Robert E. Moore

Depressive and Disruptive Disorders and Mental Health Service Utilization in Children and Adolescents

OBJECTIVE To examine the relationship of depressive and disruptive disorders with patterns of mental health services utilization in a community sample of children and adolescents. METHOD Data were from the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The sample consisted of 1,285 child (ages 9-17 years) and parent/guardian pairs. Data included child psychopathology (assessed by the Diagnostic Interview Schedule for Children), impairment, child need and use of mental health services, and family socioeconomic status. RESULTS After adjusting for potential confounding factors, disruptive disorder was significantly associated with childrens use of mental health services, but depressive disorder was not. For school-based services, no difference was found between the 2 types of disorders. Parents perceived greater need for mental health services for children with disruptive disorders than for those with depression. Conversely, depression was more related to childrens perception of mental health service need than was disruptive disorder. CONCLUSIONS The findings highlight the need for more effective ways to identify and refer depressed children to mental health professionals, the importance of improving school-based services to meet childrens needs, and the necessity to better educate parents and teachers regarding the identification of psychiatric disorders, especially depression.

Correlates of unmet need for mental health services by children and adolescents

BACKGROUND Little is known about the extent and correlates of unmet need for mental health services in community samples of children and adolescents. METHODS Data were obtained from the 1285 parent/youth pairs interviewed at four sites in the USA and Puerto Rico in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Unmet need was defined to exist if psychopathology and associated functional impairment were present but no mental health services had been received in the previous 6 months. RESULTS Of the total sample, 17.1% had unmet need. Adjusting for demographic variables, logistic regression analyses revealed that unmet need was significantly associated with: indicators of economic disadvantage, such as being on public assistance and not being covered by health insurance; opinions of the parents and children or adolescents that the latter had poor mental health; parental psychopathology; poor school grades; and parent-reported access barriers such as concern that the child would want to solve the problem unassisted, would refuse to attend mental health services, or would be hospitalized or taken away against the parents will. No youth-reported access barriers were significantly associated with unmet need. CONCLUSIONS The economic correlates of unmet need may attain increased importance in the light of current reform in health care financing in the USA. Access may be facilitated by increasing parental knowledge of mental health services and enabling children and adolescents to initiate contact with services independently of their families.

The Stigma of Homelessness: The Impact of the Label "Homeless" on Attitudes Toward Poor Persons

Poor people have long been stigmatized and blamed for their situation. According to theory about stigma and about inequality-legitimating ideologies, homeless people should be stigmatized even more severely than the generic poor. Recent research suggests that the opposite may be true, but the data used in comparing attitudes toward homeless and other poor people have not been strictly comparable. Thus the conclusions that can be drawn are limited Using a vignette experiment designed to directly compare attitudes toward a homeless and a domiciled poor man and to compare the effects of being labeled homeless with those of being labeled mentally ill, we find that (1) the homeless man is blamed no less than the domiciled man and generally is stigmatized more severely; (2) the strength of the stigma attached to the homelessness label equals that for mental hospitalization; and (3) the stigmas of homelessness and mental hospitalization are independent of one another. Thus, in addition to the hardships of the homeless condition itself homeless people suffer stigmatization by their fellow citizens. The results also suggest that the robust tendency to blame the disadvantaged for their predicament holds true for modern homelessness as well.

Psychosocial characteristics of physically abused children and adolescents

OBJECTIVE To examine the association between physical abuse and selected psychosocial measures in a community-based probability sample of children and adolescents. METHOD A sample of 9- through 17-year-olds (N = 665) and their caretakers in New York State and Puerto Rico were interviewed in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Assessments included the Columbia Impairment Scale, the Instrumental and Social Competence Scale, the Diagnostic Interview Schedule for Children, the Peabody Picture Vocabulary Test, and questions regarding physical abuse. Regression analyses were conducted controlling for family income, family psychiatric history, perinatal problems, physical health, and sexual abuse. RESULTS A history of physical abuse was reported in 172 (25.9%) of the sample. It was significantly associated with global impairment, poor social competence, major depression, conduct disorder, oppositional defiant disorder, agoraphobia, overanxious disorder, and generalized anxiety disorder but not with suicidality, school grades, or receptive language ability. CONCLUSION A community probability sample of children and adolescents demonstrated significant associations between physical abuse and psychopathology, after controlling for potential confounders. This supports comprehensive screening for psychopathology among physically abused children and for physical abuse among those with psychopathology. Interventions aimed at improving social competence may be indicated.

