Administrative update: utilization of services. II. Utilization of mental health services in a tri-ethnic sample of adolescents

Are Parents the Key? How Parental Suicide Stigma and Suicide Literacy Affect Help-Seeking Attitudes and Intentions for their Child

Suicide is the leading cause of death among Australian young people, yet rates of help-seeking for suicidal ideation and behaviors in this population are concerningly low. In this study, the relationships between parental suicide stigma, parental suicide literacy, and their attitudes and intentions toward seeking professional help for their child if they were to express thoughts of suicide are investigated. Understanding this influence is critical given parents are key facilitators of their child's access to and engagement with professional mental health services. An online survey was administered to 302 parents of children aged-12-18 (Mage = 45.36, SDage = 6.23; 91.4% female). Parental suicide stigma was significantly associated with more negative help-seeking attitudes and lower help-seeking intentions. Other significant predictors of more positive help-seeking attitudes included parental self-efficacy and having a child with no history of suicidal ideation. Higher help-seeking intentions were associated with female gender, living in an urban area, and positive help-seeking attitudes. Parental suicide literacy was not significantly associated with help-seeking. Practically, outcomes of this study may inform the development and implementation of targeted education programs to increase parental help-seeking for their children.

Challenges in ADHD care for ethnic minority children: A review of the current literature

While attention deficit hyperactivity disorder (ADHD) has been extensively studied in the past decades, the role of social and cultural practices in its assessment, diagnosis, and treatment has been often overlooked. This selective review provides an overview of research that explores social and cultural influences on help-seeking behavior in ethnic minority children with ADHD. Studies were selected that address cultural diversity in three areas of ADHD help-seeking: problem recognition, access to mental health services, and treatment. Special attention was given to studies of treatment selection and adherence in minority groups. Findings suggested that cultural disparities in ADHD care among ethnic minority children occur in the early stages of problem recognition, through service selection, and in the quality of treatment. Ethnic minority children were less likely than their nonminority counterparts to be diagnosed with ADHD and its comorbid conditions and less likely to be prescribed and adhere to stimulant drug treatment. These differences reflect cultural diversity in norms and attitudes towards mental health issues (e.g., fear of social stigma) as well as limited access to qualified health care. Paradoxically, cultural, racial, and language bias may also lead to the overidentification of ethnic minority children as disabled and to higher ratings of ADHD symptoms. This review highlights the importance of sociocultural factors in understanding developmental psychopathology and help-seeking behavior. In addition, it further supports calls for increasing cultural competence in communications during clinical assessment, diagnosis, and treatment in minority communities. Clinical, theoretical, and methodological considerations for future research are discussed.

Perceived Need for Treatment and Engagement in Mental Health Services Among Community-Referred Racial/Ethnic Minority Adolescents

This study examines clinical and family predictors of perceived need for treatment and engagement in mental health treatment services among community-referred racial/ethnic minority adolescents and their primary caregivers. Findings indicated that the majority of families perceived a need for treatment, but that perceived need was not associated with treatment engagement. Family factors (i.e., low cohesion and high conflict within the family) predicted perceived need for treatment among adolescents, whereas clinical factors (i.e., adolescent internalizing and externalizing symptomatology) predicted caregiver perceived need for adolescent treatment. Neither clinical nor family factors predicted treatment engagement.

Web-Based Parent-Training for Parents of Youth With Impairment From Anxiety

Child Anxiety Tales, an online web-based cognitive-behavioral parent-training program for parents of youth with anxiety, was developed and evaluated. Parents (N = 73; 59 females; 52.1% Caucasian, 42.5% African American, 4.1% Hispanic) who reported concerns about anxiety in their child (aged 7-14 yrs; Mean=10.1 ±1.6) were randomly assigned to (a) parent-training provided through Child Anxiety Tales (CAT), (b) parent-training provided via bibliotherapy (BIB), or (c) a waitlist control (WLC). Measures of parent knowledge, the acceptability of training, and child symptomatology were completed at pre- and post-parent-training and at 3-month follow-up. Findings support the feasibility, acceptability, and beneficial effects on knowledge of Child Anxiety Tales for parents of youth with impairment from anxiety.

Racial and Ethnic Disparities in Mental Health Care for Children and Young Adults: A National Study

Psychiatric and behavior problems are common among children and young adults, and many go without care or only receive treatment in carceral settings. We examined racial and ethnic disparities in children's and young adults' receipt of mental health and substance abuse care using nationally representative data from the 2006-2012 Medical Expenditure Panel Surveys. Blacks' and Hispanics' visit rates (and per capita expenditures) were about half those of non-Hispanic whites for all types and definitions of outpatient mental health services. Disparities were generally larger for young adults than for children. Black and white children had similar psychiatric inpatient and emergency department utilization rates, while Hispanic children had lower hospitalization rates. Multivariate control for mental health impairment, demographics, and insurance status did not attenuate racial/ethnic disparities in outpatient care. We conclude that psychiatric and behavioral problems among minority youth often result in school punishment or incarceration, but rarely mental health care.

