The Perceived Stigma of Mental Health Services Among Rural Parents of Children With Psychosocial Concerns.

OBJECTIVE: To examine parents' perceptions of stigma regarding mental health services for their child, consider stigma in the context of novel service delivery settings (e.g., telehealth, primary care, and schools), and evaluate stigma with other factors known to influence service access. METHODS: 347 caregivers of children with psychosocial concerns completed surveys regarding their perceptions of stigma, service delivery settings, and barriers to care. RESULTS: Parents endorsed low levels of stigma around services. Greater perceived stigma was related to less willingness to seek services in a mental/behavioral health center or schools but not in other settings, even when other barriers were considered. Having a younger child and a history of prior services was associated with greater willingness to seek services. CONCLUSIONS: Stigma does appear to present as a barrier, but only for some parents. Providing mental health services to young children and their parents in some nontraditional settings may increase access.

How Caregivers Make Meaning of Child Mental Health Problems: Toward Understanding Caregiver Strain and Help Seeking.

Family caregivers' conceptualizations of their child's emotional and behavioral problems (EBP) influence help-seeking for the child and caregiver strain. We analyzed 21 interviews with caregivers to explore their conceptualizations about the cause of their child's EBP, their experiences of strain, and their reported help-seeking behaviors. Caregivers had divergent conceptualizations of their child's EBP: 12 caregivers viewed the EBP as caused by a disorder and described the onset of symptoms as the central stressful event, whereas 9 caregivers described their child's problems as a response to an earlier stressor (e.g. trauma, abuse, divorce). Different patterns of caregiver strain and help-seeking were associated with caregiver conceptualization. All caregivers voiced a need for peer-to-peer support for caregivers and youth with EBP.

The Role of Quality Service Systems in Involving Families in Mental Health Treatment for Children with Severe Emotional Disturbances.

Family involvement in the planning and execution of mental health treatment has been shown to positively influence child outcomes; however, there is wide variability in the levels of involvement by families. The current study investigated the influence of child, family caregiver, service system, and community factors on the level of family involvement in the mental health treatment of children with severe emotional disturbances (SED). While prior work in this area has primarily focused on family and child characteristics, the current study adds to the knowledge base by also exploring factors associated with the quality of service delivery that may influence levels of family involvement. The current study is a secondary analysis of existing data from the Impact Study of Medicaid in Mississippi and Tennessee (Brannan & Heflinger, 2006) that used in-depth interviews with parents and case review ratings. One hundred thirty-six children and adolescents who received Medicaid coverage for mental health treatment in Mississippi and Tennessee were the focus of this study that assessed child and caregiver characteristics at the beginning of the study and rated service system factors six-month after the study began. Results of the multiple regression analysis revealed the quality of the service delivery system had the most influence on level of family involvement. Results suggest that levels of family involvement may have less to do with caregiver health, or other family characteristics, and more to do with the quality of the service delivery system.

Factors associated with attributions about child health conditions and social distance preference.

In order to better understand factors that account for the emergence and persistence of negative attitudes towards mental health problems, attributions about and stigma towards children's mental and physical illnesses were examined using National Stigma Study-Children data. Parent blame attributions were most strongly associated with attention deficit disorder, environmental causes with depression, and biology with asthma. Parent blame was more frequent for mental than physical health conditions. Child blame was associated with higher preferred social distance from the child, but no clear links were observed between social distance and attributions about genetic/biology, environment, or parent blame. Rurality was not significantly associated with attributions or social distance preference. Higher educational achievement was associated with increased endorsement of environmental stress factors and reduced odds of child blaming. The general public holds complex explanatory models of and nuanced responses to children's mental disorders that need further investigation, including effects on parents' and children's help-seeking.

Examining perceptions about mental health care and help-seeking among rural African American families of adolescents.

