 studies encompassed 3 distinct categories: families as recipients of interventions (e.g., family education, support, engagement, empowerment); (b) families as co-therapists; and (c) studies of the processes of involvement (e.g., therapeutic alliance, engagement, empowerment, expectancies, and choice). Too few experimental studies exist to conclude decisively that family-based services improve youth clinical outcomes. However, those studies that have been rigorously examined demonstrate unequivocal improvements in other types of outcomes, such as retention in services, knowledge about mental health issues, self-efficacy, and improved family interactions - all outcomes that are essential ingredients of quality care. Four implications are drawn from this review. (1) Effective family education and support interventions from studies of adults with mental illnesses and from studies of families of high-risk infants exist and can be imported into the field of children's mental health. (2) The range of outcomes that are typically assessed in clinical treatment studies is too narrow to afford an adequate view of the impact of family-based interventions. A broader view of outcomes is needed. (3) The absence of a robust literature on process variables other than therapeutic alliance limits conclusions about how and why interventions are effective. Attention to the processes by which families become involved in services will require a more robust and nuanced range of studies that attend simultaneously to processes of change and to outcome improvement. (4) Linkage of effective family-based interventions to delivery of evidence-based services is likely to amplify the impact of those services and improve outcomes for youth and families.     

Management of pediatric mental disorders in primary care: where are we now and where are we going?

PURPOSE OF REVIEW: Pediatric mental disorders are among the most common disorders of childhood and are routinely seen in primary care. We review innovative management strategies, treatment technologies, and models of collaboration with behavioral health specialists in general medical settings. Our goal is to advance the integration of behavioral health services into primary care. RECENT FINDINGS: The application of mental health interventions with proven efficacy holds great promise for youths with mental disorders. Unfortunately, traditional primary-care management of pediatric mental disorders is characterized by nonspecific counseling, low-dose prescribing, and referrals to specialty settings that are often not completed. SUMMARY: The development, study, and refinement of new assessment and treatment technologies, supplemental treatments, and collaborative models of care delivery will be necessary to ensure more effective care for youths with mental disorders and their families. The promise of pediatric mental healthcare will not be fulfilled unless primary-care clinicians and behavioral health specialists forge new collaborative relationships that enhance the delivery of evidence-based care to affected children and their families.     

Annotation: Pathways to care for children with mental health problems

BACKGROUND: Although many children with mental health problems are in contact with primary health care services, few receive appropriate help. METHODS: Using a pathways to care model, this paper systematically reviews the literature relating to access to services. It separates out the various stages of help-seeking: parental perception of problems, use of primary care services, recognition within primary care, and referral to or use of specialist health services. RESULTS: Following parental awareness of child symptoms, parental perception of problems is the key initial step in the help-seeking process. Although children with mental health problems or disorders are regular attenders within primary care and most parents acknowledge that it is appropriate to discuss concerns about psychosocial issues in this setting, few children are presented with mental health symptoms even if their parents have such concerns. Subsequently, less than half of children with disorders are recognised in primary care. Amongst recognised children, about half are referred to specialist services. Overall, up to one-third of children with disorders receive services for mental health problems. Factors such as the type and severity of disorder, parental perceptions, child age and gender, and family and social background factors determine which affected children access services. CONCLUSIONS: As there are inequities in patterns of service use, a greater emphasis on developing resources at population and primary care levels is required. Barriers involving parental perceptions and expression of concerns within consultations should be minimised at these levels. This requires both public education approaches and improved training and specialist support for primary care services to enhance their ability to provide for these children.     

Use of psychotropic agents in preschool children: associated symptoms,diagnoses, and health care services in a health maintenance organization

