Does Model Matter? Examining Change Across Time for Youth in Group Homes.

Group homes are a frequently used but controversial treatment setting for youth with mental health problems. Within the relatively sparse literature on group homes, there is some evidence that some models of treatment may be associated with more positive outcomes for youth. This article explores this possibility by examining differences across time for youth served in group homes utilizing the Teaching Family Model (TFM) and geographically proximate homes using more eclectic approaches. Data come from a longitudinal quasi-experimental study that included 554 youth. Results suggest that youth showed, on average, significant and rapid improvement during initial months in a group home. Improvement did not differ for TFM and non-TFM homes during this initial period. Post-discharge results, though, show that TFM was associated with continued improvement after discharge and significantly better outcomes by 8 months post-discharge. Results also discuss youth-level factors that may influence outcomes as well as need for additional work to more fully understand processes and practices that are key for maximizing and maintaining youths' positive outcomes during and after group home placements.

Who Goes Where? Exploring Factors Related to Placement Among Group Homes.

Despite their widespread use as a placement option for youth with mental health problems, there is relatively little research on group homes for youth. Available data highlight concerns with practices and treatment within group homes and mixed results on youth-level outcomes. However, existing research appears to collapse a wide range of group residential settings into a single amorphous category. This article explores potential variations among group homes to examine whether different programs are systematically serving different types of youth. It examines, in particular, placement in homes using the teaching family model (TFM) versus homes that do not. Findings suggest that demographics are not significantly associated with TFM placement. However, custody status, types of mental health problems, and use of psychotropic medications are. Homes appear to be serving distinct niches within a geographic area. Implications for future research and policy/practice are discussed.

Mental health service use among adolescents following participation in a randomized clinical trial for depression.

Major depressive disorder (MDD) is a common disorder among adolescents. The Treatment for Adolescents with Depression Study (TADS) was a randomized controlled trial to examine the efficacy of fluoxetine and cognitive-behavioral therapy (CBT), separately and together, compared with placebo, in adolescents 12 to 17 years of age. The Survey of Outcomes Following Treatment for Adolescent Depression (SOFTAD) was designed as a naturalistic follow-up of participants in TADS. The aims of the current analyses are to describe mental health service use during the SOFTAD period. There were 196 adolescents recruited from 12 TADS sites. The Schedule for Affective Disorders and Schizophrenia for School-Age-Children-Present and Lifetime Version was used for clinical diagnoses. Participants completed a psychiatric treatment log and the Child and Adolescent Services Assessment to assess service use. 58% received psychotherapy or nonstimulant psychotropic medication during SOFTAD. Youth with recurrent MDD had higher rates of treatment compared to youth without recurrent MDD (71% vs. 45%). However, nearly one third of the adolescents in the study did not receive treatment for a recurrent episode of depression. Service use differed by gender for those with recurrent MDD, with female participants (79%) receiving treatment at higher rates than male participants (55%), although there was no significant difference in depression severity between genders. Younger participants with recurrent MDD had higher odds of receiving psychotherapy. Use of psychotherapy and psychotropics following recurrence of depression appears to be influenced by age and gender. Even when youth respond well to treatment, a sizeable percentage are likely to experience a subsequent episode that may go untreated.

Developing quality indicators for family support services in community team-based mental health care.

Quality indicators for programs integrating parent-delivered family support services for children's mental health have not been systematically developed. Increasing emphasis on accountability under the Affordable Care Act highlights the importance of quality-benchmarking efforts. Using a modified Delphi approach, quality indicators were developed for both program level and family support specialist level practices. These indicators were pilot tested with 21 community-based mental health programs. Psychometric properties of these indicators are reported; variations in program and family support specialist performance suggest the utility of these indicators as tools to guide policies and practices in organizations that integrate parent-delivered family support service components.

The impact of Assertive Community Treatment on utilization of primary care and other outpatient health services: the North Carolina experience.

