Ethnic variation in service utilisation among children with intellectual disability

Background   This study examined whether service utilisation among children with intellectual disability (ID) varied by ethnic cultural group.
Method   Survey carried out in four special schools in London. Information was provided by school teachers using case files, and 242 children aged 7 to 17 years with mild and moderate ID were identified. Ethnic categories were derived from self-reported main categories. Service utilisation categorised as use of: child and adolescent mental health services (CAMHS), social services, physical health and education services.
Results   Child and adolescent mental health services uptake was lower for South Asians than for White British ( P  = 0.0487). There were statistically significant differences among ethnic groups for community-based social services uptake (being the highest for the Black groups and the lowest for South Asians, P  = 0.015) and respite care uptake (being the highest for the Black and White European groups and the lowest for South Asians, P  = 0.009). In regression analysis family structure predicted CAMHS service utilisation and social service community support. Ethnicity predicted use of respite care.
Conclusions   Significant ethnic differences in service utilisation among children with ID were found for both CAMHS and social service contact. There was particularly low service use for the South Asian group. These differences might arise because of differences in family organisation, as more South Asian children lived in two-parent families, which may have been better able to provide care than single-parent families. Other factors such as variation in parental belief systems and variation in psychopathology may be relevant. Implications are discussed.     

Paediatric Liaison Work by Child and Adolescent Mental Health Services

Background:  Although psychiatric morbidity is common amongst paediatric patients, little is known about the availability of CAMH paediatric liaison services.
Method:  We surveyed all Trusts with specialist CAMH services and paediatric units in Greater London, enquiring about the nature of liaison that CAMHS provide.
Results:  We found that although liaison paediatric work was common, dedicated paediatric liaison services were provided by only a minority of specialist multidisciplinary CAMHS. Their work involved most aspects of child psychopathology, and included emergencies and children with joint physical and psychiatric problems. About 2/3 of paediatricians were satisfied with CAMHS liaison services, but virtually all desired to see them developed further. There were few indications of co-ordination between specialist multidisciplinary CAMHS and other paediatric psychosocial support services.     

Father's Involvement and Psychological Adjustment in Indian and White British Secondary School Age Children

Background:  The study aimed to explore the relationship between father's involvement and psychological adjustment in Indian and White British secondary school age children.
Method:  Psychological adjustment in the 360 White British and 222 Indian children of the study was measured with the Strengths and Difficulties Questionnaire (SDQ). All children lived in biological two-parent families and attended the same secondary school in South England.
Results:  Indian girls and White British girls reported similar levels of adjustment and father's involvement, although compared to White British boys Indian boys reported both lower total difficulties scores and higher prosocial behaviour scores, as well as higher levels of father's involvement. Multiple regression analyses showed that even after controlling for age, sibship size, family's socio-economic status, and inter-parental conflict, father's involvement was positively associated with prosocial behaviour in both genders in both ethnic groups. Father's involvement was not related to Indian boys' or girls' difficulties. However, in White British boys father's involvement was negatively related to peer problems, whereas in White British girls father's involvement was negatively related to total difficulties, conduct problems, and peer problems.
Conclusions:  There would be merit in future studies extending our knowledge about differences in the relationship between father's involvement and child outcomes.     

How to improve the mental health care of children and adolescents in Brazil: Actions needed in the public sector

Introduction:Child/adolescent mental health (CAMH) problems are associated with high burden and high costs across the patient's lifetime. Addressing mental health needs early on can be cost effective and improve the future quality of life.Objective/Methods:Analyzing most relevant papers databases and policies, this paper discusses how to best address current gaps in CAMH services and presents strategies for improving access to quality care using existing resources.Results:The data suggest a notable scarcity of health services and providers to treat CAMH problems. Specialized services such as CAPSi (from Portuguese: Psychosocial Community Care Center for Children and Adolescents) are designed to assist severe cases; however, such services are insufficient in number and are unequally distributed. The majority of the population already has good access to primary care and further planning would allow them to become better equipped to address CAMH problems. Psychiatrists are scarce in the public health system, while psychologists and pediatricians are more available; but, additional specialized training in CAMH is recommended to optimize capabilities. Financial and career development incentives could be important drivers to motivate employment-seeking in the public health system.Conclusions:Although a long-term, comprehensive strategy addressing barriers to quality CAMH care is still necessary, implementation of these strategies could make.     