Chicanas/os and Mental Health Services

This article reviews recent literature pertaining to Chicanas/os’ utilization of conventional mental health services, their counselor preferences, and the psychological testing and assessment of Chicanas/os. Chicanas/os likely underutilize mental health services, instead preferring family or nontraditional helpers for assistance. However, both Chicanas/os’ level of identification with their indigenous culture as well as their level of acculturation to the majority culture appear to affect their use of services and counselor preferences. Despite longstanding concerns ranging from language barriers to clinician bias in interpreting test results, the literature continues to lack validation studies that specifically support the use of many major psychological tests with Chicanas/os. Unfortunately, these instruments continue to be routinely used clinically to assess Chicana/o clientele, even though the literature cautions that these instruments may generate an inaccurate picture of Chicanas/os’ psychological functioning. Recommendations for counseling practice and future research concerning Chicanas/os are offered.

Health Issues in Hispanic/Latino Youth

This review focuses on obesity, asthma and mental health functioning as salient health issues affecting Hispanic youth. Burden of these conditions and consequences for adult health are also discussed. Hispanic youth are affected by obesity at an early age; the prevalence of obesity among Hispanic children 6-11 years old is twice as high as the prevalence for non-Hispanic White children of the same age, but among 2-5 years old is 4 times higher. Asthma disproportionally affects certain Hispanic groups, notably children of Puerto Rican ancestry, and the comorbidity of asthma and obesity is an emerging health issue. Another area of concern is the scant data on mental health functioning among Hispanic youth. Research on Hispanic youth mental health have reported high rates of depressive symptomatology and high rates of alcohol use among Hispanic adolescents but despite these findings, they have inadequate access to mental health services. This review highlights the need for better data to gain a better understanding of the health status of Hispanic youth and help develop preventive programs that addresses the need of this population. Improving access to health services, in particular mental health services, is also a crucial aspect.

Treatment patterns of youth with bipolar disorder: results from the National Comorbidity Survey-Adolescent Supplement (NCS-A)

Despite growing evidence that bipolar disorder often emerges in adolescence, there are limited data regarding treatment patterns of youth with bipolar disorder in community samples. Our objective was to present the prevalence and clinical correlates of treatment utilization for a nationally representative sample of US adolescents with bipolar disorder. Analyses are based on data from the National Comorbidity Survey-Adolescent Supplement, a face-to-face survey of 10,123 adolescents (ages 13-18) identified in household and school settings. We found that of adolescents meeting DSM-IV criteria for bipolar I or II disorder (N = 250), 49 % were treated for depression or mania, 13 % were treated for conditions other than depression or mania, and 38 % did not report receiving treatment. Treatment for depression or mania was associated with increased rates of suicide attempts, as well as greater role disability and more comorbid alcohol use relative to those who had not received treatment. Treated adolescents had triple the rate of ADHD and double the rates of behavior disorders than those without treatment. Our findings demonstrate that a substantial proportion of youth with bipolar disorder do not receive treatment, and of those who do, many receive treatment for comorbid conditions rather than for their mood-related symptoms. Treatment was more common among youth with severe manifestations and consequences of bipolar disorder and those with behavior problems. These trends highlight the need to identify barriers to treatment for adolescents with bipolar disorder and demonstrate that those in treatment are not representative of youth with bipolar disorder in the general population.

Acculturation differences in communicating information about child mental health between Latino parents and primary care providers

Significant Latino-white disparities in youth mental health care access and quality exist yet little is known about Latino parents' communication with providers about youth mental health and the role of acculturation in influencing this communication. We estimated regression models to assess the association between time in the US and the number of psychosocial issues discussed with the medical assistant (MA) and doctor, adjusting for child and parent mental health and sociodemographics. Other proxies of acculturation were also investigated including measures of Spanish and English language proficiency and nativity. Parent's length of time in the US was positively associated with their communication of: their child's psychosocial problems with their child's MA, stress in their own life with their child's MA, and their child's school problems with their child's doctor. These differences were especially apparent for parents living in the US for >10 years. Parent-child language discordance, parent and child nativity were also significantly associated with communication of psychosocial problems. Greater provider and MA awareness of variation in resistance to communicating psychosocial issues could improve communication, and improve the prevention, diagnosis and treatment of youth mental illness.

Predictors of treatment engagement in ethnically diverse, urban children receiving treatment for trauma exposure

Keeping traditionally underrepresented children and their families engaged in treatment until completion is a major challenge for many community-based mental health clinics. The current study used data collected as part of the National Child Traumatic Stress Network Core Data Set to examine whether racial/ethnic disparities exist in treatment duration and completion in children seeking treatment for trauma exposure. We then explored whether disparities persist after accounting for other variables associated with children's social contexts and the treatment setting. The sample included 562 ethnically diverse children receiving services from a child abuse prevention and treatment agency in Southern California. The results indicated that African American children had significantly shorter trauma-informed treatment duration and higher rates of premature termination than Spanish-speaking Latino children. These disparities persisted even with other variables associated with treatment duration and completion (e.g., child's age, level of functional impairment, and receipt of group and field services) in the model. Implications and future directions for research and practice are discussed.