BACKGROUND: A number of states have implemented Assertive Community Treatment (ACT) teams statewide. The extent to which team-based care in ACT programs substitutes or complements primary care and other types of health services is relatively unknown outside of clinical trials. OBJECTIVE: To analyze whether investments in ACT yield savings in primary care and other outpatient health services. DESIGN: Patterns of medical and mental health service use and costs were examined using Medicaid claims files from 2000 to 2002 in North Carolina. Two-part models and negative binomial models compared individuals on ACT (n = 1,065 distinct individuals) with two control groups of Medicaid enrollees with severe mental illness not receiving ACT services (n = 1,426 and n = 41,717 distinct individuals). RESULTS: We found no evidence that ACT affected utilization of other outpatient health services or primary care; however, ACT was associated with a decrease in other outpatient health expenditures (excluding ACT) through a reduction in the intensity with which these services were used. Consistent with prior literature, ACT also decreased the likelihood of emergency room visits and inpatient psychiatric stays. CONCLUSIONS: Given the increasing emphasis and efforts toward integrating physical health and behavioral health care, it is likely that ACT will continue to be challenged to meet the physical health needs of its consumers. To improve primary care receipt, this may mean a departure from traditional staffing patterns (e.g., the addition of a primary care doctor and nurse) and expansion of the direct services ACT provides to incorporate physical health treatments.

Risk and protective factors for heavy episodic drinking among college students: Influence of mental health service use.

Objective: This study was designed to assess the relationship between mental health service utilization and heavy episodic drinking (HED) after controlling for demographic and student-level variables. Participants: A national sample of college undergraduate respondents to the 2017-2018 Healthy Minds Study survey (n = 67,427). Methods: Hierarchical logistic regression entering all variables on a single step. Subsequent logistic regression was used to assess interactions between mental health service variables and select demographic and student level variables. Results: Twenty-two demographic and student-level variables were associated with current HED (9 protective and 11 risk factors). Current mental health therapy was associated with a lower risk of current HED while mental health medication use in the past 12 months (but not currently) was associated with a higher risk of HED. Conclusions: Findings provide guidance to college/university community professionals given the responsibility of designing and implementing programs for mitigation of alcohol misuse on their campus.

Service use and costs of care for depressed adolescents: who uses and who pays?

Major depressive disorder is common in adolescence and is associated with significant morbidity and family burden. Little is known about service use by depressed adolescents. The purpose of this article is to report the patterns of services use and costs for participants in the Treatment for Adolescents with Depression Study sample during the 3 months before randomization. Costs were assigned across three categories of payors: families, private insurance, and the public sector. We examined whether costs from payors varied by baseline covariates, such as age, gender, insurance status, and family income. The majority (71%) of depressed youth sought services during the 3-month period. Slightly more than one-fifth had contact with a behavioral health specialist. The average participant had just under $300 (SD = $437.67, range = $0-$3,747.71) in treatment-related costs, with most of these costs borne by families and private insurers.

Psychosocial interventions for children and adolescents in foster care: review of research literature.

Between one-half and three-fourths of children entering foster care exhibit behavioral or social-emotional problems warranting mental health care. This paper, condensed and updated from a technical report prepared for Casey Family Programs in 2005, reviews evidence-based and promising interventions for the most prevalent mental conditions found among children in foster care. This paper also makes several recommendations regarding increasing access to mental health care and effective psychosocial interventions for foster care children.

Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events.

The article reviews the current status (1993-2007) of psychosocial treatments for children and adolescents who have been exposed to traumatic events. Twenty-one treatment studies are evaluated using criteria from Nathan and Gorman (2002) along a continuum of methodological rigor ranging from Type 1 to Type 6. All studies were, at a minimum, robust or fairly rigorous. The treatments in each of these 21 studies also are classified using criteria from Chambless et al. (1996), and Chambless and Hollon (1998). Trauma-Focused Cognitive-Behavioral Therapy met the well-established criteria; School-Based Group Cognitive-Behavioral Treatment met the criteria for probably efficacious. All the other treatments were classified as either possibly efficacious or experimental. Meta-analytic results for four outcomes (i.e., posttraumatic stress, depressive symptoms, anxiety symptoms, and externalizing behavior problems) across all treatments compared to waitlist control and active control conditions combined reveal that, on average, treatments had positive, though modest, effects for all four outcomes. We also cover investigative work on predictors, moderators, and mediators of treatment outcome, as well as the clinical representativeness and generalizability of the studies. The article concludes with a discussion of practice guidelines and future research directions.