Conflict management of mothers and daughters belonging to individualistic and collectivistic cultural backgrounds: a comparative study

Research on the mother-daughter relationship during adolescence is mostly conducted in Western and European cultures where individualism is stressed. To examine ethnic/cultural differences and similarities in this relationship, 80 dyads of British (white) and Pakistani mothers and their adolescent daughters were studied. On the basis of the theories of cultural variability dimension and conflict face negotiation, it was hypothesized that mothers and daughters from the two cultures would use different styles of handling disagreements/conflicts. That is, Pakistani mothers and daughters would use an avoiding style, whereas British mothers and daughters would use either a dominating or compromising style, to a greater degree. It was also argued that Pakistani daughters and mothers will express more intimacy and relational harmony, will exhibit greater connectedness and mutuality and demonstrate lesser individuality and self-assertion compared to their British counterparts. However, it appeared that both the groups used an avoiding style equally, although the British group used a dominating style more than Pakistani group. As hypothesized, Pakistani mothers and daughters expressed more intimacy, relational harmony, connectedness and mutuality and lesser individuality than British mothers and daughters.     

Patterns and predictors of service use and unmet needs among aging families of adults with severe mental illness

OBJECTIVE: This study examined patterns and predictors of use of and unmet need for support services among aging families of adults with severe mental illness by using an expanded version of the Andersen Behavioral Model. METHOD:S: Mailed surveys were completed by 157 mothers from 41 states who lived with and provided care to adult offspring with serious mental disorders, primarily schizophrenia or schizoaffective disorders. The mean age of the mothers was 67 years (range, 50 to 88 years). RESULTS: Although unique patterns were observed among individual services, overall service use was low despite high perceived need for services. The greatest unmet needs were for social or recreational programming, training in behavior management, and information on planning for the future. Regression analyses based on the expanded Andersen model revealed that greater service use occurred when offspring spent their days away from home, mothers received higher levels of informal support, and offspring were in poorer physical health. Greater unmet needs for services were reported when mothers experienced higher burden, perceived more age-related changes in themselves, and had offspring who typically spent their days at home. CONCLUSION:S: The needs and resources of the entire family, including access to informal social support, should be considered in attempts to identify predictors of the use of and need for services among persons with chronic and severe mental illness. The findings of this study also point to the need for family education in how to locate community services as well as for better and more sensitive community services intended for the entire aging family.     

Looked After Children in Residential Homes

Background: Looked after children in residential children's homes constitute a particularly vulnerable group who are known to have high rates of mental health problems and limited access to services.
Method: A survey was undertaken in Leeds to determine what proportion of these children are involved with mental health services, and to look at the different ways in which child and adolescent mental health services across the city are currently working with this group.
Results: Of the 177 children in residential children's homes in August 2000, 64% had had some contact with child mental health services in the previous 5 years and 27% were in current contact. Thirty-six percent had had no contact with services over the past five years.
Conclusions: It was anticipated from a review of the literature that a higher proportion of children would have been currently in contact with services. The findings suggest that the pattern of services offered to this group of children is changing, with an increase in consultation with, and training of, staff in residential children's homes. The paper ends with a discussion of whether or not this is a positive change and how CAMH resources might best be utilised in the future.     

What Can the FOCUS E‐mail Discussion Group Tell Us About the Issues Facing CAMH Professionals?

