Life situation and health status of children and adolescents

In the last decades an increasing number of characteristics of the child's life circumstances have been identified as risk factors for mental health problems. Up to now, the natural distribution of these factors in the population has not been systematically investigated. In the Hamburg Health Survey N=1950 children and adolescents between 4 and 18 years of age and their families representative for Germany have been examined. The questionnaire used asks for sociodemographic variables, pregnancy and birth, kindergarten and school attendance, psychosocial burden and utilization of health services. Complications in pregnancy, birth or in the first year of life arise in every fifth child. Severe childhood illnesses, serious accidents, hospital stays for longer than 14 days or early changes of caregivers have 14% of those investigated. Every tenth child has problems in the kindergarten (mostly separation anxiety), every fourth child has problems in school (especially problems in concentration or performance) and 8% suffer from stressful life events (mostly changed family relations). Mental or physical illness and disabilities are found in 8.5% of all families. Although the majority of all children and adolescents live in healthy life circumstances, risk factors are not as rare as to be neglected. Especially the frequency of problems in kindergarten and school as well as stressful life events indicate that preventive interventions are necessary.     

Establishing ongoing, early identification programs for mental health problems in our schools: a feasibility study

OBJECTIVE: To investigate the feasibility of establishing ongoing, early identification services for mental health problems in school settings. METHOD: School counselors and other mental health professionals (N = 41) in middle, junior, and high schools (N= 23) were given training and supervision in the administration of an evidence-based mental health assessment tool, the Voice Diagnostic Interview Schedule for Children IV (DISC-IV), over the course of 1 1/2 school years. RESULTS: During the study, 530 students were selected to be assessed with the DISC, and 72% were confirmed to be at risk for a mental health problem (DISC+). Among DISC+ cases, 71% had never been in treatment before. The most common problems identified by the DISC were symptoms related to suicide (28%), social phobia (20%), attention-deficit/ hyperactivity disorder (19%), and oppositional defiant disorder (19%). Based on schools' recommendations, 82% of parents with DISC+ children agreed to make an appointment for a follow-up evaluation. Of DISC+ children whose parents agreed to seek further evaluation, 65% of them were evaluated by a health or mental health professional within 2 weeks. CONCLUSIONS: Use of a computerized, evidence-based mental health assessment tool is a feasible strategy for providing early mental health identification services in schools and can help to bridge the gap between mental health providers and the unmet needs of children who are at risk for mental health problems within the community.     

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.     

A Pilot Study Examining a School-Based Parent Engagement Intervention Following School Mental Health Screening

In this pilot study, we conducted a randomized controlled trial to examine the effects of a school-based engagement intervention on parent adherence to recommendations for children screened for social, emotional, behavioral, and adaptive problems at kindergarten entry. The aims were to evaluate the impact of an enhanced feedback session on parents’ adherence to service-engagement recommendations, compared to a standard feedback session, and to examine predictors of adherence to recommendations. Parent and teacher reports of the behavior assessment system for children, second edition, were used to screen children (N = 597). Parents of children identified as at risk for social, emotional, behavioral, and adaptive problems were randomized to the standard or enhanced feedback condition. Results offer preliminary evidence that the school-based engagement strategy following the screening resulted in increased parent adherence to sharing screening results with medical doctors. Analyses also revealed that after controlling for feedback condition, parents’ previous service use predicted adherence to the recommendation of sharing screening results with the teachers. These findings highlight the importance of continued examination of school-based engagement interventions for families in the early stages of seeking mental health services.     

Parental Problem Recognition and Child Mental Health Service Use

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

Identifying adolescents at risk through voluntary school-based mental health screening

This study compares referrals for mental health services among high school students randomized to two means of referral to mental health services: referral via systematic identification through a brief mental health screening procedure (n = 365) or referral via the usual process of identification by school personnel, parents, or students themselves (n = 291). Screened students were significantly more likely than control students (AOR: 21.64 95%CI 6.66-70.36) to receive a referral for mental health services, whether it be to school-based services (AOR: 11.68 95%CI 3.52-8.73) or community-based services (AOR: 20.02 95%CI 2.66-150.41). Post-study, for those screened, 95.5% of school-based mental health services referrals, and 39.3% of community-based referrals were accessed. School based mental health screening identified a significantly greater proportion of youth to be in clinical need of mental health services than would have likely been identified without screening, and increased rates of referral resulted in greater access to mental health services.     

