A comparison of federal definitions of severe mental illness among children and adolescents in four communities

Policy Definitions for "Serious Mental Illness" Across 56 United States, Districts and Territories

The construct "serious/severe mental illness," or "SMI," is a priority within mental health initiatives in the United States. However, there is a lack of clarity regarding its operational definition in policy and practice settings. This study involved an evaluation of "SMI" policy definitions across the 50 United States, five territories, and Washington, D.C. via review of public legislation, department of health (DOH) websites and contacts. Policy definitions were available for 46 (82.2%) locations. Of those definitions, 32 (69.6%) were listed within legislation and 18 (39.1%) used pre-existing organizational or agency definitions. Only nine (19.6%) definitions indicated they were intended to determine eligibility for specific mental health services. Most locations (N = 38; 82.6%) mentioned functional impairment or disability as an eligibility criterion and suggested any psychiatric diagnosis could be considered SMI (N = 34; 73.9%). Results indicate substantial variability in SMI policy definitions across geographic locations with implications for service eligibility, delivery, and receipt.

1915(c) Medicaid Waivers for Children With Severe Emotional Disturbance: Participant Characteristics, Enrollment, and Out-of-Home Service Use

Several states have invested in 1915(c) Home and Community Based Service (HCBS) Medicaid policies to improve outcomes and reduce costs for children and youth with significant behavioral health needs, or Severe Emotional Disturbance (SED). However, little is known about these programs and the children they serve. Through a retrospective cross-sectional analysis, this study aimed to understand if the program was successfully reaching its target population: children and youth with the highest clinical need, at the greatest risk for out-of-home care, and who may not otherwise be eligible for Medicaid through other avenues. Results describe the demographic, clinical, and service use characteristics of children and youth enrolled in one SED Waiver program, comparing them with those of similar, non-waiver enrolled children with behavioral health needs. Findings report that the waiver program examined rarely served children and families not otherwise eligible for Medicaid, but that waiver-enrolled children and youth had substantially more severe clinical need, were at higher risk for out-of-home placement and incurred greater public expenditures for service use. Findings suggest the program studied is serving children with more significant psychiatric needs, as the program intends, but points to the need for further research to understand the impacts of such programs on system and clinical outcomes.

Reliability of the Term "Serious Mental Illness": A Systematic Review

OBJECTIVE

The term "serious mental illness" (SMI) is widely used across research, practice, and policy settings. However, there is no consistent operational definition, and its reliability has not been systematically evaluated. The purpose of this review was to provide a comprehensive qualitative content analysis of "SMI" empirical research, including study and sample characteristics and SMI operational definitions. These data can provide important considerations for how stakeholders conceptualize SMI.

METHODS

Systematic review of PsycInfo, PsycArticles, and PubMed databases from January 1, 2015, to December 31, 2019, identified 788 original empirical studies that characterized the sample as having "SMI."

RESULTS

Descriptive content analysis indicated that most studies (85%) provided no operational definition for SMI. Only 15% defined the term, and an additional 26% provided examples of SMI that included only psychiatric diagnostic categories (e.g., SMI, such as schizophrenia). Of the 327 studies that provided any description of SMI, variability was noted regarding whether criteria included any mental health diagnosis (N=31) or only specified diagnoses (N=289), functional impairment (N=73), or any specified duration of symptoms (N=39). Across all studies that characterized samples as having SMI, substantial variability was noted regarding included diagnostic classifications.

CONCLUSIONS

Referencing "SMI" is second nature for many stakeholders. Findings suggest that evidence-based practice and policy efforts should weigh the level of research support indicating that the construct and the term "SMI" lacks generalizability. Researchers and stakeholders are encouraged to develop precise and agreed-upon diagnostic language in their efforts to support and advocate for people with mental illnesses.