Background:  The FOCUS e-mail discussion group was established in 1998 with the aim of facilitating information-sharing between professionals working in child and adolescent mental health services (CAMHS).
Method:  A content analysis was carried out on messages sent to the FOCUS e-mail discussion group between September 2004 and August 2005.
Results:  Discussion topics were widely distributed across twelve main themes, reflecting the breadth of issues discussed by CAMH professionals. The five most frequently discussed were: clinical cases; workforce issues; interventions; service policy; and service organisation.
Conclusion:  The findings demonstrate the usefulness of the FOCUS e-mail discussion group as a means of identifying the key issues facing CAMH professionals and consequently its potential to inform healthcare practice and policy.     

Addressing the Population Burden of Child and Adolescent Mental Health Problems: A Primary Care Model

A model for primary care child and adolescent mental health (CAMH) services is presented, the overall goal of which is to reduce population burden of CAMH problems. The theoretical orientation of the model is based on ecological systems theories. Features of the model include: local population outcome measures; small area service focus; primary-care-based CAMH specialists; a locally comprehensive service framework based in primary care (schools and general practices); and an explicit process of community engagement. The model is illustrated by reference to a primary care CAMH service (currently the subject of a controlled trial) in Flintshire, North Wales.     

Evaluation of a CAMHS in Primary Care Service for General Practice

Background:  Many CAMH Services have Tier 2 provision in primary care, but there has been little published evaluation. In a service aimed at general practice, this study examined: 1) the clinical activities of the primary mental health workers; 2) the effect of the service on referrals to specialist CAMHS; and 3) the utilisation and perceived usefulness of the service.
Method:  clinical activity data collection, evaluation of referral patterns, and a postal questionnaire.
Results:  Informal (unstructured) consultation-liaison was used more than formal consultation. Referrals to specialist CAMHS increased from practices using the service. The service was perceived as helpful and accessible.
Conclusions:  The service supported primary care staff in their work with child and adolescent mental health issues. Referrals to Tier 3 may increase as a result of the service.     

Child Mental Health is Everybody's Business: The Prevalence of Contact with Public Sector Services by Type of Disorder Among British School Children in a Three-Year Period

Method:  A third of the children from the 1999 British Child and Adolescent Mental Health Survey were followed-up over 3 years. Parents provided summary information on service contacts in relation to mental health; selected subgroups provided more detailed information by telephone interview.
Results:  Common overlaps in service use were between health services, between teachers and educational specialists, and between the latter and CAMHS or social services. Services other than primary health care saw more children with externalising disorders, while children with anxiety disorders were less likely than children with other psychiatric disorders to be in contact with any service.
Conclusions:  Child mental health is everybody's business, and professionals need to be alert(ed) to the types of disorders that children using their service may have.     

Predictors of Service Use for Mental Health Problems Among British Schoolchildren

Background:  Most previous studies of service use in relation to mental health have examined services in the USA. We wanted to provide up-to-date findings from a general population sample of British schoolchildren.
Method:  A total of 2461 children aged 5–15 from the 1999 British Child and Adolescent Mental Health Survey were followed up for 3 years. We examine the relationship between a wide variety of potential predictors gathered in 1999 and the use of services over the following 3 years.
Results:  Contact with most services was predicted by three factors: the impact of psychopathology; contact with teachers or primary health care; and parents' and teachers' perceptions that the child had significant difficulties. Other predictors were specific to each service.
Conclusions:  Education of parents, teachers and other important adults might increase the proportion of children with impairing psychiatric disorders reaching services.     