Rural African American children living in poverty have a higher prevalence rate of mental health disorders than their urban counterparts. While access to mental health services is lacking in resource scarce rural communities, African American rural residents may also be the most likely to confront significant barriers to care and help-seeking. Studies of mental health help-seeking behavior among rural families are rare, even rarer are studies of African Americans living in these areas. To address this gap, the current study examined perceptions about help-seeking for adolescents with mental health problems among rural African American families. Data were obtained from African American mothers in rural Georgia to assess their perceptions of the mental health service system, help-seeking processes, and service experiences. A mixed-method approach was implemented, integrating a quantitative survey (n = 163) with qualitative interviews (subsample n = 21). Most of the mothers expressed confidence in mental health care providers' to help. Preferred sources of support, however, were family, church, and schools. Community stigma towards children with mental health problems and their families was a frequently endorsed perceived barrier to help-seeking. Although cultural mistrust was one of the two most frequently endorsed barriers in the survey, it did not emerge as a universal barrier to help-seeking for the mothers in this sample. Implications for research, policy, and practice include addressing family concerns about stigma, preferences for informal support and non-specialty services in addressing adolescents' mental health problems, and building community resources to enable all youth to participate in community life.

Barriers to and supports of family participation in a rural system of care for children with serious emotional problems.

Researchers have not adequately addressed the unique characteristics of rural areas that influence the accessibility of services for families with children who have serious emotional problems. Understanding rurality is particularly important to "systems of care" grant sites because these grants are intended to restructure mental health service delivery by building upon the strengths of a community and addressing the community's needs. This qualitative study examines the barriers to and supports for participation in services within a rural system of care site through the reported experiences of eight caregivers and nine staff. Findings indicate families face many challenges related to rurality, including stigma, transportation, isolation, poverty, and service availability. In addition to these challenges, however, participants reported many meaningful supports such as the religious community and the close-knit community of families and service providers. We present implications for planning, implementing, and evaluating systems of care in rural areas.

Stigma in child and adolescent mental health services research: understanding professional and institutional stigmatization of youth with mental health problems and their families.

To understand the low utilization rates of child and adolescent mental health services, it is necessary to recognize the kinds of professional and institutional stigma that may produce barriers to care. We address the large literature on the stigmatization of mental illness, linkages between such literature and children's mental health services use, and the kinds of professional and institutional attitudes and practices that communicate shame and low expectations to youth and their families. It will take recognition of such stigmatizing practices-including overcoming resistance to the messages presented herein-to make real progress in the effort to increase utilization of evidence-based practices. Multi-faceted, multi-level, and multi-disciplinary approaches to both research and intervention are recommended.

Community Determinants of Substance Abuse Treatment Referrals from Juvenile Courts: Do Rural Youth Have Equal Access?

Many youth in juvenile justice are in need of substance use services, yet referral to services is often inadequate. This study examines the ecological factors related to substance use service referrals made through Tennessee's juvenile courts. A series of hierarchical binomial logistic models indicated that individual-level factors accounted for 31% of the variance among courts in referral rates. Community and court factors accounted for an additional 16% of the variance. Youth were more likely to be referred if they had a higher need, were White, were male, were adjudicated in communities that had a higher service density, and appeared in courts that had good relationship and frequent contact with mental health providers. Controlling for individual need, youth in rural areas tended to have lower referral rates; however, this relationship was mediated by the frequency of contact and the quality of relations between the court and mental health providers and county average SES.

Racial and gender differences in utilization of Medicaid substance abuse services among adolescents.

OBJECTIVE: This study examined race and gender disparities in utilization of substance abuse treatment among adolescents enrolled in Medicaid in Tennessee. METHODS: By using Medicaid enrollment, encounter, and claims data, utilization of substance abuse services for the population of adolescents enrolled in TennCare was examined in two ways. The first utilization measure considered annual utilization rates and probability of use of substance abuse services for the statewide population of enrolled adolescents (approximately 170,000 per year). The second examined the age at which the first substance abuse service was received for the 8,473 youths who had that service paid for by TennCare during state fiscal years 1997 to 2001. RESULTS: Proportionally, among adolescents, more whites than blacks and more males than females used substance abuse services. The disparities were greater than differences in prevalence rates explain. Black females had the greatest disparity in service utilization. Whites and females received their first substance abuse service at a younger age than blacks or males in this Medicaid population. However, the age difference may not be clinically significant. CONCLUSIONS: The low utilization rates, in general, and the disparities in service use by race and gender raise questions about the identification of substance use problems at both provider and system levels.

Caregiver, child, family, and service system contributors to caregiver strain in two child mental health service systems.