Medicaid Waivers for Youth with Severe Emotional Disturbance: Associations with Public Health Coverage, Unmet Mental Health Needs & Adequacy of Health Coverage

Home and Community-Based Services (HCBS) Medicaid waivers for Serious Emotional Disturbance (SED) extend Medicaid eligibility to youth who otherwise would be financially ineligible and finance a broad array of highly specialized mental health services specific to the needs of youth with SED. This study examines whether these policies are associated with greater public health insurance coverage among youth with severe mental health diagnoses. It also assesses, among youth with severe mental health diagnoses who have public health coverage, whether waiver policies are associated with reduced reports of unmet mental health treatment need and increased reports of adequate mental health coverage. Analysis uses CMS reported data on state HCBS Medicaid waivers in conjunction with data from the National Survey of Children's Health for the years 2016 through 2018. Multi-level, fixed-effects logistic regression models demonstrate that living in a state with an HCBS Medicaid waiver is associated with significantly increased odds of having public insurance among children with concurrent private health coverage (OR 1.89), reduced odds of unmet mental health needs among youth with public coverage (OR 0.45), but not significantly associated with reported adequacy of mental health insurance coverage.

The Importance of Intentionality in Untangling Trauma From Severe Mental Illness

Trauma has become entangled and largely lost in the conceptualization and treatment of severe mental illness (SMI). Practitioners conceptualize and treat SMI with medical-model ideals. While researchers support using treatment approaches developed from a medical model in treating the symptoms of SMI, these treatments can be problematic for an individual with SMI who has also experienced trauma. Thus, it is imperative that counselors consider trauma separately when working with individuals presenting with SMI. Additionally, counselors need to employ holistic measures to treat trauma. This article focuses on understanding how SMI and trauma have become entangled, what they look like when separated, and why it is important to disentangle them. The conceptualization for the disentanglement process is presented from a Jungian theoretical foundation.

Epidemiology of severe mental illness in Hunan province in central China during 2014-2015: A multistage cross-sectional study

Objective

Severe mental illness (SMI) represents major social and public health problem in China, especially in low- or middle-income regions. We aim to assess the prevalence and distribution of SMI in Hunan province in central China.

Methods

Multistage stratified random sampling methods were used to select qualified subjects in 123 districts and counties in Hunan province. 89465 individuals were randomly identified, and 72999 (81.6%) completed the supplemental 12-Item General Health Questionnaire (GHQ-12) and Cue questionnaire of psychiatric abnormal behaviors. 6082 suspected individuals having high or moderate risk, or psychiatric cues, were administered the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I) by psychiatrists.

Results

720 respondents were definitely diagnosed as SMI. The 1-month and lifetime prevalence was 9.35‰ and 10.10‰, respectively. The most frequent SMI was schizophrenia, followed by bipolar disorder, intellectual disability, epileptic mental disorder, paranoid psychosis and schizoaffective disorders, with 1-month prevalence ranging from 0.11‰ to 6.50‰ and lifetime prevalence ranging from 0.24‰ to 6.86‰. Multivariate logistic regression analysis revealed that lower education, farmer occupation, retirees or jobless/unemployed, unmarried or divorced and age of 30–64 years old were major factors that associated with the increased risk of SMI. In addition, only 33.3% of 528 patients who completed questionnaire sought help in psychiatric institutions, and up to 51.7% of 720 patients were not referred to the SMI management system in Hunan province.

Conclusions

These findings provided a large-scale prevalence data of SMI in a provincial sample of China. The psychiatric disorders brought economical and psychological burden for family and society, which may shed light on the significance of scaling up province-wide mental health service and strengthening the SMI management.

