Outcomes and Findings of Program Evaluation for the Intensive Mental Health Program

We describe changes in adaptive functioning for children enrolled in the Intensive Mental Health Program (IMHP), an innovative model for serving children with the most severe forms of SED. Most children show marked improvements in multiple indicators of role performance and symptomatology. Although a high risk, high need group, most children attended school regularly and lived with a stable caregiver at discharge.     

Satisfaction with Components of the Therapeutic Model: Perspectives of Consumers and Professionals

We provide information about consumer and provider perceptions using a mixed-model pilot study within the Intensive Mental Health Project (IMHP), a school-based treatment service for children with SED and their families. Caregiver, youth, and provider questionnaires developed for this project elicited quantitative and qualitative information on treatment satisfaction, therapeutic alliance, and active involvement in treatment. Caregivers and children overall had positive perceptions of the services they received through IMHP. Providers reported very good working relationships with most children and families. Consumers also provided constructive comments about how to improve services. Our results add support to the importance of therapeutic alliance and collaboration, which are guiding principles of the IMHP.     

Factors Related to Outcome in a School-based Intensive Mental Health Program: An Examination of Nonresponders

We examined factors related to treatment responders (n = 35) and nonresponders (n = 16) in a group of 51 children admitted to the Intensive Mental Health Program (IMHP). Children’s response to treatment was coded based on their functioning at intake and discharge using total CAFAS scores. Demographic variables, length of treatment, number of diagnoses and medications, and history of physical/emotional abuse or neglect did not significantly distinguish between responders and nonresponders. Nonresponders were more likely to present with a history of suspected or confirmed sexual abuse, internalizing diagnoses, or comorbid internalizing and externalizing diagnoses. Although the small sample size may limit interpretations, our findings indicate treatment programs need augmentation when children with serious emotional disturbances (SED) may be at risk for not responding to interventions.     

Service Coordination and Children’s Functioning in a School-Based Intensive Mental Health Program

Coordination of mental health services in children with serious emotional disturbance (SED) has shown a preliminary relationship to positive outcomes in children. Yet, research in this area is sparse. Therefore, the relation between service coordination activities and adaptive functioning was examined for 51 children SED who were treated in the school-based Intensive Mental Health Program for elementary school students (IMHP; average treatment length was 12?months; mean age 9.37 at intake). Systematic review of detailed case records identified 16,669 episodes of service coordination that could be coded reliably for frequency, quality, and purpose (planning, linking, monitoring) of the service coordination component. Adaptive functioning was measured by Child and Adolescent Functional Assessment Scale (CAFAS) ratings and daily points earned on the behavior management system of the IMHP at intake, 6, 12?months, and discharge. Findings indicated that the frequency, quality, and purpose of the service coordination component varied from case to case and by time in treatment. Although service coordination activities overall decreased as treatment progressed, concentrated high quality service coordination (measured by frequency, quality, and component of service coordination) consistently predicted improved functioning on both CAFAS ratings and daily points earned. Results have both practice and policy implications for training interagency teams and clinicians on when and how to optimally coordinate services.     

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.     

Enhancing Therapeutic Gains: Examination of Fidelity to the Model for the Intensive Mental Health Program

Given that the development of treatment fidelity assessment protocol is an integral but too frequently ignored aspect of clinical trials for psychological treatments, the Intensive Mental Health Program (IMHP) sought to build fidelity activities into training, program evaluation, and clinical recordkeeping from the outset of a 3 year study period. We describe (a) operational definitions and measurement of the IMHP treatment model, (b) planned fidelity-promoting activities, (c) evaluation methods, and (d) fair to appreciable accomplishment of IMHP fidelity targets. Discussion of the circumstances and processes possibly hindering better fidelity for several IMHP treatment features accompanies presentation of fidelity data. We summarize pitfalls and compensatory strategies identified during IMHP program evaluation and offer practical suggestions to enhance accountability and evaluative activity in future clinical research.     

Memphis City Schools Mental Health Center

Summary

This article describes a nationally recognized integrated service program in operation since 1969 within the Memphis (TN) City Schools. Memphis City Schools Mental Health Center represents a comprehensive model for the delivery of integrated mental health and substance abuse services to children and youth with a wide range of problems. Notably, the model incorporates elements of primary and secondary prevention and community outreach into service delivery, components that may be under-emphasized in programs that are oriented toward specific clinical populations (e.g., SED). Program components are discussed in detail to demonstrate both unique and inter-related program features, reflecting the complex needs of the children and families being served. Future directions and challenges are also considered.     

