Child Anxiety Disorders in Public Systems of Care: Comorbidity and Service Utilization

Little is known about mental health service use among children with anxiety disorders, and even less is known about these children in public sectors of care. In this study, 1,715 children were randomly sampled from one of five public service systems. Psychiatric diagnoses were assessed with a structured interview, and standardized measures were used to assess mental health service utilization. Data from a subsample (n = 779) of youth with psychiatric disorders were analyzed. Analyses revealed that comorbidity among children with anxiety disorders was substantially higher than general population estimates. Approximately 26% of children with anxiety had a comorbid mood disorder, and 62% had a disruptive behavior disorder. Among children with anxiety disorders, those who had comorbid conditions were more likely to receive inpatient services than those without comorbidity. Comorbidity, caregiver strain, and service sector were associated with inpatient and nonspecialty service use in this group. Findings underscore the substantial comorbidity among children with anxiety disorders in public sectors of care and the potential need to adapt evidence-based interventions to meet the complex and multiple needs of these children.     

Racial differences in the mental health needs and service utilization of youth in the juvenile justice system

Mental health placement rates by the juvenile justice system differ by race. However, it is unknown whether mental health needs differ by race. This study attempted to investigate potential differences in mental health needs and service utilization among Caucasian, African American, and Hispanic juvenile justice involved youth. A stratified random sample of 473 youth petitioned, adjudicated, and incarcerated from 1995–1996 was examined using a standard chart review protocol and the Childhood Severity of Psychiatric Illness measure for mental health needs. Significant and unique mental health needs were demonstrated for all racial groups. African American youth demonstrated the greatest level of needs. Minority status indicated significantly lower rates of mental health service utilization. Minority youth in the juvenile justice system are most at risk for underserved mental health needs. Based on the current data, it can be inferred that the first contact with the state's child and adolescent serving system, which includes the juvenile justice and mental health sectors, appears to be through the juvenile justice sector for many minority youth with delinquency problems.     

Disparities in Use of Mental Health and Substance Abuse Services by Asian and Native Hawaiian/Other Pacific Islander Women

The purpose of this study was to determine if disparities exist in lifetime utilization of mental health/substance abuse services among Asian, Native Hawaiian/Other Pacific Islander (NHOPI) and white mothers. The study sample was comprised of mothers assessed to be at-risk (n = 491) and not at-risk (n = 218) for child maltreatment in the Hawaii Healthy Start Program study. Multiple logistic regression models were used to test the effects of predisposing, need, and enabling factors on utilization of services. Results revealed that, among mothers with depressive symptoms, compared with whites, Asians and NHOPI were significantly less likely to have received services. There were no significant racial differences in use of mental health/substance use services by other factors. These results suggest that racial disparities exist in utilization of mental health/substance abuse services among mothers with depressive symptoms. Future research is needed to identify barriers and facilitators to accessing needed services for Asian and NHOPI women.     

Immigrant Status,Mental Health Need,and Mental Health Service Utilization Among High-Risk Hispanic and Asian Pacific Islander Youth

This study examined youth mental health service (MHS) use as a function of family immigrant status and type of mental health need (internalizing vs. externalizing). A sample of Hispanic and Asian/Pacific Islander families (youth ages 11–18; N = 457) involved with public sectors of care provided reports of youth mental health need during an initial interview and MHS use was examined prospectively over 2 years. While externalizing need predicted specialty and school-based MHS use in the overall sample, family immigrant status moderated the association between youth need and specialty MHS use such that immigrant youth were more likely to receive services for externalizing need and less likely to receive services for internalizing need relative to non-immigrant youth.     

Factors Associated with Mental Health Services Use among Disconnected African-American Young Adult Population

Research related to mental health service use among vulnerable young adults is limited. This study used an expanded version of Andersen’s Behavioral Model of Health Services Use to evaluate factors associated with the use of different types of mental health services among a sample of predominantly African-American 16–24 year olds (n = 500) in an employment training program in Baltimore City. Results indicated that participants were more likely to have received mental health services in correctional facilities than in community- or school-based contexts. Use of mental health services in correctional facilities was significantly greater among males, those less than 18 years, and those who experienced more stressful events. Findings illustrate the need to develop seamless mental health services for vulnerable young adults in multiple contexts, including the criminal justice system.     