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

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

Towards School Mental Health in Nigeria: Baseline Knowledge and Attitudes of Elementary School Teachers

There is a shortage of child and adolescent mental health (CAMH) professionals all over the world, and this shortage is especially critical in most parts of the developing world. Schools have been identified as ideal settings to reach needy children in the community, and training teachers in CAMH issues can help improve early identification and appropriate referrals of children with mental health problems. As part of a needs assessment for developing a training programme, selected Nigerian elementary school teachers were asked to complete confidential questionnaires to determine their perceptions of mental health problems in school children. Teachers indicated that they had no previous CAMH training. Baseline assessments revealed that teachers' knowledge of CAMH was deficient, and attitudes to children with mental health problems revealed intolerance. Incorporation of CAMH care into teacher education curricula is a critical next step towards integrating school teachers as mental health collaborators in school mental health programmes in Nigeria.     

A school-based program of mental health services

The Brookdale School Program provides mental health consultation and direct services to more than 450 children in a Brooklyn school district through an unusual network involving the local hospital's psychiatry department, the community mental health center, and the school. In the Brookdale program hospital-based psychiatrists and school-based social workers, nurses, and psychologists work with teachers, administrators, and parents to provide insight into the emotional and learning difficulties of some children and to set treatment goals. Two case examples are presented.     

Russian child mental health A cross-sectional study of prevalence and risk factors

Abstract Background The fall of communism and subsequent economic crises have been followed by major social and health problems. High rates of child mental health problems are frequently cited by the Russian media, though there is little relevant evidence. Aims The aim of this study was to investigate the prevalence and associations of child mental health problems in Russia using internationally recognised measures and diagnostic systems. Method A two-stage, two-phase cross-sectional survey of the mental health of 7- to 14-year-olds involved random sampling of schools, followed by random sampling of pupils from school lists. A sample of 448 children was obtained, representing an 83% participation rate. In the first phase, screening measures of psychopathology and risk were administered to parents, teachers and 11- to 14-year-olds. In the second phase, more detailed psychiatric assessments were carried out for subgroups of screen-positive and screen-negative children (N=172). Results The prevalence of psychiatric disorder was about 70% higher than that recently found in Britain with comparable measures, but there were few differences between Britain and Russia in type of disorder or key risk factors. Conclusion There is a pressing need for evidence-based mental health treatments to be made widely available to Russian children and adolescents.     

A package of interventions to reduce school dropout in public schools in a developing country

OBJECTIVE: School dropout rates are staggeringly high in developing countries, even for elementary school children. This study aims to assess the feasibility and initial efficacy of a package of interventions tailored to reduce school dropout in public schools in an urban city in Brazil. METHOD: Two public schools with similar high rates of dropout in elementary grades were selected. In one of them, a package of universal preventive interventions was implemented during a school year, including two workshops with teachers, five informative letters to parents, three meetings with parents at school, a telephone helpline at school, and a 1-day cognitive intervention. For children who stayed ten consecutive days out of school without reason, mental health assessment and referral to mental health services in the community were offered. In the second school, no intervention was implemented. RESULTS: After this 1-year intervention, there were significant differences between the two schools in rates of both dropout (P < 0.001) and absenteeism in the last trimester (P < 0.05; effect size = 0.64). In the intervention school, 18 (45%) youths returned to school after intervention among the 40 at-risk students. Moderate engagement of school staff was the main logistic problem. CONCLUSIONS: Our findings suggest that programs combining universal primary preventive strategies and interventions focused on at-risk students can be implemented and useful in developing countries to reduce school dropout.     