Religious Activity and Pastoral Counseling Among Protestant Youth with SED

The past decade has shown a surge of interest in faith-based resources for a variety of social problems. However, these resources have not been systematically studied for children with emotional and behavioral problems. We investigated religious activity and use of pastoral counseling among Protestant youth with serious emotional disorders (SED) (N=464) and examined associated youth and caregiver characteristics. Findings indicate that the majority of SED youth do participate in religious activities, but do not frequently receive pastoral counseling for their problems. Youth with fewer externalizing problems as well as minority youth had an increased likelihood of participation in religious activities, while youth with more psychosocial impairment had an increased likelihood of using pastoral counseling. Implications of this study for research and practice are discussed.     

National leadership for children and youth with serious emotional disturbance: Progress and prospects

Despite the federal mandate to identify and provide appropriate educational and related services to children and youth with serious emotional disturbance (SED), the national profile portrays exceptionally low rates of identification; unacceptably low rates of school completion; high rates of placement in segregated environments; evidence that economic and demographic factors substantially affect identification, placement, and school completion; and a mixed, although mostly discouraging picture of outcomes after leaving the educational system. Recent national leadership, comprised of strategic planning, research, and demonstration initiatives has attained considerable momentum and is intended to improve outcomes for children with SED. Significant changes are anticipated as a result of the upcoming reauthorization of the statute governing special education and related services. These changes reflect a 20 year perspective regarding the benefits and shortcomings of current eligibility criteria and discretionary initiatives for improving outcomes for children with disabilities. The manner in which these changes may affect prospects for better serving children with SED is discussed.     

The Prevalence of Serious Emotional Disturbance: A Re-Analysis of Community Studies

The goal of these analyses was to use existing data to provide an empirically-based estimate of the prevalence in the population of Serious Emotional Disturbance (SED) in children and adolescents, to assist States in their task, required under PL 102-321, of including such estimates in their applications for Block Grant funds. Seven data sets were identified that could provide estimates of SED. The principal investigators agreed on common definitions of the key components of SED: a psychiatric diagnosis and significant functional impairment. Two definitions of impairment were used: domain-specific (impairment in one or more of three areas of functioning) and global (in the worst 10% over all). They also defined a set of correlates and risk factors for SED: age, gender, race/ethnicity, and poverty. Investigators then reanalyzed their own data, using these standard definitions, and calculated the proportion of SED youth who received mental health care. The median estimate of SED with global impairment was 5.4%, with a range from 4.3% to 7.4%. Estimates of SED with domain-specific impairment ranged from 5.5% to 16.9% (median 7.7%). Rates were slightly higher in boys. There were no clear ethnic differences. Poverty doubled the risk of SED. Only one SED child in four had recently received mental health care. Estimates of SED are critically dependent on the method used to define diagnosis and functional impairment. Using common definitions, seven studies produced fairly consistent estimates, which were similar to the estimate of prevalence of Serious Mental Illness (SMI) in adults. Implications for the estimate of State-by-State prevalence rates are discussed.     

‘Someone to talk to who'll listen’: addressing the psychosocial needs of children and families

The paper presents the Lewisham Community Child and Family Service (LCCFS), a community‐based intervention providing psychosocial help for children, young people, parents and families. The service is focused on early intervention, prevention and promotion in the improvement of local health. It works under a service framework based on inter‐agency collaboration, and a counselling model based on community and interpersonal partnerships, grounded in personal construct theory (Kelly, 1955). The policy demands and local need for accessible and acceptable mental health are discussed, and quantitative and qualitative findings of the needs assessment preceding the establishment of the LCCFS are presented, supporting the need for community mental health provision. The feasibility for the LCCFS to reconcile and meet the policy demands and the needs of parents with respect to child psychosocial help and services are discussed. Copyright © 2001 John Wiley & Sons, Ltd.     