Is more better? Examining whether enhanced consultation/coaching improves implementation.

It is extremely challenging to implement evidence-based interventions in community-based agencies with sufficient quality, fidelity, and intensity to produce desired changes in practice and outcomes. This is particularly difficult to do within the confines of existing service providers' time, personnel, and resource constraints. Over the past 15 years, Together Facing the Challenge (TFTC) has been developed, tested, and disseminated in an effort to address this set of issues to improve treatment foster care (TFC). Data from the initial randomized trial showed improved practice and outcomes in TFTC compared to usual TFC. These initial results came from study-led training and follow-up consultation. Subsequent dissemination activities suggested potential need for more intensive support for TFTC supervisors to produce more consistent and sustained implementation of the model. The current randomized trial extends this work by comparing the previously tested standard consultation versus enhanced consultation that incorporated more of a coaching approach. Initial results suggest that enhanced coaching/consultation was associated with improvements in the small- to medium-effect size range. Results are promising, but require additional work to more fully understand how and whether to enhance supports as agencies implement new evidence-based approaches. (PsycINFO Database Record

Contextual predictors of mental health service use among children open to child welfare.

BACKGROUND: Children involved with child welfare systems are at high risk for emotional and behavioral problems. Many children with identified mental health problems do not receive care, especially ethnic/minority children. OBJECTIVE: To examine how patterns of specialty mental health service use among children involved with child welfare vary as a function of the degree of coordination between local child welfare and mental health agencies. DESIGN: Specialty mental health service use for 1 year after contact with child welfare was examined in a nationally representative cohort of children aged 2 to 14 years. Predictors of service use were modeled at the child/family and agency/county levels. Child- and agency-level data were collected between October 15, 1999, and April 30, 2001. SETTING: Ninety-seven US counties. PARTICIPANTS: A total of 2823 child welfare cases (multiple informants) from the National Survey of Child and Adolescent Well-being and agency-level key informants from the participating counties. MAIN OUTCOME MEASURES: Specialty mental health service use during the year after contact with the child welfare system. RESULTS: Only 28.3% of children received specialty mental health services during the year, although 42.4% had clinical-level Child Behavior Checklist scores. Out-of-home placement, age, and race/ethnicity were strong predictors of service use rates, even after controlling for Child Behavior Checklist scores. Increased coordination between local child welfare and mental health agencies was associated with stronger relationships between Child Behavior Checklist scores and service use and decreased differences in rates of service use between white and African American children. CONCLUSIONS: Younger children and those remaining in their homes could benefit from increased specialty mental health services. They have disproportionately low rates of service use, despite high levels of need. Increases in interagency coordination may lead to more efficient allocation of service resources to children with the greatest need and to decreased racial/ethnic disparities.

Psychiatric disorder, impairment, and service use in rural African American and white youth.

BACKGROUND: The Caring for Children in the Community Study examined the prevalence of DSM-IV psychiatric disorders and correlates of mental health service use in rural African American and white youth. METHODS: Four thousand five hundred youth aged 9 to 17 years from 4 North Carolina counties were randomly selected from school databases. Parents completed telephone questionnaires about their children's behavior problems. A second-stage sample of 1302 was identified for recruitment into the interview phase of the study, and 920 (70.7%) of these were successfully interviewed at home using the Child and Adolescent Psychiatric Assessment and related measures of service use. RESULTS: Weighted back to general population estimates, 21.1% of youth had 1 or more DSM-IV psychiatric disorders in the past 3 months. Prevalence was similar in African American (20.5%) and white (21.9%) youth. The only ethnic difference was an excess of depressive disorders in white youth (4.6% vs 1.4%). Thirteen percent of participants (36.0% of those with a diagnosis) received mental health care in the past 3 months. White youth were more likely than African American youth to use specialty mental health services (6.1% vs 3.2%), but services provided by schools showed very little ethnic disparity (8.6% vs 9.2%). The effect of children's symptoms on their parents was the strongest correlate of specialty mental health care. CONCLUSIONS: In this rural sample, African American and white youth were equally likely to have psychiatric disorders, but African Americans were less likely to use specialty mental health services. School services provided care to the largest number of youths of both ethnic groups.

