Relationship between entry into child welfare and mental health service use

OBJECTIVE: This study examined the relationship between initiation of outpatient mental health service use and level of child welfare involvement. METHODS: Three levels of child welfare involvement were examined: in-home care and no child welfare services beyond an initial investigation, in-home care and additional child welfare services, and placement in out-of-home care (foster care). Longitudinal data were collected for a subsample of children (N=3,592) aged two through 14 years who were enrolled in the National Survey of Child and Adolescent Well-Being, a nationally representative sample of children undergoing investigation for abuse or neglect. Event history analysis was used to model relative risk of initiation of mental health service use over time. RESULTS: Hazard functions revealed a large increase in onset of mental health services immediately after the time of the initial contact with child welfare, varying by level of child welfare involvement and leveling off by three months after the initial contact. The multivariate Cox proportional-hazards model indicated that compared with children who were placed in out-of-home care, those in in-home care who did not receive any further child welfare services were about one-third as likely to use mental health services and those in in-home care who received additional child welfare services were one-half as likely to use mental health services. Other covariates in the model predicted mental health service use, including being older, being Caucasian, having a history of maltreatment (specifically, physical abuse, physical neglect, or abandonment), being uninsured, and need for mental health services, as measured by the Child Behavior Checklist. CONCLUSIONS: Contact with child welfare functions as a gateway into mental health services for children in child welfare, even when need for such services is controlled for.     

Mental health need and access to mental health services by youths involved with child welfare: a national survey

OBJECTIVE:This study assessed the relationship between the need for and use of mental health services among a nationally representative sample of children who were investigated by child welfare agencies after reported maltreatment. METHOD: Data were collected at study entry into the National Survey of Child and Adolescent Well-Being and were weighted to provide population estimates. RESULTS: Nearly half (47.9%) of the youths aged 2 to 14 years (N = 3,803) with completed child welfare investigations had clinically significant emotional or behavioral problems. Youths with mental health need (defined by a clinical range score on the Child Behavior Checklist) were much more likely to receive mental health services than lower scoring youth; still, only one fourth of such youths received any specialty mental health care during the previous 12 months. Clinical need was related to receipt of mental health care across all age groups (odds ratio = 2.7-3.5). In addition, for young children (2-5 years), sexual abuse (versus neglect) increased access to mental health services. For latency-age youths, African-American race and living at home significantly reduced the likelihood of care. Adolescents living at home were also less likely to receive services, whereas having a parent with severe mental illness increased (odds ratio = 2.4) the likelihood of service use. CONCLUSIONS: Routine screening for mental health need and increasing access to mental health professionals for further evaluation and treatment should be a priority for children early in their contact with the child welfare system.     

Behavioral and emotional problems among Turkish children at ages 2 to 3 years

OBJECTIVE: Within the framework of the Mental Health Surveys of Turkey, the authors investigated the distribution and prevalence of parent-reported behavioral and emotional problems in a nationally representative sample of 2- to 3-year-old children. METHOD: A cross-sectional population-based survey from October 1996 through March 1997 using a self-weighted and equal probability sample of Turkish toddlers (N = 638) was conducted. The Child Behavior Checklist Total Problem scores and Household Questionnaire reports by parent informant source (response rate 94.3%) were examined for the effects of child gender, age, urban/suburban/rural residence, and geographic region using multiple regression analyses. RESULTS: Overall, the total problem scores placed 11.9% of the children in the clinically significant range and 18.6% of the children in the borderline range. Urban residence was significantly correlated with the Total Problem scores, Internalization and Externalization scores, and six Child Behavior Checklist syndrome scale scores. The child's age, gender, or parental employment status did not affect Total Problem scores. With respect to the Child Behavior Checklist syndrome scale, girls had higher Anxious/Depressed scores than boys, and 2-year-olds had higher Somatic Complaints scores than the 3-year-old children. None of the children with reported emotional and behavioral problems were referred to any mental health services. CONCLUSION: As part of a national mental health policy in Turkey, there is an urgent need to develop early childhood intervention services that emphasize home visits, center-based child care in the community, and caregiver and provider education and training.     