Children's mental health researchers are increasingly recognizing the importance of caregiver strain (i.e., the impact on families of caring for children with emotional and behavioral disorders). This study examined the caregiver, child, family, and service variables associated with caregiver strain with special attention to the role of barriers to care. These relationships were compared across enrollees in a managed care Medicaid and a traditional fee-for-service system. Findings indicated that severity of child problems was the most consistent predictor of caregiver strain. Although there was considerable similarity in the variables associated with caregiver strain across the two systems, important differences were also evident. Caregivers in the managed care setting were significantly more likely to report provider/payer-related barriers to care. Provider/payer barriers predicted strain in the managed care sample. In the fee-for-service system, barriers related to family perceptions and inconvenient location and appointment times were significant predictors.

Access and service use by children with autism spectrum disorders in Medicaid Managed Care.

Although Medicaid is the largest public payer of behavioral health services, information on access and utilization of services is lacking, and no data on the frequency of service use or types of services provided for children with autism spectrum disorders (ASDs) are available. As states move toward managed care approaches for their Medicaid program, services information is critical. Behavioral health service data for children with autism spectrum disorders were collected from a state Medicaid Managed Care (MMC) program and analyzed from fiscal years 1995 through 2000. Findings revealed that the number of children who received services over time increased significantly; however, the rate of service use was only one tenth of what should be expected based on prevalence rates. The mean number of service days provided per child decreased significantly, about 40%, and the most prevalent forms of treatment changed. Day treatment vanished and medication and case management increased disproportionately to the number of children served. Explanations and implications of the findings are presented as well as recommendations for future research.

Patterns of Child Mental Health Service Delivery in a Public System: Rural Children and the Role of Rural Residence.

This study uses existing data from Hawaii's public mental health system for children and youth as an example of a state-level examination of service use patterns and health care disparities. The purpose of this study was to compare differences in mental health service utilization between rural and non-rural children, especially use of residential services. This study used a performance measure approach to conduct multi-level modeling on existing administrative data to examine the impact of community factors on service utilization. Rural children were found to have the most serious levels of mental health problems at intake, more likely to be placed in out-of-home care, more likely to receive only out-of-home care, more likely to in stay out-of-home longer, and less likely to receive follow-up care than their non-rural counterparts. Practice, policy, and research implications are discussed.

Effects of managed care on southern youths' behavioral services use.

Children and adolescents' access to Medicaid-financed behavioral health services was examined over 8 years in Tennessee (managed care) and Mississippi (fee-for-service [FFS]) using logistic regression. Managed care reduced access to behavioral care overall, overnight services (e.g., inpatient), and specialty outpatient services. Managed care also restricted the relative use of overnight and specialty outpatient for children and adolescents. However, managed care had pronounced effects on use of case management services. We also document differences in access and mix of behavioral services used over time by race, sex, age, and Medicaid enrollment category.

Medicaid behavioral health care plan satisfaction and children's service utilization.

This study examines associations between caregivers' satisfaction with children's Medicaid-funded behavioral health care plans and the likelihood that children with severe emotional disturbance receive mental health services. Data are from a multisite study of managed care versus fee-for-service (FFS) settings. In multivariate logistic regression analyses controlling for demographic, environmental, site, and clinical characteristics, plan satisfaction was associated with greater likelihood of subsequent service use regardless of managed care versus FFS setting. Children in managed care plans were less likely to use intensive residential and non-traditional outpatient services. Efforts to increase plan satisfaction may encourage service use, consequently, improving children's behavioral health outcomes.

Access to and patterns of use of behavioral health services among children and adolescents in TennCare.

OBJECTIVE: This study assessed trends in access to and use of behavioral health services for school-aged children in TennCare, Tennessee's Medicaid managed care program, between state fiscal years 1995 and 2000. METHODS: Claims, encounter, and enrollment data from the Bureau of TennCare were used. The data analyzed were restricted to services and enrollment periods for children and adolescents between the ages of four and 17 years at the time of service or enrollment. Measures were calculated in four areas: overall access to behavioral health services, use of inpatient services, use of outpatient specialty treatment services, and use of supportive services like case management and medication management. RESULTS: The number of youths who received a behavioral service increased by nearly 50 percent between state fiscal years 1995 and 2000. At the same time, the number of youths enrolled in TennCare increased by 19 percent. The annual access rate increased from 72.7 youths per 1000 enrollees to 91.7. However, the volume of services for children fell. Access rates were low relative to estimates of need in this population. The system made less use of inpatient services and relied more on outpatient services, particularly case management and medication management services. CONCLUSIONS: Children's access rates for behavioral health services improved even as the TennCare program expanded to cover more children. The system served more youths in part by reducing the volume of services for children receiving treatment and substituting more supportive services. Ongoing performance monitoring for policy making will require enhancements of data monitoring activities by the state.

