The Fort Bragg Continuum of care Demonstration Project: The population served was unique and the outcomes are questionable

Examination of the evaluation sample and the outcome data from the Fort Bragg Demonstration Project suggests that the children served were mildly disturbed, were atypical of those served in most public mental health clinics, spent less than optimal time in the new services developed, and were judged as making considerable progress with minimal treatment regardless of age or level of judged psychopathology. The use of normative outcome measures in a pre-post design was considered a major reason for failure to find any significant differences between differently treated children.     

Refining the Costs Analyses of the Fort Bragg Evaluation: The Impact of Cost Offset and Cost Shifting

A key aim of the evaluation of the Fort Bragg Demonstration was to determine whether delivering services through a continuum of care lowered expenditures on mental health services. The evaluation clearly showed that expenditures were actually higher in the Demonstration. Critics of the evaluation claimed that the evaluation's perspective on costs was too narrow—in particular, that the Demonstration produced cost shifting and cost offset that were not captured by the evaluation. New data allow us to include a broader array of costs: mental health services received outside the catchment areas, general medical services for the children themselves, and mental health services used by family members. Results showed that reductions in other costs do partially offset higher expenditures on mental health services for children at the Fort Bragg Demonstration. However, even when broader costs are included, total family expenditures are still substantially higher at the Demonstration.     

The costs of mental health services under the Fort Bragg Demonstration

This article examines the costs of treatment under the Fort Bragg Demonstration. It focuses on the direct costs of mental health services and suggests that expenditures on those services were much higher at the Demonstration. Increased access and greater "doses" of services provided at the Demonstration are identified as the proximal causes of the system-level cost difference. Consideration is given to whether these differences in costs and in service use can be attributed to the continuum of care per se or to differences in the financial arrangements under which care was provided. Supplemental analyses suggest that these expenditures were not offset by cost savings elsewhere. Implications for mental health policy are discussed.     

The Ventura Planning Model: a proposal for mental health reform

The Ventura Planning Model is a proposal for public mental health reform. It addresses the decline in mental health funding. It offers a rationale for increased support--and funding--for public mental health services. The Planning Model grew out of the experience of implementing and operating the Ventura Children's Demonstration Project. The model has five characteristics, or planning steps: 1) multi-problem target population; 2) systems goals; 3) interagency coalitions; 4) services and standards; and 5) systems monitoring and evaluation. The Ventura Children's Demonstration Project implemented these planning steps, with an infusion of $1.54 million in funds from the state legislature. The project offset at least 66 percent of its cost by reducing other public agency costs and improved a variety of client-oriented outcomes. The success of the project in offsetting its costs has led the legislature to provide additional funds for three more California counties to implement the model for children and youth, and $4 million a year for four years for Ventura County to test the model for adults and seniors. Emphasizing cost offsets in addition to client-oriented outcomes provides a practical rationale for proposing increases in public mental health funds. This rationale also implies substantial changes in the operations of many public mental health agencies.     

Problems reported for clinically referred American and Dutch children

Child Behavior Checklists completed by parents of 50 children of each sex at each age from 4 to 16 seen in 28 American and 21 Dutch mental health services (N = 2,600) were examined. Analyses controlling for sex, age, and socioeconomic status showed somewhat higher total problem scores for American than Dutch children, with a mean of 57.27 versus 53.18 on a scale ranging from 0 to 240. This nationality difference accounted for less than 1% of the variance in total scores. American children obtained higher scores on more externalizing items than Dutch children. Small but significant differences in total, externalizing, and internalizing problems found between the two samples may reflect nationality differences in referral patterns. Competence scores were significantly higher for American than Dutch referred children, but did not differ as much as in comparable normative samples. Competence scores may reflect cultural differences more than problem scores do.     

Longitudinal Determinants of School-Based Mental Health Service Use for Girls and Boys with Externalizing Behavior Problems

Studies suggest that girls with externalizing problems (ExtP) who receive school-based mental health services may have more severe impairments than boys. In addition, girls with ExtP who receive mental health treatments have been found do so for shorter durations, but this remains to be confirmed among children receiving school-based mental health services. This study sought to (1) examine gender differences in students’ characteristics and problem severity at study inception and in mental health service use at school at 12-, 24- and 36-month follow-up and (2) investigate longitudinal child, family and school determinants of service use among girls and boys. Participants were 370 elementary school students (149 girls) receiving school-based mental health services for ExtP. Child, family and school determinants of mental health services at school were examined ecologically from parent and teacher reports at study inception and follow-up points. Proportionally more girls than boys presented clinical ExtP and fewer retained services at each follow-up point. Multilevel generalized estimating equations models indicated that, among girls, conflict with teacher, affiliation with deviant peers and poor academic functioning significantly increased the likelihood of mental health service use over time but that ExtP severity was the most robust independent predictor. A broader set of determinants emerged for boys, including ExtP severity, internalizing problems and affiliation with deviant peers. These results suggest that adults may be more sensitive to boys’ difficulties than to girls’ and that girls who receive school mental health services typically present more severe impairments.     

