Factors Associated with the Referral of Anxious Children to Mental Health Care: the Influence of Family Functioning,Parenting, Parental Anxiety and Child Impairment

This study aims to identify factors that predict the mental health care referral of anxious children. In total, 249 children and families, aged 8–13 years, participated: 73 children were referred with anxiety disorders to mental health care [mean (M) age =10.28, standard deviation (SD) =1.35], 176 non‐referred anxious children recruited in primary schools (M age =9.94, SD =1.22). Child anxiety and other disorders were assessed with semi‐structured interviews. Child anxiety symptoms, behavioural problems, parental anxiety, the parenting styles overprotection, autonomy encouragement, rejection, and the family functioning dimensions control and relational functioning, were assessed with child, father and mother report on questionnaires. The summed interference rating of children's anxiety disorders was a predictor of referral, consistent over child and parent reports, but not comorbidity. Most family and parenting variables did not predict referral, nor differed between the referred and non‐referred sample. Contrary to our hypothesis, maternal self‐reported anxiety decreased the odds of referral and child reported parental autonomy granting increased, while child reported overprotection decreased the odds of referral. The impairment for the child due to the number and severity of their anxiety disorder(s) is, based on child, mother and father report associated with referral. This indicates that those who need it most, receive clinical treatment. Copyright © 2014 John Wiley & Sons, Ltd.     

Depressive and Disruptive Disorders and Mental Health Service Utilization in Children and Adolescents

ObjectiveTo examine the relationship of depressive and disruptive disorders with patterns of mental health services utilization in a community sample of children and adolescents.MethodData were from the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The sample consisted of 1,285 child (ages 9–17 years) and parent/guardian pairs. Data included child psychopathology (assessed by the Diagnostic Interview Schedule for Children), Impairment, child need and use of mental health services, and family socioeconomic status.ResultsAfter adjusting for potential confounding factors, disruptive disorder was significantly associated with children's use of mental health services, but depressive disorder was not. For school-based services, no difference was found between the 2 types of disorders. Parents perceived greater need for mental health services for children with disruptive disorders than for those with depression. Conversely, depression was more related to children's perception of mental health service need than was disruptive disorder.ConclusionsThe findings highlight the need for more effective ways to identify and refer depressed children to mental health professionals, the importance of improving school-based services to meet children's needs, and the necessity to better educate parents and teachers regarding the identification of psychiatric disorders, especially depression. J. Am. Acad. Chlid Adolesc. Psychiatry, 1999, 38(9):1081–1090.     

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

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

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.     

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.     

Profile of children investigated for sexual abuse: association with psychopathology symptoms and services

Sexually abused children may have poor mental health because of their victimization as well as preexisting or co-occurring family problems. However, few studies consider psychopathology in relation to both abuse and other family experiences. This study uses data from the National Survey of Child and Adolescent Well-Being (NSCAW) to create latent subgroups of 553 children investigated for sexual abuse. The study investigates children's psychological symptoms and child welfare service (CWS) patterns to understand how children's needs relate to mental health services. Analyses were conducted by child age: 3-7, 8-11, and 12-14. Factor mixture modeling and regression analyses were used. Results show meaningful subgroups of children that relate to different symptom patterns. Among 3- to 7-year-olds, behavioral symptoms are associated with caregiver domestic violence and mental illness. Among 8- to 11-year-olds, depressive symptoms are associated with severe abuse and multiple family problems, whereas posttraumatic stress is associated with chronic, unresolved abuse. Although many children received mental health services, services are not well matched to children's needs--the substantiation status of the abuse explains services. Implications for CWS and mental health services are discussed.     

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.     

Family burden and care participation: A test-retest reliability study of an interview instrument concerning families with a severely mentally ill family member

Objective: Many youngsters with mental health problems are not referred to mental health clinics. Parents play an important role in the referral process of youngster to mental health clinics. The main aim of this study was to explore the role of the parent–child relation for referral of adolescents to outpatient psychiatric clinics. Method: Employing a cross-sectional design, we compared a referred sample of 39 adolescents in outpatient psychiatric treatment with a non-referred matched control sample of 39 adolescents. The Parental Bonding Instrument and Youth Self-Report were employed to assess the characteristics of these two population groups. Results: Adolescents referred to Norwegian mental health clinics for mental health problems report more perceived care from mothers and a trend of more care from fathers compared with non-referred controls matched on level of mental health problems, age and gender. Implications of the finding for the role of parents on referral of adolescents to mental health clinics and for treatment compliance are discussed.     