Practice parameter for cultural competence in child and adolescent psychiatric practice

The United States faces a rapidly changing demographic and cultural landscape, with its population becoming increasingly multiracial and multicultural. In consequence, cultural and racial factors relating to mental illness and emotional disturbances deserve closer attention and consideration. This Practice Parameter outlines clinical applications of the principle of cultural competence that will enable child and adolescent mental health clinicians to better serve diverse children, adolescents, and their families.

Mental health problems and recidivism among detained male adolescents from various ethnic origins

This study examines differences in self-reported mental health problems between detained youths from Dutch, Moroccan, and Surinamese origin and the usefulness of mental health problems to predict violent and property recidivism in these juveniles. A sample of 296 detained boys aged between 12 and 18 years were assessed by means of the Strengths and Difficulties Questionnaire (SDQ). Official information regarding criminal history and recidivism was collected 3-6 years later. In general, Dutch youths and Surinamese youths reported more conduct problems than Moroccan youths, while Dutch youths also reported more hyperactivity than Surinamese youths. Mental health problems were not predictive of violent recidivism in any of the ethnic groups, while being related with property recidivism in Dutch and Surinamese youths. The current study showed that Moroccan youths present themselves on the SDQ as a less seriously disturbed group of youths than their Dutch and Surinamese counterparts. Our results also clearly showed that SDQ self-report scores are not predictive of future violent crimes in any of the three ethnic groups. Implications of the findings and limitations of the current study are discussed.

Racial/ethnic disparity trends in children's mental health care access and expenditures from 2002 to 2007

OBJECTIVE

To examine trends in disparities in children's mental health care.

DATA

2002-2007 Medical Expenditure Panel Survey.

STUDY DESIGN

We used the Institute of Medicine (IOM) definition of health care disparities and estimated two-part expenditure models to examine disparity trends in any mental health care use, any outpatient care, and psychotropic drug use, as well as expenditures in these three categories, conditional on use. We used 2-year longitudinal panel data to determine disparities in care initiation among children with unmet need.

PRINCIPAL FINDINGS

Assessing trends over time between 2002 and 2007, we identified that disparities persist for blacks and Latinos in receipt of any mental health care, any outpatient care, and any psychotropic drug use. Among those with positive mental health care expenditures, Latino-white disparities in overall mental health care expenditures increased over time. Among children with unmet need, significant disparities in initiation of an episode of mental health care were found, with whites approximately twice as likely as blacks and Latinos to initiate care.

CONCLUSIONS

Disparities in children's mental health care use are persistent and driven by disparities in initiation, suggesting policies to improve detection or increase initial access to care may be critical to reducing disparities.

Treatment of culturally diverse children and adolescents with depression

This article is written for the practitioners treating depression in ethnic minority youth. It will review the context in which services are delivered to these youth: Researchers have recognized persistent ethnic differences in terms of utilization of services and unmet need. Furthermore, when ethnic minority youth do receive pediatric mental health care, the services that they receive may differ from those given to White patients. The reasons for these discrepancies have been examined in numerous studies, and have included contextual variables (economics, availability, and accessibility of services), patient variables (differences in prevalence or manifestation of the disorder, cultural beliefs and attitudes, preferential use of alternative or informal services, health literacy, and adherence), and provider variables (referral bias and patient-provider communication). Information about the differences between White and minority youth in the pharmacodynamics and pharmacokinetics of the antidepressant response is still limited. There are significant challenges for developing evidence-based guidelines that inform practice with these youth, hinging on both the underrepresentation of ethnic minority groups in clinical trials, and the great variability in biological and cultural characteristics of individuals in ethnic minority categories. Awareness on the part of the practitioner of the cultural variables that influence help-seeking and ongoing utilization of mental health services may aid in the engagement, effective treatment, and retention of ethnic minority children and adolescents with depression. However, given the great heterogeneity that exists within any cultural grouping, clinicians will need to integrate information about cultural patterns with that obtained from the individual patient and family to inform optimal practices for each patient. This article is written to enhance awareness on the part of the practitioner as to the variables that influence psychiatric care for depression in culturally diverse youth. The mental health needs of minority youth are not well served: They are treated less frequently, and when they are treated, the services they receive are less frequently adequate. The reasons that have been proposed for the disparities in their care, particularly with regard to diagnosis and treatment for depression, will be reviewed. They include contextual factors (such as economics, insurance, and other variables affecting the availability of services) patient and family factors (such as prevalence, symptom presentation, and values and beliefs that influence whether patients are referred to and avail themselves of services), and provider factors (such as referral bias and patient-provider communication, which affect whether patients engage and stay in treatment). The implications for the practitioner treating ethnic minority youth with depression will be discussed. Culture, as used in this article, refers to the common values, beliefs, and social behaviors of individuals with a shared heritage. Some aspects of culture that are likely to influence service utilization include health beliefs, particularly regarding models of mental illness, and level of stigma toward mental health treatment, which are frequently shared by individuals in a cultural group. However, some caveats for the explanatory potential of "culture" should be kept in mind. Conventions for naming groups vary between investigators and over time (e.g., the restriction of the category "White" into "White NonHispanic," is quite recent). Although heterogeneity is assumed within a named cultural or racial group, the terms Hispanic, Asian, and African-American incorporate subgroups can be very different in linguistic, historical, and geographical ancestry (e.g., Stewart 2008 ), and each group incorporates individuals who may not share any components of their historical heritage. Even among those with historical ties, values, beliefs, and social behaviors can vary according to the extent to which they identify with the mainstream culture. Social class frequently creates a "culture" of its own, with individuals in the same social class across traditional cultural groupings sharing disparities in care, and many beliefs and values. Individuals are likely to belong to numerous "cultures," and may not share specific typical behaviors or beliefs with any of them.

