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.     

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.     

Characteristics of patients and patterns of psychiatric service use in ethnic minorities

BACKGROUND: The differential uptake of psychiatric services by ethnic minorities has been widely reported. Less attention has been given to comparisons of these patients and variations in the types of interventions they receive. AIMS: To assess whether for people accessing psychiatric services in the UK, differences exist across ethnic groups both in their sociodemographic characteristics and patterns of mental health care utilisation. METHODS: All adults resident in an inner city health district and using psychiatric services during a six-month period were identified. Demographic, clinical and service use data were collected from staff and records. These were compared across black Caribbean, Indian, Pakistani, Irish and white ethnic groups for two broad diagnostic categories: psychotic/bipolar and depressive/neurotic disorders. RESULTS: There were significant differences between ethnic groups on most demographic variables in each of the diagnostic categories. There were variations in the level of contact with different mental health professionals. The only significant difference in the use of specific services was for those with psychotic/bipolar disorders, black Caribbean patients being more likely to be detained in hospital compulsorily. CONCLUSIONS: Ethnic diversity both in the characteristics of patients and their patterns of psychiatric care should be addressed when planning and developing services.     

Health professionals' attitudes and emotions towards working with adults with intellectual disability (ID) and mental ill health

Objectives Mainstream mental health services are providing more care for individuals with an intellectual disability (ID); this has implications for staff and service users. Attitudes of staff towards people with ID in mental health services may be negative and negative staff attitudes may have a detrimental impact on service provision. Design A cross‐sectional design was used. Methods A questionnaire designed to investigate the attitudes and emotions of staff towards delivering mental health care to adults with ID was completed by 84 staff from mainstream and specialist ID services. Results Staff in both services experienced more positive emotions when working with clients whom they are currently employed to work with. When the frequency of contact with adults with ID, the number of individuals worked with and the amount of formal ID training received were considered, there was no significant difference between the attitudes of staff in both services. Positive correlations were found between attitude scores and positive emotional experiences in both services. Conclusions The research suggests that numerous factors, including the role of emotional experience and a number of environmental aspects, need to be considered in the context of providing mental health services to adults with ID to ensure the highest quality. Research limitations and clinical implications of the study are also considered.     

Mental health problems in children and young people from minority ethnic groups: the need for targeted research

In this editorial we argue for the need for better research evidence on the prevalence of child mental health problems in minority ethnic groups, service utilisation among these groups and whether some service barriers are specific for certain groups. Without such evidence it is not possible to influence policy and practice so that evidence-based and appropriate services can be designed and offered to these populations. The terms ethnicity, race and migration are often imprecisely defined, and mental health needs and outcomes vary between immigrants from different generations. There is also a complex interplay between minority status and social class, with terms such as ethnicity being a proxy for multifaceted sociocultural and economic variables. However, we need to start collecting better data on children from minority ethnic groups so that these relationships can be understood, services tailored on the available evidence and ultimately better care delivered to this group of children.     

BIOMED‐MEROPE* project: service provision for adults with intellectual disability: a European comparison

The aim of the present paper is to describe and compare services for adults with intellectual disability (ID) and mental health needs in five European countries: Austria, England, Greece, Ireland and Spain. A framework and structure for collecting information about service provision was designed. This information was collected through a mixture of interviews with service providers, questionnaires and a review of the research literature within each country. Information was collected on historical context, policy, legislation, assessment, treatment and the structure of services for people with ID and mental health problems. Overall, the needs of those with additional mental health needs have not been specifically addressed at a national level with perhaps the exception of England and Ireland, although there are still gaps in services in these nations. Normalization has been adopted in each of the five countries, and there are moves toward deinstitutionalization, integration and inclusion. Families and self‐advocacy groups have grown. The pace of this change varies between and even within countries. The main findings of the study include: unclear policy, trends for legislative changes, increased prevalence of mental health problems, inadequate generic service provision, a need for specialist mental health services, a need for improved interconnections of services, and a need for training developments. Policy and legislation in the five European countries under consideration tend to separate the disability aspects of people with ID from their mental health needs. Consequently, the service needs of this group remain largely invisible. This might be a direct reflection of policy clarity and legislation, or could be the result of a failure to implement existing guidelines. This has a detrimental effect on the lives of people with ID, and their families and carers.     

