Annotation: Pathways to care for children with mental health problems

BACKGROUND: Although many children with mental health problems are in contact with primary health care services, few receive appropriate help. METHODS: Using a pathways to care model, this paper systematically reviews the literature relating to access to services. It separates out the various stages of help-seeking: parental perception of problems, use of primary care services, recognition within primary care, and referral to or use of specialist health services. RESULTS: Following parental awareness of child symptoms, parental perception of problems is the key initial step in the help-seeking process. Although children with mental health problems or disorders are regular attenders within primary care and most parents acknowledge that it is appropriate to discuss concerns about psychosocial issues in this setting, few children are presented with mental health symptoms even if their parents have such concerns. Subsequently, less than half of children with disorders are recognised in primary care. Amongst recognised children, about half are referred to specialist services. Overall, up to one-third of children with disorders receive services for mental health problems. Factors such as the type and severity of disorder, parental perceptions, child age and gender, and family and social background factors determine which affected children access services. CONCLUSIONS: As there are inequities in patterns of service use, a greater emphasis on developing resources at population and primary care levels is required. Barriers involving parental perceptions and expression of concerns within consultations should be minimised at these levels. This requires both public education approaches and improved training and specialist support for primary care services to enhance their ability to provide for these children.     

Parental perceptions and satisfaction with stimulant medication for attention-deficit hyperactivity disorder

Few reports have documented parental perceptions of stimulants for attention-deficit hyperactivity disorder (ADHD), despite the recent increased use of stimulants among youths. Of 302 parents recruited from six pediatric primary care clinics, 84% completed a survey of their knowledge, attitudes, and satisfaction with the medication their child was taking for ADHD. Two thirds of the parents believed that sugar and diet affect hyperactivity. Although few parents believed that stimulants could lead to drug abuse, 55% initially were hesitant to use medication on the basis of information in the lay press, and 38% believed that too many children receive medication for ADHD. Parents were more satisfied with the behavioral and academic improvement relative to improvement in their child's self-esteem. Attitudes were positively correlated with satisfaction and were more positive among white than nonwhite parents. The findings highlight parental misconceptions and reservations about ADHD medication treatment that require clarification as to whether race/ethnicity, income, and social status influence their views and use of treatments.     

Barriers to the identification of children with attention deficit/hyperactivity disorder

BACKGROUND: In most countries, the majority of children with attention deficit/hyperactivity disorder (ADHD) are undiagnosed. In the United Kingdom, a major barrier to accessing specialist services is the limited recognition of disorders by general practitioners. However, it is unclear whether there are also barriers at other stages of the help-seeking process. For children with ADHD, this study aims to examine the correlates of the different stages of help-seeking. METHOD: Children with ADHD (n = 232) were identified from the 1999 British Child and Adolescent Mental Health Survey. Rates and correlates of parental recognition of child mental health problems and contact with services for these problems were examined. Children who had used particular types of services were compared with those who had not. RESULTS: Most (80%) parents of children with ADHD recognise that their child has a problem although few (35%) construe this in terms of hyperactivity. The impact of the symptoms on key adults, rather than child factors, best predicted parental recognition of problems. Most parents had been in contact with education-based professionals but few had consulted primary care for these problems or had sought help from relevant specialist health services. Parental recognition of problems and perceived burden, rather than child factors, were the main correlates of contact with services. Parental views that their child has hyperactivity were associated with greater severity of symptoms. CONCLUSIONS: The main barrier to care for ADHD is the limited presentation of these problems to primary care. The majority of parents discuss their concerns with professionals based in education services. There is a need for parental education about ADHD and for health service input to support education professionals in their contact with concerned parents.     

