Integrating systems of care in California for youth with severe emotional disturbance. I. A descriptive overview of the California AB377 evaluation project

This paper presents an overview and an initial set of findings from an evaluation in three California counties of a replication of an integrated system of care for youth suffering from serious emotional disturbance. The development of the innovative system of care was pioneered in Ventura County, California, and the replications were legislatively enabled through AB377 (Assembly Bill 377). This paper focuses on one set of variables being studied in the evaluation: the characteristics of the youth enrolled in the care systems. This variable is important because personnel in the counties are explicitly deciding which youth are eligible for services given limited available public resources. Within the model system of care, clinical severity and risk status (being at-risk ofor in out-of-home placement) are used as the criteria for enrollment with the intent of serving those most in need as effectively as possible. The gender, age, clinical diagnosis, ethnicity, and global assessment of functioning (GAF) scores of these youth are presented. In general, the youth served are male, have low GAF scores, and predominantly receive clinical diagnoses of affective disorders and disruptive behavior disorders. African-Americans are overrepresented in the care systems relative to the general population and Asian-Americans are underrepresented.     

The influence of race and ethnicity on psychiatric diagnoses and clinical characteristics of children and adolescents in children's services

This study examined the influence of race and ethnicity on psychiatric diagnoses and clinical characteristics of 1,189 children and adolescents participating in the federally funded Comprehensive Community Mental Health Services for Children and Their Families Program. Results showed that after controlling for age, gender, functional impairment, and socioeconomic status, there were significant race and ethnicity effects on diagnosis and clinical characteristics. Black and Native Hawaiian youth were more likely than White youth to be diagnosed with disruptive behavioral disorders. Hispanic and Native Hawaiian youth were less likely than White youth to be diagnosed with depression or dysthymia. Black, Asian American, and Native Hawaiian youth were rated as exhibiting less internalizing behavior problems than White youth. Implications for research, practice, and policy are discussed.     

Demographic, Clinical, and Functional Characteristics of Youth Enrolled in Six California Systems of Care

We describe the demographic, functional, and clinical status of children served across six California counties implementing a longstanding integrated system of care approach called the California System of Care Model. The children enrolled in the care systems are an ethnically diverse group of predominantly pre-adolescent and adolescent males. The level of functional impairment and degree of symptomatology is high. Seventy to 80% of the youth were in the clinical or borderline clinical ranges as measured by the Child Behavior Checklist. Scores on the Child and Adolescent Functional Assessment Scale, provided by the treating clinician, indicated that up to 94% of the youth were in the moderate to severe levels of impairment. Children and adolescents rated themselves on the Youth Self Report as having lower levels of impairment than did parents. Caregivers and youth ratings emphasized externalizing rather than internalizing problems. Clinician ratings as captured by the CAFAS and the clinical diagnoses, presented a mix between internalizing and externalizing diagnoses and functional impairment areas. The six counties are serving children who have levels of impairment, similar to, or higher than, youth enrolled in other systems of care nationwide.     

The Mental Health Needs of Youth with Emotional and Behavioral Disabilities Placed in Special Education Programs in Urban Schools

We describe the psychosocial characteristics of youth with an average age of 11.8 years served in special education due to emotional disturbances in urban communities (N = 158). Data were also collected describing service utilization, academic functioning, and family characteristics. Ten schools in three mid-size urban cities participated. Results from the administration of standardized assessments revealed that the majority of students scored in the clinical range on the parent version of the Child Behavior Checklist and the Columbia Impairment Scale, indicating significant levels of emotional and behavioral impairment. Further, behavior problems began at an early age with 80% of the youth using outpatient services beginning at the average age of 7.5 years and 29% of the youth using inpatient services beginning at an average age of 8.4 years of age. Most of the youths' school careers (67%) have been in a special education setting. The most common services currently being supplied by school personnel was individual counseling and this was provided for 63% of the students while child-serving agency personnel were providing individual counseling for 17% of the youth. Implications for the development of multi-agency collaborative services are presented.     

