Child outpatient mental health service use: why doesn't insurance matter?

Improving community-based mental health care for children: translating knowledge into action

There is urgent need for improvement in community-based mental health care for children and families. Multiple studies have documented serious limitations in the effectiveness of "usual care." Fortunately, many empirically-supported strategies to improve care have been developed, and thus there is now a great deal of knowledge available to address this significant public health problem. The goal of this selective review is to highlight and synthesize that empirically-supported knowledge to stimulate and facilitate the needed translation of knowledge into action. The review provides a sound foundation for constructing improved services by consolidating descriptive data on the status quo in children's mental health care, as well as evidence for an array of promising strategies to improve (a) Service access and engagement; (b) Delivery of evidence-based practices; and (c) Outcome accountability. A multi-level framework is used to highlight recommended care improvement targets.

Mental and behavioral health screening at preventive visits: opportunities for follow-up of patients who are nonadherent with the next preventive visit

OBJECTIVES

To determine the type of subsequent care received by children nonadherent with their next preventive visit and whether behavioral factors predict use of emergency or acute care in this population.

STUDY DESIGN

Data on 1703 children (4-16 years) screened at a preventive visit with the Pediatric Symptom Checklist (PSC)/Youth-PSC were examined to determine subsequent preventive care adherence (10-18 months later). Then, nonadherent children were monitored to determine whether they returned to their medical home for acute care, delayed preventive care, or visited the emergency department (ED). Multivariate analyses were conducted to determine whether demographic and behavioral factors predicted return to either acute care or ED care site.

RESULTS

Of the 461 children who were nonadherent with a second preventive care visit, most (85%) subsequently returned for acute, emergency, or delayed preventive care in the same medical system. Predictors of acute care or ED use included behavioral health risk characteristics (positive PSC, counseling, referral, parental concern), as well as adolescent age, self-pay and public insurance status, and living in lower socioeconomic communities.

CONCLUSIONS

Pediatricians should consider acute care or ED visits as opportunities for mental health screening follow-up, and intervention in populations at high risk who miss preventive care.

Racial/ethnic differences in mental health service use among adolescents with major depression

OBJECTIVE

Little is known about racial/ethnic differences in the receipt of treatment for major depression in adolescents. This study examined differences in mental health service use in non-Hispanic white, black, Hispanic, and Asian adolescents who experienced an episode of major depression.

METHOD

Five years of data (2004-2008) were pooled from the National Survey on Drug Use and Health to derive a nationally representative sample of 7,704 adolescents (12-17 years old) diagnosed with major depression in the past year. Racial/ethnic differences were estimated with weighted probit regressions across several measurements of mental health service use controlling for demographics and health status. Additional models assessed whether family income and health insurance status accounted for these differences.

RESULTS

The adjusted percentages of blacks (32%), Hispanics (31%), and Asians (19%) who received any treatment for major depression were significantly lower than those of non-Hispanic whites (40%; p < .001). Black, Hispanic, and Asian adolescents were also significantly less likely than non-Hispanic whites to receive prescription medication for major depression, to receive treatment for major depression from a mental health specialist or medical provider, and to receive any mental health treatment in an outpatient setting (p < .01). These differences persisted after adjusting for family income and insurance status.

CONCLUSION

Results indicated low rates of mental health treatment for major depression in all adolescents. Improving access to mental health care for adolescents will also require attention to racial/ethnic subgroups at highest risk for non-receipt of services.

Comparing racial/ethnic differences in mental health service use among high-need subpopulations across clinical and school-based settings

Racial/ethnic differences in mental health service use among adolescents in clinic and school settings for three high-need populations are examined. Results indicate no racial/ethnic differences in school-based use contrasted with significant differences in clinical settings. Schools may be critical avenues for reduction of unmet mental health need among racial/ethnic minorities.