A prospective study of childhood psychopathology: independent predictors of change over three years

BACKGROUND: Whilst the correlates of child mental health problems are well understood, less is known about factors that operate to maintain healthy or unhealthy functioning, or that contribute to change in functioning. A range of factors may be of interest here, including relatively stable characteristics of children or their environment, that may have long-lasting and enduring consequences for their mental health, along with events that prompt changes in a child's mental state. METHODS: Children were followed up 3 years after the original survey for a sub-sample of the 1999 British Child and Adolescent Mental Health Survey (N = 2,587 children). Latent mental health ratings drew on data provided by parent, teacher, and youth versions of the Strengths and Difficulties Questionnaire at baseline, and at follow-up. A residual scores method was used to assess change in functioning over time. RESULTS AND CONCLUSIONS: Latent mental health scores showed strong stability over time (r = 0.71) indicating the need for effective intervention with children who have impairing psychopathology, since they are unlikely to get better spontaneously. A poorer outcome was associated with: externalizing as opposed to emotional symptoms, reading difficulties; living in a single-parent or reconstituted family at baseline; and after exposure between Time 1 and Time 2 to parental separation, parental mental illness, child illness, and loss of a close friendship. All these factors could be targeted in public health or clinical interventions, particularly as predictors of change in child mental health were closely comparable across the range of initial SDQ scores, suggesting that they operated in a similar manner regardless of the initial level of (mal)adjustment.     

Pilot study for the Quebec Child Mental Health Survey: Part II. Correlates of DSM-III-R criteria among six to 14 year olds.

A pilot study for a Quebec Child Mental Health Survey was completed in 1990 with 139 six to 14 year olds from the general population. The following variables, which were correlated with child psychopathology, were studied for each age group (six to 11 years, 12 to 14 years) and informant (parent, child): child's gender and stressful life events, respondent parent's psychiatric illness, family structure, parent-child relationships, parents' relationship, socioeconomic status, respondent parent's social desirability. Correlations obtained are consistent with those found in the literature. Correlations between the parent's mental health, parent-child relationships and the children's mental health are the most important results of the study.     

Service Use and Perceived Service Effectiveness for People with Intellectual Disability and Dual Diagnosis in Israel

Introduction: Studies regarding the use of support services for persons with a dual diagnosis of intellectual disability and psychopathology are scarce; even fewer have focused on children and young adults. The aim of the present study, conducted in Israel, was to compare the use of support services and their perceived effectiveness by families of children and young adults with intellectual disability (ID) and with dual diagnosis. Methods: Data were collected from 195 family (parental) caregivers of individuals with ID or dual diagnosis, aged 10–30. Using a structured questionnaire, family caregivers reported on the use of support services and on their perceived effectiveness. Results: Findings showed that in addition to the obvious mental health services, caregivers of individuals with ID and dual diagnosis report using a range of services and resources. Caregivers of persons diagnosed only with ID perceived some of the mental health services as being more effective than did caregivers of individuals with dual diagnosis. Conclusion: We advocate for enhanced training for professionals working with individuals with dual diagnosis within all services. Furthermore, parents need to be supported in their search for services for their child and in dealing with complex situations. In addition, more research is needed to identify why individuals with dual diagnosis may not benefit from current mental health services and, in line with this, develop more effective services. Finally, we advocate for the establishment of a one-stop shop that can provide for the comprehensive needs of these individuals within one center.     

Prognostic value of parent–adolescent disagreement in a referred sample

Objective To investigate whether parent–adolescent disagreement regarding reports on adolescents’ psychopathology indicates a poor prognosis. Methods A total of 151 11- to 18-year-olds who had been assessed with the Child Behavior Checklist (CBCL) and Youth Self-Report (YSR) at referral to an outpatient psychiatry clinic were followed up. At follow-up, 4.3 years later, signs of poor outcome were assessed. Findings Discrepancies between CBCL and YSR scores predicted future disciplinary problems at school, police/judicial contacts, and drug use. Conclusions To determine the prognosis of psychopathology in adolescents who are referred to mental health services, discrepancies between parents and adolescents may be useful. Given the relatively large number of statistical comparisons (n=16) that was needed to obtain these results, future studies are needed to test if the results are robust across different settings.     

