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.     

Psychiatric Diagnoses and Clinical Characteristics of Asian American Youth in Children's Services

This study examined the psychiatric diagnoses and clinical characteristics of the 981 Asian American children enrolled in the first phase of the Comprehensive Community Mental Health Services for Children and Their Families Program. Asian Americans were less likely than non- Asian Americans to receive diagnoses of depression and ADHD and more likely to receive diagnoses of anxiety and adjustment disorder. As compared to non-Asians, Asian Americans were significantly more likely to be rated with severe functional impairment in community role performance, self-harmful behavior, and thinking. There was also a trend for fewer externalizing behavior problems. Implications for research and practice are discussed.     

Parent Satisfaction with Case Managed Systems of Care for Children and Youth with Severe Emotional Disturbance

Case management has emerged as an integral component of current efforts to reform the delivery of mental health services to children and youth with Severe Emotional Disturbance (SED). We examined parental satisfaction with one program's case management system for SED children. In order to validly address parental satisfaction, the program first turned to a group of its parents to develop a satisfaction measure, the Family Satisfaction Survey (FSS). Of the 51 parents who returned an FSS, 74% of the parents were generally satisfied while 26% indicated that they were dissatisfied with their families' case management services. Multivariate regression analyses were employed to examine the role played by client, service, and outcome variables in predicting parental satisfaction. After controlling for child diagnoses, severity of impairment, and levels of psychosocial stress, parent satisfaction with case management services was best predicted by the frequency of monthly contact and fewer days is a psychiatric hospital proportional to length of service. Our results suggest that parent satisfaction is based not only on what case managers do but on how this service impacts SED children's ability to remain at home and in their communities.     

Student Nurses' Experiences of The Clinical Psychiatric Learning Environment in an Education Institution

This study investigated lived experiences of student nurses working in a clinical psychiatric learning environment in South Africa. Participants were 29 fourth-year student nurses in the clinical psychiatric learning environment at a nursing education institution (females = 27; males =2). They engaged in focus group discussion on their experiences of the clinical psychiatric learning environment. The data were thematically analyzed using Tesch's method of open coding. The student nurses experienced the environment as growth enhancing on a professional and personal level.     

Integrating systems of care in California for youth with severe emotional disturbance III: Answers that lead to questions about out-of-home placements and the AB377 evaluation project

This paper is the third in a series of reports on preliminary empirical findings from replications 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 in three other California counties were legislatively enabled through California legislation (Assembly Bill 377). This report presents results on the expenditure and utilization of foster homes, residential placements made through special education programs, and state hospitals. Evaluation results indicate that foster home and state hospital utilization and expenditures are lower for the counties replicating the innovative system of care than for the state of California as a whole. Expenditures for special education residential placements are either at the state rate or lower in one county. The cumulative evidence supports the conclusion that the replication counties are utilizing restrictive levels of care at lower rates than would be expected, given state-wide patterns. The results, in conjunction with prior findings, are discussed in the context of questions about the possible fates of youth who no longer live in publicly funded residential facilities.     

The Effect of Racial and Ethnic Diversity on the Delivery of Mental Health Services in Pediatric Primary Care

The effects of racial and ethnic diversity on the detection and management of behavioral and emotional problems in pediatric primary care are addressed. Service access and utilization as a function of race and culture are initially examined. Important barriers within pediatric training including minimal emphases on behavioral training and the limited supply of minority physicians are underscored. The impact of ethnicity on the development and maintenance of the clinical relationship that is critical to accurately and sensitively identifying and managing behavioral and developmental problems is briefly addressed. Recommendations for further integration of racial/ethnic issues into mental health service provision within the pediatric primary care arena are presented.     