Developing Services with Limited Resources: Establishing a CAMHS in Pakistan

Background:  There are very few mental health services in Pakistan. In 2002, the Department of Psychiatry at Aga Khan University Hospital started a separate clinic for children under the age of 15 years to meet the population needs. This service took direct referrals from other physicians as well as from parents and schools.
Method:  A DSM-IV based semi-structured interview with a uniform written format was used for an initial evaluation by a child psychiatrist. Data regarding demographic characteristics, referral source, diagnoses and treatment were collected.
Results:  A total of 290 new referrals were made to the clinic over 3 years. The most common reason for referral was aggressive behaviour, although this possibly masked other kinds of mental health problems, as indicated by the assessment. Attention deficit-hyperactivity disorder was the most frequent diagnosis, made in 25% of children.
Conclusions:  Despite the limited resources and the high level of need in developing countries, resources can be used effectively within the framework of their health and educational systems, so maximising protective factors within their communities.     

Parents' and Clinicians' Perception of Severity of Referral Problems

Background:  Referral meetings are commonly used in CAMH Services to allocate a priority rating that reflects urgency, and thus severity, of the referral. Whilst it is recognised that a system is needed to manage the current level of demand, the literature suggests that decisions about severity are often inaccurate.
Method:  The current study aimed to evaluate a CAMHS referral system by looking at whether the priority ratings allocated by the Multi-Disciplinary Team (MDT) accorded with the parents' and the individual clinician's perception of the severity of the child's difficulties. Data were taken from the Service's outcome database.
Results:  The results showed that priority ratings did not reflect the parents' and the individual clinician's perception of the problem. It is therefore suggested that the current system for prioritising referrals requires some reform.
Conclusion:  There is discussion of procedures that might improve the accuracy of the priority rating process, such as using scores on standardised measures as part of the decision-making process.     

Characteristics of patients presenting for emergency psychiatric assessment at an English hospital

OBJECTIVE: The needs and characteristics of patients who are referred for psychiatric emergency services vary by the source of referral. Such differences have wider implications for the functioning of the mental health care system as a whole. This study compared three groups of patients in a two-month cohort of 189 patients who were referred for emergency psychiatric assessment at a hospital in England: those who were referred by general practitioners (family physicians), those who were receiving specialist services from community mental health teams, and those who arrived at the hospital from the broader community. METHODS: The three groups were compared on demographic characteristics, clinical and service use variables, risk to self or others, factors that contributed to the emergency presentation, and ratings on standardized scales of functioning. RESULTS: The patients who were receiving specialist services from community mental health teams had high rates of psychosis, often relapsed, and had a history of contact with a psychiatrist. These patients were the most likely to be admitted to the hospital after emergency assessment. The patients who had been referred by general practitioners tended to have fewer indicators of social problems and were more likely to be experiencing a new episode of mental illness. Their referral to the emergency department was most likely to be deemed inappropriate by emergency department clinicians. The patients who came from the broader community were more likely to be male and to exhibit self-harming behavior, substance misuse, and behavioral difficulties. CONCLUSIONS: The rate of emergency referral is one indicator of the functioning of the service system as a whole. Improvements to the system should include better access to community mental health team services and a greater capacity of the primary care system to manage mental health crises. Services need to be developed that are acceptable to male patients who are experiencing social and behavioral problems.     

Community-Based Mental Health Service Utilization Among Low-Income Latina Immigrants

Latina immigrants may be at increased risk for mental illnesses, but have less access to and seek mental health services less often than Black and White counterparts. Guided by the Andersen Behavioral Model of service utilization, the current study employed a medical chart review to elucidate factors associated with use of mental health services at a community health center. Of the clients referred for mental health services, only 36% followed through on the referral. Older age, use of case management services, and depressive symptomatology were predictors of attending mental health services. These findings have implications for community health and mental health providers.     

Patterns of Child and Adolescent Mental Health Care in Greece

During the last 20 years the mental health care system in Greece underwent a dramatic change; the implementation of the EEC Reg. 815/84 programme contributed to a significant shift towards the extramural care and rehabilitation of patients with long-term mental health problems. The child and adolescent mental health (CAMH) care system was transformed by this change to a lesser degree. Despite bureaucratic obstacles and other difficulties, a substantial number of CAMH outpatient services have been developed in Greece. They are concentrated mainly in the larger cities and they focus on providing assessment and to some extent therapy and counselling; prevention and promotion of CAMH are not yet perceived as priority areas. In addition, there is a lack of specialised day care services for specific populations such as young people with disorders of the autistic spectrum and intellectual disabilities. There have been some recent improvements in education and research in the field of CAMH but these sectors are in need of further investment and development. Unfortunately, the current economic crisis has affected both the development of new services and the optimal functioning of those already in operation. Nevertheless, Greece must invest in CAMH and the rights of the children and young people should be protected.     