Mother protection,child survival: narrative perspectives on child mental health services underutilization

In the United States, increased national attention has generated a wealth of public health and epidemiologic research examining disparities in African American children’s mental health services utilization. Research has not yet been extended to examining the social structural mechanisms that keep these disparities stable and in place. Drawing from a larger urban ethnographic field study exploring the ‘everyday’ of health and illness within and across African American families living in an inner city public housing community, in this article I document the narratives of four African American mothers to illustrate how social structural mechanisms shape their decisions to seek or not mental health services for their children. I frame mothers’ decisions in terms of everyday violence, drawing attention to the institutionalized injustices that are normalized and rendered invisible because of their routine pervasiveness. I conclude with a discussion of integrating structural interventions to modify or reduce disparities in African American children’s mental health services utilization.     

Emotional Distress and Mental Health Service Use Among Urban Homeless Adolescents

The Expanded Behavioral Model for Vulnerable Populations was used to examine the predisposing, enabling, and need factors associated with mental health service use in a homeless adolescent sample (N = 688). Among all youth, 32% perceived a need for help with mental health problems and 15% met Brief-Symptom Inventory (BSI) criteria for emotional distress. The rate of mental health service use in our sample was 32%. One enabling factor, having a case manager/discussed mental health concerns, and one need factor, which met criteria for BSI, were found to be associated with mental health service use in the past 3 months. The majority of youth who used mental health services had obtained services from crisis centers. Among those who perceived a need for help with mental health problems but who did not use services, the most common barrier was not knowing where to go or what service to use (57%). These findings suggest that due to the high prevalence of mental health problems among homeless youth, it would be helpful for service providers coming into contact with youth to make them aware of existing community resources for mental health services; making youth aware of these resources may in turn decrease the rate of crisis center use and instead allow youth to receive mental health services in outpatient settings that provide continuity of care.Research was conducted in collaboration with the David Geffen School of Medicine at University of California, Los Angeles, Department of Family Medicine (Dr. M.R. Solorio, Mr. S. Trifskin, and Dr. M.A. Rodríguez); NPI-Semel Institute for Neurosciences, Center for Community Health, University of California, Los Angeles (Dr. N.G. Milburn); and School of Public Health, Department of Health Services, University of California, Los Angeles (Dr. R.M. Andersen).     

Racial/Ethnic Disparities in Health and Health Care among U.S. Adolescents

Objective

To examine racial/ethnic disparities in medical and oral health status, access to care, and use of services in U.S. adolescents.

Data Source

Secondary data analysis of the 2003 National Survey of Children''s Health. The survey focus was children 0–17 years old.

Study Design

Bivariate and multivariable analyses were conducted for white, African American, Latino, Asian/Pacific Islander, American Indian/Alaskan Native, and multiracial adolescents 10–17 years old (n = 48,742) to identify disparities in 40 measures of health and health care.

Principal Findings

Certain disparities were especially marked for specific racial/ethnic groups and multiracial youth. These disparities included suboptimal health status and lack of a personal doctor or nurse for Latinos; suboptimal oral health and not receiving all needed medications in the past year for African Americans; no physician visit or mental health care in the past year for Asian/Pacific Islanders; overweight/obesity, uninsurance, problems getting specialty care, and no routine preventive visit in the past year for American Indian/Alaska Natives; and not receiving all needed dental care in multiracial youth.

Conclusions

U.S. adolescents experience many racial/ethnic disparities in health and health care. These findings indicate a need for ongoing identification and monitoring of and interventions for disparities for all five major racial/ethnic groups and multiracial adolescents.     

Racial and Ethnic Disparities in the Continuation of Community-Based Children’s Mental Health Services

This paper examines racial and ethnic disparities in continuation of mental health services for children and youth in California and how English language proficiency moderates the effect of race/ethnicity on the continuation of service. While previous research indicated racial/ethnic or geographic disparities in accessing mental health services among children and youth, few studies specifically focused on the continuation of mental health care. The authors used administrative data from California county mental health services users under age 25. Applying logistic regression, English language proficiency was found to be the major determinant of continuation of mental health services in this age group. With the exception of children of Asian descent, non-English speaking children and youth of diverse racial/ethnic background were significantly less likely to continue receiving mental health services compared with White English-speaking peers, even after controlling for sociodemographic, clinical and county characteristics.     