The internal consistency and concurrent validity of a Spanish translation of the Child Behavior Checklist

The Child Behavior Checklist's applicability to a Hispanic sample was assessed by an examination of the instrument's internal consistency and concurrent validity. The CBCL and TRF were administered to a community sample representative of children of Puerto Rico aged 4 to 16. Cronbach's alpha was used to assess the internal consistency of empirically derived scales. The relation of CBCL and TRF scores to clinical diagnosis, adaptive functioning, and need for services served as indicators of the concurrent validity of the instrument's Spanish version. The results indicate that the total behavior problem scores on the instruments are good continuous measures of maladjustment for children in Puerto Rico. A child with high values on the scales has a high probability of being classified as a case by a psychiatrist. High levels of internal consistency were found in most subscales. Only scales comprising low prevalence problems showed poor internal consistency.     

The CBCL Bipolar Profile and Attention,Mood, and Behavior Dysregulation

Biederman and colleagues reported that a CBCL profile identified youngsters who were diagnosed with bipolar disorder. Some studies found that this CBCL profile does not reliably identify children who present with bipolar disorder, but nonetheless this CBCL does identify youngsters with severe dysfunction. However, the nature of the impairment of youngsters who fit this profile is unclear. The goal of this study was to describe the clinical characteristics of youngsters who fit this CBCL profile. The sample included 310 youngsters referred to an outpatient psychopharmacology clinic. There were 55 youngsters who fit the CBCL profile. These youngsters were compared to 255 youngsters who did not fit the CBCL profile. Measures included the CBCL, standardized measures of aggression and ADHD symptoms, youngsters’ self-reported depression, DSM-IV diagnoses, and child and adolescent psychiatrists’ ratings of impairment and functioning. Compared to youngsters who did not fit the CBCL bipolar disorder profile, youngsters who fit the profile had significantly higher scores on all but one CBCL scale and significantly higher levels of aggression. Youngsters who fit the CBCL profile also had greater psychosocial impairment and more DSM-IV diagnoses than youngsters who did not fit the profile. Youngsters who fit the CBCL profile exhibit severe dysregulation across multiple domains of functioning including attention, affective, and behavioral dysregulation that are not easily nor efficiently captured by extant DSM-IV diagnoses. These youngsters are not uncommon and comprise slightly less than 1 in 5 referrals to a child psychiatry clinic.     

Integrating Systems of Care in California for Youth with Severe Emotional Disturbance IV: Educational Attendance and Achievement

Empirical results are presented from school-based interventions in three California counties that are pioneering participants in a carefully evaluated effort to create an innovative system of care for youth with severe emotional disturbance. Data are presented about the educational attendance and achievement of youth enrolled in clinical and academic programs designed to provide collaborative mental health and education services. Attendance levels were uniformly high. The youth were below expected grade level as measured by standardized tests at program admission. Across programs, two counties demonstrated grade level increases of one year or more for one year in school on all subscales of established measures of educational achievement. The third county demonstrated increases of slightly less than one year on two of three subscales of the educational achievement measures. These results are the first from a multisite demonstration of integrated education and mental health programs embedded within a broader system of care for youth. The findings, combined with those from our prior studies, illustrate that is possible to reduce and control placements in restrictive levels of care while improving the academic performance of a vast majority of the youth enrolled in specialized programs within the care systems.     

Measurement Equivalence of the Child Behavior Checklist among Parents of African American Adolescents

The Child Behavior Checklist (CBCL/6-18) is a widely used parent-report measure of youth internalizing and externalizing problems. Accumulating evidence, however, suggests that the CBCL may not adequately assess clinical problems in diverse populations. We investigated the measurement equivalence (ME) of the CBCL in an African American adolescent sample (N = 145). Confirmatory factor analysis indicated poor factor model fit; however, modification indices and an alternative two-factor model produced improved fit statistics. Internal consistency coefficients of CBCL scales ranged from α = .65 to .88 and were generally lower than those reported for the normative sample. The CBCL exhibited convergent validity with conceptually similar scales on the Parent Report Scale of the Behavior Assessment System for Children; however, the correlations were weaker than those reported for the normative sample. The CBCL Internalizing composite failed to predict clinician-rated Emotional problems, however, the Externalizing composite predicted clinician-rated behavior problems. In summary, the CBCL did not exhibit unequivocal evidence of ME, as it both possesses and lacks a number of statistical attributes that would demonstrate its equivalence with African Americans. Future empirical and theoretical work is discussed.     

