Children's Mental Health: Problems andServices
December 1986
NTIS order #PB87-207486
Recommended Citation:U.S. Congress, Office of Technology Assessment, Children’s Mental Health: Problems andServices-A Background Paper, OTA-BP-H-33 (Washington, DC: U.S. Government Print-ing Office, December 1986).
Library of Congress Catalog Card Number 86-600539
For sale by the Superintendent of DocumentsU.S. Government Printing Office, Washington, DC 20402
Foreword
Within the past severaldren have been the focus of
years, severalcongressional
important mental health problems of chil-attention. The incidence of adolescent sui-
cide, physical and sexual abuse of young children, alcohol and drug abuse by children,and psychiatric hospitalization of children and adolescents have been the focus of de-bate on the need for an appropriateness of mental health services. This backgroundpaper indicates that although there are no simple answers to when and what type ofmental health services are necessary, the need for a mental health system response, coor-dinated with activities of other service systems, seems well documented.
This background paper was requested by Senators Mark O. Hatfield and DanielK. Inouye through the Senate Appropriations Committee. Its development was guidedby a panel of experts chaired by Dr. Lenore Behar. The key contractor was Dr. LeonardSaxe and his colleagues at Boston University. Key OTA staff for the background paperwere Denise Dougherty and Kerry Kemp.
JOHN H. GIBBONSDirector
i l l
OTA Project Staff—Children’s Mental Health: Problems and Services
Roger C. Herdman, Assistant Director, OTAHealth and Life Sciences Division
Clyde J. Behney, Health Program Manager
Denise M. Dougherty, Study Director
Kerry Britten Kemp, Health and Life Sciences Division Editor
Brad Larson, Research Assistantl
Beckie Berka, Research Assistant2
Laura T. Mount, Research Assistant
Virginia Cwalina, Administrative Assistant
Diann G. Hohenthaner, PC Specialist/Word Processor
Carol A. Guntow, Secretary/Word Processor Specialist
Karen Davis, Clerical Assistant
Contractors
Leonard M. Saxe, Boston University, Principal Author, withTheodore Cross, Boston University, and
Nancy Silverman, Boston University
Walter F. Batchelor, Boston University
‘Until June 1986.‘Until June 1986.
iv
Contents
Page
Chapter l. Summary and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Organization of This Background Paper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Summary and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Children’s Mental Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Children’s Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Effectiveness of Mental Health Treatment and Preventive Services . . . . . . . 8Current Federal Efforts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Part I: Earlier Evaluations and the Current SituationChapter 2. Earlier Evaluations and the Current Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Earlier Evaluations of Children’s Mental Health Needs and Services . . . . . . . 17
Estimates of the Prevalence of Children’s Mental Health Problems . . . . . . . 17Recommendations About Mental Health Services for Children . . . . . . . . . . 19
The Current Availability and Use of Children’s Mental Health Services . . . 24Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
PartII: ProblemsChapter3. DSM-III Mental Disorders in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33The DSM-111 Diagnostic System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Intellectual Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Developmental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Pervasive Developmental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Specific Developmental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Behavior Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Attention Deficit Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Conduct Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Substance Abuse and Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Emotional Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Childhood Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Reactive Attachment Disorder of Infancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Psychophysiological Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Stereotyped Movement Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . ..., . . . . . 44Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Enuresis and Encopresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Adjustment Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Chapter 4. Environmental Risk Factors and Children’s Mental Health Problems . . . . . . . 49Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Interactions Among Environmental Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . .50Poverty and Membership in a Minority Ethnic Group . . . . . . . . . . . . . . . . . . . 50Parental Psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Affectively Disordered Parent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Schizophrenic Parent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Alcoholic Parent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Physical Abuse and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Teenage Parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Premature Birth and Low Birthweight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Contents—continuedPage
Parental Divorce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5$Major Physical Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Part III: ServicesChapter 5. Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Individual Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Psychodynamic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Behavioral Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Cognitive Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Group and Family Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Group Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Family Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Milieu Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Crisis Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Psychopharmacological (Drug) Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Neuroleptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Chapter 6. Treatment Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Psychiatric Hospitalization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
State and County Mental Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Private Psychiatric Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Children’s Psychiatric Hospitals and Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Chemical Dependency Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82General Hospitals With Inpatient Psychiatric Services . . . . . . . . . . . . . . . . . . 82
Residential Treatment Centers (RTCs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Day Treatment/Partial Hospitalization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Outpatient Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
CMHC Outpatient Departments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Private Outpatient Clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Private Mental Health Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Chapter 7. Treatment in Non-Mental-Health Systems, Prevention, and the Integrationof Mental Health and Other Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Children’s Mental Health Treatment in Non-Mental-Health Systems . . . . . . . 89
Treatment in the Educational System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Treatment in the General Health Care System . . . . . . . . . . . . . . . . . . . . . . . 91Treatment in the Child Welfare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91Treatment in the Juvenile Justice System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Prevention of Children’s Mental Health Problems . . . . . . . . . . . . . . . . . . . . . . . 93Primary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Secondary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Integration of Mental Health and Other Services . . . . . . . . . . . . . . . . . . . . . . . . 96Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Part IV: Effectiveness of ServicesChapter 8. Effectiveness of Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........103
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..............103Effectiveness of Child Psychotherapy in General and Methodological Issues 103
Contents—continuedPage
Reviews of Child Psychotherapy Outcome Research . . . . . . . . . . . . . . . . . . .104Methodological Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .105Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...................106
Effectiveness of Specific Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..., ....106Effectiveness of Individual Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . .......106Effectiveness of Group Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109Effectiveness of Family Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....110Effectiveness of Crisis Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . .......111Effectiveness of Psychopharmacological (Drug) Therapy. . ..............111
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..........113
Chapter 9. Effectiveness of Treatment and Prevention in Mental Health and OtherSettings, and Evaluating the Integration of Mental Health andOther Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....................117
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....117Effectiveness of Treatment in Selected Mental Health Treatment Settings ...117
Effectiveness of Psychiatric Hospitalization . . . . . . . . . . . . . . . . . . . . . ......118Effectiveness of Residential Treatment Centers . . . . . . . . . . . . . . . . . . . . ....119Effectiveness of Day Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ...120
Effectiveness of Treatment in Selected Non-Mental-Health Systems . .......121Effectiveness of Treatment in the Educational System . . . . . . . . . . . . . . . ...121Effectiveness of Treatment in the Juvenile Justice System ., .............121
Effectiveness of Selected Prevention Efforts . ............................122Effectiveness of Selected Primary Prevention Efforts . ..................122Effectiveness of Selected Secondary Prevention Efforts . ................125Summary: Effectiveness of Prevention . . . . . . . . . . . . . . . . . . ............125
Evaluating the Integration of Mental Health and Other Services. . . . . . . . ...126Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............126
Part V: Current Federal EffortsChapter 10.Current Federal Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............131
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...131Federal Programs That Support Mental Health and Related Services for
Children . . . . . . . . . . . . . . . . . . . . . . . . ................................131Financing of Mental Health Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . .. ...131Coordination of Services. . . . . . . . . . . . . . . . . . . . . . . . . . ..................140Research and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....141Prevention and Other Services. . . . . . . . . . . . . . . . . . . . . . .................142
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................143Appendix A: Workshop Participants and Other Acknowledgments . ..................147
Appendix B: List of Acronyms and Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . ... ..150
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........155
Tables
Table No. Page
1.2.