Mental Health and Other Service Use by Youth in Therapeutic Foster Care and Group Homes

Little is known about what additional services youth receive while they reside in out-of-home treatment settings. However, such information may be crucial for explaining effectiveness and variation in outcomes for youth in such settings. Our research examines patterns of multi-sector service use for youth in two settings—Therapeutic Foster Care and group homes. Data come from in-person interviews with Treatment Foster Parents and Group Home Staff for a NC state-wide sample of youth with psychiatric disorders and aggressive behavior. Findings indicated high rates of service use by youth in both settings. Analyses indicated significant differences in service types used by youth in each setting, yet similar volume of service use between settings. Clinical and demographic factors did not significantly influence types of services received. Differences in service patterns between the two groups indicated that youth in TFC were more likely to receive community-based, individualized services while youth in group homes were more likely to receive more restrictive services.     

Family Influences on Treatment Refusal in School-linked Mental Health Services

This study analyzed family influences on treatment refusal in school-linked mental health services (SLMHS). Specifically, it assessed whether levels of family cohesion, conflict, and organization were related to whether a family refused to initiate recommended treatment. Children (N = 133) referred for emotional and behavioral problems and their families participated. Results indicated that (1) family environment factors explained a significant amount of variance in treatment refusal after controlling for demographic factors, (2) families of children with predominantly internalizing symptoms were at greater risk for refusing treatment than families of children with predominantly externalizing symptoms, and (3) lower level of family cohesion was an individual risk factor for refusing treatment. Incorporating an evaluation of family environment within SLMHS assessments may aid in the identification of areas wherein intervention may be beneficial in preventing treatment refusal.     

The Role of Schools in Outcomes for Youth: Implications for Children's Mental Health Services Research

We explore the role of schools in children's mental health services research. Recent literature has suggested that schools play an important role in delivering services to children and adolescents with emotional and behavioral problems. Research in services research, though, has taken a fairly narrow view of which dimensions of school environments are relevant for inclusion in studies. We suggest that a broader view of school environments is appropriate and potentially beneficial to the field. Using Bronfenbrenner's ecological model as a guide, we conceptualize schools as microsystems. Such an approach suggests that all aspects of school environments (treatment as well as non-treatment) are likely to influence many of the outcomes that children's mental health services research frequently targets (e.g., behavioral problems, problematic peer relationships, academic achievement, school attendance). We review literature from a variety of disciplines to suggest relevant features of schools, with particular attention to the role of peer dynamics within schools. We conclude with implications of this expanded conceptualization of schools for children's mental health services research.     

Religiousness, Health, and Health Behavior in Public-Use Data of the National Center for Health Statistics

Studies of religiousness and health-related variables in large, population-based cross-sectional or, preferably, longitudinal studies, which are often prohibitively expensive, are important to complement findings from the more commonly performed studies. Inadequately known among social science researchers, the national health surveys of the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) offer large, high-quality data sets to the public at no or nominal cost and hence offer important opportunities for research in the area of religion and health, religion and reproductive behavior, sociology of religion and psychology of religion. This report provides an overview of the data sets and a bibliography of prior research using these data, which is intended to suggest how the data of NCHS may be further exploited by researchers of religiousness and health.

Integrating systems of care in california for youth with severe emotional disturbance II: Initial group home expenditure and utilization findings from the California AB377 Evaluation Project

The California AB377 Evaluation Project was established to study the replication of an innovative system of care in three California counties for youth suffering from severe emotional disturbance. Development of the innovative system of care was pioneered in Ventura County, California, and the replications were legislatively enabled through Assembly Bill 377 (AB377). This paper reports evaluative findings about a central goal of the innovative care system: the reduction of use of highly restrictive out-of-home placements though creation and maintenance of coordinated and effective community-based services. Group home facilities are the focus of the evaluation work because these facilities consume the largest proportion of all public expenditures for youth in residential placements in California. More than 10 years of aggregate county and state level monthly expenditure and utilization data are presented. The results indicate that the demonstration counties have generated lower per capita inflation adjusted rates of expenditures and per capita group home placements than California as a whole. The evaluation results provide evidence that an integrated system of care can reduce group home placements. However, the nature, quality and effectiveness of any and/or all alternative services provided remains a topic for further investigation.     