Investigating ADHD treatment trajectories: listening to families' stories about medication use

OBJECTIVE: Policymakers, federal agencies, and researchers have called for more in-depth investigation of contextual mechanisms that may explain differences in medication use among youths with attention-deficit/hyperactivity disorder (ADHD). METHOD: We conducted qualitative interviews with 28 families from varied socioeconomic and racial/ethnic and linguistic backgrounds regarding diagnostic and treatment trajectories for their children with symptoms consistent with ADHD, with a particular focus on whether and how medication use became a part of the trajectory. RESULTS: Four longitudinal patterns of help-seeking trajectories emerged: (1) a pattern characterized by delay to diagnosis, common among youths with complicated clinical and/or environmental pictures or primarily inattentive ADHD symptoms; (2) an initial nonmedication treatment pattern in which parents at first chose to use other modalities of treatment; (3) a reluctant receipt of an ADHD diagnosis and/or treatment pattern, mainly seen among the low-income, Spanish-speaking families; and (4) a rapid engagement in medication use pattern, characterized by directed movement to and maintenance of medication use. These patterns resulted from a dynamic interplay of explanatory models regarding the cause, course, and cure of a child's problems; the influence of extended social networks; and factors previously examined in medical utilization models. Additional themes included (1) parents' need for more information about ADHD, (2) families' desire for additional mental health and school services making medications less necessary, and (3) the importance of cultural sensitivity and a longitudinal relationship between the caregiver and clinician to enhance communication between families and clinicians. CONCLUSIONS: These findings deserve further study in a larger, more diverse sample.     

Use of psychotropic agents in preschool children: associated symptoms,diagnoses, and health care services in a health maintenance organization

BACKGROUND: Recent pharmacoepidemiological reports have contributed to concerns about frequent and perhaps indiscriminate psychopharmacotherapy for very young children. OBJECTIVE: To examine the diagnoses, symptoms, and health care services associated with preschool children receiving psychotropic medication. DESIGN: Population-based pharmacoepidemiological analysis of electronic medical records, paper medical and mental health charts, and pharmacy records from 1997 and 1998. SETTING: A large Pacific Northwest health maintenance organization. PARTICIPANTS: Preschool children receiving psychotropic medication (psychostimulants, antidepressants, neuroleptics, or alpha(2)-adrenergic agonists). MEASURES: Physician-reported mental health diagnoses and related symptoms, functional impairment, family and participant characteristics, and the types and level of associated medical and mental health services. RESULTS: Of 743 preschool children who clinicians identified as having behavioral or emotional problems, 120 (16%) received psychotropic medication; 57 children (48%) were prescribed a stimulant medication only, and 60 (50%) received a diagnosis of attention-deficit/hyperactivity disorder. Most children had substantial psychosocial risk factors, including parents with psychiatric or substance abuse problems (71%; n = 85), documented histories of abuse (29%; n = 35), and out-of-home placement (31%; n = 37). Four of 5 children or families (83%; n = 99) received psychosocial services in addition to pharmacotherapy. On average, children received psychotropic medication at least 6 months after initial identification of a behavioral or mental health problem. CONCLUSIONS: Despite commentary by the popular media about widespread psychopharmacotherapy for very young children, such treatment was only infrequently received in this health plan. Most children receiving psychopharmacotherapy had substantial additional risk factors and were receiving psychosocial services for mental health or behavioral management.     

The patient-centered medical home, practice patterns, and functional outcomes for children with attention deficit/hyperactivity disorder

ObjectiveTo determine whether children with attention deficit/hyperactivity disorder (ADHD) receive care in a patient-centered medical home (PCMH) and how that relates to their ADHD treatment and functional outcomes.MethodsCross-sectional analysis of the 2007 National Survey for Children’s Health, a nationally representative survey of 91,642 parents. This analysis covers 5169 children with parent-reported ADHD ages 6–17. The independent variable is receiving care in a PCMH. Main outcome measures are receiving ADHD medication, mental health specialist involvement, and functional outcomes (difficulties with participation in activities, attending school, making friends; having problem behaviors; missed school days; and number of times parents contacted by school).ResultsOnly 44% of children with ADHD received care in a PCMH. Children with ADHD receiving care in a PCMH compared with those who did not were more likely to receive medication for ADHD (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1–1.9); less likely to have mental health specialist involvement (OR, 0.6; 95% CI, 0.4–0.7); less likely to have difficulties participating in activities (OR, 0.6; 95% CI 0.4–0.8), making friends (OR, 0.6; 95% CI, 0.5–0.9), and attending school (OR, 0.4; 95% CI, 0.3?06); less likely to have problem behaviors (OR 0.6; 95% CI 0.5–0.9); had fewer missed school days (β = ?1.5, 95% CI ?2.4 to ?0.5); and parents were contacted by school less frequently (β = ?0.2, 95% CI ?0.3 to ?0.1).ConclusionsFor children with ADHD, receiving care in a PCMH is associated with practice pattern change and better outcomes. The PCMH may represent a promising opportunity to improve quality of care and outcomes for children with ADHD.     