3,
4.
5.
Estimates of Children With Mental Health Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Mental Health Services for Children: Selected Findings and Recommendations ofPast National Study Panels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Admissions of Children Under 18 Years of Age to Hospital Inpatient PsychiatricFacilities and Residential Treatment Centers, 1970, 1975, and 1980 . . . . . . . . . . . . . . . . 25Median Length of Stay in Hospital Inpatient Psychiatric Facilities Among ChildrenUnder 18 Years of Age, 1970, 1975, and 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26DSM-III's Multiaxial Diagnostic Evaluation System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
vii
Contents—continuedTable No. Page
6.7.
- 8.
9.
10.
11.
Children’s Mental Disorders Listed in DSM-III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Distribution of Full-Time Equivalent Staff Positions in Psychiatric Hospitals andResidential Treatment Centers, 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Federal Contributions to Programs Contributing to Mental Health Services forChildren, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......132Fiscal Year 1985 Estimated Allocation of the lo-Percent Set-Aside of the Alcohol,Drug Abuse, and Mental Health (ADM) Block Grant for Selected States . . . . . . . . . . .134Planned Use unselected States of Fiscal Year 1985 Set-Aside Funds for MentalHealth Services for Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. ... ... ....135Lengths of Stay Associated With Mental Disorder Diagnosis-Related Groups (DRGs)Ranked by Interquartile Range. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figures
Figure No1.
2.3.
4.
Estimated Numbers of Children Who Need and Who Receive MentalServices, 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 138
PageHealth. . . . . . . . . . . . . . 5
Organization of This Background Paper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Admission Rates for Children Under 18 Years to Psychiatric Hospitals andResidential Treatment Centers, 1970, 1975, and 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Estimated Proportions of State v. Federal and Private Expenditures for MentalHealth Treatment Provided in the Mental Health System to All Age Groups, 1983..133
. . .Vlll
Chapter 1
Summary and Policy Implications
Chapter 1
Summary and Policy Implications
INTRODUCTION
Mental health problems are a source of suffer-ing for children, difficulties for their families, andgreat loss for society. Though such problems aresometimes tragic, an even greater tragedy may bethat we currently know more about how to pre-vent and treat children’s mental health problemsthan is reflected in the care available. This back-ground paper was requested by the Senate Ap-propriations Committee through Senators MarkO. Hatfield and Daniel K. Inouye, who expressedspecial interest in learning the extent to which themental health field has reached a consensus onthe appropriate treatments and treatment settingsfor responding to the mental health needs of ourNation’s children. It examines the nature of chil-dren’s mental health problems, the mental healthservices available to aid disturbed children, andthe Federal role in providing services.
The problems that affect children’s mental healthrange from transient conditions in a child’s envi-ronment to diagnosable mental illnesses. Mentalhealth problems that meet the diagnostic criteriacontained in the third edition of the AmericanPsychiatric Association’s Diagnostic and Statis-tical Manual, the “DSM-III,”l are identified in thisbackground paper by the terms mental disorders,diagnosable mental disorders, and DSM-III dis-orders. Typically, the existence of a DSM-III dis-order is necessary for obtaining third-party reim-bursement for mental health services. Other termslike mental health problems and disturbed chil-dren refer in this background paper not only toDSM-III disorders, but also to children’s mentalhealth problems more generally —i.e., to disturbedself-esteem, developmental delays, and other sub-clinical problems that children may experience asa result of environmental stress. Currently, serv-ices for problems other than DSM-III disordersare seldom eligible for third-party payment.
‘At the time this background paper was being prepared, DSM-111 was being revised by the American Psychiatric Association. Thenew version will be known as DSM-111-R.
Interventions to prevent and treat children’smental health problems are as diverse as children’sproblems. This background paper considers sev-eral issues related to the provision of mental healthservices for children, emphasizing in particular,psychiatric hospitalization—the most restrictiveand costly form of treatment.
Although serious policy questions remain con-cerning the provision of adequate, appropriate,and cost-effective mental health services to chil-dren, several conclusions can be drawn from thisbackground paper:
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Many children do not receive the full rangeof necessary and appropriate services to treattheir mental health problems effectively.Howeverr the precise nature of the gap be-tween what mental health services are beingprovided to children and what should be pro-vided is not clear.A substantial theoretical and research basesuggests that, in general, mental health in-terventions for children are helpful, althoughit is often not clear what intervention is bestfor particular children with particular prob-lems. Most important for the focus of thispaper, the effectiveness of psychiatric hos-pitalization for treating childhood mental dis-orders has not been studied systematically.Although there seem to be shortages in allforms of children’s mental health care, thereis a particular shortage of community-basedservices, case management, and coordinationacross child service systems—all of which arenecessary to provide a comprehensive andcoordinated system of mental health carethroughout the country. Models for provid-ing community-based continuums of mentalhealth care exist, and preliminary evidencesuggests that such continuums can be effec-tive; these deserve careful and large-scaletrials with systematic evaluation.
3
4
Available epidemiologic data indicate that atleast 12 percent, or 7.5 million, of the Nation’sapproximately 63 million children suffer fromemotional or other problems that warrant men-tal health treatment—and that figure may be ashigh as 15 percent, or 9.5 million children. Theseepidemiologic data, while not based on system-atic, recent national studies, are widely acceptedand give some indication of the magnitude of chil-dren’s mental health care needs.
Like estimates of children’s mental health needs,information about mental health care utilizationby children is somewhat dated. The most recentmental health care utilization data available showthat less than 1 percent of the Nation’s children,or 100,000 children, receive mental health treat-ment in a hospital or residential treatment center(RTC) in a given year, and perhaps only 5 per-cent, or 2 million children, receive mental healthtreatment in outpatient settings (see figure 1).Using these data, OTA estimates that from 70 to80 percent of children in need may not be gettingappropriate mental health services.
It is not always clear why children do not re-ceive needed mental health services. Some chil-dren may not receive services because of thestigma attached to having a mental disorder.Other children may not receive services becausethe services are not available in their communi-ties. Still others may not receive services becausetheir families cannot afford them. Using the mostrecent data available (1977), OTA estimates that14 million of the Nation’s approximately 63 mil-lion children may not have any private healthinsurance. Furthermore, the insurance that is avail-able for mental health problems is generally re-stricted to treating diagnosable mental disorders,is significantly less generous than insurance forother disorders, and covers outpatient care lessgenerously than inpatient care.
To the extent that treatment decisions are basedon service system or financial considerations, in-appropriate mental health care may be given.Some children may be undertreated (e.g., be givenoutpatient treatment when they require hospital
‘The most recent year for which mental health service utilizationdata are available is 1980, or in some cases, 1981.
or other residential care), and some children maybe given overly intensive treatments (e.g., betreated in a psychiatric hospital when they couldbe treated without 24-hour medical supervision).Unfortunately, the data needed to understand pre-cisely which children and problems should betreated in different settings have not been col-lected.
