Sarah M. Horwitz

Mental Health Service Use in the Community and Schools: Results from the Four-Community MECA Study

ABSTRACT Objective To describe the use of mental health and substance abuse services by children and adolescents as reported from the four community sites included in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Method As part of the MECA survey, questions were developed to identify children and adolescents utilizing mental health and substance abuse services. Youths aged 9 through 17 years and a parent/ caretaker were interviewed. Because the investigators had concerns about the capacities of the younger children in the study to describe their use of mental health services, more extensive questions were asked of parents than of youths. Results The procedures developed by the MECA project identified patterns of service use that varied in the four communities surveyed. Agreement between reports of parents and youths regarding the use of mental health and substance abuse services showed substantial Inconsistencies, similar to reports of psychiatric disorders. At three of the four sites, the majority of children meeting criteria for a psychiatric disorder and scoring 60 or less on the Childrens Global Assessment Scale reported some mental health–related service in the previous year, although at two of the sites fewer than 25% of these youths were seen in the mental health specialty sector. Conclusion Community surveys show great promise for monitoring the need for mental health and substance abuse services and for identifying patterns of use.

Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research

Purposeful sampling is widely used in qualitative research for the identification and selection of information-rich cases related to the phenomenon of interest. Although there are several different purposeful sampling strategies, criterion sampling appears to be used most commonly in implementation research. However, combining sampling strategies may be more appropriate to the aims of implementation research and more consistent with recent developments in quantitative methods. This paper reviews the principles and practice of purposeful sampling in implementation research, summarizes types and categories of purposeful sampling strategies and provides a set of recommendations for use of single strategy or multistage strategy designs, particularly for state implementation research.

Treatment adherence and risk of death after a myocardial infarction

The relation of treatment adherence to mortality after a myocardial infarction was investigated among 2175 participants in the Beta Blocker Heart Attack Trial, which had data for measures of treatment adherence, clinical severity, and the psychological and social features that may influence post-infarction mortality. Overall, patients who did not adhere well to treatment regimen (ie, who took less than or equal to 75% of prescribed medication) were 2.6 times more likely than good adherers to die within a year of follow-up (95% confidence interval, 1.2, 5.6). Poor adherers had an increased risk of death whether they were on propranolol (OR = 3.1) or placebo (OR = 2.5). Furthermore, this increased risk of death for poor adherers was not accounted for by measures of the severity of myocardial infarction, sociodemographic features (eg, race, marital status, education), smoking, or psychological characteristics (high life-stress or social isolation).

Barriers to Children's Mental Health Services

OBJECTIVE To examine the characteristics associated with barriers to childrens mental health services, focusing on the effect of childrens psychosocial problems on parents. METHOD Data come from a first-grade, prevention-intervention project conducted in Baltimore, Maryland. Analyses were restricted to 116 families who participated in seventh-grade interviews and indicated the index child needed services. The Services Assessment for Children and Adolescents was used to measure barriers to childrens mental health services. RESULTS More than 35% of parents reported a barrier to mental health services. Types of barriers included those related to structural constraints, perceptions of mental health, and perceptions of services (20.7%, 23.3%, and 25.9%, respectively). Although parenting difficulties were associated with all barriers (structural: OR = 10.63, 95% CI: 2.37, 47.64; mental health: OR = 8.31, 95% CI: 1.99, 34.79; services: OR = 5.22, 95% CI: 1.56, 17.51), additional responsibilities related to attendance at meetings was associated only with structural barriers (OR = 5.49, 95% CI: 1.22, 24.59). CONCLUSIONS Researchers and policymakers interested in increasing childrens access to mental health services should consider strategies to reduce barriers related to perceptions about mental health problems and services, in addition to structural barriers. Particular attention should be given to programs that focus on the needs of families who are most affected by their childs psychosocial problems.

Prevalence of Social-Emotional and Behavioral Problems in a Community Sample of 1- and 2-Year-Old Children

OBJECTIVE To examine the prevalence of infant-toddler social-emotional and behavioral problems and associations with social-emotional competence, interference in family life, and parental worry. METHOD The sample consisted of 1- and 2-year-old children (mean [MN] age = 24.8 months) from the baseline survey of a representative sample of healthy births (N= 1,280). Parent questionnaires included the Child Behavior Checklist (CBCL/2-3), Parenting Stress Index Short Form (PSI/SF), and Infant-Toddler Social and Emotional Assessment social-emotional competence scales, as well as questions about parental worry and family activities. RESULTS Approximately 80% of eligible subjects participated. The weighted prevalence of parent-reported subclinical/clinical CBCL/2-3 scores was 11.8% for 2-year-olds. Approximately 6% of parents of 1- and 2-year-olds reported clinical-level scores on the PSI Difficult Child (PSI/DC) scale, which was included as a proxy for behavior problems among 1-year-olds, for whom measures were limited. Sex differences were not observed. CBCL/2-3 and PSI/DC scores were uniquely associated with economic disadvantage (relative risk = 1.89 and 2.24, respectively). Approximately 32% of 2-year-olds with subclinical/clinical CBCL2-3 scores had delayed social-emotional competence. Problems were also associated with parental worry about child behavior and interference in family activities. CONCLUSIONS A significant need for early identification of emotional/behavioral problems in very young children is highlighted by associations with delayed competence and disruptions in family life that may further contribute to risk for persistent problems.