Methodological issues in evaluating mental health outcomes of a children's mental health managed care demonstration

A key question of the Fort Bragg Evaluation was whether the continuum of care model implemented at the Demonstration produced better mental health outcomes for children and adolescents than a traditional system of care. This article describes a few of the key methodological issues that were addressed to help ensure that findings about mental health outcomes were valid. The research design was quasi-experimental and longitudinal. Nearly 1,000 families participated, and attrition was low throughout the study. Multiple informants responded to a comprehensive array of widely used instruments in the area of children's mental health and mental health services. Despite the absence of random assignment, sites were comparable upon entry to the study on numerous factors that might affect outcome. Further, data lost through the course of study did not vary appreciably across sites. Finally, some evidence suggests that the findings of the Outcome Study may generalize to other populations of low-middle to middle-class youth in treatment.     

Characteristics of children and adolescents in a psychiatric hospital and a corrections facility

Popular opinion holds that youngsters in corrections programs are delinquents in need of reform, whereas youngsters in psychiatric settings have mental health problems and need therapy. Yet some literature suggests that youth in the two settings may not differ greatly in their mental health status. The authors compared demographic, emotional, and behavioral characteristics of youngsters placed in public psychiatric hospital and corrections settings, and they found few differences. Child Behavior Checklist scores for social competence and total problems were high and quite similar for youngsters in the two settings. White children scored significantly worse than black children on Child Behavior Checklist Internalizing, Externalizing, and total problems in corrections settings but not in the psychiatric hospital. Moreover, race was the only variable that predicted the site in which youth were placed. The findings suggest a need to study (1) the mental health needs of youngsters in nonmental health settings and (2) the procedures by which youth are assigned to service settings.     

Unmet need for mental health care among U.S. children: variation by ethnicity and insurance status

OBJECTIVE: Policy discussions regarding the mental health needs of children and adolescents emphasize a lack of use of mental health services among youth, but few national estimates are available. The authors use three national data sets and examine ethnic disparities in unmet need (defined as having a need for mental health evaluation but not using any services in a 1-year period) to provide such estimates. METHOD: The authors conducted secondary data analyses in three nationally representative household surveys fielded in 1996-1998: the National Health Interview Survey, the National Survey of American Families, and the Community Tracking Survey. They determined rates of mental health service use by children and adolescents 3-17 years of age and differences by ethnicity and insurance status. Among the children defined as in need of mental health services, defined by an estimator of mental health problems (selected items from the Child Behavior Checklist), they examined the association of unmet need with ethnicity and insurance status. RESULTS: In a 12-month period, 2%-3% of children 3-5 years old and 6%-9% of children and adolescents 6-17 years old used mental health services. Of children and adolescents 6-17 years old who were defined as needing mental health services, nearly 80% did not receive mental health care. Controlling for other factors, the authors determined that the rate of unmet need was greater among Latino than white children and among uninsured than publicly insured children. CONCLUSIONS: These findings reveal that most children who need a mental health evaluation do not receive services and that Latinos and the uninsured have especially high rates of unmet need relative to other children. Rates of use of mental health services are extremely low among preschool children. Research clarifying the reasons for high rates of unmet need in specific groups can help inform policy and clinical programs.     

Diagnosis and pharmacotherapy issues in the care of Hispanics in the public sector

Clinical data from 1,752 ambulatory patients treated at five public mental health clinics were used to test hypotheses concerning the diagnoses and psychopharmacotherapy of Hispanic patients compared with Anglos and blacks. Hispanics were less likely than the other two groups to be labeled schizophrenic but more likely to be diagnosed as having other mental illnesses. Hispanics were less likely to receive medication than the other two groups. However, when pharmacotherapy was used there were no significant differences among groups in the number of medications prescribed. There were no differences among the groups in the doses prescribed.     

