Obstacles and advocacy in children's mental health services: managing the Medicaid maze

Of federal programs available, Medicaid offers the greatest potential for serving children's mental health needs. Obstacles to children receiving services through Medicaid are largely determined by a state's policy of regulating services. State policies affect the delivery of mental health services for children in two ways: first, by determining which services to make available, and second, by specifying the conditions of access to those services. Accordingly, this article focuses on obstacles within states' policies that prevent effective utilization of services by children. Specifically, states' choices of eligibility criteria, services, and the procedural obstacles present within payment options are examined. Suggestions for future research are made.     

Poverty and people with intellectual disabilities

Epidemiological studies have consistently reported a significant association between poverty and the prevalence of intellectual disabilities. The available evidence suggests that this association reflects two distinct processes. First, poverty causes intellectual disabilities, an effect mediated through the association between poverty and exposure to a range of environmental and psychosocial hazards. Second, families supporting a child with intellectual disabilities and adults with intellectual disabilities are at increased risk of experiencing poverty due to the financial and social impact of caring and the exclusion of people with intellectual disabilities from the workforce. It is likely that the association between poverty and intellectual disabilities accounts in part for the health and social inequalities experienced by people with intellectual disabilities and their families. Implications for policy and practice are discussed in relation to the funding of services for people with intellectual disabilities and preventative approaches to addressing the health and social inequalities experienced by people with intellectual disabilities and their families.     

Self-reported emotional intelligence, burnout and engagement among staff in services for people with intellectual disabilities

This study examined the relationship among dimensions of self-reported Emotional Intelligence, Engagement and Burnout, using the Trait Meta-Mood Scale, Maslach Burnout Inventory and Utrecht Work Engagement Scale in a sample of Spanish professionals who work at institutions for people with intellectual disabilities. The results showed that Emotional Clarity was significantly associated with Personal Accomplishment (r=.25) and Dedication (r=.25). Further, Repair to moods was significantly correlated with all Engagement dimensions (.20 Vigor, .30 Dedication, .36 Absorption) and with Personal Accomplishment (.31). These findings extend previous research with college students in which Clarity and Repair to moods subscales were relevant predictors of well-being indexes and interpersonal functioning and suggest that the Trait Meta-Mood Scale subscales also show significant relationships with emotional functioning and work-related variables in a professional sample.     

A cascade of disparities: health and health care access for people with intellectual disabilities

People with ID represent approximately 2% of the population and, as a group, experience poorer health than the general population. This article presents recent conceptualizations that begin to disentangle health from disability, summarizes the literature from 1999 to 2005 in terms of the cascade of disparities, reviews intervention issues and promising practices, and provides recommendations for future action and research. The reconceptualization of health and disability examines health disparity in terms of the determinants of health (genetic, social circumstances, environment, individual behaviors, health care access) and types of health conditions (associated, comorbid, secondary). The literature is summarized in terms of a cascade of disparities experienced by people with ID, including a higher prevalence of adverse conditions, inadequate attention to care needs, inadequate focus on health promotion, and inadequate access to quality health care services. Promising practices are reviewed from the perspective of persons with ID, providers of care and services, and policies that influence systems of care. Recommendations across multiple countries and organizations are synthesized as guidelines to direct future action. They call for promoting principles of early identification, inclusion, and self-determination of people with ID; reducing the occurrence and impact of associated, comorbid, and secondary conditions; empowering caregivers and family members; promoting healthy behaviors in people with ID; and ensuring equitable access to quality health care by people with ID. Their broadscale implementations would begin to reduce the health disparity experienced by people with ID.     