Prevalence and correlates of psychotropic medication use in adolescents with an autism spectrum disorder with and without caregiver-reported attention-deficit/hyperactivity disorder

BACKGROUND

Many youths with an autism spectrum disorder (ASD) benefit from psychotropic medication treatment of co-morbid symptom patterns consistent with attention-deficit/hyperactivity disorder (ADHD). The lack of clear indications and algorithms to direct clinical practice has led to a very poor understanding of overall medication use for these youths. The present study examined the prevalence of psychotropic medication use compared across individuals with an ASD without a caregiver-reported ADHD diagnosis (ASD-only), ADHD without ASD (ADHD-only), and an ASD with co-morbid ADHD (ASD+ADHD). Correlates of medication use were also examined.

METHODS

Data on psychotropic medication from the first wave of the National Longitudinal Transition Study 2, a nationally representative study of adolescents ages 13-17 in special education, were used to compare the prevalence of medication use across the three groups, overall and by class. Separate logistic regression models were constructed for each group to examine the correlates of psychotropic medication use. Poisson regression models were used to examine correlates of the number of medications.

RESULTS

Youths with ASD+ADHD had the highest rates of use (58.2%), followed by youths with ADHD-only (49.0%) and youths with ASD-only (34.3%). Youths with an ASD, both ASD-only and ASD+ADHD, used medications across a variety of medication classes, whereas stimulants were dominant among youths with ADHD-only. African American youths with ASD-only and with ASD+ADHD were less likely to receive medication than white youths, whereas race was not associated with medication use in the ADHD-only group.

CONCLUSIONS

Clearer practice parameters for ADHD have likely contributed to more consistency in treatment, whereas treatment for ASD reflects a trial and error approach based on associated symptom patterns. Additional studies examining the treatment of core and associated ASD symptoms are needed to guide pharmacologic treatment of these youths. Interventions targeting African American youths with ASD and the physicians who serve them are also warranted.

The Development and Evaluation of a Parent Empowerment Program for Family Peer Advocates

Family-to-family services are emerging as an important adjunctive service to traditional mental health care and a vehicle for improving parent engagement and service use in children's mental health services. In New York State, a growing workforce of Family Peer Advocates (FPA) is delivering family-to-family services. We describe the development and evaluation of a professional program to enhance Family Peer Advocate professional skills, called the Parent Engagement and Empowerment Program (PEP). We detail the history and content of PEP and provide data from a pre/post and 6-month follow up evaluation of 58 FPA who participated in the first Statewide regional training effort. Self-efficacy, empowerment, and skills development were assessed at 3 time points: baseline, post-training, and 6-month follow-up. The largest changes were in self-efficacy and empowerment. Regional differences suggest differences in Family Peer Advocate workforce across areas of the state. This evaluation also provides the first systematic documentation of Family Peer Advocate activities over a six-month period. Consistent with peer specialists within the adult health care field, FPA in the children's mental health field primarily focused on providing emotional support and service access issues. Implications for expanding family-to-family services and integrating it more broadly into provider organizations are described.

Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A)

OBJECTIVE

Mental health policy for youth has been constrained by a paucity of nationally representative data concerning patterns and correlates of mental health service utilization in this segment of the population. The objectives of this investigation were to examine the rates and sociodemographic correlates of lifetime mental health service use by severity, type, and number of DSM-IV disorders in the National Comorbidity Survey-Adolescent Supplement.

METHOD

Face-to-face survey of mental disorders from 2002 to 2004 using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview in a nationally representative sample of 6,483 adolescents 13 to 18 years old for whom information on service use was available from an adolescent and a parent report. Total and sector-specific mental health service use was also assessed.

RESULTS

Approximately one third of adolescents with mental disorders received services for their illness (36.2%). Although disorder severity was significantly associated with an increased likelihood of receiving treatment, half of adolescents with severely impairing mental disorders had never received mental health treatment for their symptoms. Service rates were highest in those with attention-deficit/hyperactivity disorder (59.8%) and behavior disorders (45.4%), but fewer than one in five affected adolescents received services for anxiety, eating, or substance use disorders. Comorbidity and severe impairment were strongly associated with service utilization, particularly in youth with behavior disorders. Hispanic and non-Hispanic Black adolescents were less likely than their White counterparts to receive services for mood and anxiety disorders, even when such disorders were associated with severe impairment.

CONCLUSIONS

Despite advances in public awareness of mental disorders in youth, a substantial proportion of young people with severe mental disorders have never received specialty mental health care. Marked racial disparities in lifetime rates of mental health treatment highlight the urgent need to identify and combat barriers to the recognition and treatment of these conditions.