The relationship of religiosity to older adults' mental health service use

This article uses data from the Naturally Occurring Retirement Community (NORC) Demonstration Project (N = 326) to examine older adults' utilization of mental health services. This study is guided by the behavioral model of health service utilization and helps to fill gaps in the literature by including religious affiliation, religiosity, and interaction terms as variables in regression models. These variables are important, as religion is more important in the lives of older adults than in the lives of their younger counterparts. This study found the rate of use of mental health services during the previous six months to be 19.0%, and those with higher levels of private religious activity and higher levels of intrinsic religiosity are more likely to have accessed some form of mental health service. However, frequency of attendance at religious services is not associated with the use or non-use of services. Information from this study suggests that more research is needed to specify the manner in which religious affiliation and religiosity work to affect the use of mental health services, and future studies must include religious variables in order for models of service use to be complete.     

The quality of services in a children's mental health managed care demonstration

The Fort Bragg Demonstration and evaluation was designed to test the cost-effectiveness of a continuum of care model of service delivery for children and adolescents. A crucial aspect of the evaluation was the measurement of the quality of services provided in the Demonstration. Two key service components were examined: intake assessment and case management. It was concluded that these key components of the continuum of care were implemented with sufficient quality to have the theoretically predicted effects on mental health.     

Effect of maternal mental health problems on child treatment response in community-based services

OBJECTIVE: Many mothers bringing children for community mental health treatment need mental health services themselves. Moreover, children of mothers with mental health problems enter treatment with more severe symptomatology than do other children. However, little is known about how maternal mental health problems affect children's response to treatment. This study examined the impact of maternal mental health status on the child's treatment response. METHODS: The mental health of 272 mother-child pairs was assessed twice, when children entered treatment at three community mental health clinics and again three months later. Analysis of variance was used to examine the impact of maternal mental health status on children's rate of improvement. RESULTS: Children of mothers with mental health problems had significantly greater behavior problems (F=34.54, p<.001) and demonstrated less improvement over time (F=4.44, p=.04) than children of mentally healthy mothers. CONCLUSION: These findings suggest that treatment for mothers as well as children could be beneficial for this population.     

Mental health services utilization in a children's mental health managed care demonstration

Service delivery under two systems of care--a traditional Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) reimbursement system and an innovative continuum of care--was examined along six dimensions: access, type, mix, volume, timing, and continuity of services received by children and adolescents. It was found that the Demonstration served over three times as many children as the Comparison. In addition to serving more children, the Demonstration also provided more and different types of services to each child treated. Finally, the Demonstration appears to have delivered services in a more timely fashion and made a considerable effort to match children's and families' needs with services.     

Dissimilarity in Vulnerability: Self-Reported Symptoms Among Children with Experiences of Intimate Partner Violence

Children with experiences of intimate partner violence (IPV) are at risk. Not all children, however, display symptoms, and differences connected to gender and age have been demonstrated. In this exploratory study, children’s own reports of symptoms were used. The 41 recruited children, between 7 and 19 years old, were entered into a group program specially directed toward children with experiences of IPV. These children reported experiencing more symptoms overall when compared with non-exposed children. The relationship to the abuser and children’s symptoms related differently for boys and for girls. Girls who had continued contact with the abusive father described more mental health problems than did other girls exposed to IPV and more than did boys with continued contact. Among children with experiences of custody disputes or other judicial processes, age rather than gender was connected to differences in self-reported symptoms. Younger children with experiences of judicial processes reported more mental health problems than did those with no experience.     

Childrens mental health and civil society in the Gaza strip

The Gaza Strip, with a population of 1.7 million, over half of whom are under 18 years old, has existed in a state of ongoing conflict and containment for years, most notably since its closure in 2007. There is much concern for the mental health of the vast young generation who have little memory of other circumstances of existence, and even less exposure to the outside world. Their society forms the site of direct conflict and social destruction pertaining to untreated stress among the adults. However, leaving the social realm for the institutional for mental health treatment carries strong taboo, especially for adults. Civil society expert organisations offering a range of mental health work primarily pertaining to childrens social development can bypass some of this taboo and can also intervene at their schools and in their families, and may be most strategically located as social rather than institutional actors. Empowering the youth and seeking to strengthen Gazan society through them and for them causes some friction with the local government. However, despite the cultural and political challenges of mental health treatment for children within the Gaza Strip, the wider fact remains that however treated and psychosocially rehabilitated, society is predictably the site of renewed trauma in the short term and foreseeable future, enmeshing the mental health of its future generation inseparably with the international politics it inhabits.     