Medication management of stimulants in pediatric practice settings: a national perspective

Using a nationally representative sample of office-based physicians, the management practices of pediatricians, psychiatrists, and family practice physicians were investigated. The major aims were to determine (1) what types of services these physicians were providing to children who received stimulants, (2) what factors predicted receipt of stimulants, and (3) whether these practices were concordant or discordant with professional consensus on diagnosis and treatment of attention-deficit hyperactivity disorders (ADHD). Prescribing and management practice data from the 1995 National Ambulatory Medical Care Survey (NAMCS) were analyzed for children ages 0 to 17 years who were seen for psychiatric problems and received stimulant medication. Results indicated that 2 million visits by children were made in 1995 to psychiatrists, pediatricians, or family practitioners in which psychotropic medications were prescribed. In pediatric visits where stimulant medication was prescribed, mental health counseling was provided 47.3% of the time and psychotherapy 21.6%. Follow-up arrangements were made in 79.1% of the visits. Psychiatrists were significantly more likely to provide psychotherapy and to specify follow-up visits than were pediatricians, but less likely to provide other health counseling. Controlling for demographic and physician effects, the factors with the most significant effect on the probability of receiving stimulants were geographic region (living in the South), race (being white), receiving mental health counseling, not receiving psychotherapy, and having health insurance. Less than 50% of pediatric visits for psychiatric reasons involving stimulant medications included any form of psychosocial intervention. In 21% of these visits, no recommendations were made for follow-up care. These practices diverge from National Institutes of Health (NIH) consensus panel recommendations and association-issued practice parameters.     

Management of attention deficit hyperactivity disorder: a parental perspective

OBJECTIVES: There are few studies exploring parental perceptions of the diagnosis and overall treatment of their children with attention deficit hyperactivity disorder (ADHD). This community-based study was conducted to consider this important aspect of care. METHODS: A total of 7 226 (65%) parents responded to a community survey of 11 184 children aged 10-12 years living in northern Sydney in 2000, out of which 278 children with ADHD were identified. Their parents completed an anonymous questionnaire covering their perceptions relating to diagnosis, treatment and overall management. RESULTS: Only 66% of parents recalled the use of questionnaires or rating scales. There were 82% of children who had trialed medication and 66% of these were still taking it. Behavioural intervention had occurred in 42% of the children. Non-conventional treatments, most commonly elimination diet and/or fatty acid supplementation, had been used in 71% of the children. These were considered helpful in one-third of cases. A total of 55% of parents reported being either satisfied or very satisfied with their child's care. Parents were more likely to report satisfaction when their children were on medication and when reviews were held at least 6 monthly. Lack of educational support and teachers' understanding of ADHD were identified as ongoing issues. CONCLUSION: Parental responses suggested that adherence to recommended diagnostic guidelines was inadequate. Behavioural intervention was underutilized despite its documented positive role. Non-conventional therapies were widely used and considered helpful in one-third of the children who used them. Use of stimulant medication and frequent reviews were more likely to be associated with overall management satisfaction.     

Benefits for employees with children with ADHD: findings from the Collaborative Employee Benefit Study

Parents of most children with attention-deficit hyperactivity disorder (ADHD) are employed. Employers have interest in decreasing employee absenteeism and improving workplace productivity, partly through employee benefits. The authors interviewed employers to (1) determine how they view the needs of employees with children with ADHD and (2) identify benefits that might help employees with children with ADHD. The authors carried out a systematic interview study of mainly family-friendly, large employers in four U.S. urban markets (Boston, Cleveland, Miami, Seattle). Multidisciplinary interview teams used a protocol to gather basic company information, benefit philosophy, current insurance and other employee benefits, and knowledge of ADHD and its impacts on employees. Initially, the interview team and then the larger project team reviewed all protocols for common themes. The authors interviewed staff of 41 employers (human resource managers, work/life program directors, benefits directors). Only 15 of 41 interviewees knew about ADHD, its prevalence, or its effects on parents. They had little knowledge of how differences in managed behavioral health may affect families' access to diagnostic and treatment services for ADHD, although most had experience with primary care management of depression among employees. Employers offer a variety of other benefits, including work/life and employee assistance programs, occasionally providing employees help with caring for a child with a mental health condition, on-site parent training programs, or assistance with child care. Other potentially useful employee benefits include flexible work and leave policies and information and referral services that can link parents with community programs. Although employers have limited awareness of ADHD and its potential effect on employees' work, this study identified opportunities to improve both health insurance and other benefits for employees with children with ADHD.     