Disparities in treatment for substance use disorders and co-occurring disorders for ethnic/racial minority youth

OBJECTIVE

To review the literature on racial and ethnic disparities in behavioral health services and present recent data, focusing on services for substance use disorders (SUD) and comorbid mental health disorders for children and adolescents.

METHOD

A literature review was conducted of behavioral health services for minority youth. Articles were included if specific comparisons in receipt of SUD services for youth were made by race or ethnicity. The review was organized according to a sociocultural framework.

RESULTS

Compared with non-Latino Whites with SUD, Black adolescents with SUD reported receiving less specialty and informal care, and Latinos with SUD reported less informal services. Potential mechanisms of racial and ethnic disparities were identified in federal and economic health care policies and regulations, the operation of the health care system and provider organization, provider level factors, the environmental context, the operation of the community system, and patient level factors. Significant disparity decreases could be achieved by adoption of certain state policies and regulations that increase eligibility in public insurance. There is also a need to study how the organization of treatment services might lead to service disparities, particularly problems in treatment completion. Institutional and family characteristics linked to better quality of care should be explored. Because treatments appear to work well independent of race/ethnicity, translational research to bring evidence-based care in diverse communities can bolster their effectiveness.

CONCLUSIONS

This review suggests promising venues to decrease ethnic and racial disparities in behavioral health services for ethnic and racial minority youth.

Leaving no children or families outside: the challenges of immigration

This study addresses potentially stressful events that accompany the process of immigration for children and their families. Acculturation stress, combined with service disparities, may contribute to a higher risk for psychopathology among immigrant children and youth, as compared to their parents. Culturally informed, evidence-based treatment and preventive interventions that meet the mental health and cultural needs of immigrant children and families have the potential to minimize this higher risk of adverse mental health consequences.

Socioeconomic position predicts specialty mental health service use independent of clinical severity: the TRAILS study

OBJECTIVE

To investigate associations between different indices of family socioeconomic position (SEP) and the use of specialty mental health services (SMHS) and whether the associations exist after adjusting for severity of mental problems.

METHOD

Using data from a large longitudinal study of adolescents (N = 2,149; mean age = 13.6 years [SD = 0.53, range = 12 to 15 years]; 51% girls), we assessed the relations of family SEP indices with SMHS use while accounting for severity of mental problems in logistic regression models. Multiple informants (parent, self, and teachers) assessed severity of mental health problems using the Achenbach scales. A parent questionnaire was used to assess family SEP (parents' education, parents' occupation, and family income) and SMHS use. Baseline response rate was 76%, and 96.4% of responders were reassessed at a 2.5-year follow-up visit. Baseline assessments ran from March 2001 through July 2002 and follow-up from September 2003 to December 2004.

RESULTS

Overall, 6.7% of the total sample and 42.9% of those with mental problems accessed SMHS. Univariable analyses yielded no significant associations between SMHS and all the indices of SEP. Adjustment for the severity of mental problems resulted in substantial and statistically significant associations of indices of SEP with SMHS use. Adolescents were particularly more likely to use SMHS with increasing levels of maternal education. Compared to mothers with elementary education, those with university education were three times more likely to consult SMHS independent of severity of their offspring's mental health problems (odds ratio [OR] = 3.18, confidence interval [CI] = 1.22, 8.30). For the aggregate measure of SEP, high SEP was associated with increased use of SMHS compared with low SEP (OR = 1.63, CI = 1.04, 2.55).

CONCLUSIONS

Higher levels of maternal education and overall SEP predict more SMHS use when the severity of mental problems was accounted for. Without correcting for the severity of mental problems, the true association between SEP and SMHS use is obscured in early adolescents.

One size does not fit all: taking diversity, culture and context seriously

Evidence suggests that the current mental health system is failing in the provision of quality mental health care for diverse children and families. This paper discusses one critical domain missing to improve care: serious attention given to diversity, culture, and context. It discusses what we mean by understanding culture and context at the individual, family, organizational, and societal level. Focusing on key predictors of children's adjustment in natural contexts would increase attention to building community and family capacities that strengthen children's mental health. To conclude, we suggest changes in organizational culture to build natural supports to enhance children's mental health.

Factors associated with use of mental health services for depressed and/or suicidal youth aged 15-24

Using data from a national survey, this study examined different factors and their association with mental health service use in youth aged 15-24 with depression and/or suicidality. Our sample consisted of 1,252 youth with depression and/or suicidality. In youth aged 15-18 years old, two factors influenced service use: (1) co-occurrence of depression and suicidality (OR 3.23, 95% CI 1.43, 7.32) and (2) chronic health condition (OR 2.44, 95% CI 1.22, 4.84). Several factors were associated with service use in youth aged 19-24 including gender (female) (OR 1.77, 95% CI 1.14, 2.76), and low income (OR 1.89, 95% CI 1.11, 3.23). The findings suggest differences in the factors associated with mental health service use between youth aged 15-18 and 19-24 with depression and/or suicidality.

Disparities in treating culturally diverse children and adolescents

This article considers disparities in the psychiatric care of racial and ethnic children and adolescents, with respect to their under-utilization and under-treatment, especially with psychotropic medications. Culturally adapted psychotherapeutic approaches are discussed, as well as the notion of a culturally competent clinician who strives to apply his or her clinical skills while constantly making adjustments to the beliefs, habits, and circumstances of culturally diverse children and their parents, one patient at a time.