The significance of childhood neurosis for adult mental health: a follow-up study.

The author compared the mental health of 42 young adults who had suffered from a neurosis in childhood with that of 20 control subjects. Various aspects of functioning were clinically assessed using the Current and Past Psychopathology Scales and the Health-Sickness Rating Scale. More than 75% of the former patients were at least mildly ill at follow-up, compared with only 15% of the control group. Intergroup differences in diagnoses and symptoms are described. The findings establish the fact that neurotic children require much more effective treatment than they have traditionally received in order to attain a good prognosis for adult mental health.     

Cost-outcome analysis and service planning in a CMHC

The outcome of outpatient treatment of 497 children and 396 adults at a large community mental health and mental retardation center was associated with cost of services and with clients' number of sessions, length of stay, and density of treatment. The cost of one hour of outpatient services averaged $53.15 for adults and $52.32 for children. Treatment outcome was not directly related to cost of treatment, but clients who regressed used more resources than did clients whose conditions remained the same. Adults who improved were in therapy for a shorter period than were adults who became worse, but they were treated more times per month. The cost-outcome analysis methodology described here can be useful in forecasting the effects of budget reductions on case mix and treatment outcome, in developing effective service models for various funding levels, and in identifying optimal caseloads.     

Severity of children's psychopathology and impairment and its relationship to treatment setting.

OBJECTIVE: The study investigated the settings in which children and adolescents were treated to determine whether clinicians assigned individuals who had greater needs to more intensive treatment. METHODS: Subjects were 603 children four to 16 years of age who visited a mental health treatment facility in Western Australia, where, as is the case throughout Australia, universal publicly funded health care is provided. DSM-IV criteria were used to make diagnoses, and clinicians assessed each child's level of impairment. The clinicians assigned the children to inpatient treatment, day treatment, or outpatient treatment, or they saw the child only for a psychiatric consultation. Measures included parents' and children's reports of children's psychopathology and parents' reports of family functioning, family life events, and parental mental health symptoms and treatment. RESULTS: Clinicians' ratings of impairment were highest for children assigned to the inpatient and day treatment settings. Parents' ratings of total psychopathology and of internalizing and externalizing symptoms were highest for children in the inpatient and day treatment settings. Parents' reports also indicated that family dysfunction and parental alcohol problems were most severe in the inpatient group. No differences in parents' mental health problems were found across treatment settings. CONCLUSIONS: Children with more severe psychopathology and more severe family dysfunction and parental problems were more likely to be provided treatment in the most costly and time-intensive treatment settings. The results provide empirical evidence for what many clinicians consider best clinical practice-to assign children and families to treatment settings appropriate to their level of impairment.     

Have there been changes in children's psychiatric symptoms and mental health service use? A 10-year comparison from Finland

OBJECTIVE: To study the differences in children's psychiatric symptoms and child mental health service use at two time points: 1989 and 1999. METHOD: Two cross-sectional representative samples of 8- to 9-year-old children from southern Finland were compared. The 1989 sample consisted of 985 children, of whom 95% participated, and the 1999 sample consisted of 962 children, of whom 86% participated. Information was gathered from parents and teachers using Rutter's questionnaires and other related determinants of service use and from children using the Child Depression Inventory. The sampling, procedure, and methods were similar at both time points. RESULTS: The overall rate of children's problems assessed by parents and teachers had not increased during the period 1989 to 1999. Boys had fewer psychiatric symptoms in 1999 than in 1989, whereas no clear change had occurred in girls' symptoms, except that, according to parents, girls in 1999 had more hyperactive symptoms. However, children themselves reported more depressive symptoms in the 1999 than in the 1989 sample. In 1989, 2.3% and in 1999, 5.3% of children had used child mental health services. The increase in service use among girls was fourfold. Parental evaluations of child psychopathology and teacher evaluations whether the child was psychologically healthy were the strongest determinants for referral at both time points. Parents preferred to seek help for their children's problems from teachers, school nurses, and school psychologists rather than from specialized child psychiatric services. CONCLUSIONS: There has been an increase in mental health service use especially among girls as well as a convergence of symptom levels by gender. It is important to develop child psychiatric services that are as close to the child's living environment as possible to further reduce the threshold for seeking help and to promote early detection and intervention.