A Program Evaluation Strategy in a Community-Based Behavioral Health and Education Services Agency for Children and Families

Evaluation research and outcomes measurement in the arena of behavioral health services for children must be adapted for the community agency setting. Through evaluation research, it is possible to address service goals as well as more traditional academic research goals. This article examines a variety of activities that have been implemented to evaluate children’s behavioral and educational services in a Northern California non-profit community agency. It is noted that there are multiple formats for collecting information from and providing comments to children’s parents, their clinicians, and program administration staff, all of which can be used to effectively address service-focused evaluation research goals. Challenges to doing scientifically rigorous research in a community setting require additional considerations regarding organizational culture and structure. Based on the experiences of the authors and the experiences of others, the article describes general principles that can guide evaluation research and outcomes measurement with children and their families in the community health agency setting.

Prevalence of Psychiatric Disorders Among Turkish Children: The Effects of Impairment and Sociodemographic Correlates

This study was designed to assess the prevalence of psychiatric disorders and the impact of impairment criteria on rates of diagnoses in a representative sample of elementary school children from a country in a region. We sampled 419 primary school children by using a one-stage design in Izmir, Turkey. The response rate was 99.5 % and 417 cases were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children Present and Lifetime Version and a scale to assess the impairment criterion. The results showed that 36.7 % of the sample met DSM-IV criteria independent of impairment and that 14.1 % of the population had one or more DSM-IV disorders when a measure of impairment specific to each diagnosis was considered. The most prevalent disorders were attention-deficit/hyperactivity disorder and anxiety disorders. This study provided the first estimates of the prevalence of specific DSM-IV-defined psychiatric disorders in Turkish population of children.

Using systems of care to reduce incarceration of youth with serious mental illness

Youth with serious mental illness come into contact with juvenile justice more than 3 times as often as other youth, obliging communities to expend substantial resources on adjudicating and incarcerating many who, with proper treatment, could remain in the community for a fraction of the cost. Incarceration is relatively ineffective at remediating behaviors associated with untreated serious mental illness and may worsen some youths' symptoms and long-term prognoses. Systems of care represent a useful model for creating systems change to reduce incarceration of these youth. This paper identifies the systemic factors that contribute to the inappropriate incarceration of youth with serious mental illness, including those who have committed non-violent offenses or were detained due to lack of available treatment. It describes the progress of on-going efforts to address this problem including wraparound and diversion programs and others utilizing elements of systems of care. The utility of systems of care principles for increasing access to community-based mental health care for youth with serious mental illness is illustrated and a number of recommendations for developing collaborations with juvenile justice to further reduce the inappropriate incarceration of these youth are offered.

Clinical prevalence and correlates of substance use in adolescent psychiatric emergency patients

OBJECTIVES

This study used clinical and administrative data to describe the clinical prevalence and correlates of substance use disorders (SUDs) in 622 adolescents aged 12 to 17 years who were evaluated with 1 or more psychiatric diagnoses after presenting to an urban psychiatric emergency service.

METHODS

Clinical and administrative data including demographics, diagnosis, psychiatric severity, suicidality, treatment history, treatment disposition, social support, and overall functioning were retrospectively obtained from patient records. These data were used to describe the prevalence and correlates of SUDs in this sample of adolescents with psychiatric disorders.

RESULTS

Twenty-eight percent of youth had an SUD. Marijuana and alcohol use disorders were the most common. The diagnosis of SUD was not associated with specific psychiatric diagnostic categories (mood, anxiety, and psychotic), psychiatric symptom severity, or suicidality, in the overall sample. There was limited evidence for a mediating/moderating effect of sex on the correlation between psychiatric measures and SUD diagnosis. Older age, SUD treatment history, and role dysfunction (ie, poor school functioning) were independently associated with any SUD diagnosis or a drug use disorder when accounting for sex. Older age and history of SUD treatment were independently correlated with alcohol use disorders. Twenty-three percent of youth with SUDs were referred for SUD treatment.

CONCLUSIONS

Substance use disorders were prevalent in this population, and the rate of SUD treatment disposition was lower than anticipated. Substance use disorders were associated with lower functioning but not independently correlated with psychiatric diagnostic categories or symptom severity. This study supports the need for improved screening, intervention, and referral options for SUDs in this setting.