Schools' mental health services and young children's emotions, behavior, and learning

Recent empirical research has found that children's noncognitive skills play a critical role in their own success, young children's behavioral and psychological disorders can severely harm their future outcomes, and disruptive students harm the behavior and learning of their classmates. Yet relatively little is known about wide-scale interventions designed to improve children's behavior and mental health. This is the first nationally representative study of the provision, financing, and impact of school-site mental health services for young children. Elementary school counselors are school employees who provide mental health services to all types of students, typically meeting with students one-on-one or in small groups. Given counselors' nonrandom assignment to schools, it is particularly challenging to estimate the impact of these counselors on student outcomes. First, cross-state differences in policies provide descriptive evidence that students in states with more aggressive elementary counseling policies make greater test score gains and are less likely to report internalizing or externalizing problem behaviors compared to students with similar observed characteristics in similar schools in other states. Next, difference-in-differences estimates exploiting both the timing and the targeted grade levels of states' counseling policy changes provide evidence that elementary counselors substantially influence teachers' perceptions of school climate. The adoption of state-funded counselor subsidies or minimum counselor–student ratios reduces the fraction of teachers reporting that their instruction suffers due to student misbehavior and reduces the fractions reporting problems with students physically fighting each other, cutting class, stealing, or using drugs. These findings imply that there may be substantial public and private benefits derived from providing additional elementary school counselors.

Perceived barriers to treatment for adolescent depression

BACKGROUND AND OBJECTIVE

Adolescent depression is common, disabling, and is associated with academic, social, behavioral, and health consequences. Despite the availability of evidence-based depression care, few teens receive it, even when recognized by primary care clinicians. Perceived barriers such as teen worry about what others think or parent concerns about cost and access to care may contribute to low rates of care. We sought to better understand perceived barriers and their impact on service use.

DESIGN

After completing an eligibility and diagnostic telephone interview, all depressed teens and a matched sample of nondepressed teens recruited from 7 primary care practices were enrolled and completed telephone interviews at baseline and 6 months (August 2005-September 2006).

PARTICIPANTS

Three hundred sixty-eight adolescent patients aged 13 to 17 (184 depressed and 184 nondepressed) and 338 of their parents.

MEASURES

Perceived barriers to depression care and use of services for depression (psychotherapy and antidepressant medication).

RESULTS

Teens with depression were significantly more likely to perceive barriers to care compared with nondepressed teens. Parents were less likely to report barriers than their teens; perceived stigma and concern about family member response were among the significant teen barriers. Teen perceived barriers scores were negatively associated with any use of antidepressants (P < 0.01), use of antidepressants for at least 1 month (P < 0.001), and any psychotherapy or antidepressant use (P < 0.05) at 6 months.

CONCLUSIONS

To improve treatment for adolescent depression, interventions should address both teen and parent perceived barriers and primary care clinicians should elicit information from both adolescents and their parents.

Differences in mental health service sector utilization among African American and Caucasian youth entering systems of care programs

Differences in unmet need and access to services between African American and Caucasian youth have been established; less is known about differences in specific mental health service sectors. This study examined differences in past year outpatient, school-based, day treatment and residential/inpatient service utilization among African American and Caucasian youth (n = 3,649) entering a federally funded system of care program. Random effect logistic regression models were implemented to examine the relationship between race and past year service utilization. Analyses revealed that African American youth were less likely than Caucasian youth to have utilized school-based and residential/inpatient mental health services in the past year. Findings suggest that racial disparities exist in service use for certain types of service sectors and highlight the importance of understanding and identifying individual, family, and community factors that contribute to disparities in service utilization.

Child mental health and human capital accumulation: the case of ADHD

One in five U.S. youngsters has a mental disorder, but we know little about the effects of these disorders on child outcomes. We examine U.S. and Canadian children with symptoms of Attention Deficit Hyperactivity Disorder (ADHD), the most common child mental health problem. Our innovations include the use of nationally representative samples of children, the use of questions administered to all children rather than focusing only on diagnosed cases, and the use of sibling fixed effects to control for omitted variables. We find large negative effects on test scores and schooling attainment suggesting that mental health conditions are a more important determinant of average outcomes than physical health conditions.

Mental health screening in pediatric practice: factors related to positive screens and the contribution of parental/personal concern

OBJECTIVES

The goals were to examine factors related to positive Pediatric Symptom Checklist scores in an urban practice and to examine the relative contribution of parental/personal concern about emotional and behavioral problems to mental health problem identification.