Parent caregiver-related predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid.

INTRODUCTION: This study examined the associations between characteristics of the parent caregiver and health care service utilization by children with cerebral palsy enrolled in Medicaid. METHODS: A questionnaire was administered to the parents of children with cerebral palsy being treated in a North Carolina hospital, and the responses were linked with health services claims data from Medicaid. Data were available for 93 patients who maintained 1 year of continuous enrollment. The impact of selected demographic variables (race, years the child had the condition, employment, transportation) and behavioral variables (belief the child was receiving appropriate care, willingness to use home nursing and respite services, self-assessment of the severity of the child's condition, and use of orthopedic aids) on the frequency and costs of health care services was explored with use of multiple regression analysis. RESULTS: Parents who were willing to use home nursing and respite services were more likely to utilize these services, as well as inpatient facilities and orthopedic care, for their children (P <.05). However, parents who perceived that their child was receiving adequate care were less likely to utilize orthopedic care and home nursing for their children (P <.05). DISCUSSION: The belief of the parents in the adequacy of care received by their child, as well as their willingness to utilize supplemental health care services, were major predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid. Parents who believed that their children receive enough care may need to be targeted for care management and disease management programs to ensure the continuum of treatment and care for these children.     

Community perspectives of childhood behavioral problems and ADHD among African American parents.

OBJECTIVE: To explore parents' perceptions of childhood behavior problems and attention-deficit/hyperactivity disorder (ADHD) among a sample of African American (AA) parents. METHODS: Five focus groups were conducted in inner-city Baltimore and the Washington, DC, metropolitan region with 5 to 7 AA parents per group. Adults with children under the age of 17 years were recruited from pediatric practices. One investigator moderated each focus group, and a second took notes. Sessions averaged 1.5 hours long, were recorded on audiotape, and were transcribed verbatim. The narrative data were coded for recurring themes. RESULTS: Five major themes emerged from the analysis: causes of behavioral problems in children, the legitimacy of ADHD as a diagnosis, attitudes about doctors, opinions of medication, and perceptions of the school environment. Many participants felt that behavior issues, including those accompanying ADHD, were caused by inappropriate parenting and disciplinary practices. Some viewed the diagnosis as a label applied with racial inequality to exert social control over AAs. Several expressed distrust in physicians who were quick to make a diagnosis of ADHD and recommend medications. Others worried that medication would lead to drug addiction in adulthood. Some perceived that children were labeled with ADHD because of poor educational environments that were unresponsive to the needs of AA children. CONCLUSIONS: These focus groups identified important community perceptions about ADHD and its medical treatment. Understanding how these perceptions contribute to racial disparities in ADHD diagnosis and treatment can help inform culturally sensitive interventions to improve the management of ADHD among AA children.     

Correlates, Associated Impairments and Patterns of Service Utilization of Children with Attention Deficit Disorder: Findings from the Ontario Child Health Study

The objective of this paper is to report on the correlates of attention deficit disorder with hyperactivity (ADDH), the associated impairments of ADDH children, and to describe briefly their utilization of services. Our results suggest that household, family, parental, and developmental variables are associated with this disorder. However, child-centered, rather than psychosocial, variables emerge as important if one controls for the presence of other disorders. Compared to children without any disorder, ADDH children are also impaired in their relationships with others, their school performance, and competence in extra-curricular activities. ADDH children utilized mental health, social, and special education services more than non-ADDH children. Nevertheless, it was found that only a minority of ADDH children had received specialized mental health or social services in the past 6 months.     