OTA’s finding that many children with men-tal health problems do not receive needed care is,perhaps disappointingly, wholly consistent withthe findings of commissions and study groupsover the past half century. In recent years, asknowledge of the effects of children’s mentalhealth problems has grown, the urgency of ad-dressing these problems has increased. Providingthe most appropriate mental health services forchildren is a daunting task. The immensity of thedifficulties, however, should not restrain specificefforts to improve current policy and practice.
5
Figure l.— Estimated Numbers of Children Who Need and Who Receive Mental Health Services, 1980”8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0
All otherm e n t a l l y disturbedchildren
4.5b
Childrenadmitted to
inpatientor other
residentialfacilities
for mentalhealth
treatment0.1
\
Childrenreceiving
othermentalhealth
services d
?
Children in need of services Children who receive services
aExcludes prevention%he President’s Commission on Mental Health Indicated in 1978 that as many as 15 percent of the Nation’s children–which would translate to 9.5 million of the total
63.8 mill ion children m 1980—were /n need of mental health services (excludlng prevention) (514). Gould, Wunsch-Hltzlg, and Dohrenwend have since estimated that11.8 percent—or 7.5 mllllon —of the Nation’s chi ldren have mental health disturbances (248). A number of factors account for dif ferences in estimates of ch!ldren Inneed of mental health services (see text).
cExtrapolatlons from surveys of adults suggest that the number of children recelwng outpatient mental health Semlces could be as high as 4.02 mllllon. A ‘Irmer
destimate awaits the results of NIMH’s epidemiologic catchment area survey for chtldren (see text).Partial hospltallzatlon, etc.
SOURCES: Seriously mentally disturbed children in need of services: President’s Commwslon on Mental Health, Report to the Pres/dent from the F’res/dent’s CornrrrIs.sIon on Menfal Health, VOI 1 (Commlsslon R e p o r t ) ( W a s h i n g t o n , D C U . S . G o v e r n m e n t Print Ing O f f i c e , 1 9 7 8 ) , a n d J Knltzer, Unc/a/rned Ctr//dren(Washington, DC” Children’s Defense Fund, 1982).Total number of mental ly disturbed children in need of services: President’s Commission on Mental Health, Report to the Pres/dent From the Pres/dent’sComm/ss/on on tderrtal Health, vol. 1 (Commission Report) (Washington, DC: U.S. Government Printing Off Ice, 1978). and M S Gould, R Wunsch.Hltzlg, andB Dohrenwend, “Estlmattng the Prevalence of Childhood Psychopathology: A Cntlcal Rev iew,” Journa/ of the Amer/can Academy of Ch//d Psych/a fry20’482, 1981Children receiving inpatient or other residential mental health services: U.S. Department of Health and Human Sewices, Publlc Health Serwce, Alcohol,Drug Abuse, and Mental Health Administration, National Institute of Mental Health, Mental Health, United States. 1985, C A Taube and S A Barrett (eds ),D H H S P u b No, (ADM) 85-1378 (Rockville, MD: 1985).Children receiving outpatient mental health services: Adapted from U.S Department of Health and Human Services, Publlc Health Service, National Centerfor Health Statistics, Naf/ona/ Med/ca/ Care Ut///zaorrrr and Experrd/fure Survey, Data Report No 5, “Utltlzatlon and Expenditures for Ambulatory MentalHealth Care During 1980,” DHHS Pub No 84-20000 (Washington, DC: U S Government Prlntlng Off Ice June 1984)
6
ORGANIZATION OF THIS BACKGROUND PAPER
The remainder of this chapter summarizes thisbackground paper and considers policy implica-tions. The nine remaining chapters of this back-ground paper provide additional detail on chil-dren’s mental health problems and services. Thechapters are organized in five sections (see figure2).
Part I describes efforts to assess children’s men-tal health problems. Chapter 2 links conclusionsof past study commissions about the incidence andprevalence of mental and emotional problems inchildren to current estimates and notes the simi-larities between the current situation and whatwere identified as problems decades ago.
Part II reviews children’s mental disorders andthe interrelationships of children’s mental healthproblems and environmental conditions. Chap-ter 3 presents mental disorders in terms of thediagnostic categories in DSM-III. Chapter 4 con-siders factors in a child’s family and psychoso-cial environment that may cause or exacerbatecertain mental health problems and that may needto be considered in designing services.
Part 111 focuses on various approaches to treat-ing or preventing certain children’s mental healthproblems. Chapter 5 describes the primary ther-apies: individual psychotherapy based on psy-chodynamic, behavioral, and cognitive models;
group therapy; family therapy; milieu therapy;crisis intervention; and psychopharmacological(drug) therapy. Chapter 6 describes mental healthtreatment settings, including hospital inpatient set-tings, RTCs, day treatment or partial hospitali-zation, and outpatient settings. Chapter 7 pro-vides an overview of the mental health servicesprovided to children involved in the educational,health care, child welfare, and juvenile justice sys-tems. That chapter also describes programs aimedat preventing mental health problems and inte-grating mental health with other services.
Part IV examines the effectiveness of interven-tions used to treat and prevent children’s mentalhealth problems. Chapter 8 summarizes the re-search on effectiveness of the specific therapies dis-cussed in chapter 5. Chapter 9 summarizes the re-search on effectiveness of treatment in mentalhealth and other settings and the effectiveness ofprevention programs. Efforts to integrate mentalhealth and other services have not yet beenevaluated.
Part V analyzes the present Federal policiesaimed at alleviating children’s mental health prob-lems. Chapter 10 describes a number of Federalprograms that have a direct or indirect effect onchildren’s mental health.
SUMMARY AND POLICY IMPLICATIONS
Children’s Mental Health Problems
At least 7.5 million children in the UnitedStates—representing approximately 12 percent ofthe Nation’s 63 million children under 18—are be-lieved to suffer from a mental health problem se-vere enough to require mental health treatment.The actual number of children suffering frommental disorders that meet the diagnostic criteriaof DSM-III is unknown, but a fairly precise estimatewill be possible with the conduct of a NationalInstitute of Mental Health (NIMH) epidemiologicsurvey of children similar to that completed re-cently for adults. In addition to children who have
diagnosable mental disorders, some children areat risk for mental suffering and disability becauseof environmental risk factors such as poverty, in-adequate care, parental alcoholism, or divorce.These children may also benefit from mentalhealth services.
Mental health problems of children are in manyrespects unlike those of adults and are much moredifficult to identify. Distinguishing between nor-mal aspects of a child’s development and mentalhealth problems that may worsen if not treatedis a difficult task for parents, teachers, physicians,and mental health care professionals.