Sociocultural studies of families of children with intellectual disabilities

This article reviews recent sociocultural studies of families of children with intellectual disabilities to introduce the range of research conducted from this perspective and to highlight the methodological, conceptual, and theoretical contributions of this approach to the study of mental retardation. Sociocultural studies examine families within their cultural, historical, and sociopolitical contexts. This type of research is comparative across different cultural groups, but is not limited to such comparisons. Sociocultural studies use varied theories and methods, but they share a focus on families' coproduction of meanings and practices related to intellectual disability; families' responses and adaptations to disability; and how their understandings and experiences are shaped within larger social institutions and inequities. Sociocultural approaches take into account community contexts that matter to families with members with mental retardation or developmental delay, and they examine the broader systems that define and position individuals with disabilities and their families. As a whole, these studies provide a more experiential and holistic view of families' beliefs and adaptations within sociopolitical worlds, and offer new tools by which to study the families of children with developmental delays within and across different cultural groups.     

Physical and motor skill training for children with intellectual disabilities

This study investigated the effectiveness of using special training machines for children with intellectual disabilities to strengthen their body's inner muscles and improve their ability to maintain standing posture and improve walking movement. The participants were 23 high school age boys with intellectual disabilities who had difficulties expressing greetings, and needed to be led by the hand when walking. Four special training machines were used for walking movements, for standing and walking balance, for leg-hip extension, and for ipsilateral movement in a sitting position. Each participant underwent 30 min. of training once a week over a 3-mo. period during school time. Body control ability required to perform each training exercise was improved over the training period. A significant improvement was observed in the 50-m dash, mean 10-m walk time, and 10-m obstacle course walk. The hip joint split angle showed a significant increase. Legal guardians all reported their child had "improved and/or progressed" for each of the targeted movements.     

Expressed emotion in families of children and adults with intellectual disabilities

Expressed emotion (EE) is a measure of the affective relationship between two people characterized by criticism, hostility, and emotionally over-involved attitudes. Outside of the field of intellectual disabilities, there has been considerable interest in EE as an environmental marker that explains variance in the severity and/or course of a number of psychiatric disorders. Researchers have also studied EE in parents and found strong associations with children's behavior problems. In this review, we focus on the data from 11 published studies of EE in families of children and adults with intellectual disabilities. We conclude that there is evidence for the presence of high EE in some families, and that this alone should concern researchers and clinicians and set an agenda for considerable future research effort. We also note a lack of attention to the measurement of EE in intellectual disability. In terms of the existing evidence base, we suggest that there is support for the hypothesis that behavior problems in children and adults with intellectual disabilities may be related to high EE in parents, and a small amount of data predicting over time support the putative causal effect of high EE on maintaining or exacerbating behavior problems. Given that EE is perhaps best conceptualized as the result of an interaction between caregivers and those cared for, there is a need to explore interventions that may help to remediate high EE within families. It is also important to understand from this position that EE may be a normative part of the experience of caring for someone under very stressful circumstances and not something for which families are blamed. Other future research priorities and some implications for practice are also discussed.     

Curricular options and services for youth with disabilities

The purpose of this research was to identify and discuss the curricular options, modes of delivering services, and related instructional matters for youth with disabilities. To carry out that we gathered data in six high schools of various sizes and types. Based on a conceptual framework designed by Goodlad, we identified 12 research questions. Data of four types (observations, interviews, surveys, and documents) were gathered from all six sites in response to those questions. Reports were written for each of the high schools that included several recommendations. These recommendations were explained to individuals at the schools and researchers were apprised of the extent which the suggestions were either considered or put into practice. Results from the six schools with respect to the 12 research questions are summarized.     

Intelligent diagnosing of intellectual disabilities in offenders: food for thought

Research on offenders with intellectual disabilities (IDs) in the criminal justice arena is on the rise, reflected by a growing number of relevant publications each year. However, there is a long recognized methodological problem that hampers the comparability of empirical studies and that raises doubts about the accuracy of prevalence rates, comorbidities, and various correlates and characteristics. In this paper we will argue that the crux of the problem can, on the one hand, be found in the plurality of assessment methods for intelligence and adaptive functioning, which are not all sufficiently reliable and valid. On the other hand, assessment of IQ in criminal justice and mental health-related areas appears to be informed more by practical aspects and needs rather than grounded in a solid theoretical model. Hence, we suggest that the Cattell-Horn-Carroll (CHC) model of intelligence has potential value in this regard, and deserves a closer look. Finally, we will discuss its incorporation into, and possible implications for, criminal justice practice and future study designs.     