Global Appraisal of Individual Needs Short Screener (GSS): psychometric properties and performance as a screening measure in adolescents

Psychiatric and substance use disorders, separately or combined, are frequent in adolescence. Brief, psychometrically sound screening tools are needed to identify those at-risk. The Global Appraisal of Individual Needs-Short Screener (GAIN-SS) is a brief, inexpensive screener that was derived from the well researched full GAIN interview. However, its validity has not been independently investigated based on independent validated screening instruments in an adolescent clinical population. In this project, the internal consistency, validity, and optimal screening cutoff scores were examined in 95 adolescents, most of whom were receiving treatment, and suffered from internalizing (52%; n = 49), externalizing (66%, n = 63), and co-occurring substance use disorders (55%, n = 56). Results indicated adequate internal consistency and overall and subscale construct validity. Receiver operating characteristics (ROC) analyses revealed that the GSS substance use disorder subscale had adequate sensitivity (88%) and specificity (89%). Psychiatric disorder subscales performed less well. The discussion focuses on the strengths and potential weaknesses of use of the GSS and its potential utility in other populations.

Rates of DSM-IV psychiatric disorders among adolescents in a large metropolitan area

We present prevalence data for adolescents in a large metropolitan area in the US and the association of DSM-IV diagnoses to functional impairment and selected demographic correlates. We sampled 4175 youths aged 11-17 years from households enrolled in large health maintenance organizations. Data were collected using questionnaires and the Diagnostic Interview Schedule for Children, Version IV (DISC-IV). Impairment was measured using the Child Global Assessment Scale and diagnostic specific impairment in the DISC-IV. 17.1% of the sample met DSM-IV criteria for one or more disorders in the past year; 11% when only DISC impairment was considered and 5.3% only using the CGAS. The most prevalent disorders were anxiety (6.9%), disruptive (6.5%), and substance use (5.3%) disorders. The most prevalent specific disorders were agoraphobia, conduct and marijuana abuse/dependence, then alcohol use and oppositional defiant disorder. Younger youths and females had lower odds for any disorder, as did youths from two parent homes. There was increased odds associated with lower family income. Females had greater odds of mood and anxiety disorders, males of disruptive and substance use disorders. There were greater odds of mood and disruptive disorders for older youths. Prevalences were highly comparable to recent studies using similar methods in diverse non-metropolitan populations. We found associations with age, gender, and to a lesser extent, socioeconomic status reported in previous studies. The inclusion of both diagnosis-specific impairment and global impairment reduced prevalence rates significantly. Our results suggest commonality of prevalences and associated factors in diverse study settings, including urban and rural areas.

Comorbidity of substance use disorders and other psychiatric disorders among adolescents: evidence from an epidemiologic survey

This paper extends our knowledge of comorbidity of substance use disorders (SUDs) and other psychiatric disorders by examining comorbidity of specific types of SUDs and risk of comorbidity separately for abuse and dependence. The research question is whether there is specificity of risk for comorbidity for different SUDs and whether greater comorbidity is associated with dependence. Data are presented from a probability sample of 4175 youths aged 11-17 assessed with the NIMH DISC-IV and self-administered questionnaires. SUDs outcomes are alcohol, marijuana and other substances in past year. Mean number of other comorbid disorders ranged from 1.9 for marijuana abuse to 2.2 for other substance abuse and 1.9 for marijuana dependence to 2.8 for other substance dependence. None of the abuse SUDs does not increase risk of anxiety disorders, but dependence does. Both abuse and dependence increased risk of comorbid mood disorders. Similar results were observed for disruptive disorders. Patterns of comorbidity varied by substance, by abuse versus dependence, and by category of other psychiatric disorders. In general, there was greater association of comorbidity with other disorders for dependence versus abuse. Marijuana is somewhat less associated with other disorders than alcohol or other substances. The strongest association is for comorbid disruptive disorders, regardless of SUDs category. Having SUDs and comorbid other psychiatric disorders was associated with substantial functional impairment. Females with SUDs tended to have higher rates of comorbid disorders, as did older youths. There were no differences observed among ethnic groups. When comorbidity of SUDs with other disorders was examined, controlling for other non-SUDs disorders for each specific disorder examined, the greater odds for dependence versus abuse essentially disappeared for all disorders except disruptive disorders, suggesting larger number of comorbid non-SUDs in part account for the observed effects for dependence.