Homeless Youths and Young Adults in Los Angeles: Prevalence of Mental Health Problems and the Relationship Between Mental Health and Substance Abuse Disorders

Although understanding of the subsistence patterns, service utilization, and HIV-risk behaviors of homeless youths and young adults is increasing, relatively little is known about the epidemiology of mental health problems in this group or the relationships between mental health problems and substance use. This study measured symptoms of depression, low self-esteem, ADHD, suicidality, self-injurious behavior (SIB), and drug and alcohol use disorder in a sample of homeless youth and young adults living in Hollywood, CA. Results indicated extremely high prevalences of mental health problems, as compared with corresponding rates of mental health problems found among housed youths in previous studies. Prevalence of mental health problems differed by age and ethnicity. African Americans were at lower risk of suicidal thoughts and SIB than were those of other ethnicities. Older respondents and females were at increased risk of depressive symptoms, and younger respondents were at increased risk of SIB. Previous history of sexual abuse and/or assault was associated with increased risk of suicidality and SIB. Risk factors for drug abuse disorder included ethnicity other than African American, homelessness for 1 year or more, suicidality, SIB, depressive symptoms, and low self-esteem. Risk factors for alcohol abuse disorder included male gender, white ethnicity, homelessness for 1 year or more, suicidality, and SIB. Extremely high rates of mental health problems and substance abuse disorders in this sample suggest the need for street-based and nontraditional mental health services targeted toward these youths and young adults.     

Social network predictors of bullying and victimization

This study examined whether bullies, victims, and aggressive victims (those who are both bullies and victims) differed on classroom social network variables, gender, and ethnicity. Survey data were collected from a primarily Latino and Asian sample of 1,368 Southern California 6th graders (mean age = 11.3 years). Logistic regression analyses were performed to determine whether network characteristics and ethnicity were associated with each of the outcome variables. Consistent with social cognitive theory, friends' participation in aggressive behaviors was positively associated with being a bully or an aggressive victim, and negatively associated with being a victim. Consistent with social dominance theory, the number of friendship nominations received was negatively associated with being a victim. Female bullies received fewer friendship nominations, but had a higher proportion of reciprocated friendships. Victims were disproportionately Asian. The findings suggest that bullying prevention efforts targeting highly aggressive students may also diffuse to their friends, and that assertiveness training in handling aggressive situations may successfully combat bullying and aggression.     

Mental Health and Incarcerated Youth. I: Prevalence and Nature of Psychopathology

The incarceration of mentally ill youth is a serious problem not receiving the same attention as in adults. In this study, we examine the prevalence of psychopathology and level of behavioral symptomatology in incarcerated youth versus youth receiving community mental health services or hospitalization. We randomly recruited youth from middle South Carolina served by a local CMHC (n = 60), youth served by the state adolescent inpatient program (n = 50), and youth in the S.C. Dept. of Juvenile Justice facilities from the same region (n = 75). We used the DISC-PC 2.3 to evaluate DSM-III-R diagnoses and the CBCL and YSR to evaluate behavioral symptomatology. On the DISC, incarcerated youth had significantly higher mean number of diagnoses and symptoms than CMHC youth, but lower numbers than hospitalized youth. Level of caseness (at least one diagnosis) was 86% in hospital youth, 72% in incarcerated youth, and 60% in CMHC youth. The groups differed in CBCL mean total T, internalizing T, and externalizing T scores as well as mean YSR internalizing T scores. Our results indicate the comparability in level of psychopathology in incarcerated and community-treated populations of youth, and the need to develop diversionary programs to prevent the entry of such youth into the juvenile justice system.     

The relationship between spirituality and depressive symptom severity,psychosocial functioning impairment,and quality of life: examining the impact of age,gender, and ethnic differences

Research has documented the contribution of spirituality on overall health and mental health among college students. However, very few studies have explored the impact of cultural and ethnic differences on the effect of spirituality on mental health outcomes in this population. The aims of this study were to examine the relationships among spirituality, depressive symptom severity, psychosocial functioning impairment, and quality of life in a large multi-ethnic sample of college students and explore the impact of age, gender, and ethnicity on these relationships. The sample consisted of Latino, African-American, Caucasian, and Caribbean/West Indian college students. Findings indicated that spirituality, believing in God's presence, age, gender, and ethnicity were significantly related to depressive symptoms. These factors were also associated with impairment in psychosocial functioning and quality of life related to depression.     