Annotation: New research into general psychiatric services for adults with intellectual disability and mental illness

Background   There are a variety of models for the mental health care of adults with comorbid intellectual disability (ID) and mental illness. There has been a long-running debate as to whether this should be provided by general psychiatric or specialised ID services. A previous review concluded that there was no clear evidence to support either model with research being often of a poor quality, lacking replication, and outcome measures were often inappropriate or varied between studies. This review aims assess differences in outcome for patients with ID and mental disorders treated in general or specialised ID mental health services.
Method   A literature review was conducted using electronic databases and websites of ID and mental health organisations to locate all references where people with ID receive mental health care in general psychiatric services from 2003. No meta-analysis was attempted because of the divergent nature of the studies.
Results   People with ID (especially severe ID) have reduced access to general psychiatric services. General psychiatric inpatient care is unpopular especially with carers but can be improved by providing specially trained staff and in-reach from community ID teams. Opportunities may exist to enhance the care of people with borderline intellectual functioning within general psychiatric services.
Conclusions   Although no new randomised controlled trials have been published, the weight of research is accumulating to suggest that provision of general psychiatric services without extra help is not sufficient to meet the needs of people with ID.     

Ethnic minority status and adolescent mental health services utilization

Adolescents who are members of ethnic minority groups constitute a large and ever increasing proportion of the population. While the information base regarding mental health problems and mental health services utilization in adolescents in general is slowly increasing, relatively little knowledge has accumulated about the particular needs and practices of youth of color. The purpose of this article is to review the available literature about adolescent mental health needs and service utilization as well as literature regarding adult ethnicity and mental health service utilization. The conclusion of this review is that significant gaps exist in our knowledge base regarding ethnicity in adolescents and its implications for the utilization of mental health services. The limited data available suggest that significant numbers of adolescents of color have multiple needs for mental health care and that a complex set of barriers exists to prevent them from obtaining appropriate services. A variety of suggestions are offered to improve the opportunities for and the quality of mental health services for ethnic minority adolescents.     

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.     

A qualitative study of barriers to mental health services utilisation among migrants from mainland China in south-east Sydney

BACKGROUND: Chinese-language speakers comprise the largest non-English speaking population in Australia but they have among the lowest rates of mental health services utilisation. MATERIAL: A bilingual (Mandarin/English) researcher conducted in-depth interviews with China-born mental health patients and members of the general community, and mental health service providers. DISCUSSION: Participants identified several factors that limit access to mental healthcare as well as the quality of care received: mental health literacy, communication difficulties, stigma, confidentiality concerns, service constraints and discrimination. Cross-cultural communication was not just a matter of hearing individual words but also appreciating idioms and cultural and social references. CONCLUSION: Findings have implications for the prevention and treatment of mental disorders among migrants from China, and caution against assuming heterogeneity within ethnic groups. Mental health services must become more culturally competent in their attempts to engage the target group and to deliver both acute and continuing care.     

The development of a new measure for the assessment of psychopathology in adults with intellectual disability

Background   People with intellectual disability (ID) and untreated psychiatric disorder lead unnecessarily difficult and unhappy lives. The prevalence of mental illness in children and adults with ID is greater than that found in the general population. A carer-completed checklist of psychopathology that could be used with both children and adults would help identify those individuals with ID most likely to have a mental health problem, help ensure that they receive the limited services that are usually available and also assist the process of clinical assessment, diagnosis and management.
Method   This research aimed to develop a reliable and valid carer-completed checklist of psychopathology for adults with ID by redeveloping an existing measure for children with ID, the Developmental Behaviour Checklist (DBC-P). The new checklist, The Developmental Behaviour Checklist for Adults (DBC-A) was devised by changing, deleting and adding to DBC-P items. Reliability studies were conducted with paid and family carers, and DBC-A scores were compared with the results from two other measures of psychopathology.
Results   One DBC-P item was deleted, seven items changed and 12 items added. The psychometric properties of this new checklist, the DBC for Adults with ID (DBC-A), were investigated and found to be satisfactory. Intraclass correlations for test-retest and inter-rater reliability ranged from 0.72 to 0.85, and concurrent validity with two measures of emotional and behavioural disturbance was satisfactory.
Conclusions   The carer-completed DBC-A provides a broad and comprehensive survey of the emotional and behavioural problems of adults with ID. It has satisfactory psychometric properties and therefore can be used with confidence in clinical, research and service settings, and its development allows continuous assessment of psychopathology across the lifespan for all people with ID.     

Mental health services and young people with intellectual disability: is it time to do better?