The health of homeless children revisited

To the extent that representative data are available for specific health conditions (eg, under-immunization, asthma prevalence), the authors' data suggest that the gap between the health status of homeless children and housed children in minority, low-income families is narrowing. Studies of the health status of homeless children allow a window into the health status of medically underserved children whose needs may not be readily documented because of their lack of access to the health care system. Although prevalence rates of most of the health conditions discussed in this article exceeded national norms, they were generally consistent with rates characteristic of health disparities based on race-ethnicity and income. It must be emphasized that in most instances, children were seen for their first pediatric visit within weeks of entering the homeless shelter system. The health conditions identified were often present before the child and family became homeless. The high prevalence of asthma among homeless children should therefore be a matter of concern to health providers and payors, because the authors' data strongly suggest that this is not confined to children in homeless shelters as a special population. Similarly, childhood obesity predates homelessness (or at least the episode of homelessness during which health care was provided) and as such the authors' data may indicate the extent of this problem more generally among medically underserved children in the communities of origin. These conditions seem to be exacerbated by the specific conditions associated with homeless shelter life. Asthma care, assuming it was previously available, is disrupted when housing is lost, and shelter conditions may have multiple asthma triggers. Nutrition often suffers as a result of inadequate access to nutritious food and cooking facilities in shelters, as indicated by the high rate of iron-deficiency anemia among very young children. It is clear that homeless children in shelters require enhanced access to primary and specialist care. Shelter placement necessarily disrupts prior health care relationships (if any), while simultaneously placing additional stress on the child's physical and emotional well being. A medical home model is strongly recommended to allow for continuous, culturally competent care. Developmental and mental health problems are also more prevalent among homeless children. These conditions may jeopardize life successes. The overcrowding associated with homeless shelters and the housing conditions that frequently precede episodes of homelessness are associated with the higher prevalence of otitis media found among young children. This in turn is associated with developmental delay. Also contributing to the developmental risk associated with homelessness is exposure to DV, which is also frequently an antecedent of homelessness. Developmental surveillance for young, homeless children, monitoring of school attendance and academic performance, and assessment of mental status for homeless adolescents are recommended to facilitate early identification of problems and delivery of necessary interventions. For young children, providers of health care to the homeless should be well networked into the Early Intervention and Preschool Special Education programs in their locality. Given the multiplicity of needs for homeless families, which of course includes help finding affordable housing, health care providers serving this population should also develop linkages with community agencies, including those that can help parents develop the skills necessary for economic self-sufficiency and long-term ability to sustain independent housing.

Multiple-family group treatment as an effective intervention for children with psychological disorders

An estimated 20% of children suffer from psychological disorders and only 10-20% receive adequate treatment. A lack of empirically supported treatments is one reason why relatively few children receive treatment for their psychological difficulties. Multiple-family group treatment (MFGT) is an empirically supported intervention for adults with chronic mental illnesses that may be an effective treatment for children with psychological disorders. This article reviewed the adult MFGT model and its empirical support. The quantity and quality of child MFGT research was then reviewed. Child MFGT models are compared with one another and to the adult MFGT model. All studies provided initial support of MFGT as an appropriate treatment for childhood disorders. However, the child literature as whole was relatively limited, unfocused, and lacked replication. Suggestions for future research are made, focusing on a structured and scientific approach to establishing MFGT as an empirically supported intervention for children.