7
4Part 1:
Earlier Evaluations andthe Current Situation
4Part 1:
Problems
Part Ill:Services
I
Part IV:Effectivenessof Services
Part v:Current Federal
Efforts
1
Figure 2.—Organization of This Background Paper
Ch. 1: Summary and Policy Implications
Ch. 2: Earlier Evaluations and the Current Situation
Ch. 3: DSM-III Mental Disorders Ch. 4: Environmental Risk Factors andin Children Children’s Mental Health Problems
I
SOURCE Off Ice of Technology Assessment, 1986
I Ch. 10: Current Federal EffortsI
According to DSM-III, children maybe afflictedby so-called childhood-onset mental disorders(meaning the disorder is usually manifest first inchildhood) or by other disorders whose onset isnot restricted to childhood. DSM-III groups men-tal disorders that have their onset in childhoodby the area of functioning that is most impaired:
● intellectual disorders (mental retardation);● developmental disorders (pervasive and spe-
cific developmental disorders);● behavior disorders (attention deficit disorder
and conduct disorder);
● emotional disorders (anxiety disorders, otheremotional disorders of childhood or adoles-cence); and
● psychophysiological disorders (stereotypedmovement disorders, eating disorders, andother disorders with physical manifestations).
Other mental disorders that affect children, butwhich more commonly begin in adulthood, in-clude organic mental disorders; substance use dis-orders; schizophrenic disorders; affective dis-orders such as major depression; adjustmentdisorders; and a number of other disorders.
8
This background paper does not consider intel-lectual or developmental childhood-onset disordersexcept as they interrelate with other problems re-quiring mental health services. This exclusion re-flects in part the specific wording of the requestfrom the Senate Appropriations Committee andin part the fact that the causes, treatment, andtreatment goals in the case of intellectual/devel-opmental disorders differ from those associatedwith other mental disorders.
For the most part, the causes of mental dis-orders are unknown. However, some environ-mental factors, particularly psychosocial ones,pose significant risks for children’s mental health.
Environmental factors that pose risks to chil-dren’s mental health include poverty; parentalpsychopathology (e.g., schizophrenia or alco-holism); maltreatment; a teenage parent; prema-ture birth; parental divorce; and serious childhoodphysical illness. These factors rarely occur in iso-lation and frequently interact with other aspectsof a child’s family, educational, and social envi-ronment. Although environmental factors do notnecessarily result in mental disorders that meetthe diagnostic criteria of DSM-III, they can causemaladjustment and place a child at risk for laterand potentially more serious problems.
The consequences of mental health problemsin children can be mild and transitory or severeand longstanding. Children with the most severeproblems may be unable to function in either theirhome or school environments and may be dan-gerous to either themselves or others. Unresolvedproblems can lead to other serious problems withfamily, schools, and the criminal justice system.Much of the interest in identifying children’s men-tal health problems has as its focus the under-standing and prevention of disorders so as to re-duce the risk of future difficulties.
Children’s Mental Health Services
Interventions to treat children’s mental healthproblems are based on a variety of theories abouthuman development and behavior. Therapiesused with children include those which are psy-chodynamically based, behaviorally based, andcognitively based, as well as those involving psy-choactive medications.
Within the mental health system, a wide rangeof settings has been developed to treat children’smental health problems. These settings —frompsychiatric hospitals to outpatient mental healthclinics—can be described as forming a continuumof intensiveness. Mental health authorities agreethat it is desirable to provide treatment in the“least restrictive setting” possible. Severely dis-turbed children sometimes need intensive andrestrictive service settings such as hospitals orRTCs. Typically, however, intensive settings suchas these are needed only for relatively brief periods,with followup care in less restrictive environmentssuch as community-based outpatient programs.
The choice of treatment and treatment settingfor each mentally disturbed child is based on sev-eral factors. Certainly, the symptoms and theseverity of the child’s disorder are primary. Otherfactors that play a part in treatment decisions in-clude the child’s developmental status, the avail-ability of family support, social and environ-mental conditions, the availability of financingfor services, and the geographic availability of cer-tain services.
Opportunities for preventing and treating chil-dren’s mental health problems arise not only inthe mental health system but within the educa-tional, health care, child welfare, and juvenile jus-tice systems. Models for providing mental healthservices in these settings have been developed.Programs to integrate mental health and otherservices at Federal, State, and local levels havealso been developed. Such programs include in-dividual case manager programs, with profes-sionals to advocate for necessary and comprehen-sive treatment and to represent the child beforeall relevant programs so that services are co-ordinated.
Effectiveness of Mental HealthTreatment and Preventive Services “
Clinical and policy decisions based on knowl-edge about the effectiveness and appropriatenessof services, rather than on their availability, wouldbe desirable, but drawing firm conclusions aboutthe effectiveness of treatment, treatment settings,and preventive services for children’s mental
9
health problems is difficult. The research base islimited and not methodologically rigorous.
Overall, however, OTA’s analysis indicatesthat treatment is better than no treatment and thatthere is substantial evidence for the effectivenessof many specific treatments. Behavioral treat-ment, for example, is clearly effective for phobiasand enuresis, and cognitive-behavioral therapy iseffective for a range of disorders involving self--control (except aggressive behavior). Group ther-apy has been found to be effective with delinquentadolescents, and family therapy appears to be ef-fective for children with conduct disorders andpsychophysiological disorders. Psychopharmaco-logical treatment, while not curative, has beenfound to have limited effectiveness with childrenwith attention deficit disorder and hyperactivity(ADD-H), depression, or enuresis, and also inmanaging the behavior of children who are se-verely disturbed. Further, more rigorous researchmay demonstrate the usefulness of several othertreatments for which there is preliminary evidenceof effectiveness.
Questions about the effectiveness of mentalhealth treatment in psychiatric hospitals and RTCsare difficult to answer because of the lack of sys-tematic research. The lack of methodologicallysound evidence for the effectiveness of mentalhealth treatment provided through psychiatrichospitals and RTCs does not necessarily implythat these treatment settings are inappropriate—only that there is no solid evidence one way orthe other. Whether or not some mentally disturbedchildren would be better off in alternative treat-ment settings is not known.
Available research on treatment settings doesoffer some evidence to support the potential ef-fectiveness of a system of services ranging fromoutpatient community-based care to intensiveresidential-based care. The long-term effectivenessof psychiatric hospitalization and other forms ofresidential treatment, for example, appears to berelated to the presence and quality of followupcare. The effectiveness of day or night hospitali-zation appears to be related to the inclusion ofthe family in treatment plans.
Additional information about treatment effec-tiveness could be used to revise financial incen-
tives—both public and private—to promote thedelivery of mental health care in the least restric-tive setting possible for effective treatment, whilepermitting reimbursement for the range of serv-ices necessary. Thus, a more comprehensive andappropriate mental health treatment delivery sys-tem could be developed.
The effectiveness of prevention programs,whether developed primarily as a mental healthintervention or designed as part of other servicesystems such as schools, is supported by severalstudies. Interventions to provide family support,for example, appear to have substantial potentialto prevent and remedy a range of mental healthproblems and lead to better school achievementin children. Prevention programs in schools andpreschools and pregnancy prevention programsfor teenagers have also been found to be effec-tive. Not only have many prevention programsled to positive changes in social, emotional, andacademic measures, but such programs appear ca-pable of preventing later governmental expendi-tures through the justice and welfare systems.