Measurement of risk for mental disorders and competence in a psychiatric epidemiologic community survey: the National Institute of Mental Health Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

Abstract This paper describes the implementation of the National Institute of Mental Health Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) studys goals of measuring risk factors and competence. The emphasis is on the development and testing of the measures. Relevant constructs for measurement of risk and competence in relation to psychopathology were selected and pilot tested prior to the field trials. A structured interview was developed and field tested using lay interviewers. Using the full sample from the field trials (n = 1285 caretaker-youth pairs), sample means, standard deviations, internal consistencies, parent-youth agreement, and associations with childhood disorder were computed. Descriptive statistics reveal a range of scores and means consistent with norming samples, when available. Internal consistencies were moderate to high. Parent-youth agreement on factual items was excellent and on scales was consistent with the literature. Several strong associations were found between risk factors and disorder, although most were related to disorder in general and not specific to a diagnostic category. This instrument provides a means of obtaining data that will be useful to researchers conducting epidemiologic and clinical studies designed to contribute to the understanding of mental disorders in children and adolescents, including nosology, risk factors, context, adaptive functioning, and treatment.

Relationship between specific adverse life events and psychiatric disorders

This study examines whether certain psychiatric disorders are associated more closely with adverse life events than other disorders are, and whether some adverse life events are associated with a specific group of disorders (e.g., depressive disorders), but not with other disorders (e.g., anxiety disorders). A probability sample of youth aged 9–17 at 4 sites is used (N = 1,285). Univariate and multivariate logistic regressions identify specific relationships between 25 adverse life events and 9 common child and adolescent psychiatric disorders, measured by the Diagnostic Interview Schedule for Children. Conduct Disorder, Oppositional Defiant Disorder, Major Depressive Disorder, and Dysthymia are significantly associated with many of the adverse life events examined, whereas Attention Deficit/Hyperactivity Disorder, Agoraphobia, and Social Phobia are related to very few. This study suggests that certain psychiatric disorders may be more closely associated with adverse life events than other psychiatric disorders are, and that some adverse life events seem to be related to specific types of disorders.

Public knowledge, attitudes, and beliefs about homeless people: evidence for compassion fatigue.

Media reports suggest that the public is becoming impatient with the homeless—that so-called “compassion fatigue” has gripped the nation. This characterization of public sentiment could have important policy consequences—restrictive measures can be justified by growing public impatience, and progressive housing policies seem infeasible within a hostile climate of opinion. But evidence to support the compassion fatigue notion is anecdotal. We examine the issue by tracking the results of public opinion polls and by reporting detailed evidence from a nationwide random-digit dial telephone survey (N=1,507) concerning knowledge attitudes and beliefs about homeless people. To be sure, the public sees homelessness as an undesirable social problem and wants something done about it. However, although the homeless are clearly stigmatized, there is little evidence to suggest that the public has lost compassion and is unwilling to support policies to help homeless people.

Resilience in the Face of Maternal Psychopathology and Adverse Life Events

Maternal psychopathology has long been recognized as a risk factor for psychopathology in offspring; however, some resilient youth achieve a favorable outcome in the presence of maternal psychopathology. We identified factors that predicted resilience among youth who were exposed to adverse life events, and also examined whether the same factors protected youth against maternal psychopathology and adverse life events. Main and interaction effects of child and family factors were examined employing cross-sectional data from a household probability sample of 1285 youth aged 9 through 17 collected at four sites. On average, children exhibited a greater degree of resilience when they had higher IQ, closer parental monitoring, better family functioning, higher educational aspiration, and were female. Interaction between maternal psychopathology and IQ was significant, and there was a trend between maternal psychopathology and gender. A higher IQ is a protective factor against both maternal psychopathology and adverse life events; whereas being a girl seems to be a protective factor against maternal psychopathology, but not adverse life events.