BACKGROUND: Recent pharmacoepidemiological reports have contributed to concerns about frequent and perhaps indiscriminate psychopharmacotherapy for very young children. OBJECTIVE: To examine the diagnoses, symptoms, and health care services associated with preschool children receiving psychotropic medication. DESIGN: Population-based pharmacoepidemiological analysis of electronic medical records, paper medical and mental health charts, and pharmacy records from 1997 and 1998. SETTING: A large Pacific Northwest health maintenance organization. PARTICIPANTS: Preschool children receiving psychotropic medication (psychostimulants, antidepressants, neuroleptics, or alpha(2)-adrenergic agonists). MEASURES: Physician-reported mental health diagnoses and related symptoms, functional impairment, family and participant characteristics, and the types and level of associated medical and mental health services. RESULTS: Of 743 preschool children who clinicians identified as having behavioral or emotional problems, 120 (16%) received psychotropic medication; 57 children (48%) were prescribed a stimulant medication only, and 60 (50%) received a diagnosis of attention-deficit/hyperactivity disorder. Most children had substantial psychosocial risk factors, including parents with psychiatric or substance abuse problems (71%; n = 85), documented histories of abuse (29%; n = 35), and out-of-home placement (31%; n = 37). Four of 5 children or families (83%; n = 99) received psychosocial services in addition to pharmacotherapy. On average, children received psychotropic medication at least 6 months after initial identification of a behavioral or mental health problem. CONCLUSIONS: Despite commentary by the popular media about widespread psychopharmacotherapy for very young children, such treatment was only infrequently received in this health plan. Most children receiving psychopharmacotherapy had substantial additional risk factors and were receiving psychosocial services for mental health or behavioral management.     

The organization of services for chronically ill children and their families

Despite a political climate that deters optimism for rapid growth in the field of maternal and child health, we believe that there are reasonable steps that can and ought to be taken in the years immediately ahead. These steps would lead to important and lasting changes in the delivery, organization, and financing of services to chronically ill children and their families. Furthermore, pediatricians can play important roles--as they have historically--in reshaping care for children with special needs. First, children with chronic illness and their families require a set of services substantially different from those required by the majority of the nation's children. Just as there is no escaping the presence of a chronic illness for a child and family, the health care system cannot escape its responsibility to provide these services. This nation has been extraordinarily attentive to the medical services that these children need. Advances in the diagnostic and medical treatment procedures for many chronic illnesses have been remarkable, allowing many children to live far longer and in much better health than anyone would have expected two decades ago. This nation has not been so attentive to other services. A child with diabetes may have the finest medical care available in the region, yet her family lacks the money for gas to visit her in the hospital. The cystic fibrosis specialist may develop a comprehensive management strategy for his patient, but it fails to have full effect because the family's local pediatrician remains uninformed. These and many other examples convince us that the first step toward improving the organization of services for these children and their families must involve sustained national attention to their broad and special needs. Pediatricians are in an excellent position for this effort. Though most pediatricians will not have in their practice many children with the same chronic illness, they are likely to be the only medical practitioners who will get to know a broad spectrum of chronically ill children and their families. Because of this perspective they can be a truly informed and effective voice, articulating to their local communities the need for special services for this population of children. Second, services should be organized in such a way as to de-emphasize dependence on expensive tertiary care hospitals and instead to foster the delivery of care closer to the child's and family's own community.(ABSTRACT TRUNCATED AT 400 WORDS)     

Role of the medical home in family-centered early intervention services

There is growing evidence that early intervention services have a positive influence on the developmental outcome of children with established disabilities as well as those who are considered to be "at risk" of disabilities. Various federal and state laws now mandate the establishment of community-based, coordinated, multidisciplinary, family-centered programs that are accessible to children and families. The medical home, in close collaboration with the family and the early intervention team, can play a critical role in ensuring that at-risk children receive appropriate clinical and developmental early intervention services. The purpose of this statement is to assist the pediatric health care professional in assuming a proactive role with the interdisciplinary team that provides early intervention services.     

Care of the well newborn

The birth of an infant is one of the most memorable experiences a family shares. Pediatric health care professionals are privileged to participate in this experience and recognize it as a time to promote the health of the newborn and family. Ideally, a well-designed care system would be replete with comprehensive supports during the prenatal period, birth, and transition to home. Opportunities exist to improve the care we deliver with universal screening of all pregnant women; coordinated assessments of family health, including mental health; and access to coordinated supports and services for mother and infant. If 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, it is estimated the United States would save billions of dollars per year and prevent more than 900 deaths, nearly all of which would be in infants. All infants, whether breastfed or formula fed, should receive 400 IU supplemental vitamin D. Influenza and TdaP vaccination of postpartum mothers and other caregivers helps cocoon the vulnerable infant from influenza and pertussis until he or she can be fully vaccinated. When children reach the highest weight or length allowed by the manufacturer of their infant-only seat, they should continue to ride rear-facing in a convertible seat. It is best for children to ride rear-facing as long as possible to the highest weight and height allowed by the manufacturer of their convertible seat.     