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.

Language Delay in a Community Cohort of Young Children

OBJECTIVE To document the prevalence of expressive language delay in relation to age and gender in 12- to 39-month-old children. To document the characteristics, particularly social competence and emotional/behavioral problems, related to deficits in expressive language. METHOD Parents of an age- and sex-stratified random sample of children born at Yale New Haven Hospital between July 1995 and September 1997 who lived in the New Haven Meriden Standard Metropolitan Statistical Area were enrolled when their children were 12 to 39 months of age (79.8% participation;N = 1,189). The main outcome for these analyses is expressive language delay measured by the MacArthur Communicative Development Inventory, short forms. RESULTS Expressive language delays range from 13.5% in 18- to 23-month-olds to 17.5% in children 30 to 36 months of age. By 18 to 23 months, children are more likely to experience delays if they come from environments characterized by low education, low expressiveness, poverty, high levels of parenting stress, and parents who report worry about their childrens language problems. When social competence is adjusted for in the multivariable model, behavior problems are no longer associated with language delay, suggesting that poor social competence rather than behavior problems may be the critical early correlate of low expressive language development. CONCLUSIONS Expressive language delays are prevalent problems that appear to be associated with poor social competence. Given that such problems may be risk factors for social and emotional problems, early identification is critical.

The Service Assessment for Children and Adolescents (SACA): Adult and Child Reports

OBJECTIVE To describe differences in parent-child responses to the Service Assessment for Children and Adolescents (SACA). METHOD Studies were done at UCLA and Washington University based on service-using and community subjects drawn from community households or public school student lists, respectively. Results are presented for 145 adult-youth pairs in which the youth was 11 or older. RESULTS The SACA adult-youth correspondence for lifetime use of any services, inpatient services, outpatient services, and school services ranged from fair to excellent (kappa = 0.43-0.86, with most at 0.61 or greater). Similarly, the SACA showed a good to excellent correspondence for services that had been used in the preceding year (kappa = 0.45-0.77, with most greater than 0.50). The parent-youth correspondence for use of specific service settings in the above generic categories ranged from poor to excellent (kappa = 0.25-0.83, with half at 0.50 or greater). CONCLUSIONS The SACA has better adult-youth correspondence than any service use questionnaire with published data, indicating that both adult and youth reports are not needed for all research on mental health services. This is especially encouraging news for researchers working with high-risk youth populations, in which a parent figure is often not available.

Understanding the Components of Quality Improvement Collaboratives: A Systematic Literature Review

CONTEXT In response to national efforts to improve quality of care, policymakers and health care leaders have increasingly turned to quality improvement collaboratives (QICs) as an efficient approach to improving provider practices and patient outcomes through the dissemination of evidence-based practices. This article presents findings from a systematic review of the literature on QICs, focusing on the identification of common components of QICs in health care and exploring, when possible, relations between QIC components and outcomes at the patient or provider level. METHODS A systematic search of five major health care databases generated 294 unique articles, twenty-four of which met our criteria for inclusion in our final analysis. These articles pertained to either randomized controlled trials or quasi-experimental studies with comparison groups, and they reported the findings from twenty different studies of QICs in health care. We coded the articles to identify the components reported for each collaborative. FINDINGS We found fourteen crosscutting components as common ingredients in health care QICs (e.g., in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in QI methods). The collaboratives reported included, on average, six to seven of these components. The most common were in-person learning sessions, plan-do-study-act (PDSA) cycles, multidisciplinary QI teams, and data collection for QI. The outcomes data from these studies indicate the greatest impact of QICs at the provider level; patient-level findings were less robust. CONCLUSIONS Reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active QIC ingredients linked to improved care. Although QICs appear to have some promise in improving the process of care, there is great need for further controlled research examining the core components of these collaboratives related to patient- and provider-level outcomes.

Concordance Between Parent Reports of Children's Mental Health Services and Service Records: The Services Assessment for Children and Adolescents (SACA)

The concordance between parent reports of childrens mental health services and medical and administrative service records were assessed in a field test of the Services Assessment for Children and Adolescents (SACA) interview instrument. Service use reports from primary caregivers, usually mothers, for their childs emotional or behavioral problems were compared against inpatient, outpatient, and school records in St. Louis, one of the pilot sites for the Multi-Site Study of Service Use, Need, Outcomes and Costs in Child and Adolescent Populations (UNOCCAP). A global “any use” service variable, comprised of inpatient, outpatient, and school reports, yielded an overall service use concordance kappa of .76 between parent reports and records. Parent reports of inpatient hospitalization services using the SACA yielded the highest agreement with medical records, with kappa statistics of 1.00 for use of any inpatient hospital care and for medication use. Parent reports of specific inpatient services concurred with medical records more moderately, yielding kappas from .50 to .66. Reports of any outpatient mental health services yielded variable rates of agreement, with kappas ranging from .67 for any use of outpatient care, to .66 for medication use, to negligible kappas for specific treatments. Parent reports of school services were weakly related to records for most services, except for moderate agreement (.48) on placement in special classrooms for emotional or behavioral problems. Family burden or impact discriminated more powerfully than other variables between respondents who concurred with records and those who did not.