Who Stays in Treatment? Child and Family Predictors of Youth Client Retention in a Public Mental Health Agency

The present study examined possible predictors of youth client retention in therapy in a large community-based sample. We used several conceptualizations of retention, including (a) "intake retention" (i.e., returned to treatment after intake session); (b) "mutual termination" (i.e., termination agreed upon by family and therapist), (c) "mean treatment duration" (i.e., completing the mean number of sessions in the agency), and (d) "total treatment duration" (i.e., total number of sessions). Archival data from over 400 children and adolescents who sought treatment at a large public mental health clinic were analyzed using regression analyses. Although different predictors were identified across the various conceptualizations, a few robust predictors emerged including ethnicity and client symptom severity. Clinical implications and future research directions are discussed.

Perceived barriers to mental health services among youths in detention

OBJECTIVE

To examine perceived barriers to mental health service use among male and female juvenile detainees.

METHOD

The sample included 1,829 juveniles newly detained in Chicago. The Diagnostic Interview Schedule for Children and Children's Global Assessment Scale were used to determine the need for services. Service use and barriers to services were assessed with the Service Utilization and Risk Factors interview.

RESULTS

Approximately 85% of youths with psychiatric disorders reported at least one perceived barrier to services. Most common was the belief that problems would go away without help. Generally, attitudes toward services were remarkably similar across sex and race. Among females, significantly more youths with past service use or referral to services reported this barrier than did youths who had never received or been referred to services. Among males, significantly more youths who had been referred, but never received, services were unsure about where to go for help than youths with past service use. Significantly more youths with no past service use or referrals were concerned about the cost of services than youths with past service use.

CONCLUSIONS

Despite the pervasive need for mental health services, the findings of this study suggest that detained youths do not perceive the mental health system as an important or accessible resource. Youths who believe their problems can be solved without assistance are unlikely to cooperate with referrals or to independently seek mental health services. Service providers must be sensitive to clients' perceived barriers to mental health services and work to reduce negative perceptions of services.

The experience of Black consumers in the mental health system--identifying barriers to and facilitators of mental health treatment using the consumers' perspective

Research has shown that relative to Whites, Blacks are less likely to seek outpatient mental health treatment and more likely to seek emergency services. Furthermore, Blacks often terminate treatment prematurely. The goal of the present study was to identify barriers to and facilitators of mental heath treatment among Blacks who have a documented need for mental health services. Thirty-four Black mental health consumers were interviewed for this purpose. Comments were categorized into four main categories: (a) barriers to treatment, (b) treatment facilitators, (c) recommendations for improvement of services, and (d) advice to potential consumers. The most common barriers were the importance of family privacy, lack of knowledge regarding available treatments, denial of mental health problems, and concerns about stigma, medications, and treatment. Participants also reported system barriers, such as not receiving appropriate information about services or receiving inadequate, dehumanizing services. Acknowledging the need for mental health services, having a supportive environment, and positive past treatment experiences were identified as treatment facilitators. Community outreach, adequate follow-up, and coordination of services also were important messages delivered by consumers. The results of this study indicate the importance of educating the general public, not just mental health consumers, about the nature of mental illness and available services.

Factors associated with mental health service utilization among bipolar youth

OBJECTIVES

This study aims to characterize patterns of mental health service utilization within a sample of bipolar youth. Demographic variables, youth bipolar characteristics, youth comorbid conditions, and parental psychopathology were examined as predictors of treatment utilization across different levels of care.

METHODS

A total of 293 bipolar youth (aged 7-17 years) and their parents completed a diagnostic interview, family psychiatric history measures, and an assessment of mental health service utilization. Demographic and clinical variables were measured at baseline and mental health service use was measured at the six-month follow-up.

RESULTS

Approximately 80% of bipolar youth attended psychosocial treatment services over the span of 6 months. Of those who attended treatment, 67% attended only outpatient services, 22% received inpatient/partial hospitalization, and 12% received residential/therapeutic school-based services. Using multinomial logistic regression, older age, female gender, and bipolar characteristics, including greater symptom severity and rapid cycling, were found to predict higher levels of care. Youth suicidal and non-suicidal self-injurious behavior, comorbid conduct disorder, and parental substance use disorders also predicted use of more restrictive treatment settings.

CONCLUSIONS

Results underscore the importance of assessing for and addressing suicidality, comorbid conduct disorder, and parental substance use disorders early in the treatment of bipolar youth to potentially reduce the need for more restrictive levels of care.

Children's mental health services and ethnic diversity: Gujarati families' perspectives of service provision for mental health problems

The aim of this study was to explore Gujarati parents' and adolescents' perceptions of child and adolescent mental health services and how these should be improved to best meet their needs. Semi-structured qualitative interviews were carried out with 15 parents and 15 young people, recruited from a community centre. Overall, the quality of the service appeared more important than its responsiveness to culture or ethnicity for both young people and their parents. These findings indicate the need for further evidence and debate on whether Black and ethnic minority families should be treated as though they are a homogenous group.

