Ethnic Differences in Children’s Entry into Public Mental Health Care via Emergency Mental Health Services

For children and youth making a mental health crisis visit, we investigated ethnic disparities in whether the children and youth were currently in treatment or whether this crisis visit was an entry or reentry point into mental health treatment. We gathered Medicaid claims for mental health services provided to 20,110 public-sector clients ages 17 and younger and divided them into foster care and non-foster care subsamples. We then employed logistic regression to analyze our data with sociodemographic and clinical controls. Among children and youth who were not placed in foster care, African Americans, Latinos, and Asian Americans were significantly less likely than Caucasians to have received mental health care during the three months preceding a crisis visit. Disparities among children and youth in foster care were not statistically significant. Ethnic minority children and youth were more likely than Caucasians to use emergency care as an entry or reentry point into the mental health treatment, thereby exhibiting a crisis-oriented pattern of care.     

Mental Health Problems of Children in Foster Care

We compared the rates of mental health problems in children in foster care across three counties in California. A total of 267 children, ages 0 to 17, were assessed two to four months after entry into foster care using a behavioral screening checklist, a measure of self-concept and, in one county, an adaptive behavior survey. Results confirmed previous research and indicated consistently high rates of mental health problems across the three counties. Behavior problems in the clinical or borderline range of the CBCL were observed at two and a half times the rate expected in a community population. Fewer children fell within the clinical range on the self-concept measure. No significant differences in rates between the three county foster care cohorts were observed, despite the different demographic characteristics of the counties. On the adaptive behavior scale, the mean scores for children in foster care were more than one standard deviation below the norm. Our findings suggest that the most important mental health screening issue with children in foster care is to identify what specific mental health problems need to be addressed so that the most effective treatment services can be provided.     

Outpatient Psychotropic Medication Use in the US: A Comparison Based on Foster Care Status

Using data from the Client/Patient Sample Survey, a nationally representative study of outpatient mental health service utilization, the prevalence and correlates of psychotropic medication receipt for youth who live with families and in foster care are compared. The medication rate is similar for both groups, with slightly more than one-third of youth treated with medication. Additionally, when medication is prescribed, it is the sole intervention provided for close to one half of each group, and the distribution of other services received (such as clinical case management and collateral services) is similar, regardless of living situation. However, the predictors of medication use differ for the two groups. Among foster care youth, only presenting problems of depressed mood, being withdrawn, and suicidality significantly increase the odds of medication; among youth with families, sociodemographic characteristics (male gender), and a range of clinical factors (disruptive behavior disorder, presenting problems of hyperactivity and sleep disturbance, prior mental health service receipt, and inpatient or residential care referral sources) increase the likelihood of medication. The conclusion that distinct sets of factors predict medication for the two groups was reinforced by results of multivariate analyses; foster care status moderates the association between medication receipt and only one of the correlates examined (gender). Implications, limitations, and areas for future research are presented.     

A Role for Occupational Therapy in Foster Care

The purpose of this publication is threefold. First, it is an attempt to document the need for occupational therapy services within the foster care population. Second, it describes methods that can be used by occupational therapists to provide appropriate interventions to people affected by foster care. And third, it highlights the need for and identifies specific assessments that can be used to evaluate individuals affected by foster care and to measure the effectiveness of occupational therapy services delivered to foster care agencies.     

Toward a Culturally Responsive Model of Mental Health Literacy: Facilitating Help‐Seeking Among East Asian Immigrants to North America

Studies have consistently found that East Asian immigrants in North America are less likely to use mental health services even when they experience levels of distress comparable to Euro‐Americans. Although cultural factors that may prevent East Asian immigrants from seeking mental health care have been identified, few studies have explored ways to foster appropriate help‐seeking and use of mental health services. Recent work on mental health literacy provides a potential framework for strategies to increase appropriate help‐seeking and use of services. This paper reviews the literature on help‐seeking for mental health problems among East Asian immigrants living in Western countries to critically assess the relevance of the mental health literacy approach as a framework for interventions to improve appropriate use of services. Modifications needed to develop a culturally responsive framework for mental health literacy are identified.     