The Relationship Between Maternal and Child Symptom Change in Community Mental Health

The mental health of mothers and children are closely linked. This study examined the relationship between child and maternal symptom change during a period in which children participated in community mental health treatment. Symptom change was measured using the Child Behavior Checklist for children and the Beck Depression Inventory for Mothers. Results indicate that mothers whose children improve in community mental health treatment are significantly more likely to report a reduction in maternal depressive symptoms than mothers whose children do not improve. Implications of these findings for mental health service settings are discussed.     

Parent–teacher disagreement regarding behavioral and emotional problems in referred children is not a risk factor for poor outcome

OBJECTIVE: To investigate whether parent-teacher disagreement regarding the presence of psychopathology predicts poor outcome in children who have been referred to mental health services METHODS: A total of 532 6- to 12-year-old children who had been referred to an outpatient department for child and adolescent psychiatry were followed up across an average period of 6.3 years. At initial assessment, standardized parent and teacher ratings of the child's psychopathology were obtained with the Child Behavior Checklist (CBCL) and Teacher's Report form (TRF). At follow-up, indices of poor outcome were assessed. RESULTS: Several CBCL and TRF scale scores predicted poor outcome. Discrepancies between CBCL and TRF scores were not useful as additional predictors. Some additive effects were found; future police/judicial contacts and disciplinary problems in school were predicted by CBCL and TRF scores. CONCLUSIONS: The findings underscored the need for information from different informants in clinical practice. However, discrepancies between parent and teacher ratings do not predict outcome, and should not alert clinicians.     

Psychotropic medication use in a national probability sample of children in the child welfare system

OBJECTIVES: The aim of this study was to estimate the point prevalence of psychotropic medication use, and to describe relationships between child-level characteristics, provider type, and medication use among children in the child welfare system. METHODS: The National Survey of Child and Adolescent Well-Being is the first nationally representative study of children coming into contact with the child welfare system. We used data from its baseline and 12-month follow-up waves, and conducted weighted bivariate analyses on a sample of 3114 children and adolescents, 87% of whom were residing in-home. RESULTS: Overall, 13.5% of children in child welfare were taking psychotropic medications in 2001-2002. Older age, male gender, Caucasian race/ethnicity, history of physical abuse, public insurance, and borderline scores on the internalizing and externalizing subscales of the Child Behavior Checklist were associated with higher proportions of medication use. African-American and Latino ethnicities, and a history of neglect, were associated with lower proportions of medication use. CONCLUSIONS: These national estimates suggest that children in child welfare settings are receiving psychotropic medications at a rate between 2 and 3 times that of children treated in the community. This suggests a need to further understand the prescribing of psychotropic medications for child welfare children.     

DSM-IV disorders in children with borderline to moderate intellectual disability. II: child and family predictors

OBJECTIVE: To identify child and family factors that predict DSM-IV disorders in children with intellectual disability. METHOD: In 1997, a total of 968 6- to 18-year-olds were randomly selected from Dutch schools for intellectual disability (response 69.3%). Parents completed the Child Behavior Checklist, Developmental Behavior Checklist, Vineland Screener, and instruments addressing their child's physical health, family functioning, and parental mental health. One year later, parents of 474 children, randomly selected from the 1997 participants (response 86.8%), completed the anxiety, mood, and disruptive disorder modules of the Diagnostic Interview Schedule for Children-IV. RESULTS: Both child and family factors were significantly related to DSM-IV outcome 1 year later. Social incompetence, inadequate daily living skills, child health problems, negative life events, emotional and behavioral problems, and parental mental health problems were the strongest predictors of DSM-IV disorders 1 year later. After correcting for the level of behavioral problems in the previous year, the first four factors proved to be significant risk factors for DSM-IV outcome. CONCLUSIONS: These factors can improve the identification of children at risk and point to topics that need attention in diagnostic and intervention procedures.     