The Links Among Perceived Adherence to the System of Care Philosophy,Consumer Satisfaction,and Improvements in Child Functioning

The present study investigated the associations among perceived adherence to the system of care philosophy, changes in internalizing and externalizing behaviors, and consumer satisfaction with services. Participants included 98 families, interviewed at two time points across a one-year period. Hierarchical multiple regressions indicated that the more a child and family perceived services to be consistent with the system of care philosophy, the greater their level of satisfaction with services and the fewer internalizing and externalizing behaviors they reported one year after receiving services (controlling for initial levels of problem behaviors). Implications for children’s mental health service delivery are offered.     

Health and Social Services for Male-to-Female Transgender Persons of Color in San Francisco

SUMMARY

This article presents findings from an investigation of health needs, service utilization, and perceived barriers to services among male-to-female (MtF) transgender persons of color in San Francisco. Focus groups (n = 48) and survey interviews (n = 332) were conducted with convenience samples recruited from the community. Participants reported a range of health and social services needed during the previous year, with African-Americans and Latinas showing particularly strong service needs. Rates of utilizing services were high for basic health care but lower for social services, substance abuse treatment, psychological counseling, and gender transition-related medical services. No significant ethnic group differences in health service utilization were found. Qualitative findings evinced the call for transgender-specific programs and advanced provider training on transgender issues such as hormone use, gender transition, HIV/ AIDS care and prevention, substance abuse, and mental health problems.     

Impact of a System of Care on a Community's Children's Social Services System

Researchers and practitioners have questioned how the implementation of a system of care influences the broader context of children's social services within a community. We examined the impact that the Dawn Project system of care had on children's services in Marion County, Indiana. A series of semi-structured interviews were conducted in order to gain a broad understanding of stakeholder perspectives related to how system-level and other community leaders viewed system of care influences. Qualitative analyses uncovered several common themes including positive impact at the community level, challenges to implementation, and feelings of ambivalence related to program impact. Results were generally positive and suggested that most respondents saw core system of care principles beginning to emerge within the community related to the establishment of the care system. In addition, challenges to implementing the system of care also were uncovered, including some underlying resistance to system-level changes. Implications from our study highlight the importance of continuously working to enhance strengths and collaboration among systems, integrate and coordinate across systems and services, and authentically involve families at all levels.     

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.     

Outcomes in a System of Care for Youths with Emotional and Behavioral Disorders: An Examination of Differential Change Across Clinical Profiles

We assessed the utility of an empirically-derived classification system for youths with emotional and behavioral disorders in a system of care with a strong representation of juvenile delinquents. Eighty-seven youths served in a system of care were categorized by variables related to past history, current behavioral functioning, and current psychological functioning into four clinical clusters. We evaluated preliminary clinical outcomes after six months of interagency involvement for youths within each cluster and across the four clusters. Results indicated that youths in different clusters improved significantly in need-specific areas. Trends in our data indicated differential change in clinical outcomes across clusters. We discuss our findings within the context of emerging outcomes of youths involved in comprehensive community-based programs and consider implications for outcome research, treatment of juvenile delinquents, and mental health policy.     

A Study of Pastoral Care,Referral, and Consultation Practices Among Clergy in Four Settings in the New York City Area

Clergy (N = 179) in the catchment areas of four hospitals in New York and Connecticut were surveyed about their pastoral care activities. Factor analysis revealed two separate sets of problems presented in pastoral counseling, with respect to clergys ratings of their competence to address them. The first factor included grief, death and dying, anxiety, and marital problems, in descending order of frequency. The second factor consisted of depression, alcohol/drugs, domestic violence, severe mental illness, HIV/AIDS, and suicide. Clergy were significantly less confident of their ability to deal with Factor 2 problems, yet clergy rarely consulted with mental-health professionals about either type of problem. Less than half of the clergy had training in Clinical Pastoral Education, but those who did tended to feel they were more competent to deal with both types of problems. On average, clergy devoted 3.7 hours per week to visiting patients and nearly 55% said they were definitely more likely to refer a patient to a hospital with a pastoral care department.