Preliminary evidence of the impact of early childhood maltreatment and a preventive intervention on neural patterns of response inhibition in early adolescence

Maltreated youths in foster care often experience negative developmental and psychological outcomes, which have been linked with poor response inhibition. Recent evidence suggests that childhood maltreatment is also associated with alterations in the neural circuitry underlying response inhibition. However, a burgeoning line of research has begun to explore the mitigating effects of preventive interventions on neural functioning. The current study used event‐related functional magnetic resonance imaging to explore the impact of early childhood maltreatment and a preventive intervention on response inhibition in early adolescence. Thirty‐six demographically similar adolescents (ages 9–14 years) completed a Go/NoGo task. The sample included nonmaltreated adolescents (n = 14) and maltreated adolescents who were in foster care as preschoolers and randomly assigned to receive services as usual (n = 11) or a preventive intervention, Multidimensional Treatment Foster Care for Preschoolers (n = 11). The groups demonstrated similar behavioral performance but significantly different neural patterns. The maltreated adolescents who received services as usual demonstrated subcortical hypoactivity during successful response inhibition and subcortical hyperactivity during unsuccessful response inhibition. In contrast, the nonmaltreated adolescents and maltreated adolescents who received the intervention exhibited strikingly similar neural patterns during successful response inhibition, but the maltreated adolescents who received the intervention demonstrated prefrontal hypoactivity during unsuccessful response inhibition. These findings offer preliminary evidence that early childhood maltreatment alters the neural patterns underlying response inhibition in early adolescence and that participating in a preventive intervention could mitigate maltreatment‐related effects on these neural systems.     

Education and Training of Children's Mental Health Professionals: The Existing and Potential Role of Schools of Public Health

Since the early 1980s, increasing attention has been devoted in the literature to the conceptualization, development, and implementation of integrated and comprehensive mental health systems of care for children and adolescents. In establishing this new children's mental health paradigm of community-based systems of care, there are presently very few well-trained professionals and leaders focused on collaborative (including interagency) initiatives in the delivery of children's mental health services. Nevertheless, the field of public health offers an interdisciplinary setting for the education and training of individuals in children's mental health services. This national survey of all 27 accredited schools of public health in the United States and Puerto Rico examined the existing capacity for and potential to expand educational and training opportunities in the organization, financing, and delivery of children's mental health services.     

Understanding the Behavioral Determinants of Mental Health Service Use by Urban, Under-Resourced Black Youth: Adolescent and Caregiver Perspectives

Black adolescents with mental health problems are less likely than non-Black adolescents with mental health problems to receive treatment, primarily for non-financial reasons including negative perceptions of services and providers, and self-stigma associated with experiencing mental health problems. To better understand these obstacles, 16 adolescents and 11 caregivers, recruited from two K-8th grade elementary-middle schools, participated in four focus groups guided by the unified theory of behavior to explore mental health help-seeking behaviors and perceptions of mental health services. In the focus groups, caregivers acknowledged more positive attitudes about seeking mental health services than adolescents, but both expected the experience of actually doing so to be negative. Adolescents and caregivers also acknowledged social norms that inhibit their mental health help-seeking. Therefore, we conclude that interventions targeting expectancies and social norms might increase the connection of urban, under-resourced Black adolescents and their families to mental health services, and be particularly important given the long-term consequences of untreated mental health problems for this group.     

Lessons Learned About Barriers to Implementing School-Based Interventions for Adolescents: Ideas for Enhancing Future Research and Clinical Projects

The majority of youth with mental health problems do not receive treatment, highlighting the critical need to transport evidence-based interventions into community settings, such as schools. Despite being able to reach a large number of adolescents and minority youth, the process of implementing evidence-based interventions to schools is challenging. This paper discusses some expected and unexpected challenges experienced during the implementation of an open trial and a pilot randomized controlled trial examining the acceptability and effectiveness of a school-based preventive intervention for adolescents at risk for internalizing disorders. First, we highlight key programs and findings on preventive interventions for adolescents at risk for depression and anxiety. Next, we provide a brief overview of the preventive intervention we implemented in schools. This provides a context for the section that describes implementation issues and highlights specific challenges and potential solutions for intervention implementation. Finally, the paper offers recommendations for researchers and clinicians interested in implementing school-based mental health services for adolescents.     