Increase in untreated cases of psychiatric disorders during the transition to adulthood.

OBJECTIVE: During the transition to adulthood, youths face challenges that may limit their likelihood of obtaining services for psychiatric problems. The goal of this analysis was to estimate changes in rates of service use and untreated psychiatric disorders during the transition from adolescence to adulthood. METHODS: In a prospective, population-based study, participants were assessed up to four times in adolescence (ages 13-16; 3,983 observations of 1,297 participants, 1993-2000) and three times in young adulthood (ages 19, 21, and 24-26; 3,215 observations of 1,273 participants, 1999-2010). Structured diagnostic interviews were used to assess service need (participants meeting DSM-IV diagnostic criteria for a psychiatric disorder) and use of behavioral services in 21 service settings in the past three months. RESULTS: During young adulthood, 28.9% of cases of psychiatric disorders were associated with some treatment, compared with a rate of 50.9% for the same participants during adolescence. This decrease included a near-complete drop in use of educational and vocational services as well as declines in use of specialty behavioral services. Young adults most frequently accessed services in specialty behavioral or general medical settings. Males, African Americans, participants with substance dependence, and participants living independently were least likely to get treatment. For cases of psychiatric disorders among young adults, insurance and poverty status were unrelated to likelihood of service use. CONCLUSIONS: Young adults were much less likely to receive treatment for psychiatric problems than they were as adolescents. Public policy must address gaps in service use during the transition to adulthood.

Patterns of maltreatment and diagnosis across levels of care in group homes.

Patterns of Axis I psychiatric diagnosis and maltreatment history were explored among youth in group homes, including match of clinical need to level or restrictiveness of care. Data on demographics, diagnoses, maltreatment, and group home level of care (Level I, II, or III homes, representing lower to higher intensity of supervision and treatment) were obtained from 523 youth who participated in a quasi-experimental study of group homes. Three quarters of youth had a diagnosis and two-thirds of youth had a maltreatment history. Youth in higher level homes had more diagnoses and higher rates of all disorders except adjustment disorders. Youth in Level I homes had a history of more maltreatment types, particularly high rates of neglect. Sexual abuse, physical abuse, and emotional abuse were most common among youth in higher level homes. Regardless of diagnosis history, comparable proportions of youth had a maltreatment history, and similar patterns were found across levels of care. Together, findings indicate that group homes with varying degrees of restrictiveness serve youth with different psychiatric diagnosis and maltreatment histories. Youth triaged to higher level homes had more diagnoses, while youth placed in the least restrictive homes had a history of more maltreatment subtypes. Further, distinct patterns of diagnosis types and maltreatment subtypes were seen across homes. Implications include the importance of assessing unique clinical needs of youth to promote an appropriate match to level of care and treatment plan.

Assessment of four stakeholder groups' preferences concerning outpatient commitment for persons with schizophrenia.