Perceptions of mental health among recently immigrated Mexican adolescents

Rates of anxiety, depression, and suicidal ideation are high among Latino adolescents in the U.S., many of whom are immigrants. Immigration during adolescence creates risk factors for mental health problems. The purpose of this study was to explore the health-related perceptions of Mexican-origin immigrant adolescents to inform the design of culturally and developmentally appropriate mental health services. This focused ethnography was guided by Bronfenbrenner's ecological framework and symbolic interactionism. Fourteen adolescents were recruited from two non-health-based community settings. Data from one-to-one semi-structured interviews and a visual narrative project were coded and analyzed inductively. Three thematic patterns were identified: "mentally healthy," "mentally unhealthy," and "health promotion." Increased awareness of cultural influences and immigration on Latino adolescents' mental health is needed. Mental health nurses are in a unique position to educate and to influence accessibility of services.

Ethnic variation of self-reported psychopathology among incarcerated youth

Research on ethnic minority populations has shown them to be undertreated, underdiagnosed and perceived as more psychopathological in comparison to the Caucasian population. This study aimed to assess ethnic variation of self-perceived psychopathology in a population of incarcerated youths. The Youth Self-Report (YSR) was completed by 5964 incarcerated adolescents (95% male; mean age = 16.5) in the California Youth Authority (CYA) system. Overall, ethnic minorities (African-Americans and Hispanics) self-report lower levels of psychiatric problems than Caucasians. These differences were more pronounced in males than females. Further research is needed to better ascertain the reasons for these differences.

Gender disparities in mental health service use of Puerto Rican children and adolescents

BACKGROUND

Differences in service utilization indicating that boys use more mental health services than girls were analyzed to see if they could be explained by known correlates of service use. These correlates were arranged into individual (severe emotional disturbance, level of impairment and externalizing disorders), family (parental education, psychopathology and parental concern) and school factors (difficulties with school work). The objectives were to understand and identify the factors accounting for gender differences in mental health service utilization in order to develop alternatives to promote equity in service delivery.

METHODS

A representative sample of 1,896 children 4 to 17 years of age and their primary caretakers were interviewed for this study. Reports of service use were obtained using the Service Assessment for Children and Adolescents. Logistic regression was used to assess the relationship between gender and service use, adjusting for known correlates.

RESULTS

Our results showed that, except for impairment, other individual, family and school factors did not explain gender differences in service utilization. Males with impairment were 2.87 times more likely to receive services than impaired females (p <or= .01), and this result continued to hold true for impaired undiagnosed boys compared to impaired diagnoses-free girls (p <or= .001).

CONCLUSIONS

Our findings showed a service disparity between impaired boys and girls who did not meet criteria for a DSM IV diagnosis, but no observed differences in service use between boys and girls who met criteria for severe emotional disturbance (SED). Continued investigations are necessary to analyze, assess and understand the different circumstances that bring boys and girls into treatment, followed by the development of appropriate intervention programs at the school and community levels.

Decoupling the relation between risk factors for conduct problems and the receipt of intervention services: participation across multiple components of a prevention program

This study examined whether the link between risk factors for conduct problems and low rates of participation in mental health treatment could be decoupled through the provision of integrated prevention services in multiple easily-accessible contexts. It included 445 families of first-grade children (55% minority), living in four diverse communities, and selected for early signs of conduct problems. Results indicated that, under the right circumstances, these children and families could be enticed to participate at high rates in school-based services, therapeutic groups, and home visits. Because different sets of risk factors were related to different profiles of participation across the components of the prevention program, findings highlight the need to offer services in multiple contexts to reach all children and families who might benefit from them.

Culturally competent systems of care for children's mental health: advances and challenges

There has been a remarkable growth in cultural diversity in the United States over the past 20 years. The population of minority groups has increased at a much faster rate than the European-background population in America, and faster even among children and youth. At the same time, minority youth face increasing disparities in their mental health and in access to mental health services. These are related to the multiple challenges they already face in socioeconomic status, but are aggravated by the lack of culturally competent services that can address their specific mental health needs within the context of their culture, family, and community. This paper reviews the current knowledge about the mental health of culturally diverse youth in the United States, and provides guidance on approaches to address the disparities they face.

Race and ethnicity, mental health services and cultural competence in the criminal justice system: are we ready to change?

By the end of 2003, 3.2% of the U.S. adult population or 6.9 million adults were incarcerated, on probation or on parole. While non-whites constitute approximately 25% of the general U.S. population, they represent the majority of the prison (62%) and jail population (57%), a 33% increase since 1980. Approximately 15% of this prison and jail population has active symptoms of serious mental illness with two-thirds likely to have a co-occurring substance use disorder diagnosis. Meanwhile, the lack of adequate mental health and substance abuse treatment within all levels of the criminal justice system continues to exist. This is further exaggerated by the dearth of evidence showing appropriate cultural awareness and competence in delivery of these much needed services to a majority non-white population. This article will review the existing racial disparities present in the criminal justice system, the lack of appropriate psychiatric services, and the effect of cultural dissonance in service provision when services do exist. Policy implications and recommendations are included in the conclusion with a call for action to all agencies directly and indirectly affected by this multifaceted problem.

