Decreasing Psychiatric Symptoms by Increasing Choice in Services for Adults with Histories of Homelessness

Despite the increase in consumer-driven interventions for homeless and mentally ill individuals, there is little evidence that these programs enhance psychological outcomes. This study followed 197 homeless and mentally ill adults who were randomized into one of two conditions: a consumer-driven “Housing First” program or “treatment as usual” requiring psychiatric treatment and sobriety before housing. Proportion of time homeless, perceived choice, mastery, and psychiatric symptoms were measured at six time points. Results indicate a direct relationship between Housing First and decreased homelessness and increased perceived choice; the effect of choice on psychiatric symptoms was partially mediated by mastery. The strong and inverse relationship between perceived choice and psychiatric symptoms supports expansion of programs that increase consumer choice, thereby enhancing mastery and decreasing psychiatric symptoms.     

Developing Effective Prevention Services for the Real World: A Prevention Service Development Model

A Prevention Service Development Model (PSDM) is presented as an approach to develop prevention programs that are both effective and that are readily adopted for implementation in community settings. The model is an integration of concepts and methods from two fields, prevention research and marketing research as applied to new service development. Questions that are posed at each stage of the PSDM are described. Studies from the development of two preventive interventions are presented to illustrate research at several of the stages of the model.     

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.     

Assessing Parental Satisfaction with Children’s Mental Health Services with the Youth Services Survey for Families

We assessed parent satisfaction with childrens mental health services with a new instrument: The Youth Services Survey for Families (YSSF). The Dillman method was used to administer the survey to a random sample of 1,500 parents of Medicaid youth from Kentuckys 14 community mental health centers (CMHCs). The response rate was 37% (n = 534 parents). A factor analysis of YSSF identified five parent-perceived factors: (a) Appropriateness, (b) Outcome, (c) Participation in Treatment, (d) Access, and (e) Cultural Sensitivity. About 70% of parents reported a high level of endorsement with the Appropriateness factor, but only 47% reported high levels of endorsement with the Outcome factor. Results were interpreted as providing support for the reliability of the YSSF in evaluating childrens mental health services in CMHCs.     

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.     

Does the Gats Undermine Democratic Control Over Health?

This paper examines the General Agreement on Trade in Services (GATS), which is one of the World Trade Organisations free trade agreements. In particular, I examine the extent to which the GATS unduly restricts the scope for national democratic choice. For purposes of illustration, I focus on the domestic health system as the subject of policy choice. I argue that signatories to the GATS effectively acquire a constitutional obligation to maintain a domestic health sector with a certain minimum degree of privatisation. Like constitutional obligations, the restrictions the GATS imposes on the freedom of future generations to structure their domestic health sector are (i) very difficult, though not strictly impossible, to alter; and (ii) not chosen in any ordinary sense by the subject generation. To gain democratic legitimacy, therefore, the relevant provisions of the GATS must pass some higher standard of democratic scrutiny, such as ratification by a super-majority. Ordinary legislative ratification does not suffice.     

School-based applications of the wraparound process: Early results on service provision and student outcomes

The application of a school-based wraparound approach presents different challenges, perspectives, and knowledge from those seen in mental health or child welfare settings. For the past three years, the La Grange Area Department of Special Education's Wraparound Project has been implementing a school-based individualized service network that is now being integrated into the larger local and state special education, mental health, and social service systems. We present school-based applications of wraparound for students with emotional and behavioral disabilities, including the community and system context, program application, evaluation process and preliminary results. Students who were identified through self-contained special education classrooms were compared to students who were identified from various other school and mental health settings. Students from the school-based program were less clinically involved than students identified from other settings. Service provision differed between program groups and by out-of-home experiences. Finally, the use of wraparound approaches across a variety of educational settings to prevent out-of-school and out-of-home care are discussed.     

Children and adolescents discharged from public psychiatric hospital: Evaluation of outcome in a continuum of care

Ninety children and adolescents admitted to two state-operated psychiatric hospitals were followed from the time of their admission through one year post discharge. Data were collected from the children and adolescents, their families and clinicians at three intervals (during hospitalization, three months post discharge, and one year post discharge) to identify demographic, clinical, and service history characteristics of the children and adolescents, as well as to track their placement and other dispositional status following discharge from the hospital. The data indicated that the children and adolescents were seriously emotionally and behaviorally disturbed, came from families which were economically disadvantaged, and did not typically live in two-parent families. While the majority of the children and adolescents received recommended aftercare services during the three months following discharge from the hospital, there was a decline in placement stability for the children at the one-year post discharge followup. The most important predictors of successful outcome at discharge were living with a family member at the time of hospitalization and the participation of the family in the treatment planning during hospitalization.     

Oral contraceptive use among African American adolescents: Individual and community influences

Side effects of oral contraceptives are a noteworthy problem, particularly among low-income young women who reside in inner-city communities. The problem may be compounded by inadequate family planning services, particularly when such services are provided by general medical practices with high volumes of clients. This study examined the prevalence and correlates of pill-related side effects, with particular attention to the role of clinic characteristics. Participants were 177 pregnant and parenting African American adolescents and young women (average age=18.34). The experience of a pill-related side effect was the most frequently cited barrier to birth control use, and it was significantly related to contraceptive behavior. Finally, although participants attending comprehensive clinics experienced more barriers to medical service use than those attending neighborhood clinics, they reported fewer problems with pill-related side effects and better psychological functioning. Implications for future research and policy are discussed. This study was completed with the assistance of grants from the Illinois Department of Alcoholism and Substance Abuse, the National Institute of Child Health and Human Development, and the Office of Research on Women's Health to Jean Rhodes. Portions of this paper were presented at the 1993 Biennial Meeting of the Society for Community Research and Action, Williamsburg, Virginia. The authors gratefully acknowledge the assistance of Julian Rappaport, Joel Meyers, Hope Landrine, Lori Ebert, the Reverend Annette Collins, Margaret Daniels, Khya Lawrence, and the professionals and participants at the service settings.     

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.