The important questions, rather than beingabout the overall effectiveness of children’s men-tal health services, may be:
●
●
●
●
●
●
●
●
what specific types of services are effective?under what conditions?for which children?at what developmental level?with which problems?under what environmental and family con-ditions?in what settings? andwith what followup or concomitant paren-tal, family, school, and other system; inter-ventions?
Current Federal Efforts
State governments play the major role in pro-viding and financing children’s mental health serv-ices, although Federal Government and privatesector roles are substantial. The Federal Govern-ment finances treatment for children’s mental dis-orders primarily through the Alcohol, Drug Abuse,and Mental Health block grant, the Medicaid pro-gram, and the Civilian Health and Medical Pro-
10
gram of the Uniformed Services. These and otherfinancing programs also influence financing pol-icy in the private sector.
Federal involvement in health, welfare, nutri-tion, and social services for children is also con-siderable; and Federal programs in these areasprobably have a major impact in preventing andalleviating mental health problems, although theiractual impact is difficult to measure. However,the lack of cohesive policies toward children, andacross service programs, may create difficultiesfor those who would move public policy towardthe continuum of care that many observers con-clude is needed to address children’s mental healthneeds.
Past national studies have observed that fewmental health policies and programs—public orprivate-appear to take into account the complex-ity of influences in children’s lives. Fragmentationof treatment programs and support services hasresulted. Currently, programs at the Federal,State, and local levels are attempting to promoteintegration of services across professional, agency,and geographic boundaries. The Federal Child andAdolescent Service System Program, for exam-ple, provides grants to States to improve coordi-nation among service systems, thus improving ac-cess to appropriate mental health services. TheState Comprehensive Mental Health Services PlanAct of 1986 will institute another grant programto assist States to develop comprehensive serv-ices for the chronically mentally ill of all ages.
The Federal Government is virtually the onlysource of training and research support in themental health area. Despite Federal programs ofstudent assistance, the number of trained profes-sionals available to deliver children’s mentalhealth services remains far below all estimates ofthe need. Currently, about 15 percent of NIMH’straining funds appears to be directed to trainingclinicians to treat children.
A major difficulty in development of this back-ground paper and in designing more effective chil-dren’s mental health programs was the lack ofdata on many treatment regimens and service sys-tems. Although NIMH commits approximately 20percent of its current research budget to children’sissues, available dollars have not kept pace with
assessments of the funds necessary. Most mentalhealth care interventions are appropriate for eval-uation studies—and most could benefit from theinformation that research provides. In addition,basic information about the characteristics andutilization of the contemporary mental healthservice system is not available. The financial sav-ings from a more comprehensive database are po-tentially enormous; the benefits to children andsociety of more effective programs are incalculable.
Conclusion
OTA’s analysis suggests several needs in rela-tion to children’s mental health problems andservices. Two needs are: a more informed esti-mate of the number of children who require men-tal health services, and a description of the avail-ability and use of children’s mental health services.
A more immediate need is for improved deliv-ery of mental health services to children. Clearly,the mental health services currently available tochildren are inadequate, despite a substantial theo-retical and research base suggesting that mentalhealth interventions for children are effective.
The need for improved children’s mental healthservices is not new; it has been highlighted by anumber of past national studies and commissions.If the need is to be met, changes may be neces-sary in the way mental health services are con-ceptualized, financed, and provided. In an idealsystem, an adequate range and number of preven-tive, treatment, and aftercare services would beavailable, particularly in the communities wherechildren reside, so that families and others can beinvolved. Access to treatment on an outpatientbasis, and before a child develops a diagnosabledisorder, seems especially important. Access totreatment could be facilitated by reducing restric-tions on mental health benefits,
OTA found that new efforts to coordinate serv-ices between the mental health system and othersystems that children may come in contact with—the general health care, educational, social wel-fare, and juvenile justice systems—are encourag-ing to many mental health professionals. Thesenew coordination programs may result in new ef-forts to detect and treat mental health problems.
11
Finally, additional information about the causes ety of promising approaches could greatly aid theof mental health problems, the services available development of a system that would match theto prevent and treat them, the extent to which the mental health needs of children.services are used, and the effectiveness of a vari-
Part 1: Earlier Evaluationsand the Current Situation
Chapter 2
Earlier Evaluations and theCurrent Situation
Chapter 2
Earlier Evaluations and the Current Situation
INTRODUCTION
Services for children’ with mental health prob-lems have long been a focus of national concern.This chapter summarizes the work of several ma-jor policy-related studies and commissions, giving
‘Throughout this background paper, the term “children” is usedto refer generally to all infants, children, and adolescents under age18. Where necessary, further distinctions are drawn among childrenof various ages and developmental stages.
their conclusions about the prevalence of mentalhealth problems in children and their recommen-dations for services. The chapter also presentsavailable information pertaining to trends in theavailability and use of children’s mental healthservices. Although data to assess the current sit-uation are limited, it is nevertheless clear that sev-eral key policy recommendations of past studiesand commissions have yet to be implemented.
EARLIER EVALUATIONS OF CHILDREN’S MENTAL HEALTHNEEDS AND SERVICES
Estimates of the Prevalence ofChildren’s Mental Health Problems
Estimating the prevalence of mental health prob-lems among children is hard for several reasons.Distinguishing between distinct mental health prob-lems and normal changes during a child’s devel-opment, for example, is often difficult. Also, somechildren without a diagnosable disorder may re-quire mental health services because of problemsin their social and physical environment (see ch.4). These factors complicate the task of enumer-ating specific disorders and identifying childrenin need.
To complicate matters further, various panelsthat have tried to estimate the prevalence of chil-dren’s mental health problems in the past havevaried in the age range of children and the typesof problems included in their estimates. Also, be-cause of changes in psychiatric nomenclature, prev-alence estimates used in individual studies or re-ports cannot be reliably replicated by subsequentgroups. Nevertheless, all of the various panels’estimates have been roughly similar (see table 1),and the panels have all agreed that the need forchildren’s mental health services exceeds the avail-ability of services.
Joint Commission on the Mental Health ofChildren (1969)
One of the most detailed assessments of themagnitude of children’s mental health problemswas conducted by the Joint Commission on theMental Health of Children (324). Established in1965 (Public Law 89-97), the Joint Commissionon the Mental Health of Children was specificallymandated to develop a coordinated study of thediagnosis, prevention, and treatment of “emo-tional illness” in children and adolescents. Anearlier commission whose work had led to the1963 act establishing community mental healthcenters throughout the country had not dealt ex-plicitly with children (324).