Experiences of mental health services by people with intellectual disabilities from different ethnic groups: a Delphi consultation

Background Patient experience of those accessing mental health services has been found to be different between ethnic groups. Although the needs of people with intellectual disabilities (ID) from different ethnic communities are being increasingly recognised, little has been published about their experiences of mental health services. The aim of this study was to establish whether there are any differences in the experiences of people with ID and mental health problems from two ethnic communities in South London. Method A two‐round Delphi process was utilised. White British and Black or Black British service users from a specialist community‐based mental health service for adults with ID completed a specially compiled questionnaire. Statements on participants' experiences, including satisfaction with care, staff members' attitudes, cultural awareness and level of support, were rated using a Likert scale. Results Twenty‐four out of 32 participants (75%) completed both rounds of the Delphi consultation. Consensus (≥80% agreement with the group median) was reached for 20 items in the White group and five items in the Black group. All responses that reached consensus were positive about the services that were being received. The Black group were less positive about a range of their experiences, including the use of medication. Conclusions People with ID from two ethnic groups were able to successfully complete a Delphi consultation regarding their experiences of mental health services. Broad consensus on positive experiences of services was reached in the White group but not for the Black participants.     

Mental health service use among 18-year-old adolescent boys: a prospective 10-year follow-up study

OBJECTIVE: To study prevalence and factors associated with mental health service use among 18-year-old adolescent boys. METHOD: Predictors at age 8 and factors at age 18 associated with mental health service use during the preceding 12 months were studied in a general population sample of 2,316 Finnish boys born in 1981 attending military call-up (79% of the original sample). RESULTS: Within the preceding 12 months, 2.1% of the boys had used mental health services. At age 18, internalizing, anxious-depressive, and withdrawal symptoms; health problems; not living with parents; use of illicit drugs; high level of alcohol use; and regular smoking were independently associated with service use. At age 8, a high level of emotional and behavioral symptoms, need for referral, and low school performance according to teacher evaluations predicted service use 10 years later. CONCLUSIONS: Only a minority of adolescents with severe problems had used mental health services. Because of the wide range of problems and comorbidity among service users, there is a need for integration of different services. Education services have a central role in the early detection of those who will later use mental health services.     

Access to specialty mental health services among women in California

OBJECTIVE: The Anderson behavioral model was used to investigate racial and ethnic disparities in access to specialty mental health services among women in California as well as factors that might account for such disparities. METHODS: The study was a cross-sectional examination of a probability sample of 3,750 California women. The main indicators of access to services were perceived need, service seeking, and service use. Multivariate models were constructed that accounted for need and enabling and demographic variables. RESULTS: Significant racial and ethnic variations in access to specialty mental health services were observed. African-American, Hispanic, and Asian women were significantly less likely to use specialty mental health services than white women. Multivariate analyses showed that Hispanic and Asian women were less likely than white women to report perceived need, even after frequent mental distress had been taken into account. Among women with perceived need, African-American and Asian women were less likely than white women to seek mental health services after differences in insurance status had been taken into account. Among women who sought services, Hispanic women were less likely than white women to obtain services after adjustment for the effects of poverty. Need and enabling factors did not entirely account for the observed disparities in access to services. CONCLUSIONS: Additional research is needed to identify gender- and culture-specific models for access to mental health services in order to decrease disparities in access. Factors such as perceived need and decisions to seek services are important factors that should be emphasized in future studies.