Ethical,Legal, and Psychosocial Issues in Care of Transgender Adolescents

SUMMARY

Complete care for transgender adolescents must be considered in the context of a holistic approach that includes comprehensive primary care as well as cultural, economic, psychosocial, sexual, and spiritual influences on health. Not all transgender adolescents have gender dysphoria or wish to undergo sex reassignment. In this article we focus on general care of transgender adolescents by the non-specialist working in primary care, family services, schools, child welfare, mental health, and other community settings.     

Cognitive-Based Compassion Training: A Promising Prevention Strategy for At-Risk Adolescents

Compared to the general population, youth in foster care experience multiple psychosocial difficulties due to exceptionally high rates of maltreatment. Many youth in care receive psychological and/or psychotropic treatment but not all require or are willing to accept that level of intervention. For many, a “mental health” approach feels pathologizing. Nevertheless, these youth have suffered maltreatment and interventions to improve their ability to cope with past trauma and their often uncertain present are clearly needed. Cognitively-Based Compassion Training (CBCT) provides an alternative perspective on suffering and can be framed as a wellness intervention that is appropriate for all humans. The present study examined whether a 6-week CBCT intervention would improve psychosocial functioning among adolescents in foster care. Seventy adolescents were randomized to CBCT (twice weekly) or a wait-list condition. Youth were assessed at baseline and after 6 weeks. Groups did not differ on measures of psychosocial functioning following training; however practice frequency was associated with increased hopefulness and a trend for a decrease in generalized anxiety. Qualitative results indicated that participants found CBCT useful for dealing with daily life stressors. Adolescents in care were willing to engage in CBCT. The majority reported CBCT was very helpful and almost all reported they would recommend CBCT to a friend. Participants reported specific instances of using CBCT strategies to regulate emotion, manage stress, or to respond more compassionately towards others. Standardized self-report measures were not sensitive to qualitative reports of improved functioning, suggesting the need for measures more sensitive to the positive changes noted or longer training periods to demonstrate effects. Practical issues surrounding implementation of such programs in high-risk youth populations are identified. Recommendations are provided for further development.     

Cultural Mistrust of Mental Health Professionals Among Black Males Transitioning from Foster Care

We examined cultural mistrust of mental health professionals among Black males who are transitioning from the foster care system (N = 74) and its relationship to their level of satisfaction with child welfare services and the frequency of negative social contextual experiences. Results of hierarchical regression analysis showed that the level of satisfaction with child welfare services moderated the relationship between negative social contextual experiences and cultural mistrust of mental health professionals. Specifically, more frequent negative social contextual experiences were related to greater cultural mistrust of mental health professionals for Black males reporting low satisfaction with child welfare services, but not for those reporting high satisfaction with child welfare services. Implications for service delivery are discussed.     

What is the Impact of Placement Type on Educational and Health Outcomes of Unaccompanied Refugee Minors? A Systematic Review of the Evidence

Record numbers of unaccompanied refugee minors have been arriving in high-income countries since 2015. Child welfare agencies and non-governmental organisations tasked with providing services have struggled to cope with demands on their services as a result. Despite this, there is little research on how best to meet their needs and in particular what services can mitigate the psychological difficulties they face. As a result, the evidence base for social services for refugee children remains very limited. This paper is a systematic review and meta-analysis of the evidence on the relationship between care placement type and the educational, mental health and physical health outcomes of unaccompanied refugee minors. We searched ten databases and identified 3877 citations which were screened for inclusion. Nine studies were included in the final review, with seven included in the meta-analysis. Eight studies examined the link between accommodation type and mental health outcomes, and two analysed the relationship between accommodation type and education. There were no studies looking at physical health outcomes. Included studies suggest that foster care and placements that are culturally sensitive may be associated with better mental health outcomes. This review highlights the paucity of research on the impact of services provided by child welfare agencies and non-governmental organisations.     