The usefulness of assessing suggestibility and compliance in prisoners with unidentified intellectual disabilities

Søndenaa, E., Rasmussen, K., Palmstierna, T. & Nøttestad, J. A. (2010). The usefulness of assessing suggestibility and compliance in prisoners with unidentified intellectual disabilities. Scandinavian Journal of Psychology, 51, 434–438. This present study explored the relationship of interrogative suggestibility (n = 133) and compliance (n = 118) to intellectual functioning among prison inmates. The Norwegian versions of the Gudjonsson Suggestibility Scale (GSS) and the Gudjonsson Compliance Scale (GCS) were used. The results supported previous findings of a negative correlation between the Gudjonsson scales and IQ, and the scales were found useful throughout the IQ range. The impact of a memory artifact was discussed in the light of recent studies and criticism of the scales.     

The organizational context of children's mental health services

This paper reviews what is known about the organizational context of children's mental health services and describes organizational constructs, conceptual models, research methods, and intervention strategies that can be used to link organizational context to service quality and outcomes. Using evidence from studies of business and industrial organizations as well as studies of children's service organizations, the paper presents a model of organizational effectiveness that depends on several contextual characteristics that include organizational culture, structure, climate, and work attitudes. These characteristics are believed to affect the adoption of efficacious treatments (EBPs [evidence-based practices]), adherence to treatment protocols, therapeutic alliance, and the availability, responsiveness, and continuity of services. Finally, 10 components of the ARC(Availability Responsiveness and Continuity) organizational intervention are described as examples of strategies that can be used to develop organizational contexts with the prescribed characteristics. Mental health researchers are encouraged to consider including these constructs, conceptual models, research methods, and intervention strategies in dissemination, effectiveness, and implementation studies that address the gap between research-based knowledge about mental health treatment and what is actually offered in the community.     

Conceptualization and measurement of family outcomes associated with families of individuals with intellectual disabilities

The purpose of this review is to (a) document the current status of conceptualizing and measuring family outcomes related to having a member with an intellectual disability and (b) determine the extent to which family research focuses on internal family characteristics as contrasted to external family support. The reviewers collected 28 articles using the terms well-being, adaptation, family functioning, or family quality of life in the title. Results of our analyses are presented as a comparison between well-being, adaptation, and family functioning articles in one group and family quality of life articles in a second group. Both groups lacked explicit conceptual definitions, theory, and random/representative samples. The articles placed an undue emphasis on maternal participation, and tended to report a single family member score as representative of the whole family. Two major differences between the groups was a tendency for family quality of life studies to be grounded in conceptual frameworks and focus on new instrument development. Recommendations for future research directions are included.     

The relations between intellectual disabilities,social information processing,and behaviour problems

Social information processing (SIP) in children with mild intellectual disabilities (MID) has been said to differ from SIP in children without MID. However, findings have been inconsistent and MID have been confounded with behaviour problems. It is not clear whether SIP is uniquely related to intellectual disabilities, to the behaviour problems of children with MID, or to both. In the present study, 56 children with MID and 31 children without MID between the ages of 10 and 14 years therefore completed a number of SIP tasks involving video vignettes and their externalizing behaviour problems were assessed. It was hypothesized that intellectual disabilities would be related to both SIP and behaviour problems. Findings show children with MID to encode more negative cues, generate more responses, and show more variability in their responses than children without MID. Children with MID also generated fewer assertive responses, evaluated assertive responses less positively, were less confident about the enactment of assertive responses, and selected fewer assertive responses than children without MID. Submissive responses were more often generated spontaneously by children with MID, more positively evaluated by them, and given more confidence for enactment by children with MID compared to children without MID. Regression analyses were conducted to assess the relations between SIP, MID, and behaviour problems. Variance in the generation of submissive responses was related to both intellectual disabilities and externalizing behaviour problems. Variance in the encoding of cues, the number of responses generated, the variability of generated responses, the evaluation of assertive and submissive responses, self-efficacy, and the selection of assertive responses was found to be related to intellectual disabilities. Variance in the generation of aggressive responses was related to externalizing behaviour problems. In other words, not responding assertively was related to intellectual disabilities while responding aggressively was related to behaviour problems.     