Unmet health care needs and impact on families with children with disabilities in Germany.

OBJECTIVES: We sought to determine the independent effect of unmet health needs on family burden, in addition to the effects of functional impairment and parental care load, in children and adolescents with disabilities. METHODS: We conducted a cross-sectional survey of 273 families with children with disabilities using ambulatory services at an academic children's hospital in Germany. We measured family burden using a translated version of the Impact on Family Scale (FABEL). Independent variables were unmet health needs in 4 areas (medical care, care coordination, health education, and psychosocial services), level of functional disability, and nursing care load at home. Control variables included the child's age and gender, maternal employment status, and parental educational attainment. RESULTS: Most children had complex health conditions such as brain injury, congenital malformations, metabolic disease, myopathies, and brain tumors. Nearly half of families (44.6%) received home nursing cash benefits, indicating high care load. Parents reported most unmet needs in the areas of psychosocial counseling (17.2%) and care coordination (8.1%). After controlling for sociodemographic factors, unmet health needs predicted family burden independently of type (mental retardation or mobility impairment) and number of disabilities and nursing care load. Although only a few parents reported lack of medical services, this factor also contributed significantly to family burden. Multivariate analysis with these variables explained 45% of the variance in impact on the family. CONCLUSIONS: Addressing unmet health needs may alleviate the impact of caring for a child with a disability. Further studies are needed to show more definitively that families can benefit from integrated services including psychosocial counseling.     

Health care delivery: perspectives of young people with chronic illness and their parents

OBJECTIVE: To identify and compare perceptions of health care service delivery held by young people with chronic illness and their parents. METHODS: A convenience sample of young people with chronic illness and their parents were invited to complete a confidential self-report survey. The adolescents were aged 13-18 years inclusive and attended a specialist medical clinic. RESULTS: Participants comprised 53 young people (response rate 88%, 53/60) and 45 parents (response rate 75%, 45/60). Both young people and their parents rate honesty, confidentiality, having good medical knowledge and good listening skills as the most important qualities for a health care provider. Compared to the parent group, fewer young people report the presence of these desired qualities in their current health care provider. A quarter of young people (25%, 13/53) report they do not always trust health professionals to keep their information confidential, and 19% (10/53) of young people report having withheld information from a health professional due to a lack of trust. Some parents and young people would like to discuss a wider range of health topics, including mental health issues, than they currently do with their health provider. Young people and their parents report limited planning with their current health provider for transition to adult health services. CONCLUSIONS: Young people with chronic illnesses have significant levels of dissatisfaction with the health care they receive; this has the potential to impact on their use of health care services and their health outcomes. There is a need for increased provider awareness of the important qualities of health care service delivery to young people.     

Medical assessment for child sexual abuse: A post‐code lottery?

Aim: To describe the number of children and young people in New Zealand who receive a medical assessment for sexual abuse, the proportion of those where there is concern about sexual abuse who receive such assessments and the way in which assessment services are structured. Methods: Medical assessments for child and adolescent sexual abuse over 12 months were counted by direct communication with health providers throughout New Zealand, and compared with the number of cases substantiated by statutory child protective services, the number of claims for counselling for mental injury from sexual abuse and the regional population. All doctors providing medical assessments were surveyed as to how this was organised by region. Results: There were 804 medical assessments. Child protective services regarded 1207 cases as substantiated, and 1434 claims for mental injury were lodged. There was marked regional variation. In a matched sample, only 38% of cases of substantiated sexual abuse were seen for a medical assessment. A doctor with expertise in the assessment of sexual abuse was available in most areas, but service structure varied widely. The availability of nurse or social work support was poor. The proportion of children and adolescents receiving a medical assessment, and the quality of service structure, was directly related to regional population. Conclusions: Health assessments for alleged child and adolescent sexual abuse are relatively infrequent, nationally inconsistent and often poorly supported by local health systems. There is also marked but apparently unrelated regional variation in statutory child protection practice.