Treatment of atypical anorexia nervosa in the public school: An autistic girl

Because of the increase in public school programs for severely handicapped children, teachers are more likely than ever to be confronted with serious medical or psychological problems like anorexia nervosa. In this case study, desensitization successfully treated the eating disorder of a preadolescent autistic girl. However, the case also accentuated the problems teachers face in making appropriate decisions due to conflicting literature findings, traditional role responsibilities, and lack of expert resources and supportive services in the public school settings. If programs are to meet the needs of these children in the future, service and resource models for the public school settings must be developed.     

Psychological disturbance among 5- to 8-year-old school children: a study from India

This paper presents findings on the prevalence of psychological disturbance among a sample of 5- to 8-year-old Indian school children. The study was cross-sectional with a two-instrument, two-phase design. In the first phase (screening), 48 teachers rated 1535 children (810 boys and 725 girls) drawn from five schools in Bangalore city on the 26-item Children's Behaviour Questionnaire (CBQ). This resulted in 281 children being identified as disturbed, giving a prevalence of 18.3%. In the second phase, 279 of the children identified as disturbed on the CBQ and a matched group of 272 'non-disturbed children' (182 boys and 90 girls) were again rated by teachers, this time using the Child Behaviour Checklist – Teacher Report Form, yielding a corrected prevalence rate of 19.8%. In the same phase, 166 of the disturbed children and a matched group of 169 non-disturbed children were rated by parents using the Child Behaviour Checklist, yielding a corrected prevalence rate of 31.7%. A larger proportion of boys than girls were identified as disturbed by teachers, whereas parents identified a large proportion of disturbed girls. Boys were found to manifest externalizing problems more often, while girls more frequently showed internalizing problems. Learning problems were identified in a substantial number of disturbed boys and girls. Accepted: 8 October 1996     

Prognosis and Continuity of Child Mental Health Problems from Preschool to Primary School: Results of a Four-Year Longitudinal Study

In a four-year longitudinal study, changes in and continuity of behavioral and emotional problems were examined in 814 subjects from kindergarten to primary school. Mental health problems were assessed by means of the Child Behavior Checklist (CBCL). The distribution of the CBCL broadband groups revealed a high level of continuity of internalizing symptoms over the four-year period and a shift from externalizing symptoms at baseline towards a combination of internalizing and externalizing symptoms at follow-up. The presence of mental health problems at follow-up was correlated with gender (higher amongst boys), pre-existing mental health problems at baseline, and separation or divorce of the parents, but not with single-family status or the age and educational level of the mother. The increasing number of children with a combination of internalizing and externalizing symptoms demonstrates the increasing complexity of child mental health problems in the developmental span from preschool age to school age.     

Racial/Ethnic Disparities in Parent Perception of Child Need for Mental Health Care Following School Disciplinary Events

Disciplinary problems at school potentially affect parent perception of child need for mental health care. This article explores effects of a child's first school suspension or expulsion on parent perception of child need for services in three racial-ethnic subgroups. Subjects were mothers participating in a national longitudinal study and their children. First-time school suspension or expulsion positively affected service use and parent-reported service need among white non-Hispanic children, but had little or no effect for African American and Hispanic children. These results suggest that information on child behavior provided to parents by teachers and school administrators can influence parent perception of child service need, but that racial-ethnic differences may exist in parent interpretation of and response to this information. Culturally appropriate approaches to relaying information to parents about child service need may help reduce these differences.     

Assessment, prevention, and intervention activities in a school-based program for children experiencing homelessness

Children who experience homelessness are at increased risk for a range of health and mental health problems. In spite of this increased risk, they are often less likely to receive appropriate services. School-based programs offer considerable potential to reduce the gap between needs and appropriate services for these youth; however, there are few examples of such programs in the published literature. This article provides information from a mental and physical health prevention program and needs assessment for at-risk children, who were experiencing homelessness or were from very low-income families, which was piloted during a summer camp program in an urban school. Results of the needs assessment indicated that children residing in homeless shelters reported less consistent access to medical and dental care than children residing with their families. It is interesting that children experiencing homelessness were more likely to report that they had participated in counseling than did children from low-income families. Satisfaction ratings of prevention activities conducted in the program were positive for students and teachers.     

