Mental health in pediatric settings: distribution of disorders and factors related to service use.

OBJECTIVES: To examine child psychiatric disorders in pediatric settings and identify factors associated with parents' use of pediatricians as resources concerning emotional/behavioral issues and use of mental health services. METHOD: The sample consists of 5- to 9-year-olds (mean = 7.17 years, SD = 1.41) from a representative sample (N = 1,060) of pediatric practices. Parent interviews included assessments of psychiatric disorders with the Diagnostic Interview Schedule for Children (DISC-R), parental depression/anxiety, possible child abuse, stress, support, and the use of mental health services. RESULTS: The prevalence of any DISC disorder was 16.8%. Parental depression/anxiety and possible child abuse were associated independently with 2- to 3-times higher rates of disorder. Many parents (55%) who reported any disorder did not report discussing behavioral/emotional concerns with their pediatrician. Factors associated with discussing behavioral/emotional issues were the presence of any disorder and financial stress. Factors related to seeing a mental health professional were discussing behavioral/emotional issues with the pediatrician, single parenthood, and stressful life events. CONCLUSIONS: The prevalence rates of disorders in this setting suggest that pediatricians are well-placed to identify and refer children with psychiatric disorders. However, most parents do not discuss behavioral/emotional issues with their pediatrician. Methods for improving rates of identification and referral (e.g., routine screening) are considered.

NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses.

OBJECTIVE: To describe the National Institute of Mental Health Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV) and how it differs from earlier versions of the interview. The NIMH DISC-IV is a highly structured diagnostic interview, designed to assess more than 30 psychiatric disorders occurring in children and adolescents, and can be administered by "lay" interviewers after a minimal training period. The interview is available in both English and Spanish versions. METHOD: An editorial board was established in 1992 to guide DISC development and ensure that a standard version of the instrument is maintained. Preliminary reliability and acceptability results of the NIMH DISC-IV in a clinical sample of 84 parents and 82 children (aged 9-17 years) drawn from outpatient child and adolescent psychiatric clinics at 3 sites are presented. Results of the previous version in a community sample are reviewed. RESULTS: Despite its greater length and complexity, the NIMH DISC-IV compares favorably with earlier versions. Alternative versions of the interview are in development (the Present State DISC, the Teacher DISC, the Quick DISC, the Voice DISC). CONCLUSIONS: The NIMH DISC is an acceptable, inexpensive, and convenient instrument for ascertaining a comprehensive range of child and adolescent diagnoses.

Parent and child contributions to diagnosis of mental disorder: are both informants always necessary?

OBJECTIVE: To examine the unique cases contributed by parent and child informants to diagnostic classification, with the goal of identifying those diagnoses for which either or both informants are needed. METHOD: The authors examined survey data from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, a 4-community epidemiology survey of 9- to 17-year-old children and their parents. Parent-child dyads (1,285 pairs) were independently interviewed by lay persons with the Diagnostic Interview Schedule for Children; a subset of these pairs (n = 247) were also interviewed by clinicians. Agreement between parents and children was examined with respect to levels of impairment, need for/use of services, and clinicians' diagnoses. RESULTS: Parents and children rarely agreed on the presence of diagnostic conditions, regardless of diagnostic type. Nonetheless, most child-only- and parent-only-identified diagnoses were similarly related to impairment and clinical validation, with 2 exceptions: child-only-identified attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). CONCLUSIONS: Overall findings suggest that most "discrepant" diagnoses (those reported by one but not the other informant) reflect meaningful clinical conditions. In some instances, however, diagnoses reported by one but not the other informant should be treated with caution, as they may not reflect the full diagnostic condition (e.g., possibly child-only-identified ADHD or ODD). Further research is needed to determine the salience of child-only- or parent-only-reported cases.

Psychiatric comorbidity among adolescents with substance use disorders: findings from the MECA Study.

OBJECTIVE: To investigate the extent to which adolescents in the community with current substance use disorders (SUD) experience co-occurring psychiatric disorders. METHOD: Diagnostic data were obtained from probability samples of 401 children and adolescents, aged 14 to 17 years, and their mothers/caretakers, who participated in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. RESULTS: The rates of mood and disruptive behavior disorders are much higher among adolescents with current SUD than among adolescents without SUD. Comparison with adult samples suggests that the rates of current comorbidity of SUD with psychiatric disorders are the same among adolescents as adults, and lower for lifetime disruptive disorders/antisocial personality disorder among adolescents than adults. CONCLUSIONS: The high rate of coexisting psychiatric disorders among adolescents with SUD in the community needs to be taken into account in prevention and treatment programs.

The NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study: background and methodology.