In defining and estimating the prevalence ofemotional disorders in children, the Joint Com-mission was hindered by a lack of specific diag-nostic criteria. The Joint Commission adopted arather broad definition of an “emotionally dis-turbed child” based on its synthesis of researchand expert opinion:
. . . one whose progressive personality develop-ment is interfered with or arrested by a varietyof factors, so that he shows an impairment in thecapacity expected of him for his age and endow-
17
18
Table 1 .—Estimates of Children WithMental Health Needsa
Children under 18 years of agewith mental health needs
Percent Numberb
All mentally disturbed children:Joint Commission on the Mental
Health of Children (1969) 13.6% 8.8 millionPresident’s Commission on Mental
H e a l t h ( 1 9 7 8 ) 5% to 15% 3.0 to 9.6 millionG o u l d , e t a l . ( 1 9 8 1 ) . 11 .8%C 7,5 million
Severely mentally disturbed children:National Plan for the Chronically
Mentally Ill (1980) 8% 9.1 millionKni tzer /CDF (1982) . , . , 5.0% 3 millionaEStlrnateS differ because mcormstent defmttlons of children’s mental health needs have been
used The U S Department of Health and Human Serwces IS currently evaluahng the vahdltyof a dlagnosttc Interwew schedule for use with children In order to conduct an epldemlologlcalstudy of the presence of mental disorders
bThe number of Children m need of serwces IS calculated as c1 percent Of the 1980 POPulatlOnof 638 mihon Individuals under 18 years of age
Csubsquenl analyses concur with this estimate See text
SOURCES Joint Commwvon on the Mental Health of Children, Crms m Cfrdd Menfa/ Hea/f/rCha//errge for the 1970’s (New York Harper & Row, 1969), President s Commissionon Mental Health Reporf to Me Pres/derrt From (he Preslderrf’s Corrvrvwon on kferrfa/Hea/ffr, VOI 1 (Commlsston Report) and VOI 3 (Task Panel Reports) (Washington DCU S Government Prmtmg Office, 1978), M S Gould, R Wunsch-Hltzlg, and 8 Dohren-wend, ‘‘Estlmatmg Ihe Prevalence of Chddhood Psychopathology A Crltlcal Rewew,Jourrra/of MeAmerlcan AcadernyofChddPsycfr/airy 20462, 1981, L Salver, “ChronicMental Illness m Children and Adolescents Scope of the Problem, ” paper for the Na-tional Conference on Chronic Mental Illness In Children and Adolescents, sponsoredby the American Psychiatric Asscaatlon, Dallas TX, March 1985 J Krvtzer UflclamedCfuldren (Washington, OC Chddren ”s Defense Fund 1982)
ment; (1) for reasonably accurate perception ofthe world around him; (2) for impulse control;(3) for satisfying and satisfactory relations withothers; (4) for learning; or (5) for any combina-tion of these.
Using this definition to interpret available re-search, the Joint Commission on the Mental Healthof Children estimated that up to 13.6 percent ofchildren were “emotionally disturbed. ” This in-cluded a small percentage (0.6 percent) of childrenwho were considered psychotic, 2 to 3 percentwho were severely disturbed, and an additional8 to 10 percent who suffered from emotional prob-lems serious enough to require mental healthservices.
U.S. Department of Health, Education, andWelfare: Project on the Classification ofExceptional Children (1975)
The issues of classifying children’s mental healthproblems were also of concern subsequent to theJoint Commission’s report. In 1972, a project wasinitiated by the Secretary of the U.S. Departmentof Health, Education, and Welfare (DHEW), now
the U.S. Department of Health and Human Serv-ices, to consider issues in the classification of “ex-ceptional” children, including but not limited tothose with mental health problems. Supported bya consortium of DHEW agencies and directed byHobbs, the Project on the Classification of Excep-tional Children brought together a group of ex-perts to develop a better understanding of the is-sues involved in classification and a rationale forpolicy and services for “exceptional” children.
The final report of the project cited a DHEWBureau of Education (298,299) estimate that therewere about 7 million children aged O to 19 in vari-ous “exceptional” categories (physically handi-capped, retarded, and emotionally disturbed), butit did not estimate prevalence for specific disabil-ities. Another 1 million children (2.9 percent ofchildren aged 10 to 17) had been in trouble withthe law in 1972, and 10 million poor and 10 mil-lion nonwhite children were also of concern tothe advisors to DHEW.
The report concluded that although there weresignificant problems associated with labeling chil-dren, categorization was often necessary to estab-lish policy and to ensure that services were de-livered. The report noted, however, that theclassification of emotional disorders was particu-larly difficult and therefore recommended the de-velopment of multidimensional classification sys-tems. A central feature of this recommendationwas that such systems classify disorders, ratherthan children.
President’s Commission on Mental Health andIts Task Panel on Infants, Children, andAdolescents (1978)
The President’s Commission on Mental Healthwas established in 1977 to undertake a broad-based review of national mental health needs andto make recommendations to the President as tohow those needs might be met (514). One of theprincipal “task panels” of the Commission ad-dressed the mental health needs of children. Usingstudies conducted since the time of the Joint Com-mission on the Mental Health of Children, thistask panel estimated that from 5 to 15 percent ofchildren aged 3 to 15 had handicapping mentalhealth problems. The panel’s lower estimate cor-responds to estimates of the number of psychotic
19
and severely disturbed children; its higher estimatecorresponds to the number of children with “neu-roses” and behavior problems for whom mentalhealth intervention may be useful.
The Commission as a whole stated that thecountry’s mental health problems could not “bedefined only in terms of disabling mental illnessesand identified psychiatric disorders. ” Mental healthproblems “must include the damage to mentalhealth associated with unrelenting poverty andunemployment and the institutionalized discrimi-nation that occurs on the basis of race, sex, class,age, and mental or physical handicaps, ” and “con-ditions that involve emotional or psychologicaldistress which do not fit conventional categoriesof classification or services” (514).
Recent Estimates of the Prevalence ofChildren’s Mental Health Problems
Epidemiologic research on mental health prob-lems needed in order to estimate prevalence hascontinued to develop. Over two dozen studies ofthe prevalence of mental disorders in children andadolescents have now been conducted (229,248,389,609).
Some of the most important research on prev-alence, conducted in the United Kingdom by Rut-ter and colleagues (562,566), is believed to be rele-vant to the situation in the United States. On thebasis of a convergence of identifications by men-tal health professionals, parents, and teachers,Rutter estimated that 13.2 percent of children inthe United Kingdom were in need of mental healthservices.
In a detailed 1981 review, Gould, et al., con-cluded that the percentage of children and adoles-cents in need of mental health services in theUnited States was probably “no lower than 11.8percent” (248). Later reviews, by Gilmore, et al.(229), and Silver (609), concur with the 11.8-percent figure.
Gould and her colleagues’ estimate that about12 percent of the children in the United States—7.5 million—are in need of mental health serv-ices seems to be one on which there is generaI con-currence. This estimate, however, reveals noth-ing about the severity of disturbances and levels
of care children need—distinctions that are essen-tial for the development of comprehensive pub-lic policy.
Increasing interest is being directed to childrenwith severe mental health disturbances, both interms of identification and for developing appro-priate treatment options (396). Estimates of thenumber of severely disturbed children, however,differ substantially. In comparison to the findingsof the President’s Commission on Mental Health(514), for example, the 1980 National Plan for theChronically Mentally 111 (609) estimated thatabout 9.1 million (8 percent) children are severelydisturbed and in need of services.