Identification of childhood psychiatric disorder by informant: comparisons of clinic and community samples.

OBJECTIVE: To compare the identification of psychiatric disorder as informed by parents versus teachers in children aged 6-11 years and parents versus adolescents in youth aged 12-16 years in clinic versus community samples. METHOD: Study data come from parallel surveys in Hamilton, Ontario, of children aged 6-16 years. The surveys included consecutive referrals (N = 1150) between 1989 and 1991 to the region's 2 agencies providing outpatient child mental health services. Also, a simple random sample (N = 1689) was used, drawn in 1989 from students attending public schools. Conduct disorder, hyperactivity, emotional disorder, and somatization disorder were assessed by informants using the original Ontario Child Health Study scales. RESULTS: The percentage of children identified with a disorder was markedly higher in the clinic sample, irrespective of the type of disorder, the age and sex of the child, and who provided the assessment. Also, there was a statistically significant differential shift between parents and teachers in the percentage of children identified with disorder. The ratio of children aged 6-11 years identified with conduct disorder or hyperactivity by parents versus teachers was higher in the clinic sample than in the community sample. Among youth aged 12-16 years, a similar pattern emerged for parents as informants versus the adolescents themselves, but it was statistically nonsignificant. CONCLUSIONS: The data suggest that the relative contribution of informants to the identification of childhood psychiatric disorder varies by sample type: clinic and community. If risk factors for child disorder are influenced by contextually specific factors wedded to informants, then studies conducted in clinic versus community samples may lead to discrepant information about the determinants of psychopathology. The extent of this problem needs to be assessed by comparing the results of parallel studies conducted in clinic versus community samples.     

Management of trauma in special populations after a disaster

Special populations are particularly vulnerable to mental health problems in the aftermath of a disaster. Efficient delivery of mental health services, the integrated use of psychosocial services and mental health facilities, and the active intervention of trained community health care workers can offer effective management of the psychosocial problems of special populations. Women, children, adolescents, the poor, the elderly, and individuals with preexisting health problems have been identified as special populations who often suffer psychological morbidity as a result of a catastrophic disaster. Understanding the cultural, ethnic, and socioeconomic factors in a postdisaster situation is crucial to helping special populations overcome debilitating mental illness and declining quality of life. Planning the delivery of mental health services is critical and includes hazard mapping to identify vulnerable geographic and social areas, screening instruments to identify at-risk populations, and education of community leaders and health care workers. An integrated approach using psychosocial and institutionalized interventions can provide better outcomes than either approach alone. A community-based approach with trained grassroots health care workers can provide effective psychosocial support and rehabilitation services.     

The effect of system intervention on the cognitive control of preschool children.

In response to the high rate of learning problems among socially deprived children, the Baltimore Early School Admission Project set up a system intervention model engaging three points of entry: parents, educators, and mental health workers. The emphasis was on: a) the redefinition of the roles of all participants; b) the school as a self-reliant system, discouraging referrals to outside agencies; c) the development of the children's functioning and adaptive potentials, based on their individual cognitive styles. The program included five public schools. Ninety-one children between the ages of 4 and 5 years were involved. All of these were selected from a hard core socioeconomically deprived population. Eighty-three percent were black and 17 per cent white. Fifteen children were identified as "vulnerable" according to specific criteria provided to the teachers and the parents. Of the vulnerable group, nine children's learning problems were related primarily to emotional and environmental factors, five had perceptual, sensory-motor dysfunction mixed with emotional factors, and one suffered primarily from brain damage. Results indicated that only one of the vulnerable children required referral outside of that provided in the above design. Eleven vulnerable children performed as well as the nonvulnerable group, and three showed a moderate improvement. Furthermore, five children with serious learning problems responded to the systemic intervention as well as they might have with specialized professional help.