Background There is evidence that the mental health needs of children with disabilities are inadequate. The aim of the present study was to determine the extent of specialist health service use during adolescence by a group of individuals with intellectual disability (ID) and mental health problems. Method The study population consisted of 80 young people with ID, who were examined in childhood and adolescence for psychiatric and behaviour disorder. These young people were interviewed again in early adult life for the presence of psychiatric and behaviour disorder. Evaluation questionnaires were used during the follow‐up study to assess service use from adolescence. Results The key finding was that the great majority (64%) of subjects with persistent challenging behaviour from childhood into adult life and those with an established childhood psychiatric disorder received no specialist mental health care. Conclusions The development of mental health services for this vulnerable group with complex psychiatric and behaviour disorders has been poor for a number of reasons, including lack of recognition at the primary care level and insufficient numbers of trained professionals within specialist services.     

Child and adolescent mental health in South Africa

Mental health problems in childhood and adolescence pose a major threat to public health. Epidemiological studies in high, middle and low income countries indicate that approximately one in five children and adolescents suffer from a mental disorder. In many instances these persist into adulthood. In South Africa, HIV infection, substance use, and exposure to violence increase vulnerability to mental disorders. Child and adolescent mental health services play a key role in reducing the burden of mental disorders in childhood and later in adulthood. This paper focuses on service needs for children and adolescents in South Africa. It commences with a discussion of the prevalence of child and adolescent psychiatric disorders after which the legal and policy context of child and adolescent psychiatric services is described. A framework for child and adolescent mental health service provision is presented, following which steps for reducing the extent of unmet service need are considered. The paper concludes with a call to scale up child and adolescent mental health services in South Africa, based on the stark realities of unmet need and the constitutional rights of children and adolescents to appropriate mental health care.     

The role of ethnicity in clinical psychopathology and care pathways of adults with intellectual disabilities

The objective of this study was to explore whether people with intellectual disability from ethnic minority groups have higher rates of mental health problems and access different care pathways than their White counterparts. Clinical and socio-demographic data were collected for 806 consecutive new referrals to a specialist mental health service for people with intellectual disabilities in South London. Referrals were grouped according to their ethnic origin. The analyses showed that there was an over-representation of referrals from ethnic minority groups with diagnoses of schizophrenia spectrum disorder. In addition, Black participants were more likely to have an autistic spectrum disorder. Referrals of ethnic minority groups were considerably younger than White referrals, and less likely to be in supported residences. The results are discussed in the context of cultural and familial factors in particular ethnic groups that may play an important role in accessing and using mental health services.     

The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and well-being

OBJECTIVE: To identify the prevalence of three mental disorders (Depressive Disorder, Conduct Disorder and Attention-Deficit/Hyperactivity Disorder), the prevalence of mental health problems, the health-related quality of life of those with problems, and patterns of service utilisation of those with and without mental health problems, among 4-17-year-olds in Australia. To identify rates of health-risk behaviours among adolescents with mental health problems. METHOD: The mental disorders were assessed using the parent-version of the Diagnostic Interview Schedule for Children Version IV. Parents completed the Child Behaviour Checklist to identify mental health problems and standard questionnaires to assess health-related quality of life and service use. The Youth Risk Behaviour Questionnaire completed by adolescents was employed to identify health-risk behaviours. RESULTS: Fourteen percent of children and adolescents were identified as having mental health problems. Many of those with mental health problems had problems in other areas of their lives and were at increased risk for suicidal behaviour. Only 25% of those with mental health problems had attended a professional service during the six months prior to the survey. CONCLUSION: Child and adolescent mental health problems are an important public health problem in Australia. The appropriate balance between funding provided for clinical interventions focusing on individual children and families and funding for interventions that focus on populations, requires careful study. The latter are an essential component of any strategy to reduce mental health problems as the high prevalence of problems makes it unlikely that individual care will ever be available for all those needing help. Clinical and population health interventions must take into account the comorbid problems experienced by children with mental disorders.     

Posttraumatic stress symptoms and mental health services utilization in adolescents with social anxiety disorder and experiences of victimization

Recent findings from studies on adults show similarities between social anxiety disorder (SAD) and posttraumatic stress in the form of recurrent memories and intrusive and distressing images of earlier aversive events. Further, treatment models for SAD in adults have been successfully developed by using transdiagnostic knowledge on posttraumatic stress symptoms (PTSS). Studies on adolescents are though missing. The present study aimed at exploring the association between PTSS and SAD in Swedish adolescents. A second aim was to study mental health services utilization in relation to these conditions. A total of 5,960 high-school students participated and reported on SAD, life time victimization, PTSS and mental health service utilization. Socially anxious adolescents reported significantly higher levels of PTSS than adolescents not reporting SAD and this difference was seen in victimized as well as non-victimized subjects. Contact with a school counselor was the most common mental health service utilization in subjects with SAD and those with elevated PTSS. In the prediction of contact with a CAP-clinic, significant odds ratios were found for a condition of SAD and elevated PTSS (OR = 4.88, 95 % CI = 3.53–6.73) but not for SAD only. Screening of PTSS in adolescents with SAD is recommended. The service of school counselors is important in detecting and helping young people with SAD and elevated PTSS. Clinical studies on SAD and PTSS in adolescents could aid in modifying treatment models for SAD.     

