Faculty Bibliography

OBJECTIVE: This study examined the test-retest reliability of a new instrument, the Services Assessment for Children and Adolescents (SACA), for children's use of mental health services. METHODS: A cross-sectional survey was undertaken at two sites. The St. Louis site used a volunteer sample recruited from mental health clinics and local schools. The Ventura County, California, site used a double-blind, community-based sample seeded with cases of service-using children. Participating families completed the SACA and were retested within four to 14 days. The reliability of service use items was calculated with use of the kappa statistic. RESULTS: The SACA- Parent Version had excellent test-retest reliability for both lifetime service use and previous 12-month use. The SACA also had good to excellent reliability when administered to children aged 11 and older for lifetime and 12-month use. Reliability figures for children aged nine and ten years were considerably lower for lifetime and 12-month use. The younger children's responses suggested that they were confused about some questions. CONCLUSIONS: This study demonstrates that parents and older children can reliably report use of mental health services by using the SACA. The SACA can be used to collect currently unavailable information about use of mental health services.

This paper provides a synthetic review of research on school-based mental health services. Schools play an increasingly important role in providing mental health services to children, yet most school-based programs being provided have no evidence to support their impact. A computerized search of references published between 1985 and 1999 was used to identify studies of school-based mental health services for children. Study inclusion was determined by (i) use of randomized, quasi-experimental, or multiple baseline research design; (ii) inclusion of a control group; (iii) use of standardized outcome measures; and (iv) baseline and postintervention outcome assessment. The application of these criteria yielded a final sample of 47 studies on which this review is based. Results suggest that there are a strong group of school-based mental health programs that have evidence of impact across a range of emotional and behavioral problems. However, there were no programs that specifically targeted particular clinical syndromes. Important features of the implementation process that increase the probability of service sustainability and maintenance were identified. These include (i) consistent program implementation; (ii) inclusion of parents, teachers, or peers; (iii) use of multiple modalities; (iv) integration of program content into general classroom curriculum; and (v) developmentally appropriate program components. Implications of these findings and directions for future research are discussed.

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

OBJECTIVE: To describe differences in parent-child responses to the Service Assessment for Children and Adolescents (SACA). METHOD: Studies were done at UCLA and Washington University based on service-using and community subjects drawn from community households or public school student lists, respectively. Results are presented for 145 adult-youth pairs in which the youth was 11 or older. RESULTS: The SACA adult-youth correspondence for lifetime use of any services, inpatient services, outpatient services, and school services ranged from fair to excellent (kappa = 0.43-0.86, with most at 0.61 or greater). Similarly, the SACA showed a good to excellent correspondence for services that had been used in the preceding year (kappa = 0.45-0.77, with most greater than 0.50). The parent-youth correspondence for use of specific service settings in the above generic categories ranged from poor to excellent (kappa = 0.25-0.83, with half at 0.50 or greater). CONCLUSIONS: The SACA has better adult-youth correspondence than any service use questionnaire with published data, indicating that both adult and youth reports are not needed for all research on mental health services. This is especially encouraging news for researchers working with high-risk youth populations, in which a parent figure is often not available.

OBJECTIVE: To summarize knowledge on treatment services for children and adolescents with attention-deficit hyperactivity disorder (ADHD), trends in services from 1989 to 1996, types of services provided, service mix, and barriers to care. METHOD: A review of the literature and analyses from 2 national surveys of physician practices are presented. RESULTS: Major shifts have occurred in stimulant prescriptions since 1989, with prescriptions now comprising three fourths of all visits to physicians by children with ADHD. Between 1989 and 1996, related services, such as health counseling, for children with ADHD increased 10-fold, and diagnostic services increased 3-fold. Provision of psychotherapy, however, decreased from 40% of pediatric visits to only 25% in the same time frame. Follow-up care also decreased from more than 90% of visits to only 75%. Family practitioners were more likely than either pediatricians or psychiatrists to prescribe stimulants and less likely to use diagnostic services, provide mental health counseling, or recommend follow-up care. About 50% of children with identified ADHD seen in real-world practice settings receive care that corresponds to guidelines of the American Academy of Child and Adolescent Psychiatry. Physicians reported significant barriers to service provision for these children, including lack of pediatric specialists, insurance obstacles, and lengthy waiting lists. CONCLUSIONS: The trends in treatment services and physician variations in service delivery point to major gaps between the research base and clinical practice. Clinical variations may reflect training differences, unevenness in the availability of specialists and location of services, and changes in health care incentives.

The Head Start Mental Health Research Consortium (HSMHRC) is a research partnership between the Administration on Children, Youth and Families (ACYF) and the National Institute of Mental Health (NIMH). Funded jointly by these two agencies, a research consortium with five core sites brought together a range of disciplinary perspectives with three primary goals: (1) to develop assessment strategies for identifying young children's social and emotional development; (2) to assess Head Start families' access to mental health services; and (3) to investigate the effectiveness of both universal and targeted intervention models for Head Start children, including those co-occurring language and behavioral problems. This collaborative mental health research will yield information about the types of mental health needs of children from low-income families, the optimal approaches for assessing these needs, and the impact of research-based intervention models delivered within a Head Start context.

The concordance between parent reports of children's mental health services and medical and administrative service records were assessed in a field test of the Services Assessment for Children and Adolescents (SACA) interview instrument. Service use reports from primary caregivers, usually mothers, for their child's emotional or behavioral problems were compared against inpatient, outpatient, and school records. Ss (aged 4-17 yrs) had received services within the previous 12 mo from a psychiatric facility and whose diagnoses included nonpsychotic disorders. A 2nd sample included 150 parent (aged 21-65 yrs)/child pairs. A global "any use" service variable, comprised of inpatient, outpatient, and school reports, yielded an overall service use concordance kappa of .76 between parent reports and records. Parent reports of inpatient hospitalization services using the SACA yielded the highest agreement with medical records. Parent reports of specific inpatient services concurred with medical records more moderately. Reports of any outpatient mental health services yielded variable rates of agreement. Parent reports of school services were weakly related to records for most services, except for moderate agreement on placement in special classrooms for emotional or behavioral problems.

Parents' ability to make reliable and valid reports about health service utilization is a key research design consideration for studies about the unmet needs of children and adolescents with emotional or behavioral problems. This research report addresses the validity of parents' reports, in particular, parents' rates of false-negative reporting about their children's mental health service use. Findings show that only a few parents of known service users fail to report that their child or adolescent has received services for an emotional or behavioral problem. However, when parents are asked to report about their child's service use with specific providers or in specific service settings, the rate of false-negative reporting tends to increase, and in some circumstances this increase is dramatic. Logistic regression results indicate that false-negative reporting is more likely to occur among parents whose children are male, less frequent service users, or service users whose use is less recent. After controlling for these factors, the authors did not find a significant difference in the rate of false-negative reporting for parents of Anglo and Latino children.