Child and adolescent mental health service use in Finland

Background: The study examines the associations of parent, teacher and self-report evaluations of child psychopathology, help-seeking variables and family factors with the use of child mental health services. Method: The study comprised an 8-year follow-up of the Epidemiological Child Psychiatry Study in Finland. Children were evaluated at age 8 with Rutter parent and teacher scales and with the Child Depression Inventory, and at age 16, with the Child Behavior Checklist and the Youth Self Report. Information was obtained from about 70 % of the follow-up sample (n=857). Results: About 7 % of the sample had been in contact with child mental health services during the follow-up. The most potent predictors at age 8 of later referral were total problem behaviours and antisocial problems in parental evaluation, teacher's evaluation of the child's need for referral and living in other than a biological two-parent family. At age 16, externalizing and internalizing problems, total competence and family composition were independently associated with service use. Conclusions: Both child psychopathology and family disruption were associated with service use. Only a minority of children at risk of psychiatric disorders had used child mental health services. Accepted: 8 February 2001     

Screening for psychopathology in child welfare: the Strengths and Difficulties Questionnaire (SDQ) compared with the Achenbach System of Empirically Based Assessment (ASEBA)

Whilst children in child welfare suffer more psychopathology than their community peers, only a small percentage of them actually receive mental health care. Previous literature suggested that all children entering child welfare should be screened. This study evaluated whether the Strengths and Difficulties Questionnaire (SDQ) could be used for this purpose. The extended version of the SDQ and the Achenbach System of Empirically Based Assessment (ASEBA) questionnaire were administered to parents and caregivers of 292 children in child welfare. Children older than 11 years also completed the SDQ self-report and the Youth Self Report (YSR). Furthermore, the child’s history of service use was recorded and informants were asked if the actual care was sufficient. Inter-informant correlations for the scores from the SDQ and ASEBA were high and comparable or favoured the use of the SDQ (for parents and caregivers). Internal consistency was satisfactory to good. For all informants, high correlations were found between SDQ and ASEBA. Despite high scores on the SDQ, only 29% of the children had received mental health care. Service use was only correlated with the parent SDQ and the CBCL and TRF. Additional help, as requested by 21% of the parents and 37% of the caregivers, correlated moderately with the SDQ and ASEBA scores. Compared to the total difficulties score, the impact supplement is a better predictor of service use and the informant’s request for additional help. This study illustrates that the Dutch version of the SDQ, similar to the English and German versions, has equal validity as the Dutch ASEBA for screening children. Caution is warranted when the SDQ is the only source of information for referrals to specialized care.     

A preliminary meta-analysis of the child behavior checklist in pediatric bipolar disorder.

BACKGROUND: A possible explanation for the ongoing controversy surrounding pediatric bipolar disorder is that differences in assessment methodologies lead to conflicting results. One way to address methodological differences in assessment across studies is to use a single standardized assessment of psychopathology to calibrate the findings reported in different studies. To this end, we conducted a meta-analysis of several studies that have employed the Child Behavior Checklist in the assessment of children with a diagnosis of bipolar disorder. METHODS: MEDLINE was searched for all publications that utilized the Child Behavior Checklist in addition to structured diagnostic interviews to assess pediatric bipolar disorder. Random effects models were used to calculate combined estimates of Child Behavior Checklist clinical subscales. RESULTS: Children with bipolar disorder had scaled scores of >70 in the Aggression, Attention Problems, and Anxious/Depressed subscales of the Child Behavior Checklist. The Child Behavior Checklist was useful in distinguishing bipolar from attention-deficit/hyperactivity disorder subjects. CONCLUSIONS: While there was a significant heterogeneity in estimates between studies, a consistent pattern of elevations in inattention/hyperactivity, depression/anxiety, and aggression was identified.     