CAREGIVER'S DEPRESSIVE SYMPTOMS AND YOUNG CHILDREN'S SOCIOEMOTIONAL DEVELOPMENT DELAYS: A CROSS‐SECTIONAL STUDY IN POOR RURAL AREAS OF CHINA

Poverty and its associated factors put people at risk for depression. The aims of this study were to describe the prevalence of depressive symptoms (DS) of primary caregivers and socioemotional development (SED) delays of young children in poor rural areas of China, and to explore the association between them. Cross‐sectional data of 2,664 children aged 3 to 35 months and their primary caregivers were used for analysis. Characteristics of the child, caregiver, and family were collected through face‐to‐face caregiver interviews. DS were assessed by the Zung Self‐Rating Depression Scale (W.W. Zung, 1965, as cited in World Health Organization, 2016b ), and SED was evaluated by the Ages and Stage Questionnaires: Social‐Emotional (J. Squires, D. Bricker, & L. Potter, 1997). The χ² test, stratification analysis, and logistic regression analyses were used to explore the association. Among the caregivers, 40.3% (95% confidence interval [CI] [38.4, 42.1]), reported DS. Caregivers who were male, older and ethnic minorities as well as had a low level of education, a low family income, or more children were more likely to have DS. Of the children, 24.4% (95% CI [22.8, 26.0]) were recognized with SED delays. Older children displayed more delays than did younger children, but no significant differences between males and females were found. SED delays were significantly associated with mother outmigrating, male caregivers, older age, ethnic minorities, and low education or families with a single parent, low‐income, and having more children. Caregivers having DS, odds ratio (OR) = 2.40, 95% CI [1.99, 2.88], was a significant predictor of increased odds of SED delays; other factors were single‐parent family, OR = 1.99, 95% CI [1.37, 2.89], inadequate care, OR = 1.69, 95% CI [1.30, 2.21], physical punishment, OR = 1.61, 95% CI [1.33, 1.95], ethnic minorities, OR = 1.41, 95% CI [1.17, 1.71], and child age in months, OR = 1.03, 95% CI [1.02, 1.04], according to the logistic regression analysis. DS are prevalent among caregivers with young children in poor rural areas. Interventions to improve the mental health of caregivers and their parenting behaviors are needed to improve children's SED.     

Bows and ribbons,tape and twine: Wrapping the wraparound process for children with multi-system needs

The wraparound process for children with multi-system needs is one of the most innovative and popular reform efforts in children's services. Nonetheless, the articles in this special issue are indicative of a service reform process that is still maturing and evolving. In this commentary, three key questions regarding the wraparound process are posed: (a) What is wraparound? (b) What is the current state of research regarding wraparound services? and (c) What are the implications for the future? It is argued that the future of wraparound depends at least in part on: (a) carefully defining the wraparound process, including how to best integrate the process with reforms based on the principles of a comprehensive system of care; and (b) making a strong commitment at all levels to the process of cumulative knowledge, of building and creating innovative research and program efforts over time, one upon the other. It is concluded that a failure to invest in careful definition, refinement, implementation, and research on the wraparound process consitutes a failure to invest in children and families with multi-system needs.     

To Value and Address Diversity: From Policy to Practice

A basic assumption of Target 3 of the National Agenda is that the rates of identification, placement, and achievement of children and adolescents with serious emotional disturbance (SED) are strongly correlated with dimensions of diversity, such as race, gender, socioeconomic status, and culture. A related assumption is that culturally competent and linguistically appropriate exchanges and collaborations among families, professionals, students, and communities will enable our school systems to achieve better educational outcomes for all children, including those with SED. We discuss these assumptions in the context of current policies and suggest ways of translating these policies into practices.     

Serving Culturally Diverse Children with Serious Emotional Disturbance and Their Families

Over the coming decades, we can expect that cultural diversity will abound within the U.S. population and the imagery of an American melting pot will long be discarded. One significance of this trend will be the imperative to account for cultural diversity in assessing the needs of children with serious emotional disturbance (SED), to ensure that assessments, diagnoses, and treatments are accurate, fair, and meaningful. To achieve that end, however, will first require that all persons in the fields of education, mental health, social services, and juvenile justice become fully prepared to support children with SED and their families, prepared to bring to the process a sophisticated understanding of the interplay between culture and social behaviors. Nothing less than that level of preparedness will enable practitioners to develop unbiased interventions that competently and sensitively weigh cultural influences and target the needs of diverse students with emotional and behavioral difficulties. In this paper, we present the need for culturally competent practitioners in the area of SED, ways in which service providers can increase their cultural knowledge, and strategies for more effective service with this population.     