METHODS

Annual screening using the Pediatric Symptom Checklist was implemented in Cambridge Pediatrics (Cambridge, MA). A social worker was colocated in the clinic to provide therapeutic interventions for patients. A sample of 1668 screened patients between 4 years 11 months and 19 years of age was used for analysis. Bivariate and multivariate analyses were conducted to determine factors predictive of positive Pediatric Symptom Checklist scores, including demographics, socioeconomic indicators, enrollment in counseling, and parental/personal concern. Parental/personal concern, counseling, and positive Pediatric Symptom Checklist scores were examined to determine their efficacy as screening methods.

RESULTS

Six percent of the population had positive Pediatric Symptom Checklist scores. There were statistically significant relationships between a positive score and being in counseling, parental/personal concern, having public insurance, and living in an area with median household incomes of less than 50,000 dollars. Parental/personal concern was 40% sensitive for a positive score. A positive Pediatric Symptom Checklist score with or without parental/personal concern identified 3.8% of the population; parental/personal concern with or without a positive Pediatric Symptom Checklist score identified 4.5%.

CONCLUSIONS

Mental health screening can be effectively implemented in a pediatric practice. Colocated mental health professionals provide additional support. The combination of a screening tool and questions about parental/personal concern and present counseling can provide critical information about a child's mental health.

How well does Medicaid work in improving access to care?

OBJECTIVE

To provide an assessment of how well the Medicaid program is working at improving access to and use of health care for low-income mothers.

DATA SOURCE/STUDY SETTING

The 1997 and 1999 National Survey of America's Families, with state and county information drawn from the Area Resource File and other sources.

STUDY DESIGN

Estimate the effects of Medicaid on access and use relative to private coverage and being uninsured, using instrumental variables methods to control for selection into insurance status.

DATA COLLECTION/EXTRACTION METHOD

This study combines data from 1997 and 1999 for mothers in families with incomes below 200 percent of the federal poverty level.

PRINCIPAL FINDINGS

We find that Medicaid beneficiaries' access and use are significantly better than those obtained by the uninsured. Analysis that controls for insurance selection shows that the benefits of having Medicaid coverage versus being uninsured are substantially larger than what is estimated when selection is not accounted for. Our results also indicate that Medicaid beneficiaries' access and use are comparable to that of the low-income privately insured. Once insurance selection is controlled for, access and use under Medicaid is not significantly different from access and use under private insurance. Without controls for insurance selection, access and use for Medicaid beneficiaries is found to be significantly worse than for the low-income privately insured.

CONCLUSIONS

Our results show that the Medicaid program improved access to care relative to uninsurance for low-income mothers, achieving access and use levels comparable to those of the privately insured. Our results also indicate that prior research, which generally has not controlled for selection into insurance coverage, has likely understated the gains of Medicaid relative to uninsurance and overstated the gains of private coverage relative to Medicaid.

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.

The relationship between school characteristics and the availability of mental health and related health services in middle and high schools in the United States

Problems related to mental illness are increasingly becoming the focal point of public concern over the safety and performance of schools, yet little is known about the availability and quality of school-based mental health services in the United States. In this article it is estimated that approximately 50% of US middle and high schools have any mental health counseling services available onsite and approximately 11% have mental health counseling, physical examinations, and substance abuse counseling available on-site. There are substantial differences in mental health counseling availability by region, urbanicity, and school size, with rural schools, schools in the Midwest and South regions, and small schools being least likely to offer mental health counseling. Multivariate estimates suggest that disparities between schools in the availability of mental health counseling and related health services may be partly explained by differences in access to Medicaid for financing of health services provided at school.

Trends And Issues In Child And Adolescent Mental Health

An estimated 11 percent of American children have a mental health impairment, yet they rely upon a piece of the health care system that does not work well. Government policies for children's mental health operate in two ways: by affecting health insurance for children, and by funding services directly. Major changes within both categories have shaped the types, sources, and financing of services for children with mental health problems. These policies, along with scientific advances in child mental health, social changes, and health policy more generally, have contributed to an improvement in child mental health services over the past fifteen years.