The equivalence of the Child Behavior Checklist/1 1/2-5 across parent race/ethnicity, income level, and language

This study examined the equivalence of the Child Behavior Checklist/1 1/2-5 (CBCL/1 1/2-5) in 682 parents of 2- to 4-year-old children stratified by parent race/ethnicity (African American, Latino, and non-Latino White), family income (low vs. middle-upper), and language version (Spanish vs. English). Externalizing Scale means differed by income and child gender. Internalizing Scale means differed by income and parent race/ethnicity. Differential item analyses showed that few items functioned differently by racial/ethnic, language, and income group. A confirmatory factor analysis demonstrated that the Externalizing Scale provided a good fit with the data across racial/ethnic and income groups. However, model fit was improved for the Internalizing Scale when factor weights were allowed to vary. Findings support the equivalence of the CBCL/1 1/2-5 when used with parents of low-income preschool children from African American and Latino backgrounds, although further study of the factor structure for the Internalizing Scale is recommended.     

Inter-Parent Agreement on the Syndrome Scales of the Child Behavior Checklist (CBCL): Correspondence and Discrepancies

Using multiple informants from a clinical setting, potential associations between inter-parental agreement and age, gender, and child diagnosis were explored in the current study. Archival data from psychological evaluations conducted on 174 children ages 5–18 through a hospital-affiliated outpatient psychology clinic were analyzed, focusing on mothers’ and fathers’ scores on the syndrome and index scales of the Child Behavior Checklist (CBCL). Although inter-parent correspondence levels on each of the subscales were found to be moderately high (averaging r = .50), significant discrepancies between the severity levels of parent reports were found on nine of 11 subscales, with mothers’ ratings consistently being slightly higher. Data from this clinical sample suggest that although single-informant ratings of child behavior may be generally representative of reports from both parents on many of the CBCL narrow-band scales, age, gender, and child diagnosis were related to several patterns of agreement on specific syndrome scales. Therefore, it is important to include fathers, because they provide a unique perspective on social problems, delinquency, and attention problems, in particular. Both correspondence and discrepancies between parent reports of specific child problems can provide valuable clinical information that is useful for child assessment and treatment.     

Long-term stability of the Child Behavior Checklist in a clinical sample of youth with attention deficit hyperactivity disorder.

Evaluated the long-term stability of the Child Behavior Checklist (CBCL) in a longitudinal clinical sample of youth with attention deficit hyperactivity disorder (ADHD), testing the hypothesis that the CBCL scales will show stability over time. Participants were 105 Caucasian, non-Hispanic boys with ADHD between the ages of 6 and 17 assessed at baseline and at a 4-year follow-up. Stability of CBCL scales were computed for dimensional (intraclass correlation coefficients [ICCs], Pearson correlations) and dichotomized scale scores (kappa coefficients and odds ratios [ORs]). Evidence was found for stability of the categorical and dimensional types of scores, as demonstrated by statistically significant stability of the Pearson correlation coefficients, kappas, and ORs. The robust findings obtained from ICCs and kappa coefficients document substantial stability for CBCL scales over time within individuals with ADHD. These results support the informativeness of the CBCL as a useful measure of longitudinal course in clinical samples of youth with ADHD.     

Characteristics of the Florida cognitive activities scale in older African Americans

Substantial research effort has recently focused on the potential protective effect of cognitively demanding activities on cognitive decline in late life. A significant methodological issue in this effort has been the lack of consistency in approaches to the operational measurement of cognitive activity. In this study, data in support of the reliability and construct validity of the recently developed Florida Cognitive Activities Scale (FCAS) in a sample of 223 African American older adults are provided. Consistent with the findings of the Schinka et al. study using a sample of Whites, the FCAS full scale showed a reasonably high level of internal consistency, small negative correlations with age and a measure of depressive symptomatology, and moderate positive correlations with years of education and neuropsychological measures of overall cognitive functioning, memory, and executive functioning. Even after controlling for the effects of age, education, and gender, the full scale score contributed significantly to the prediction of global cognitive functioning. The results of this study suggest that the FCAS is a reliable and valid measure of cognitive activities in older African Americans and provides additional, although not causative, evidence in support of the hypothesis of a protective effect of cognitive activity against cognitive decline regardless of ethnicity or race.     