Adolescents entering chemical dependency treatment in private managed care: ethnic differences in treatment initiation and retention

PurposeThere has been little research on adolescents of different ethnicities in chemical dependency (CD) treatment, despite a focus on ethnic disparities in health care in recent years. In particular, little is known about ethnic differences in utilization of adolescent CD services.MethodsWe examined treatment initiation and treatment retention in a sample of African American, Native American, Latino, Asian American, and Caucasian adolescents entering CD treatment in a private, managed care health plan (n = 419). Our conceptual framework included ethnicity as the main factor as well as measures of external pressure and internal motivation/readiness for treatment, family environment, psychiatric co-morbidities, and severity of alcohol and drug problems. Logistic and Poisson regression were used to examine differences.ResultsThe study found ethnic differences in treatment initiation and treatment retention. Native American adolescents had lower odds of returning after intake to initiate treatment compared with Caucasians (odds ratio [OR] .35, p = .009), and African American youth spent less time in treatment than Caucasians (RR: .49, p < .001).ConclusionsStudy findings indicate differences in treatment initiation for Native Americans and in treatment retention for African Americans. Intake and orientation sessions offer an opportunity to intervene with Native American youth. Given their high psychiatric co-morbidity, they may also benefit from the availability of psychiatric services. Even after adjusting for severity, we found shorter treatment retention for African American adolescents and suggest that organizational factors, such as cultural competency, may play an important role.     

Health and Mental Health Care Utilization by Clients of Resources for Homeless Persons in Quebec City and Montreal,Canada: A 5-Year Follow-Up Study

The objective of this cohort study is to describe the service utilization by clients of homeless resources in Quebec and Montreal (Canada) over a 5-year period. Participants (N = 426) were recruited from a survey conducted in 1999 about clients’ utilization of resources intended for homeless people in Montreal and Quebec. Data analyzed in this study were also drawn from three administrative databanks managed by the Quebec health care system. Results revealed that: (1) in general, mental health services are less used than physical health services; (2) generally, women, older persons, nonhomeless persons, and persons with mental health problems utilized proportionately more health services; and (3) participants involved in this study tend to continue using services over years in a system where health services are free. These findings are discussed in terms of long-term service utilization by clients of homeless resources.     

A multi-site study of medicaid-funded managed care versus fee-for-service plans' effects on mental health service utilization of children with severe emotional disturbance

Although Medicaid-funded managed care arrangements are commonly used in the delivery of mental health and substance abuse services to low-income children and youth, little is known about the effectiveness of such efforts. This article examines differences in mental health services utilization between children and youth with severe emotional disturbance covered by Medicaid-funded managed care behavioral health plans and those covered by fee-for-service plans. Data are from a federally funded multi-site study. In multivariate analyses controlling for child and caregiver demographic and clinical factors, enrollment in a managed care behavioral health plan was associated with lower inpatient/residential, psychiatric medication, and nontraditional services utilization. No difference was found in outpatient services utilization. Medicaid-funded managed care behavioral health plans appear to reduce use of some types of mental health services, but it is important to address the question of whether low-income children's enrollment in such programs deprives them of needed services.     

Differences in Use of Health Services Between White and African American Children Enrolled in Medicaid in North Carolina

Objectives: Racial differences in health status and use of health services persist in the United States and are not completely explained by differences in socioeconomic status. This study examines differences in use of health services between White and African American children enrolled in Medicaid, controlling for other factors that affect service use. We make comparisons for use of primary preventive services, diagnosis and treatment of selected common childhood illnesses, and Medicaid expenditures. Methods: We linked Medicaid enrollment records, Medicaid paid claims data, and data on use of child WIC services to birth certificates for NorthCarolina children born in 1992 to measure use of health services and Medicaid expenditures by race for children ages 1, 2, 3, and 4. Logistic and Tobit regression models were used to estimate the independent effect ofrace, controlling for other variables such as low birth weight, WICparticipation, and mother's age, education, and marital status. Since allchildren enrolled in Medicaid are in families of relatively low income, racial differences in socioeconomic status are partially controlled.Results: African American children had consistently lower Medicaidexpenditures and lower use of health servicesthan did White children,after statistically controlling for other maternal and infantcharacteristics that affect health service use, including child WICparticipation. For example, total annual Medicaid expenditures were $207–303 less for African American children than for White children,controlling for other variables. African America children were significantly less likely to receive well-child and dental services than were White children. Conclusions: African American children enrolled in Medicaid use healthservices much less than White children, even when controlling forsocioeconomic status and other factors that affect service use. Linkingstate administrative databases can be a cost-effective way of addressingimportant issues such as racial disparities in health service use.     