Behavioral disordered children's conceptions of moral,conventional, and personal issues

This study employed a series of sorting tasks with 22 normal and 20 children with behavioral disorders (BD) to determine whether BD children discriminate among three classes of social actions viewed by normal children as distinct. These categories are (1) the moral (actions having intrinsic effects upon the rights or well-being of others), (2) the conventional (actions whose propriety is determined by social consensus), and (3) the personal (actions whose propriety is a matter of individual prerogative). Findings were that although BD children distinguished among the three forms of behavior, they differed with normals in the classifications of specific acts and in the reasons given for act classifications. Chief among these differences was the finding that BD children were less likely than normals to identify acts as within their personal domain.We wish to thank Mary Confray, Denise Jaffe, and Christopher Pellikan for their help with the data collection. Thanks are also due to Diana Algminas of the Proviso Area Exceptional Children's Program, Ted Lawrence of the West Suburban Association for Special Education, and Wayne Thorne of the Board of Education District No. 89 (Maywood and Melrose Park, Illinois) for the cooperation of schools in their respective districts. We wish also to thank Mark Oberlander and Ronald Brown for their suggestions regarding identification of the BD sample. Portions of these data were presented at the annual meeting of the American Educational Research Association, Los Angeles, April 1981.     

Narrative skill and testimonial accuracy in typically developing children and those with intellectual disabilities

Children must describe maltreatment coherently for their testimony to be influential in court. We know little about how well children with intellectual disabilities (CWID) describe their experiences relative to typically developing (TD) children, despite CWID's vulnerability to maltreatment. We investigated children's reports of an experienced event and compared coherence in CWID (mild to moderate impairment: 7–11 years) with TD children matched for mental (4–10 years) or chronological age (7–11 years). All children included important markers of narrative coherence in their reports. Children with lower mental ages, particularly those with an intellectual disability, included fewer markers of narrative coherence in their reports than children with higher mental ages. Individual markers of narrative coherence, particularly recall of content, predicted accuracy of testimony and resistance to suggestion even when disability and mental age were taken into account. These findings highlight the importance of helping children to describe their experiences coherently.     

Evidence-based practice implementation and staff emotional exhaustion in children's services

Understanding the implementation of evidence-based practice (EBP) in community service settings is critical for the successful translation of research to practice. However, we have limited research evidence about the impact of EBP implementation on the mental health and social service workforce. In a previous study we demonstrated reduced staff turnover where an EBP was implemented with fidelity monitoring in the form of supportive ongoing supervision and consultation. Other research has shown that staff burnout and emotional exhaustion in particular is associated with poor quality of care and increased staff turnover intentions and turnover. Current research, however, has focused less on the effects that EBP implementation may have on staff emotional exhaustion. The present study investigates the association of EBP implementation and fidelity monitoring with staff emotional exhaustion in a statewide EBP implementation study. The 21 case-management teams in this study were randomized in a 2 (EBP vs. services as usual [SAU]) by 2 (monitoring vs. no monitoring) design. The EBP in this study was SafeCare^®, a home-based intervention that aims to reduce child neglect in at-risk families. SafeCare was developed from a behavior analysis approach and is based in cognitive behavioral principles. In keeping with our previous research, we hypothesized that providers implementing SafeCare with monitoring would have the lowest levels of emotional exhaustion and those receiving additional monitoring not in the context of EBP implementation would have higher emotional exhaustion relative to the other groups. Results supported our hypotheses in that we found lower emotional exhaustion for staff implementing the EBP but higher emotional exhaustion for staff receiving only fidelity monitoring and providing SAU. Together, these results suggest a potential staff and organizational benefit to EBP implementation and we discuss implications of the findings relative to EBPs and to fidelity monitoring.