The Effectiveness of Cultural Adjustment and Trauma Services (CATS): Generating Practice-Based Evidence on a Comprehensive, School-Based Mental Health Intervention for Immigrant Youth

A collaborative study of Cultural Adjustment and Trauma Services (CATS), a comprehensive, school-based mental health program for traumatized immigrant children and adolescents, was conducted to generate practice-based evidence on the service delivery model across two school districts. Program effectiveness was assessed by testing whether client functioning and PTSD symptoms improved as a result of 7 separate service elements. An array of clinical services including CBT, supportive therapy, and coordinating services were provided to all students, and an evidence-based intervention for trauma, TF-CBT, was implemented with a subset of students. Greater quantities of CBT and supportive therapy increased functioning, while greater quantities of coordinating services decreased symptoms of PTSD. TF-CBT services were associated with both improved functioning and PTSD symptoms, although TF-CBT was implemented with fidelity to the overall comprehensive service model rather than the structured intervention model. Results suggest the comprehensive school-based model was effective, though different service components affected different student outcomes. Implications of these findings for immigrant mental health interventions and implementing structured evidence-based practices into community mental health programs are discussed. Suggestions are made for future research on existing mental health practices with immigrants.     

Recruiting and Retaining High-Risk Adolescents into Family-Based HIV Prevention Intervention Research

The purpose of this study was to examine the effectiveness of evidence-based recruitment and retention strategies for a longitudinal, family-based HIV prevention intervention study targeting adolescents in psychiatric care by (1) determining consent rate (recruitment), rate of participation at the first intervention session (retention), and follow-up attendance rate (retention); and (2) examining socio-demographic factors, family-level processes, sexual risk-related indices, and intervention factors (i.e., treatment arm) associated with study retention. Only one-third of the families contacted ultimately enrolled in the study. 81% of those enrolled participated in the workshop and 72% attended the booster sessions with no significant differences between families on any variable based on attendance. Retention over 1?year was 85% and did not differ by treatment arm. Strategies employed were successful at retaining families once they were enrolled. Findings highlight barriers to enrollment for adolescents in psychiatric care and suggest that it may be critical to integrate HIV prevention programs within community-based mental health services in order to counteract recruitment challenges.     

THE CHALLENGE TO MENTAL HEALTH SERVICES IN THE 1980s

Robert W. Gibson MD, is interviewed concerning the potential impact of restricted funding for mental health services in the 1980s, particularly as this applies to the practice of occupational therapy. Topics covered include the decreasing length of inpatient hospitalization; the possibility of a shifting emphasis lo the treatmcnt of the severely and chronically ill; increasing utilization of rehabilitative services; and suggestions to facilitate greater interprofessional collaboration. Thc establishment of measurable outcomes for continued or improved reimbursement of occupational therapy services is stressed, and the potential for multiprofession group practices as a cost-effective approach to reduced business and industry health care costs is suggested.     

Access to Child and Adolescent Mental Health Services

Adequate access to child and adolescent mental health services for young people in high need populations is an important concern of service systems researchers and program evaluators. We present results of a statewide study of access to community mental health services for eight populations of special concern. The analysis relied exclusively on existing databases in conjunction with innovative statistical techniques to provide comprehensive measures of access to care. Our findings indicate that access to care varied substantially across special populations, although children and adolescents in each of our eight “special populations” had greater access to public mental health services than members of the general population of the state. The interpretation of the findings and directions for future research are discussed.     

Racial disparities in mental health service use by adolescents who thought about or attempted suicide

Differences in rates and predictors of mental health service use among 2,226 Black, Hispanic, and White adolescents (aged 12-17) who reported recent suicidal thoughts or an attempt were examined. Black adolescents were 65% (OR = .65, p < .05), and Hispanic adolescents were 55% (OR = .55, p < .001), as likely as White adolescents to report service use, even when controlling for need for care and ability to secure services. Suicide attempt and psychiatric symptoms each interacted with race to increase the odds of service use uniquely for White adolescents. Results indicate that racial disparities characterize adolescents' mental health service use even when suicide risk increases.     

Preventing Behavior Problems and Health-risking Behaviors in Girls in Foster Care

Transition into middle school presents complex challenges, including exposure to a larger peer group, increased expectations for time management and self-monitoring, renegotiation of rules with parents, and pubertal changes. For children in foster care, this transition is complicated by their maltreatment histories, living situation changes, and difficulty explaining their background to peers and teachers. This vulnerability is especially pronounced for girls in foster care, who have often experienced sexual abuse and are at risk for associating with older antisocial males. Failures in middle school can initiate processes with cascading negative effects, including delinquency, substance abuse, mental health problems, and health-risking sexual behaviors. An intervention is described to prevent these problems along with a research design aimed at testing the intervention efficacy underlying mechanisms of change.