Multiple exposure to life events and clinical psychopathology in adults with intellectual disability

BACKGROUND: Relatively few studies have examined the impact of life events on mental health in the field of intellectual disability (ID), despite the possibility that adults with ID and mental health problems might be particularly vulnerable to multiple events. AIMS: To examine the impact of multiple life events on mental health in people with ID. METHOD: The sample consisted of 281 men and women with ID consecutively referred to a specialist mental health service in South-East London. For each participant, key informants completed the PAS-ADD Life Events list, while psychiatric diagnoses were made by clinicians based on ICD-10 criteria. RESULTS: Logistic regression analysis revealed that single exposure to life events was significantly associated with female gender, schizophrenia, personality disorders and depression. However, multiple exposure to life events was associated with personality disorder, depression and adjustment reaction. CONCLUSIONS: The present results suggest an increased vulnerability to life events in people with ID. A better understanding of the relationship between life events and mental health can enhance the development of interventions, which may benefit substantially this particular population.     

Understanding ethnic differences in mental health service use for adolescents’ internalizing problems: the role of emotional problem identification

Although immigrant adolescents are at least at equal risk of developing internalizing problems as their non-immigrant peers, immigrant adolescents are less likely to use mental health care. The present study is the first to examine ethnic differences in problem identification to find explanations for this disparity in mental health service use. Specifically, the extent to which emotional problem identification mediates the relationship between immigrant status and mental health service use for internalizing problems in three immigrant populations in the Netherlands (i.e., Surinamese, Turkish, and Moroccan) was investigated. A two-phase design was used to include adolescents at risk for internalizing problems. Data were used from the second phase, in which 349 parents and adolescents participated (95 native Dutch, 85 Surinamese, 87 Turkish, and 82 Moroccan). Results indicated that mental health service use for internalizing problems is far lower among immigrant adolescents than among native Dutch adolescents, although differences between immigrant groups were also substantive. A lack of emotional problem identification was identified as an essential mediator in the relationship between immigrant status and mental health service use. Since the results suggest the low levels of problem identification in our immigrant samples may serve an explanatory role in the relationship between immigrant status and mental health service use, future research should aim at understanding these ethnic differences in problem identification.     

Change in children’s emotional and behavioural problems over a one-year period

Although children with emotional or behavioural problems are at increased risk of future problems, knowledge of factors associated with persistence and change in child problems, once these problems exist, is limited. Using repeated measures analyses of variance, the present study investigated the association of parental problem recognition, professional and informal service use, and sociodemographic factors with change in child problems over a one-year period, in a sample of 360 children and adolescents with emotional and behavioural problems. Higher overall problem levels were found in children (aged 4–11 years at baseline) versus adolescents (aged 12–17 years), in boys, and in children with less educated parents, which indicates the need to address preventive actions at these groups. Although rates of service use were low, children who had been in contact with general practitioners or mental health services had higher overall problem levels, suggesting that children who need it most end up receiving professional care. Although child emotional and behavioural problems decreased significantly over time, this change was not associated with utilisation of professional or informal services. Our findings imply the need for methodologically sound research into the effectiveness of professional and informal services for child emotional and behavioural problems.     

Working with Children Affected by Hurricane Katrina: Two Case Studies in Play Therapy

In August 2005 Hurricane Katrina hit the Louisiana and Mississippi Gulf Coast Regions. Throughout history, mental health professionals have primarily focused on adults as the identified victims of natural disasters. More recently, mental health professionals are focused on integrating mental health services to children and adolescents. This article discusses the impact natural disasters have on children, and the related traumatic stress response and post traumatic stress disorder often experienced by children. Treating children can be complicated and a developmentally appropriate intervention is needed. Evidenced-based research has shown play therapy to be a developmentally effective intervention with traumatised children. This article presents two case studies of play therapy with children affected by Hurricane Katrina.