Modelling sources of informant variance in parent and teacher ratings of child psychopathology

Factors influencing agreement between parent and teacher ratings of child psychopathology were studied in a population-based survey of 1458 children aged six to 11. Child psychopathology was assessed with the Child Behaviour Checklist. Agreement on the internalizing scale, the externalizing scale, and the total score was assessed using log-linear models. Characteristics of the children and the informants, as well as variables pertaining to the testing conditions, were examined as possible predictors of informant agreement. In general, parent–teacher agreement was low on all three scales, especially on the internalizing scale, although it was significantly better than chance. Most of the beyond-chance agreement was due to the tendency for parents to give higher ratings when teachers did (correlation of ratings). Measures representing the teacher's familiarity and contact with the child were significant predictors of agreement for both the internalizing and externalizing scales. Agreement on the externalizing ratings was also influenced by several other factors, including the child's age and religion, the parent informant's gender and education, as well as school grade. Predictors of agreement on the total score included the child's age and gender, factors related to the child's academic functioning and need for treatment as perceived by the parent, and the parent's and teacher's preference for different mental health treatment providers. Copyright © 1998 Whurr Publishers Ltd.     

Mental health service use among 18-year-old adolescent boys: a prospective 10-year follow-up study

OBJECTIVE: To study prevalence and factors associated with mental health service use among 18-year-old adolescent boys. METHOD: Predictors at age 8 and factors at age 18 associated with mental health service use during the preceding 12 months were studied in a general population sample of 2,316 Finnish boys born in 1981 attending military call-up (79% of the original sample). RESULTS: Within the preceding 12 months, 2.1% of the boys had used mental health services. At age 18, internalizing, anxious-depressive, and withdrawal symptoms; health problems; not living with parents; use of illicit drugs; high level of alcohol use; and regular smoking were independently associated with service use. At age 8, a high level of emotional and behavioral symptoms, need for referral, and low school performance according to teacher evaluations predicted service use 10 years later. CONCLUSIONS: Only a minority of adolescents with severe problems had used mental health services. Because of the wide range of problems and comorbidity among service users, there is a need for integration of different services. Education services have a central role in the early detection of those who will later use mental health services.     

Longer-term effects of school-based counselling in UK primary schools

Children’s mental health is deteriorating while access to child and adolescent mental health services is decreasing. Recent UK policy has focused on schools as a setting for the provision of mental health services, and counselling is the most common type of school-based mental health provision. This study examined the longer-term effectiveness of one-to-one school-based counselling delivered to children in UK primary schools. Data were drawn from a sample of children who received school-based counselling in the UK in the 2015/16 academic year, delivered by a national charitable organisation. Mental health was assessed at baseline, immediately post-intervention, and approximately 1 year post-intervention, using the Strengths and Difficulties Questionnaire (SDQ) completed by teachers and parents. Paired t tests compared post-intervention and follow-up SDQ total difficulties scores with baseline values. Propensity score matching was then used to identify a comparator group of children from a national population survey, and linear mixed effects models compared trajectories of SDQ scores in the two groups. In the intervention group, teacher and parent SDQ total difficulties scores were lower at post-intervention and longer-term follow-up compared to baseline (teacher: baseline 14.42 (SD 7.18); post-intervention 11.09 (6.93), t(739) = 13.78, p < 0.001; follow-up 11.27 (7.27), t(739) = 11.92, p < 0.001; parent: baseline 15.64 (6.49); post-intervention 11.90 (6.78), t(361 = 11.29, p < 0.001); follow-up 11.32 (7.19), t(361) = 11.29, p < 0.001). The reduction in SDQ scores was greater in the intervention compared to the comparator group (likelihood ratio test comparing models with time only versus time plus group-by-time interaction: χ² (3) = 24.09, p < 0.001), and model-predicted SDQ scores were lower in the intervention than comparator group for 2 years post-baseline. A one-to-one counselling intervention delivered to children in UK primary schools predicted improvements in mental health that were maintained over a 2 year follow-up period.

     

Contextual predictors of mental health service use among children open to child welfare

BACKGROUND: Children involved with child welfare systems are at high risk for emotional and behavioral problems. Many children with identified mental health problems do not receive care, especially ethnic/minority children. OBJECTIVE: To examine how patterns of specialty mental health service use among children involved with child welfare vary as a function of the degree of coordination between local child welfare and mental health agencies. DESIGN: Specialty mental health service use for 1 year after contact with child welfare was examined in a nationally representative cohort of children aged 2 to 14 years. Predictors of service use were modeled at the child/family and agency/county levels. Child- and agency-level data were collected between October 15, 1999, and April 30, 2001. SETTING: Ninety-seven US counties. PARTICIPANTS: A total of 2823 child welfare cases (multiple informants) from the National Survey of Child and Adolescent Well-being and agency-level key informants from the participating counties. MAIN OUTCOME MEASURES: Specialty mental health service use during the year after contact with the child welfare system. RESULTS: Only 28.3% of children received specialty mental health services during the year, although 42.4% had clinical-level Child Behavior Checklist scores. Out-of-home placement, age, and race/ethnicity were strong predictors of service use rates, even after controlling for Child Behavior Checklist scores. Increased coordination between local child welfare and mental health agencies was associated with stronger relationships between Child Behavior Checklist scores and service use and decreased differences in rates of service use between white and African American children. CONCLUSIONS: Younger children and those remaining in their homes could benefit from increased specialty mental health services. They have disproportionately low rates of service use, despite high levels of need. Increases in interagency coordination may lead to more efficient allocation of service resources to children with the greatest need and to decreased racial/ethnic disparities.     