Clinician Perspectives of Diagnosis and Perceived Client Change in “Real World” Psychotherapy for Youth Emotional and Behavioral Disorders

We investigated the extent to which clinician-assigned diagnoses of emotional and behavioral disorders and clinicians’ perceptions of client change are consistent with structured measures of youth clinical functioning and parent/family characteristics within the context of usual care or “real world” psychotherapy. A total of 54 therapists from two publicly-funded youth outpatient mental health clinics and 128 youths and parents from the therapists’ combined caseloads were included in the study. Clinician-assigned diagnosis and youth and family demographics were collected at the initial visit, clinician-reported perceived client change was collected at 6-month follow-up, and structured measures of youth clinical functioning and parent/family characteristics were collected at both time points. Results indicate some overlap between clinician-assigned diagnosis, clinician-reported perceived client change, and structured measures of youth clinical functioning and parent/family characteristics after controlling for demographic factors. Results are discussed in terms of implications for the implementation of evidence-based practices in real world community settings.     

Mental Health and Incarcerated Youth. II: Service Utilization

The incarceration of mentally ill youth is a serious problem not receiving the same attention as in adults. In this study, we examine the level of prior service utilization in incarcerated youth versus youth receiving community mental health services. We randomly recruited youth from middle South Carolina served by a local community mental health center (CMHC; n = 60), hospitalized in the state adolescent inpatient program (n = 50), and incarcerated in the S.C. Dept. of Juvenile Justice facilities (n = 75). We used a Services History to evaluate episodes of prior utilization of mental health, social service, educational, residential, and volunteer services, as well as the DISC-PC 2.3 to evaluate DSM-III-R diagnoses and symptoms and the CBCL and YSR to evaluate behavioral symptomatology. Incarcerated, hospitalized, and CMHC youth utilized similar levels of educational services and social services. Incarcerated youth had a significantly lower lifetime utilization of outpatient and acute mental health services and significantly higher utilization of out-of-home residential services than the other groups. These services utilization variables, along with gender and age, significantly distinguish incarcerated youth from the clinical groups, with clinical variables not serving to significantly distinguish them. Our results indicate the need to develop programs to prevent the entry of mentally ill/emotionally disturbed youth into the juvenile justice system. Youth who are at risk for incarcenation may benefit from intensive mental health services to prevent out-of-home placement and later incarceration.     

Concurrent Validation of the Treatment Outcome Package (TOP) for Children and Adolescents

The Treatment Outcome Package for children and adolescents (TOP) is a behavioral health and well-being assessment used widely in clinical and child welfare populations. The primary purpose of this study was to examine the concurrent validity of the Child and Adolescent versions of the TOP with the Child Behavior Checklist (CBCL) and the Strengths and Difficulties Questionnaire (SDQ) with a community sample. Children and adolescents (N = 203) 3–18 years of age from a community sample completed the CBCL, the SDQ, and the TOP. Significant correlations emerged between the TOP and theoretically similar scales on the SDQ and the CBCL. Analyses demonstrated that the TOP has excellent concurrent validity on most subscales with both the CBCL and the SDQ. These results provide additional evidence for the TOP’s utility and validity as a measure of psychological well-being and functioning.     

Relation Between Parent Psychiatric Symptoms and Youth Problems: Moderation through Family Structure and Youth Gender

Links between parents’ psychiatric symptoms and their children’s behavioral and emotional problems have been widely documented in previous research, and the search for moderators of this association has begun. However, family structure (single versus dual-parent households) has received little attention as a potential moderator, despite indirect evidence that risk may be elevated in single-parent homes. Two other candidate moderators—youth gender and age—have been tested directly, but with inconsistent findings across studies, perhaps in part because studies have differed in whether they used youth clinical samples and in which informants (parents vs. youths) reported on youth problems. In the present study, we examined these three candidate moderators using a sample of exclusively clinic-referred youths (N?=?333, 34 % girls, aged 7–14,) and assessing youth problems through both parent- and youth-reports. Both family structure and youth gender emerged as robust moderators across parent and youth informants. Parent symptoms were associated with youth internalizing and externalizing problems in single-parent but not dual-parent homes; and parent symptoms were associated with youth internalizing problems among boys, but not girls. The moderator findings suggest that the risks associated with parent psychopathology may not be uniform but may depend, in part, on family structure and youth gender.