Mental health of immigrants and refugees

The United States is a country of immigrants. With the exception of Native-Americans, every other American is, or descends from, an immigrant. First and second generation immigrant children are the most rapidly growing segment of the American population, with the great majority of this population being of non-European origin. This paper reviews the unique risk factors and mental health needs of our new immigrant populations, as well as treatment and services approaches to address their unique needs.

Racial group differences in help-seeking behaviors

The authors evaluated variations in help-seeking behaviors among Blacks and Whites and the role of cognitive-affective variables as mediators of these variations. Participants were 70 Black and 66 White community college students who completed the SCL-90-R (L. R. Derogatis, 1977, 1994), the Revised Multidimensional Health Locus of Control (T. Bekhuis et al., 1995), the Symptom Interpretation Questionnaire (J. M. Robbins & L. J. Kirmayer, 1991), and a measure of help-seeking behaviors and demographic information. Relative to White college students, Black college students significantly less frequently used psychological or social services and significantly more frequently used religious services. The authors accounted for group differences in religious help-seeking behaviors by beliefs in the power of God and by normalizing symptom attributions. The cognitive-affective variables that were studied did not account for differences in psychological help-seeking behaviors. The authors inferred that to better meet the needs of Black college students, collaboration between mental health services and religious services would likely be beneficial.

Determinants of service use among young Canadians with mental disorders

OBJECTIVE

To identify the determinants of service use by young Canadians with mental health problems.

METHODS

Data were drawn from a recent large Canadian mental health survey. The analyses were conducted on a subsample of 1092 Canadians aged 15 to 24 years and identified as presenting a mood disorder, an anxiety disorder, or a substance-related disorder in the 12 months preceding the survey. We classified variables potentially associated with any type of service use for a mental health problem over a 12-month period according to predisposing, enabling, and need factors. We conducted weighted multivariate logistic regressions to determine the association of each factor with service use.

RESULTS

In the final model, being female and living alone were the predisposing factors associated with service use. None of the enabling factors predicted help seeking. In regard to the perceived need factors, those who had difficulties with social situations were more likely to use services. Having a mood disorder and (or) having a diagnosed chronic illness were the evaluated need factors associated with service use.

CONCLUSION

Certain groups of young Canadians are less likely to seek help for mental health problems and could be the target of interventions aimed at increasing service use.

Factors that impact adolescents' intentions to utilize alcohol-related prevention services

The current study is the first to examine factors that may be associated with middle school students' intentions to use alcohol-related prevention services. Youth (N = 1506; 46% male; 11-14 years old) completed surveys on their intentions to use alcohol-related services, beliefs about services, previous use of services, and substance use. Students who reported stronger positive beliefs reported greater intentions to use services. Girls, younger students, and whites also reported stronger interest in using services than boys, older students, and youth of mixed ethnicity, respectively. Adolescents who reported current use of substances were less willing to use prevention services. Current research highlights the importance of creating prevention services for this age group that are developmentally relevant and that focus on features that will attract youth, such as utilizing an interactive discussion format. Beginning to understand what motivates adolescents to seek help can facilitate the creation of better prevention programs.

Psychiatric, Family, and Ethnicity-Related Factors That Can Impact Treatment Utilization Among Hispanic Substance Abusing Adolescents

There is great significance to improving our understanding of predictors of treatment utilization among Hispanic substance abusing youth. One hundred and ten Hispanic substance abusing adolescents and their parents participated in a study of treatment utilization. Analyses showed that adolescents with lower numbers of externalizing disorders (χ2 = 4.18, df = 1, p < .05) and parents with better parenting strategies (χ2 = 8.73, df = 2, p < .05), predicted overall treatment utilization (residential + outpatient). Better parenting practices and higher parental years in the U.S. predicted more utilization of outpatient services and lower parenting stress predicted more utilization of residential services. Without specialized engagement strategies, adolescents and families most in need may be the least likely to engage in recommended treatment.

Child mental health in Latin America: present and future epidemiologic research

OBJECTIVE

This report reviews population studies of child and adolescent mental health carried out in Latin America over the past 15 years. Also considered is the issue of how to meet the needs of children and adolescents who may present mental health problems in Latin America, given that most of them live in poverty in economies that are underdeveloped, providing limited resources.

METHOD

Ten studies from six different countries were identified that employed some form of randomized sampling method and used standardized instruments for assessment. The authors present a summary of the main characteristics of these studies, highlighting methodological features that may account for differences in the rates obtained.

RESULTS

Overall, a similar pattern of prevalence and risk factors for mental health problems in children and adolescents in Latin American countries emerged. Moreover, rates of disorders in these children are similar to the 15 to 20% found in other countries. These findings are similar to those observed when adult mental health problems are considered. Prevention and treatment strategies are discussed and the peculiarities of the delivery of mental health services for children and adolescents are explored.

CONCLUSIONS

Future research needs to focus on understanding of resilience and formal and informal mental health delivery systems of care available in different Latin American countries. Such research has high potential for ameliorating the prevention and treatment of child and adolescent mental health problems in this region of the world.