Seasonal variations in internalizing, externalizing, and substance use disorders in youth

Seasonal variations were assessed in symptoms of internalizing (anxiety and mood), externalizing (attention-deficit/hyperactivity and oppositional defiant disorders), and substance use disorders in youth. This study is based on secondary data analysis of two NIMH-funded epidemiologic-services studies: (a) Alternative Service Use Patterns by Youth with Serious Emotional Disturbance (N=936, ages 9-17); and (b) Methods for the Epidemiology of Child and Adolescent Mental Disorders (N=1285, ages 9-17). Child psychiatric diagnoses were measured by the Diagnostic Interview Schedule for Children. Variables that indicate site of the interview and service system, as well as age, gender, and ethnicity, were used as covariates. Significant annual variations were found in symptom counts of overanxious disorder, obsessive-compulsive disorder, separation anxiety disorder, social phobia, and major depressive disorder, with the estimated nadir in August-October. There may be weak seasonal variations in attention-deficit/hyperactivity disorder with estimated nadir in August, oppositional defiant disorder with estimated nadir in August-September, and marijuana use with estimated zenith in August-September. Significant seasonality in alcohol, other substance use, agoraphobia, and panic disorder was not found. There may be an instrument-specific bias in estimated nadir. Real nadirs may be up to 3 months prior to the estimated nadirs specified above. Findings suggest that seasonality in symptoms should be considered when assessment instruments of childhood psychiatric disorders are developed, as well as when epidemiological and clinical data are collected and analyzed.

Child Outpatient Mental Health Service Use: Why Doesn't Insurance Matter?

BACKGROUND: Several recent studies of child outpatient mental health service use in the US have shown that having private insurance has no effect on the propensity to use services. Some studies also find that public coverage has no beneficial effect relative to no insurance. AIMS: This study explores several potential explanations, including inadequate measurement of mental health status, bandwagon effects, unobservable heterogeneity and public sector substitution for private services, for the lack of an effect of private insurance on service use. METHODS: We use secondary analysis of data from the three mainland US sites of NIMHs 1992 field trial of the Cooperative Agreement for Methodological Research for Multi-Site Surveys of Mental Disorders in Child and Adolescent Populations (MECA) Study. We examine whether or not a subject used any mental health service, school-based mental health services or outpatient mental health services, and the number of outpatient visits among users. We also examine use of general medical services as a check on our results. We conduct regression analysis; instrumental variables analysis, using instruments based on employment and parental history of mental health problems to identify insurance choice, and bivariate probit analysis to examine multiservice use. RESULTS: We find evidence that children with private health insurance have fewer observable (measured) mental health problems. They also appear to have a lower unobservable (latent) propensity to use mental health services than do children without coverage and those with Medicaid coverage. Unobserved differences in mental health status that relate to insurance choice are found to contribute to the absence of a positive effect for private insurance relative to no coverage in service use regressions. We find no evidence to suggest that differences in attitudes or differences in service availability in childrens census tracts of residence explain the non-effect of insurance. Finally, we find that the lack of a difference is not a consequence of substitution of school-based for office-based services. School-based and office-based specialty mental health services are complements rather than substitutes. School-based services are used by the same children who use office-based services, even after controlling for mental health status. DISCUSSION: Our results are consistent with at least two explanations. First, limits on coverage under private insurance may discourage families who anticipate a need for child mental health services from purchasing such insurance. Second, publicly funded services may be readily available substitutes for private services, so that lack of insurance is not a barrier to adequate care. Despite the richness of data in the MECA dataset, cross-sectional data based on epidemiological surveys do not appear to be sufficient to fully understand the surprising result that insurance does not enable access to care. IMPLICATIONS FOR POLICY AND RESEARCH: Limits on coverage under private mental health insurance combined with a relatively extensive system of public mental health coverage have apparently generated a situation where there is no observed advantage to the marginal family of obtaining private mental health insurance coverage. Further research using longitudinal data is needed to better understand the nature of selection in the child mental health insurance market. Further research using better measures of the nature of treatment provided in different settings is needed to better understand how the private and public mental health systems operate.