Changes in psychiatric problems and service use among 8-year-old children: a 16-year population-based time-trend study

OBJECTIVE: To study differences in children's psychiatric symptoms and child mental health service use at three time points: 1989, 1999, and 2005. MethoD: Three cross-sectional representative samples of 8-year-old children were compared from southern Finland. The sampling, procedure, and methods were similar at all three time points. Information was gathered from parents and teachers using Rutter questionnaires and other related determinants of service use and from children using the Children's Depression Inventory. The participation rate at the three time points was 96% in 1989, 86% in 1999, and 84% in 2005. RESULTS: Overall, parent and teacher reports of children's problems did not show a significant increase during the 16-year period. Parent reports of boys' conduct symptoms decreased from 1989 to 1999. However, self-reported depressive symptoms among girls increased from 1989 to 2005. Low parental education level, broken family, and negative life events were associated with depressive symptoms among girls. Although 4% of boys and 1% of girls had used child mental health services in 1989, the respective figures in 2005 were 12% and 4%. The majority of children who were screen positive on either parent or teacher ratings of emotional and behavioral problems using Rutter scales had received some educational support from school in 2005. CONCLUSIONS: Reports of depressive symptoms increased among girls, and this finding merits further studies. Use of services has continuously increased. School services play an important role in providing support and early detection of children who need to be referred to child mental health services.     

Psychiatric disorders in Norwegian 8- to 10-year-olds: an epidemiological survey of prevalence, risk factors, and service use

OBJECTIVE: The Bergen Child Study is a longitudinal study of child mental health from the city of Bergen, Norway. We present methods and results from the first wave of the study, focusing on prevalence of disorders, associations with risk factors, and the use of services. METHOD: The target population included all 9,430 children attending grades 2 to 4 in Bergen schools during the academic year 2002/2003. The main screening instrument was the Strengths and Difficulties Questionnaire, whereas diagnoses were based on the Development and Well-Being Assessment. Information about child and family risk factors and service use was also obtained in this second stage. RESULTS: In the first phase, the teacher Strengths and Difficulties Questionnaire was obtained for 9,155 (97%) of the target children and the matching parent Strengths and Difficulties Questionnaire for 6,297 (67%); 1,011 children (11%) were assessed with the Development and Well-Being Assessment in the second phase. The weighted prevalence for any DSM-IV psychiatric disorder was 7.0% (95% confidence interval 5.6%-8.5%). Disorders were associated with age, gender, learning difficulties, family type, and poverty. Although 75% of children with attention-deficit/hyperactivity disorder had been in contact with specialist mental health services, this was true for only 13% of those with pure emotional disorders. CONCLUSIONS: The overall prevalence of psychiatric disorders in children is relatively low in this Norwegian sample, when assessed with the Development and Well-Being Assessment. Children with emotional disorders have limited access to specialist services.     

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.     

Mental health status in children exposed to tsunami

As a vulnerable group, children are more prone to experiencing trauma and its sequelae. After the Asian tsunami we set out to evaluate the effect of exposure to the tsunami nearly one year after the event and to explore the family history of psychopathology on the mental health of children. This community-based study of 230 children was conducted in Srinivasapuram, a coastal village in Tamil Nadu. A youth self-report form (YSR) of the Child Behaviour Checklist (CBCL), exposure to the tsunami, post-traumatic stress disorder (PTSD) and family history of psychopathology were assessed. The severity of exposure to the tsunami correlated with anxiety and somatic domains of the DSM IV and PTSD symptoms. Family history of psychopathology correlated with affective and somatic symptoms. Multiple regression analysis revealed that family psychopathology influenced affective problems (R²?=?0.071 (n?=?199), F?=?15.13, p?=?0.00) while exposure to the tsunami influenced anxiety problems (R²?=?0.046 (n?=?208), F?=?9.91, p?=?0.002). The findings from this study reveal that targeted specialized mental health services are needed for children with severe exposure to the tsunami and positive family history of psychopathology.