Recommendations About MentalHealth Services for Children
Concern about the inadequacy of mental healthservices for children is not a recent phenomenon.As long ago as 1909, a White House Conferenceon Children recommended new programs to carefor mentally disturbed children (324). A WhiteHouse Conference in 1930 echoed the earlier rec-ommendation and maintained that mentally dis-turbed children have the “right” to develop theway other children do. A similar conclusion hasbeen reached by nearly every subsequent commis-sion or panel (324). These panels and study com-missions have made numerous detailed and spe-cific recommendations conceiving policy relevantto the mental health needs of children. Only theflavor of their recommendations can be providedhere. Selected conclusions and recommendationsof various commissions and panels are summar-ized in table 2, and the work of the more recentgroups is discussed in detail below.
Joint Commission on the Mental Health ofChildren (1969)
The Joint Commission on the Mental Health ofChildren (324), in its 1969 report Crisis in ChildMental Health, stated that large numbers of emo-tionally, physically, and socially handicappedchildren did not receive necessary or appropriateservices and that the mental health service sys-tem for children and youth was wholly inade-quate. Although the most disturbed and disrup-
Table 2.—Mental Health Services for Children: Selected Findings and Recommendations ofPast National Study Panels
Selected conclusions Selected recommendations Subsequent Federal actions
White House Conference on Children (1909):Develop new programs to care for emotionally disturbed children
White House Conference on Children (1930):Emotionally disturbed children have the “right” to Develop new programs to care for emotionally disturbed children
develop like other children,
Joint Commission on the Mental Health of Children (1969):Large numbers of emotionally, physically, and so- Establish a child advocacy system to coordinate Federal, State, and local
cially handicapped children do not receive action,necessary or appropriate services, Establish community services focused on prevention and remediation
Expand prevention services to include family planning, prenatal care, nutrition,and other physical health care,
Deliver treatment in settings resembling normal Iiving conditionsIncrease research on diagnosis and treatment
Project on the Classification of Exceptional Children (1975):Services for all kinds of children remain a tangled Classify disorders, not children Education for All Handi-
thicket of conceptual confusions, competing Coordinate and plan services, capped Children Actauthorities, contrary purposes, and professional Educate all children; make public schools advocates for all services for all (Public Law 94-142)rivalries, leading to the fragmentation of serv- children, passed in 1975.ices and the lack of sustained attention to theneeds of Individual children and their families,
President’s Commission on Mental Health or its Task Panal on infants, Children, and Adolescents (1978):A delay in the delivery of mental health services Provide prevention services (e. g., prenatal care) to all families with children. Mental Health Systems Act
is no more justifiable than a delay in the deliv- Services should ‘‘respect ethnic differences, be adapted to children’s specific (1980) authorized pro-ery of physical health services, needs, treat significant others. grams to improve the
Adolescents are one of the most underserved Incorporate mental health services (e.g., developmental assessments, diagnostic delivery and coordinationgroups in Nation, services) into general health care. of services for severely
Mental health commissions have to date garnered Involve parents m development of treatment, educational, and service plans, emotionally disturbed chil-Iittle action for minority group programs Develop a network of psychiatric, pediatric, counseling, special education, and dren and adolescents
occupational training services (repealed in 1981)Organize mental health services along a continuum of intensivenessIncrease residential and outpatient care.Make mental health care available at reasonable costs to all who need it.Address adolescent suicide, teenage pregnancy, delinquency, and substance
abuse.Increase the number of mental health professionals trained to work with
children,Fund more basic and evaluation research,
Select Panel for the Promotion of Child Health (1981):Public Law 94-142 (the Education for All Handi- Develop better means of Identifying and evaluating children with handicapping
capped Children Act) has wrought significant conditions, including serious emotional disturbance.Improvements, but substantial variations exist Require delivery of health and mental health services to handicapped children,m the availability of services, Improve Federal and State monitoring, technical assistance, and enforcement of
Public Law 94-142.Expand mental health services to include early detection and treatment of de-
velopmental problems, other preventive services for children and families,high quality residential treatment services, and community supportmechanisms,
Develop new means of coordinating physical and mental health services, andmental health services with educational and social services,
Involve families in delivery of mental health services.
Knuitzer/Children’s Defense Fund Survey of State Mental Health Programs:All services (residential and nonresidential) are in- Increase efforts to Identify children and adolescents in need of services or who
adequateChild and Adolescent Service
are inappropriately served System Program (CASSP)Inpatient psychiatric care is the most accessible, Develop incentives for creating coordinated services. was funded to promote co-
but also the most costly and restrictive, Coordinate juvenile justice, education, child welfare, and mental health services ordination of mental healthStates do not monitor children’s progression by means of a child advocacy system, services within States,
through mental health system. Target Federal Alcohol, Drug Abuse & Mental Health (ADM) block grant funds Ten percent of ADM mentalService systems (juvenile, educational, child wel- for children’s services, health block grant funds
fare, mental health) are uncoordinated, was set aside for childrenSeriously emotionally disturbed children appear to or other underserved pop-
be underserved under Public Law 94-142. ulations,
SOURCES Joint Commmon on the Mental Health of Children, Crisis in Chdd MerrL?/ Hea/ttr Cfra//enge for the 1970’s (New York Harper & Row, 1969). N Hubbs, The Futures of C)rddren Categories,LaDe/s and The/r Corrsequences (San Francwco, CA Jossey-Bass, 1975), President’s Commlsslon on Mental Health, Report to the Preslderrf From the F’res/denf’s CornrnmJorI orI Menfa/ Heallh,VOI 1 (Commlsslon Report) and VOI 3 (Task Panel Reports) (Washington, DC U S Government Printing Off Ice, 1978), Select Panel for the Promotion of Child Health, Better Hea/th for OurCtWdren A rVaf/orta/ Sfrategy, presented 10 the U S Congress and the Secretary of Health and Human Services, Washlnglon, OC, 1981, J Krwtzer, (hrdamred Clr//dren (Washington, DCChddren’s Defense Fund, 1982)
21
tive children could receive treatment services, theCommission found that treatment provided tothem very often was inappropriate and ineffec-tive. The Joint Commission was particularly con-cerned that severely disturbed children were be-ing institutionalized in State mental hospitals andthat such facilities provided custodial rather thantreatment services for children. The Joint Com-mission was also concerned about the “corrosive”effects of poverty and the fact that mental healthproblems were more acute and services less avail-able among poor children.
A principal recommendation of the Joint Com-mission on the Mental Health of Children was thata child advocacy system be established to coordi-nate Federal, State, and local actions. The Com-mission believed that advocacy was essential fordevelopment of a comprehensive network to meetchildren’s mental health, physical, and social needs.
The Joint Commission also recommended theestablishment of community services that focusedon prevention and “remediation. ” Recommendedprevention services included family planning, pre-natal care, and mental health services associatedwith schools. Remedial mental health services,which the Commission estimated would be re-quired for 10 percent of children, were to be basedon children’s functional level, rather than on le-gal or clinical classification systems.
The Joint Commission further recommendedthat children (particularly the severely handi-capped) be cared for in settings that most closelyresembled normal living situations. An additionalrecommendation was for increased research ondiagnosis and treatment of children’s mental healthproblems. The Joint Commission believed thatboth basic and applied research was essential andsuggested a variety of research priorities, both forthe National Institute of Mental Health (NIMH)and for the National Institutes of Health.