一次偶发劫持事件后对儿童心理卫生状况影响的对照研究

目的了解劫持事件对儿童心理卫生状况的影响。方法在上海某小学发生学生被劫持事件后的一月，对被劫持事件发生班级中暴露于劫持事件的全体39名学生使用Achenbach儿童行为量表（CBCL），儿童焦虑性情绪障碍筛查量表（SCARED），Rutter父母及教师问卷进行评估。选取同年级的另外一个班级的所有45名学生作为对照组，采用同样方法进行评估。结果除研究组女生CBCL社交退缩因子与对照组之间有统计学差异外（分别为1．4±1．8，3．1±2．6；t=2．218，P=0．033），研究组与对照组在其他CBCL因子、SCARED和Rutter父母及教师问卷得分差异无统计学意义。结论本次研究未发现偶发劫持事件对儿童心理卫生状况的影响。     

Pathways into and through mental health services for children and adolescents

OBJECTIVE: This study examined points of entry into the mental health service system for children and adolescents as well as patterns of movement through five service sectors: specialty mental health services, education, general medicine, juvenile justice, and child welfare. METHODS: The data were from the Great Smoky Mountains Study, a longitudinal epidemiologic study of mental health problems and service use among youths. The sample consisted of 1,420 youths who were nine, 11, or 13 years old at study entry. Each youth and a parent were interviewed at baseline and every year thereafter about the use of services for mental health problems over the three-year study period. RESULTS: Population estimates indicated that 54 percent of youths have used mental health services at some time during their lives. The education sector was the most common point of entry and provider of services across all age groups. The specialty mental health sector was the second most common point of entry for youths up to age 13 years, and juvenile justice was the second most common point of entry for youths between the ages of 14 and 16. Youths who entered the mental health system through the specialty mental health sector were the most likely to subsequently receive services from other sectors, and those who entered through the education sector were the least likely to do so. CONCLUSIONS: The education sector plays a central role as a point of entry into the mental health system. Interagency collaboration among three primary sectors-education, specialty mental health services, and general medicine-is critical to ensuring that youths who are in need of mental health care receive appropriate services.     

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.     

Methodological Challenges in Assessing Children's Mental Health Services Utilization

This paper describes the reliability and validity of the service assessment for children and adolescents (SACA) for use among Spanish-speaking respondents. The test-retest reliability of the instrument was assessed in a randomly selected clinical sample of 146 Puerto Rican children and adolescents aged 4–17. Both parents and children were administered the SACA twice by independent interviewers over an average 12-day follow-up period. The accuracy of parental and youth self-reports was assessed by comparing these reports to information obtained from medical records. The results showed that parents and children (aged 11–17) were able to report with fair to moderate reliability any last year use of mental health services, any outpatient mental health services, and school services. Residential and hospitalization services were reported by both informants with substantial test-retest reliability. Slight or no test-retest reliability was obtained for parent and child on the use of the specific type of mental health professionals, as well as parental reports of several treatment modalities. Substantial sensitivity of the SACA was obtained when comparing medical records to parental and child reports to lifetime use of any service and outpatient mental health service. Moderate sensitivity was obtained for last year use of mental health services for both parent and child informants.     

Child Welfare Recommendations to Improve Mental Health Services for Children who have Experienced Abuse and Neglect: A National Perspective

This study uses a key informant approach to understand the nature, extent, and quality of outpatient mental health services for children in the child welfare system (CWS) in the United States. We interviewed 89 county child welfare administrators to determine the status of outpatient mental health services and provide recommendations for enhancing care and service delivery. Developed for this study (Caring for Children in Child Welfare), the interview was incorporated in the second formal data collection wave (i.e., 18 months after study baseline assessment) of the National Survey of Child and Adolescent Well-Being. The results highlighted general variability in the degree to which these agencies used evidence-based interventions within outpatient services, demonstrated clinical expertise with this population, and met the needs of their families. Community agency use of evidence-based interventions was found to predict their effectiveness in improving clients’ mental health problems. Proposed suggestions for service improvement varied across domains and reflected the need for more communication/coordination, service access, options and resources, and practice refinements to accommodate families’ needs. We discuss the implications of these recommendations from CWS stakeholders for enhancing the service delivery system. We appreciate the assistance and consultation of Jennifer Rolls-Reutz, Barbara J. Burns, Barbara L. Baumann, Michael Hurlburt, and John Landsverk.     