Sexual Risk-Taking Behaviors Among Adolescents with Severe Emotional Disturbance

We investigated the sexual risk-taking behaviors of adolescents with severe emotional disturbance (SED). Subjects (N = 70) were clients of the South Carolina Continuum of Care. Information on sexual intercourse, sexual risk-taking, aggressive behaviors, substance use, and suicidal behavior was gathered using a modified version of the US Centers for Disease Control and Prevention self-report Youth Risk Behavior Survey. Forty-two percent of each race-gender group reported first intercourse before age 13, except for African American females at 63%. Seventy-five to 79% of all race-gender groups reported first sexual intercourse by age 18. Drinking alcohol before age 13 and carrying a weapon in the past 30 days were associated with first intercourse before age 13. Youth reporting first intercourse between ages 13 and 18 were about 12 times more likely to report suicide ideation than those youth who reported never having sexual intercourse. Youth with SED reporting first intercourse before age 13 appear to have an increased risk for unintended pregnancy and for contracting a sexually transmitted disease compared to youth with SED reporting first intercourse after age 13.     

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.     

Effectiveness of School-Based Mental Health Services for Children: A 10-Year Research Review

A review of the literature from 1985 to 1995 on school-based mental health services for children was conducted using a computerized data-base search. Of the 5,046 references initially identified, 228 were program evaluations. Three inclusion criteria were applied to those studies: use of random assignment to the intervention; inclusion of a control group; and use of standardized outcome measures. Only 16 studies met these criteria. Three types of interventions were found to have empirical support for their effectiveness, although some of the evidence was mixed: cognitive-behavioral therapy, social skills training, and teacher consultation. The studies are discussed with reference to the sample, targeted problem, implementation, and types of outcomes assessed, using a comprehensive model of outcome domains, called the SFCES model. Future studies of school-based mental health services should (a) investigate the effectiveness of these interventions with a wider range of children's psychiatric disorders; (b) broaden the range of outcomes to include variables related to service placements and family perspectives; (c) examine the combined effectiveness of these empirically-validated interventions; and (d) evaluate the impact of these services when linked to home-based interventions.     

The Effects of Capitation on Outpatient Mental Health Episodes of Children

We analyzed the effects of the Colorado Medicaid Capitation Program on the duration and services of over 21,000 outpatient mental health episodes for young children. The study spanned a three year period before and after capitation was implemented, and compared episodes of outpatient care for children from 14 capitated Community Mental Health Centers (CMHCs) with those from three CMHCs that remained fee-for-service. Proportional hazards regressions revealed that capitation resulted in an increase in outpatient episode duration, over and above similar effects for the comparison fee-for-service episodes. The hypothesis that there were longer capitated episodes for children who were hospitalized was not supported. Children with behavioral and anxiety disorders had longer capitated episodes. Service intensity decreased over time in the managed care sites. Changes in case mix may have had an impact on changes in episode duration and service intensity. That outpatient episode duration increased over time while costs were lowered in the capitated agencies indicates some effects of capitation in changing patterns of care.     

The Age of Uncertainty: Parent Perspectives on the Transitions of Young People with Mental Health Difficulties to Adulthood

For young people aged 16–24, the transition from adolescence to young adulthood involves predictable and unpredictable changes and they may encounter challenges in their roles, relationships, and responsibilities. Young people with mental health difficulties face additional challenges as they and their families navigate this transition. As a result, families commonly experience anxiety, uncertainty, frustration, and turbulent relationships. After learning to become advocates to secure appropriate services for their children, in late adolescence and young adulthood, parents are likely to find themselves excluded from their children’s treatment planning and services. This article reports findings from a recent qualitative study of the experiences and perceptions of 42 family members supporting their children with mental health difficulties during the transition years. Family members described their goals for their children, their frustrations trying to access appropriate services for their children, and their strategies to provide the support their children needed. Recommendations are for service providers to connect transition age youth with practical assistance and supportive mentoring relationships. Family members requested service providers to consider them as resources and potential collaborators in supporting young people with mental health difficulties to live successful lives in the community.