Rural–urban disparities in the utilization of mental health inpatient services in China: the role of health insurance

Reducing rural–urban disparities in health and health care has been a key policy goal for the Chinese government. With mental health becoming an increasingly significant public health issue in China, empirical evidence of disparities in the use of mental health services can guide steps to reduce them. We conducted this study to inform China’s on-going health-care reform through examining how health insurance might reduce rural–urban disparities in the utilization of mental health inpatient services in China. This retrospective study used 10 years (2005–2014) of hospital electronic health records from the Shandong Center for Mental Health and the DaiZhuang Psychiatric Hospital, two major psychiatric hospitals in Shandong Province. Health insurance was measured using types of health insurance and the actual reimbursement ratio (RR). Utilization of mental health inpatient services was measured by hospitalization cost, length of stay (LOS), and frequency of hospitalization. We examined rural–urban disparities in the use of mental health services, as well as the role of health insurance in reducing such disparities. Hospitalization costs, LOS, and frequency of hospitalization were all found to be lower among rural than among urban inpatients. Having health insurance and benefiting from a relatively high RR were found to be significantly associated with a greater utilization of inpatient services, among both urban and rural residents. In addition, an increase in the RR was found to be significantly associated with an increase in the use of mental health services among rural patients. Consistent with the existing literature, our study suggests that increasing insurance schemes’ reimbursement levels could lead to substantial increases in the use of mental health inpatient services among rural patients, and a reduction in rural–urban disparities in service utilization. In order to promote mental health care and reduce rural–urban disparities in its utilization in China, improving rural health insurance coverage (e.g., reducing the coinsurance rate) would be a powerful policy instrument.     

Barriers to mental health treatment services for low-income African American women whose children receive behavioral health services: an ethnographic investigation

Despite the prevalence of mental illness among low-income African American women, only a limited number seek and/or accept help from mental health service delivery systems. A qualitative analysis of 64 ethnographic interviews of low-income African American women whose children receive behavioral health services was completed to assess what barriers to care were reported for the women themselves. These African American women were interviewed as part of a larger study seeking to determine why mothers seek mental health treatment for their children, but not themselves, after many of the women (n = 32) met the baseline criteria for anxiety and/or depression. Our finding revealed that (1) the fear of losing their children, (2) economic stressors, (3) role strain, (4) perceptions of the system, and (5) violence and survival are key factors to consider when engaging low-income African American women in mental health treatment services. These factors have a negative influence on help seeking that should be considered for eliminating disparities in access to and utilization of mental health services.     

Referral sources,diagnoses, and service types of youth in public outpatient mental health care: A focus on ethnic minorities

Racial/ethnic variations in clinical and service delivery characteristics among youth in public outpatient mental health services were examined using data from San Diego County mental health service programs for fiscal year 1996 to 1997 (N=3,962). Differences in referral sources, primary diagnoses, and service types were investigated for three racial/ethnic groups (African Americans, Asian/Pacific Islander Americans, and Latinos) compared to non-Hispanic whites. Controlling for age, gender, functional impairment, and prior service use, significant differences by race/ethnicity were found for all three variables studied. Possible explanations for these variations and future directions for research are discussed.     

Psychopathology as a Predictor of Medical Service Utilization for Youth in Residential Treatment

Rising health care costs have led to an emphasis on identifying factors that contribute to medical service utilization. Previous research has suggested an association between youth psychopathology and service utilization; however, prospective studies among high-risk populations are needed. The current study examined youth psychopathology as a predictor of subsequent medical service utilization among a large sample (N?=?536) of youth entering residential treatment. Youth psychopathology and medical status were assessed at intake, and medical service utilization was tracked across the duration of the residential placement. Results indicated that higher levels of psychopathology predicted greater youth medical service utilization, even after controlling for the presence of a diagnosed medical condition. Internalizing problems was a significant independent predictor of utilization, but externalizing problems was not. These findings highlight the association between mental health and medical service utilization and suggest that effective behavioral health services may be helpful in reducing costly medical service needs.     

Residential segregation,geographic proximity and type of services used: Evidence for racial/ethnic disparities in mental health

Residential characteristics influence opportunities, life chances and access to health services in the United States but what role does residential segregation play in differential access and mental health service utilization? We explore this issue using secondary data from the 2006 Medical Expenditure Panel Survey, 2006 American Medical Association Area Research File and the 2000 Census. Our sample included 9737 whites, 3362 African Americans and 5053 Latinos living in Metropolitan Statistical Areas. Using logistic regression techniques, results show respondents high on Latino isolation and Latino centralization resided in psychiatrist shortage areas whereas respondents high on African American concentration had access to psychiatrists in their neighborhoods. Predominant race of neighborhood was associated with the type of mental health professional used where respondents in majority African American neighborhoods were treated by non-psychiatrists and general doctors whereas respondents in majority Latino neighborhoods saw general doctors. Respondents high on Latino Isolation and Latino Centralization were more likely to utilize non-psychiatrists. These findings suggest that living in segregated neighborhoods influence access and utilization of mental health services differently for race/ethnic groups which contradicts findings that suggest living in ethnic enclaves is beneficial to health.