Use of and need for professional help for emotional and behavioral problems among preadolescents: a prospective cohort study of 3- to 12-year-old children

OBJECTIVE: To determine the effect of child-, parent- and family-related factors on the use of and need for mental health services by 12 years of age. METHOD: A prospective population-based questionnaire study of 1,287 first-born children was launched in Finland in 1985. The Child Behavior Checklist (CBCL) was completed by 1,086 parents when the children were aged 3 years. At the age of 12, the CBCL, the Youth Self-Report, and other potential determinants of service need and use were obtained from 908 parents and 900 children (80% response rate). RESULTS: Of the total sample, 7.2% had used professional services, and 3.3% had needed services without obtaining them. Elevated scores on the age 3 CBCL Total Problems and Externalizing scale predicted independently later service use but not perceived need of services. In cross-sectional data at age 12, parental ratings of the child's problem behavior were associated with both the need for and use of services. Poor social competence and parental distress were independently associated with use of services. CONCLUSIONS: Recognizing behavior problems in early childhood and evaluating family stress factors are important in social and health care systems designed for children.     

Case series: mental health needs and perspectives of rural children reared by parents who abuse methamphetamine

OBJECTIVE: This case-based, mixed-methods study was undertaken to understand the perspectives and mental health needs of rural children exposed to parental methamphetamine abuse. METHOD: Participants were 23 children involved with a state child protective agency because of parental methamphetamine abuse. A semistructured interview provided information on children's perspectives of their families. Information on children's mental health needs was obtained from the Child Behavior Checklist and Trauma Symptom Checklist. Case records and caseworker reports provided information on children's family experiences. RESULTS: Children described emotional pain; few social resources for coping with emotions, problem solving, or talking about their experiences; and avoidant or passive coping skills. Sixty-five percent of children evidenced significant dissociative or posttraumatic symptoms on standardized assessments; 57% had other significant emotional and behavioral problems. Challenges to understanding children's perspectives included children's perceptions that talking about methamphetamine abuse was taboo and underreporting of significant symptoms on the Trauma Symptom Checklist. CONCLUSIONS: The high rate of mental health problems suggests the need for nontraditional strategies for services delivery in rural areas that are targeted toward these vulnerable children. Early identification and treatment of mental health problems should be a priority. Clinicians should be alert to the complexities in assessing children's mental health needs.     

Factors Influencing Perceptions of Need for and Decisions to Solicit Child Mental Health Services by Parents of 9–12 Year-Old Korean Children

As children with emotional or behavioral problems often fail to receive the treatment available to them, this study examined (1) the degree of perceived need (PN) among Korean parents regarding mental health services for their children, (2) the factors associated with such perceptions, (3) the degree to which Korean parents actually engage mental health services for their children, and (4) the factors associated with such use. To determine the degrees of PN and actual use, 1,058 children aged between 9 and 12 years were asked to complete the Children’s Depression Inventory, while their parents completed the Child Behavior Checklist. About 11.4% of the parents demonstrated PN, compared to 2.7% who actually engaged child mental health services. While most of the CBCL factors were associated with PN, the child’s self-report significantly affected the perception as well. The attention problem score in the CBCL was the only factor that strongly corresponded to the actual use of services in Korea, a country where academic achievement is considered paramount, which suggests that cultural forces may play a powerful role in determining parents’ decisions regarding child mental health care.     

Placement into foster care and the interplay of urbanicity, child behavior problems, and poverty

Child welfare involvement is related to involvement with poverty, but the dimensions of that relationship have not been fully explored. Data from the National Survey of Child and Adolescent Well-Being were used to test the relationship between poverty indicators and placement into foster care. Poverty, ages of children, urban or nonurban settings, and the presence of mental health disorders interact to contribute to placement decisions. In urban areas, poverty is strongly associated with involvement with child welfare services, but children's mental health problems are not. In nonurban areas, children's mental health problems are a far greater contributor to child welfare involvement than poverty. Implications for understanding the dual functions of child welfare placements are provided. Child welfare services continue to address the needs of families with children with substantial behavioral problems--yet, federal child welfare policy includes no recognition of this important role.