A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder

There remain large discrepancies between pediatricians' practice patterns and the American Academy of Pediatrics (AAP) guidelines for the assessment and treatment of children with attention-deficit/hyperactivity disorder (ADHD). Several studies raise additional concerns about access to ADHD treatment for girls, blacks, and poorer individuals. Barriers may occur at multiple levels, including identification and referral by school personnel, parents' help-seeking behavior, diagnosis by the medical provider, treatment decisions, and acceptance of treatment. Such findings confirm the importance of establishing appropriate mechanisms to ensure that children of both genders and all socioeconomic, racial, and ethnic groups receive appropriate assessment and treatment. Publication of the AAP ADHD toolkit provides resources to assist with implementing the ADHD guidelines in clinical practice. These resources address a number of the barriers to office implementation, including unfamiliarity with Diagnostic and Statistical Manual of Mental Disorders criteria, difficulty identifying comorbidities, and inadequate knowledge of effective coding practices. Also crucial to the success of improved processes within clinical practice is community collaboration in care, particularly collaboration with the educational system. Such collaboration addresses other barriers to good care, such as pressures from parents and schools to prescribe stimulants, cultural biases that may prevent schools from assessing children for ADHD or may prevent families from seeking health care, and inconsistencies in recognition and referral among schools in the same system. Collaboration may also create efficiencies in collection of data and school-physician communications, thereby decreasing physicians' non-face-to-face (and thus nonreimbursable) elements of care. This article describes a process used in Guilford County, North Carolina, to develop a consensus among health care providers, educators, and child advocates regarding the assessment and treatment of children with symptoms of ADHD. The outcome, ie, a community protocol followed by school personnel and community physicians for >10 years, ensures communication and collaboration between educators and physicians in the assessment and treatment of children with symptoms of ADHD. This protocol has the potential to increase practice efficiency, improve practice standards for children with ADHD, and enhance identification of children in schools. Perhaps most importantly, the community process through which the protocol was developed and implemented has an educational component that increases the knowledge of school personnel about ADHD and its treatment, increasing the likelihood that referrals will be appropriate and increasing the likelihood that children will benefit from coordination of interventions among school personnel, physicians, and parents. The protocol reflects a consensus of school personnel and community health care providers regarding the following: (1) ideal ADHD assessment and management principles; (2) a common entry point (a team) at schools for children needing assessment because of inattention and classroom behavior problems, whether the problems present first to a medical provider, the behavioral health system, or the school; (3) a protocol followed by the school system, recognizing the schools' resource limitations but meeting the needs of community health care providers for classroom observations, psychoeducational testing, parent and teacher behavior rating scales, and functional assessment; (4) a packet of information about each child who is determined to need medical assessment; (5) a contact person or team at each physician's office to receive the packet from the school and direct it to the appropriate clinician; (6) an assessment process that investigates comorbidities and applies appropriate diagnostic criteria; (7) evidence-based interventions; (8) processes for follow-up monitoring of children after establishment of a treatment plan; (9) roles for central participants (school personnel, physicians, school nurses, and mental health professionals) in assessment, management, and follow-up monitoring of children with attention problems; (10) forms for collecting and exchanging information at every step; (11) processes and key contacts for flow of communication at every step; and (12) a plan for educating school and health care professionals about the new processes. A replication of the community process, initiated in Forsyth County, North Carolina, in 2001, offers insights into the role of the AAP ADHD guidelines in facilitating development of a community consensus protocol. This replication also draws attention to identification and referral barriers at the school level. The following recommendations, drawn from the 2 community processes, describe a role for physicians in the collaborative community care of children with symptoms of ADHD. (1) Achieve consensus with the school system regarding the role of school personnel in collecting data for children with learning and behavior problems; components to consider include (a) vision and hearing screening, (b) school/academic histories, (c) classroom observation by a counselor, (d) parent and teacher behavior rating scales (eg, Vanderbilt, Conner, or Achenbach scales), (e) consideration of speech/language evaluation, (f) screening intelligence testing, (g) screening achievement testing, (h) full intelligence and achievement testing if discrepancies are apparent in abbreviated tests, and (i) trials of classroom interventions. (2) Use pediatric office visits to identify children with academic or behavior problems and symptoms of inattention (history or questionnaire). (3) Refer identified children to the contact person at each child's school, requesting information in accordance with community consensus. (4) Designate a contact person to receive school materials for the practice. (5) Review the packet from the school and incorporate school data into the clinical assessment. (6) Reinforce with the parents and the school the need for multimodal intervention, including academic and study strategies for the classroom and home, in-depth psychologic testing of children whose discrepancies between cognitive level and achievement suggest learning or language disabilities and the need for an individualized educational plan (special education), consideration of the "other health impaired" designation as an alternate route to an individualized educational plan or 504 plan (classroom accommodations), behavior-modification techniques for targeted behavior problems, and medication trials, as indicated. (7) Refer the patient to a mental health professional if the assessment suggests coexisting conditions. (8) Use communication forms to share diagnostic and medication information, recommended interventions, and follow-up plans with the school and the family. (9) Receive requested teacher and parent follow-up reports and make adjustments in therapy as indicated by the child's functioning in targeted areas. (10) Maintain communication with the school and the parents, especially at times of transition (eg, beginning and end of the school year, change of schools, times of family stress, times of change in management, adolescence, and entry into college or the workforce).     

Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder

Treatment of attention deficit hyperactivity disorder (ADHD), one of the most common behavioral disorders in children in the United States, remains controversial because of concern about stimulant medication use. Extending a previous study of pediatricians, the present study surveyed a random national sample of family practitioners and then directly screened 457 patients of 10 pediatricians and family practitioners in two small midwestern cities. Responses to the national survey indicated that stimulant medication remains the main treatment prescribed by primary care physicians for children with ADHD. In the direct patient screening, the prevalence of ADHD diagnoses was 5.3% (pediatricians) and 4.2% (family practitioners) of all elementary-school-aged children screened. Eighty-eight percent of these children were treated with methylphenidate. Although medication was considered an effective treatment by the parents of 85% of the children given the medication, efficacy was unrelated to the accuracy of diagnosis. When explicit DSM-III-R criteria were used, only 72% of those assigned a diagnosis of ADHD by the physicians would have received that diagnosis based on a structured psychiatric interview with the parents and only 53% received that diagnosis based on teacher report of symptoms, even when the child was not receiving medication. Although the majority of physicians (in both the surveys and the direct screenings) reported using at least some behavioral treatments with their patients, parents reported infrequent use of nonpharmacologic forms of therapy, such as behavior modification. These data thus indicate a relatively modest rate of stimulant medication use for ADHD, but a serious underuse of systematic behavioral treatments in primary care.(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparison study of an elementary school-based health center: effects on health care access and use

OBJECTIVE: To assess the effects of an elementary school-based health center (SBHC) on access to and the use of physical and mental health services by children aged 4 to 13 years. STUDY DESIGN: A retrospective cohort analysis of parent surveys from a comparable intervention (SBHC) and a comparison of urban elementary schools. INTERVENTION: Elementary SBHC services, including preventive physical health care; the care of minor short-term illnesses, injuries, and stable ongoing medical conditions, dental screenings; and mental health counseling. PARTICIPANTS: All parents of students at both schools were asked to complete a survey. Return rates on the survey were 78.3% (570/728) and 77.0% (440/571) at the intervention and comparison schools, respectively. MAIN OUTCOME MEASURES: The use of health services, access to health services, and health service satisfaction. RESULTS: Compared with respondents at comparison schools, respondents whose children had access to an SBHC had less difficulty (P = .01) receiving physical health care for their children, ie, treatment of illnesses and injuries, immunizations, and physical examinations (odds ratio, 0.66; 95% confidence interval, 0.48-0.91). Access to an SBHC was independently and significantly related to less emergency department use (odds ratio, 0.63; 95% confidence interval, 0.40-0.99; P<.05), a greater likelihood of having had a physician's visit since the school year began (odds ratio, 1.92; 95% confidence interval, 1.39-2.65; P<.01), and a greater likelihood of having had an annual dental examination (odds ratio, 1.36; 95% confidence interval, 1.01-1.83; P<.05). Measured by a 12-item scale, respondents who reported the SBHC as their most-used health service were significantly more satisfied with their service than respondents who mostly used community clinics (z=-5.21; P<.01) or hospital clinics (z=-4.03; P<.01). CONCLUSIONS: Independent of insurance status and other confounding variables, underserved minority children with SBHC access have better health care access and use than children without SBHC access, signifying that SBHCs can be an effective component of health delivery systems for these children.