A multi-site study of Medicaid-funded managed care versus fee-for-service plans' effects on mental health service utilization of children with severe emotional disturbance.

Although Medicaid-funded managed care arrangements are commonly used in the delivery of mental health and substance abuse services to low-income children and youth, little is known about the effectiveness of such efforts. This article examines differences in mental health services utilization between children and youth with severe emotional disturbance covered by Medicaid-funded managed care behavioral health plans and those covered by fee-for-service plans. Data are from a federally funded multi-site study. In multivariate analyses controlling for child and caregiver demographic and clinical factors, enrollment in a managed care behavioral health plan was associated with lower inpatient/residential, psychiatric medication, and nontraditional services utilization. No difference was found in outpatient services utilization. Medicaid-funded managed care behavioral health plans appear to reduce use of some types of mental health services, but it is important to address the question of whether low-income children's enrollment in such programs deprives them of needed services.

Effects of alcohol and drug use on inpatient and residential treatment among youth with severe emotional disturbance in Medicaid-funded behavioral health care plans.

This study examined the use of alcohol and recreational drugs among 875 youth with severe emotional disturbance (SED) enrolled in Medicaid-funded behavioral health care plans, and whether co-occurring SED and substance use affected the subsequent likelihood of receiving inpatient and/or residential treatment. Youth at five sites nationwide were interviewed about their use of drugs and alcohol, while interviews with their caregivers elicited information about youths' service utilization, degree of functional impairment, and a series of demographic and environmental variables. Results indicated that half of the youth (52%) reported lifetime use of alcohol, street drugs, or over-the-counter medications for recreational purposes, while 18% reported use in the past 30 days. Among those reporting recent use, 32% reported using drugs only, 34% alcohol only, and 33% reported use of both drugs and alcohol. In multivariate logistic regression analyses, the effect of recent use was stronger than that of lifetime use; however, the largest effect occurred for those reporting recent use of both drugs and alcohol, versus either alone, or none. Differences remained significant when controlling for managed care versus fee for service enrollment as well as child, family, and environmental characteristics including study site. These results mirror those of prior studies that found an association between substance use and greater likelihood of inpatient services, even in managed care settings.

Community characteristics and implementation factors associated with effective systems of care.

How are characteristics of communities associated with the implementation of the principles of systems of care (SOC)? This study uses multilevel modeling with a stratified random sample (N = 225) of US counties to explore community-level predictors of the implementation factors of the System of Care Implementation Survey. A model composed of community-level social indicators fits well with 5 of 14 factors identified as relevant for effective SOCs. As hypothesized, community disadvantage was negatively and residential stability positively associated with the implementation of SOC principles. Designation as a mental health professional shortage area was positively related to some implementation scores, as was the percentage of minority residents, while rurality was not significantly associated with any of the factors. Given the limitations of the study, the results should be interpreted with caution, but suggest that further research is merited to clarify these relationships that could inform efforts directed at promoting SOCs.

Patterns of medicaid disenrollment for youth with mental health problems.

Young people who receive Medicaid-funded mental health services during the transition to adulthood often face disenrollment from Medicaid without continuity into publicly funded services. This article investigates the longitudinal predictors of these coverage gaps and disenrollment from age 16 to 23 years. Cox regression analyses estimated predictors of time until the first loss of coverage for 180 days or more, and time until final disenrollment with no subsequent reenrollment. Females were much more likely to regain and retain coverage after initial loss. Funding source and diagnoses predicted Medicaid retention differentially by gender. For both genders, funding through Social Security Income or a diagnosis of Mental Retardation/ Developmental Disabilities was related to Medicaid retention. Disenrollment especially affected males precisely at their 18th and 19th birthdays. Nearly one third of females qualified for Medicaid because of pregnancy. Eligibility guidelines relate to retention and loss during the transition to adulthood and may need reevaluation to ensure continuity of care.