OBJECTIVE: A collaborative study was conducted to develop methods for surveys of mental disorder and service utilization in unscreened population-based samples of children and adolescents. METHOD: Probability household samples of youths 9 through 17 years of age were selected at four sites and interviews were conducted with a total of 1,285 pairs of youths and their adult caretakers in their homes. Lay interviewers administered a computer-assisted version of the NIMH Diagnostic Interview Schedule for Children Version 2.3 and structured interviews to assess demographic variables, functional impairment, risk factors, service utilization, and barriers to service utilization. RESULTS: More than 7,500 households were enumerated at four sites, with enumeration response rates above 99%. Across sites, 84% of eligible youth-caretaker pairs were interviewed for about 2 hours each. Ninety-five percent of both youths and caretakers found the interview to be acceptable enough to recommend to a friend. CONCLUSIONS: These findings indicate that large-scale epidemiological surveys of mental disorders and mental health service use involving lengthy interviews in the homes of unscreened population-based samples of youths and their adult caretakers are acceptable to the community and can achieve good response rates. The other reports in this Special Section address the reliability and validity of the various survey instruments and other key findings.

The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study.

OBJECTIVE: To describe the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 and to provide data on its performance characteristics in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. METHOD: Data were collected on the DISC-2.3 at four sites on 1,285 randomly selected children, aged 9 through 17 years, and their parents. Two hundred forty-seven of these child-parent pairs were reassessed on the DISC-2.3 by a clinician interviewer, 1 to 3 weeks later. RESULTS: Administration time was approximately 1 hour and the interview was acceptable to more than 90% of subjects. The reliability of questions to parents assessing impairment and age of onset was generally good to acceptable for most diagnoses but was less satisfactory for the child interview. Using information from parent and child, the prevalence for any diagnosis ranged from 50.6 if no impairment criteria were required to 5.4 if a Global Assessment Scale score of 50 or less was necessary. The prevalence of anxiety disorders and enuresis was markedly reduced by requiring attributable impairment. CONCLUSIONS: The DISC-2 is a reliable and economical tool for assessing child psychopathology. Reliability of the DISC-P-2.3 is superior to that of the child DISC for most diagnoses but is least good for anxiety disorders. The 2.3 version of the instrument provides a significant improvement over earlier versions.

Criterion validity of the NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3).

OBJECTIVE: To examine the criterion validity of the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, using a design that permitted several comparisons of DISC-generated diagnoses with diagnoses based on clinician symptom ratings. METHOD: Two hundred forty-seven youths were selected from the 1,285 parent-youth pairs that constituted the four-site MECA sample. Subjects who screened positive for any of the five diagnostic areas under investigation in the validity study (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, depressive disorder, and the major anxiety disorders) were recruited, as well as a comparable number of screen negatives. Clinicians reinterviewed separately both the youth and the primary caregiver using the DISC followed by a clinical-style interview, and then they rated the presence of symptoms and impairment. Computer algorithms combined this information into diagnoses using comparable rules for both DISC and clinical rating diagnoses. RESULTS: In general, the DISC showed moderate to good validity across a number of diagnoses. CONCLUSIONS: Results suggest some specific diagnostic areas in which further revision of the DISC is warranted. Three main sources of variability in DISC-clinician diagnostic agreement were evident over and above that due to the instrument itself, including (1) the informant used, (2) the algorithm applied in synthesizing symptom reports, and (3) the design of the validity comparison.

No safe haven: a study of violence exposure in an urban community.

OBJECTIVE: To examine levels of violence exposure and reports of feeling unsafe in relation to psychological and behavioral characteristics for a general population sample of youths from an urban setting. METHOD: A comprehensive survey of high-risk behaviors, attitudes, indicators of adaptive behavior, and daily involvements was administered to a sample of 2,248 students in the 6th, 8th, and 10th grades in an urban public school system. RESULTS: More than 40% of the youths surveyed reported exposure to a shooting or stabbing in the past year, and 74% reported feeling unsafe in one or more common environmental contexts. Multiple regression analyses indicated significant relationships between violence exposure/feeling unsafe and a set of indicators of psychological and behavioral adaptation and expressed attitudes. CONCLUSIONS: These results attest to the picture of violence as a common fact of inner-city life and to the demand that is placed on urban youths to accommodate in their psychological development to chronic threat and lack of safety.

Sociodemographic characteristics of dropouts from a child guidance clinic.

OBJECTIVE: This study examined the characteristics of families who dropped out and families who maintained contact with a children's psychiatric outpatient clinic through various phases of intake and treatment. METHODS: One year after intake, the authors examined the status of all patients (N = 555) who had sought treatment at an urban, university-affiliated children's psychiatric outpatient clinic over a two-year period and had completed the intake process. Factors associated with dropout were identified at four points in the clinic process: during intake, during evaluation, at completion of evaluation, and during treatment. RESULTS: Urban residence, minority status, single-parent status, and Medicaid status were related to dropout at intake and during evaluation but not at subsequent clinic phases. Nonminority, two-parent, suburban families of higher socioeconomic status were more likely to drop out at the completion of the evaluation. CONCLUSIONS: These results indicate that factors associated with attrition vary with the clinic phase. Further investigations of the clinical course of minority children and families involved with children's mental health services are necessary to understand the needs of this population and to design interventions such as increasing minority staff and providing training in multi-cultural competence.