OBJECTIVE: Study findings indicating that involuntary outpatient commitment can improve treatment outcomes among persons with severe mental illness remain controversial. Opponents of outpatient commitment argue that its coerciveness is unacceptable even given its arguable benefits. However, it is unclear to what extent the public debate surrounding outpatient commitment represents the preferences of persons with a stake in the benefit or harm resulting from outpatient commitment. This study examines and compares views of outpatient commitment among four stakeholder groups: 1) persons in treatment for schizophrenia and related disorders, 2) family members of persons with these disorders, 3) clinicians treating persons with these disorders, and 4) members of the general public. METHOD: Subjects from the Piedmont region of North Carolina who were members of the four stakeholder groups were presented with short vignettes that depicted potential outcomes that were associated alternatively with outpatient commitment and with voluntary treatment. Subjects rated each vignette according to how positively or negatively they viewed the overall situation for the individual described. Multivariate regression techniques were used to estimate preference weights for each stakeholder group. RESULTS: With some exceptions, each group gave the highest preference to avoiding involuntary hospitalization, followed by avoiding interpersonal violence and maintaining good interpersonal relationships. No group gave appreciable importance to outpatient commitment, which suggests that avoiding its coerciveness is a lesser concern compared to other outcomes. CONCLUSIONS: The findings suggest that these stakeholders are willing to accept the coerciveness of outpatient commitment to gain improved outcomes for certain persons with schizophrenia and related disorders.

Detection and outcomes of substance use disorders in adolescents seeking mental health treatment.

OBJECTIVE: To compare detection rates, service use, and outcomes of substance use disorder (SUD) in adolescents seeking mental health treatment. METHOD: Adolescents (n = 237) and their parents or caregivers completed parallel, self-administered versions of the Adolescent Treatment Outcomes Module (ATOM) at intake and 6-month follow-up. SUD was assessed using the Diagnostic Interview Schedule for Children (DISC). RESULTS: Although 42 (16.6%) adolescents seeking mental health treatment met DISC criteria for any SUD at baseline, clinicians detected only 19 of these (kappa = 0.51). Sensitivity and specificity were high for a screening tool for adolescent SUD (95.2 and 82.0, respectively). Adolescents with undetected SUD were less likely to receive SUD services and to have more legal problems at 6-month follow-up compared to adolescents with detected SUD. CONCLUSIONS: SUD rates may be high in adolescents seeking mental health treatment, confirming the need for routine screening in this population. Results confirm that a large gap exists between the need for and access to SUD treatments, which may contribute to poorer outcomes for all adolescents with SUD.

Mental health need and access to mental health services by youths involved with child welfare: a national survey.

OBJECTIVE: This study assessed the relationship between the need for and use of mental health services among a nationally representative sample of children who were investigated by child welfare agencies after reported maltreatment. METHOD: Data were collected at study entry into the National Survey of Child and Adolescent Well-Being and were weighted to provide population estimates. RESULTS: Nearly half (47.9%) of the youths aged 2 to 14 years (N = 3,803) with completed child welfare investigations had clinically significant emotional or behavioral problems. Youths with mental health need (defined by a clinical range score on the Child Behavior Checklist) were much more likely to receive mental health services than lower scoring youth; still, only one fourth of such youths received any specialty mental health care during the previous 12 months. Clinical need was related to receipt of mental health care across all age groups (odds ratio = 2.7-3.5). In addition, for young children (2-5 years), sexual abuse (versus neglect) increased access to mental health services. For latency-age youths, African-American race and living at home significantly reduced the likelihood of care. Adolescents living at home were also less likely to receive services, whereas having a parent with severe mental illness increased (odds ratio = 2.4) the likelihood of service use. CONCLUSIONS: Routine screening for mental health need and increasing access to mental health professionals for further evaluation and treatment should be a priority for children early in their contact with the child welfare system.

Review of the evidence base for treatment of childhood psychopathology: internalizing disorders.

This article reviews the empirical literature on psychosocial, psychopharmacological, and adjunctive treatments for children between the ages of 6 and 12 with internalizing disorders. The aim of this review was to identify interventions that have potential to prevent substance use disorders in adolescence by treating internalizing disorders in childhood. Results suggest that a variety of behavioral, cognitive-behavioral, and pharmacological interventions are effective in reducing symptoms of childhood depression, phobias, and anxiety disorders. None of the studies reviewed included substance abuse outcomes. Thus, little can be said about the relationship between early treatment and the prevention of later substance use. The importance of evaluating the generalizability of research-supported interventions to community settings is highlighted and recommendations for future research are offered.