Barbara J. Burns

Effective treatment for mental disorders in children and adolescents.

As pressure increases for the demonstration of effective treatment for children with mental disorders, it is essential that the field has an understanding of the evidence base. To address this aim, the authors searched the published literature for effective interventions for children and adolescents and organized this review as follows: (1) prevention; (2) traditional forms of treatment, namely outpatient therapy, partial hospitalization, inpatient treatment, and psychopharmacology; (3) intensive comprehensive community-based interventions including case management, home-based treatment, therapeutic foster care, and therapeutic group homes; (4) crisis and support services; and (5) treatment for two prevalent disorders, major depressive disorder and attention-deficit hyperactivity disorder. Strong evidence was found for the treatment of attention-deficit hyperactivity disorder, depression, anxiety, and disruptive behavior disorders. Guidance from the field relevant to moving the evidence-based interventions into real-world clinical practice and further strengthening the research base will also need to address change in policy and clinical training.

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.

Psychiatric disorders among American Indian and white youth in Appalachia: the Great Smoky Mountains Study

OBJECTIVES This study examined prevalence of psychiatric disorders, social and family risk factors for disorders, and met and unmet needs for mental health care among Appalachian youth. METHODS All 9-, 11-, and 13-year-old American Indian children in an 11-county area of the southern Appalachians were recruited, together with a representative sample of the surrounding population of White children. RESULTS Three-month prevalences of psychiatric disorders were similar (American Indian, 16.7%; White, 19.2%). Substance use was more common in American Indian children (9.0% vs 3.8% in White children), as was comorbidity of substance use and psychiatric disorder (2.5% vs 0.9%). American Indian poverty, family adversity (e.g., parental unemployment, welfare dependency), and family deviance (parental violence, substance abuse, and crime) rates were higher, but the rate of family mental illness, excluding substance abuse, was lower. Child psychiatric disorder and mental health service use were associated with family mental illness in both ethnic groups but were associated with poverty and family deviance only in White children. Despite lower financial barriers, American Indian children used fewer mental health services. CONCLUSIONS This study suggests that poverty and crime play different roles in different communities in the etiology of child psychiatric disorder.

Ethnicity and the use of outpatient mental health services in a national insured population.

OBJECTIVES Factors affecting ethnic differences in the use of outpatient mental health services are analyzed in an insured, nonpoor population to determine if lower use by Blacks and Hispanics persists when socioeconomic and other factors are controlled. METHODS To identify significant predictors of the probability and amount of use, insurance claims data for a population of 1.2 million federal employees insured by Blue Cross/Blue Shield in 1983 were analyzed with the Andersen and Newman model of health service utilization. Logistic and ordinary least squares regression models were estimated for each ethnic group. RESULTS Blacks and Hispanics had lower probabilities and amounts of use when compared with Whites after controlling for a number of variables. CONCLUSIONS Since ethnic differences in the use of outpatient mental health services exist even in an insured, nonpoor population, factors other than lower socioeconomic status or insurance coverage--for example, cultural or attitudinal factors and service system barriers--are likely responsible. Such findings have policy implications in the current climate of health care reform to increase access to care for the underserved.

Brief psychosocial screening in outpatient pediatric practice

The Pediatric Symptom Checklist (PSC) is a brief screening questionnaire designed to help pediatricians in busy office practice select children who are likely to have psychosocial difficulties and thus could benefit from further evaluation. We report two preliminary validation studies that indicate that PSC correlates well with the Childhood Behavior Checklist, a longer, well-validated questionnaire, and most children referred for psychiatric evaluation score above the PSC cutoff score. Developing a valid and practical psychosocial screening procedure for office practice is methodologically difficult but highly relevant to clinical practice.

Outcomes of Mental Health Care for Children and Adolescents: I. A Comprehensive Conceptual Model

OBJECTIVE Accountability for mental health care has become a standard of clinical practice. With the expansion of managed care as a corporate response to health reform, attention to outcomes will intensity. Assessment of clinical treatment has typically focused on symptom reduction at an individual level, whereas assessment of service effectiveness has more often targeted service-level change. METHOD A dynamic and interactional model of outcomes is presented that broadens the range of intended consequences of care. The model comprises five domains: symptoms, functioning, consumer perspectives, environmental contexts, and systems. RESULTS The model reflects the changeable interaction between childrens evolving capacities and their primary environments (home, school, and community). CONCLUSIONS As health care practices shift, attention to improved care is likely to depend increasingly on scientifically credible evidence of its impact. Greater integration between research and standard practice will be needed. Such a partnership can be strengthened by a more comprehensive view of the impact of care.

Use, persistence, and intensity: patterns of care for children's mental health across one year.

This paper explores the use, persistence, andintensity of services for childrens mental healthproblems across a variety of service sectors during aone year period. Data come from the Great SmokyMountains Study. Analyses focus on childrens psychiatricsymptomatology and impairment, service use, and factorsthat may influence the relationship between psychiatricproblems and service use across a one year period. Findings show that approximately 20% ofchildren used some mental health services from somesector during the year. Childs symptomatology andcharacteristics of parents were associated with use and persistence of services. Parentsperceptions of impact on the family were associated withservice use, persistence, and intensity.

Mental disorders in primary care: Epidemiologic, diagnostic, and treatment research directions

An extensive series of investigations over the past 2 decades clearly demonstrate that mental disorders are present in approximately 25% of primary care patients and that physicians underdiagnose these illnesses. The factors producing this bias are poorly understood and should be focused upon in future research. Also requiring much more study is the efficacy of pharmacologic and psychosocial treatments initially validated with psychiatric populations. Clinical trials should determine whether standardized interventions can be utilized with medical patients whose symptom profiles and organic comorbidity may differ from those of psychiatric populations.

The Child and Adolescent Services Assessment (CASA) Description and Psychometrics

The Child and Adolescent Services Assessment (CASA) is a self- and parent-report instrument designed to assess the use of mental health services by children ages 8 years to 18 years. The CASA includes 31 settings covering inpatient, outpatient, and informal services provided by a variety of child-serving providers and sectors. This instrument collects information on whether a service was ever used and more detailed information (length of stay/number of visits, focus of treatment) on services used in the recent past. A description of the instrument, information on interviewer training and coding of data, psychometric data on clinical samples, and a case study are presented.

Psychiatric diagnoses of medical service users: evidence from the Epidemiologic Catchment Area Program.

Based on data from the five sites of the National Institute of Mental Health-sponsored Epidemiologic Catchment Area (ECA) Program, this paper examines the prevalence of psychiatric disorder among recent medical service users versus nonusers, with a particular focus on affective disorders, substance abuse/dependence, and phobias. The rate of current Diagnostic Interview Schedule (DIS) disorders among medical users in all five ECA sites is 21.7 per cent (slightly higher than general population rates) versus 16.7 per cent among nonusers; there is generally no difference between users and nonusers with past DIS diagnoses. Affective disorders were among the most common mental disorders of medical service users, especially among females, with little variation between sites: females: users: 6.9 per cent to 9.3 per cent, nonusers: 3.4 per cent to 6.4 per cent, and males: users: 3.3 per cent to 6.5 per cent, nonusers: 1.2 per cent to 4.1 per cent. Rates of phobias among persons using medical services are also higher than among nonusers. Substance abuse disorders are at least as common among persons who use medical services (8 per cent to 14 per cent of male users) as among those who do not (9 per cent to 11 per cent of male nonusers). The high rates of affective disorders among women and of substance abuse among male medical service users underscore the need to increase the ability of general medical practitioners to recognize and manage or refer these conditions.