U.S. Department of Health, Education, andWelfare: Project on the Classification ofExceptional Children
Perhaps because it was concerned with “excep-tional” children of several kinds (handicapped,disadvantaged, and delinquent), the Project onthe Classification of Exceptional Children was per-
haps even more concerned than the Joint Com-mission on the Mental Health of Children withthe coordination of services across agencies andcategories of children. Thus, the Project’s final re-port (298,299) recommended that the U.S. Con-gress and the legislative bodies of each State andcommunity establish an agency to serve a plan-ning and coordinating function for all programsbearing on families and children. The Project re-port also suggested that at every level, citizens’councils advise the planning agencies on programdevelopment and agency operations. The Projectalso made recommendations concerning specificprograms which might be implemented under thepurview of the legislative bodies, and noted sev-eral needs that should be given priority attention:
● support for parents,● improved residential programs for children,● fairness to disadvantaged and minority group
children,● improved classification systems,● better organization of services, and● new knowledge to inform policy.
One of the Project’s recommendations, that allchildren including the handicapped have accessto education, was implemented with the passageof Public Law 94-142, the Education for All Hand-icapped Children Act. Public Law 94-142 alsoimplicitly made the public schools the primary
A number of national studies and commissionshave concluded that mental health services for children
are inadequate.
22
source of advocacy for children, another recom-mendation of the Project on the Classification ofExceptional Children.
President’s Commission on Mental Health andIts Task Panel on Infants, Children, andAdolescents (1978)
The President’s Commission on Mental Health(514) found that many of the Joint Commission’s1969 recommendations had not been implemented.Children and adolescents, the President’s Com-mision found, continued to receive inadequatemental health care:
Services that reflect the unique needs of chil-dren and adolescents are frequently unavailable.Our existing mental health services system con-tains too few mental health professionals andother personnel trained to meet the special needsof children and adolescents. Even when identi-fied, children’s needs are too often isolated intodistinct categories, each to be addressed separatelyby a different specialist. Shuttling children fromservice to service, each with its own label, addsto their confusion, increases their despair, andsets the pattern for adult disability.
The Commission’s subtask panel on infants,children, and adolescents recommended preven-tive services for all children, not only those iden-tified as mentally disturbed. Services such as de-velopmental assessments and access to diagnosticmental health services, it suggested, should be in-corporated within children’s general health care.
The subtask panel also recommended a net-work of “psychiatric, pediatric, counseling, spe-cial education and occupational training services”for children with severe psychiatric disorders.These services were necessary, according to thepanel, because no matter how successful preven-tion efforts were, some children would always re-quire special help. The services provided, thepanel recommended, should be adapted to chil-dren’s specific needs and should include counsel-ing with parents and others significant in a child’slife. In addition, the panel believed, it was essen-tial that services “respect ethnic differences. ”
The subtask panel on infants, children, andadolescents emphasized that children’s mentalhealth services should be provided within a sys-tem of care that “insofar as possible maintain a
continuing relationship between child and fam-ily.” To prevent disruption in the relationship be-tween children and their families, the panel rec-ommended that health insurance plans eliminatebarriers to reimbursement for outpatient treat-ment services. The panel also recommended thatparents be involved in the development of spe-cial education and other treatment plans, espe-cially for intensive services provided for severelydisturbed children.
Another recommendation of the subtask panelwas that children’s mental health services be orga-nized along a continuum of intensiveness, so thatchildren could move along the continuum as theirneeds changed. Good residential facilities special-izing in the treatment of severely disturbed chil-dren and adolescents, the panel suggested, wereurgently needed. The panel supported the JointCommission calling for development of a betterresearch and evaluation base, characterizing thetendency to reduce research funding in order toprovide treatment services as “penny wise andpound foolish” (514). Noting that without moreresearch and evaluation, “the potential for wasteof resources is great, ” the panel recommended alo-percent set-aside of total program funds for re-search, demonstrations, and evaluation.
The subtask panel called the mental health sys-tem for adolescents “woefully inadequate, ” notingthat adolescents were one of the most underservedgroups in the Nation. This panel urged that serv-ices be provided to address such problems as ado-lescent suicide, teenage pregnancy, delinquency,and substance abuse. The panel’s recommenda-tions focused on development of an integratednetwork of mental health services in schools, ju-venile courts, neighborhood centers, and occupa-tional training facilities.
One impact of the work of the President’s Com-mission was the development and enactment ofthe Mental Health Systems Act. The act author-ized programs to improve the delivery and coordi-nation of services for severely emotionally dis-turbed children and adolescents. The act becamelaw in 1981, but was repealed before it becameeffective and was replaced by the Alcohol, DrugAbuse, and Mental Health (ADM) block grant(Public Law 97-35; see ch. 10).
23
Select Panel for the Promotionof Child Health (1981)
Established at about the same time as the Presi-dent’s Commission on Mental Health was the Se-lect Panel for the Promotion of Child Health es-tablished under Public Law 95-626. The SelectPanel had a broad mandate; it attempted to de-velop recommendations that:
. . . reflected] hardheaded analysis of seriousunmet needs in child and maternal health . . .and a sober and pragmatic assessment of the ca-pacity of our institutions to provide parents, pro-fessionals and . . . others working to improvechild health with the scientific, financial and or-ganizational support they need.
The Select Panel reported its findings in Decem-ber 1980 (595). The general recommendations ofthe Panel, much like those of its predecessors, em-phasized the interrelationships among servicesprovided by health care agencies, schools, fam-ilies, and social service institutions. The SelectPanel’s analysis suggested changes to a wide rangeof Federal programs affecting children. With re-spect to mental health needs, the Panel focusedon implementation of the Education for All Hand-icapped Children Act (Public Law 94-142, enactedin 1975) and mental health service systems thatwere to be affected by the Mental Health SystemsAct (enacted in 1980, but then repealed in 1981).
Public Law 94-142 mandates that handicappedchildren be provided access to a free and appro-priate public education. Public Law 94-142 au-thorizes a program for States to receive Federalfunds, but it also “guarantees” the right to edu-cation for handicapped children without regardto the provision of Federal funds to support suchservices. Although the Select Panel found that sig-nificant improvements had resulted from PublicLaw 94-142, particularly in changing attitudesabout the handicapped, it was concerned that sub-stantial variations existed across States in theavailability of services. The Panel stressed theneed for better methods of identifying and evalu-ating children with handicapping conditions andmore stringent requirements for delivering healthand mental health services to these children. Toensure compliance with the law, it recommendedFederal and State monitoring, technical assistance,and enforcement.
The Select Panel also considered the role ofcommunity mental health centers and other men-tal health service systems and recommended thatthese systems expand mental health services forchildren. Although children’s mental health serv-ices had been mandated earlier (Part F of the 1970Amendments to the Community Mental HealthCenters Act), direct Federal support specificallyfor children’s programs had been withdrawn in1975. The Select Panel believed that developmen-tal assessment and other preventive services, aswell as high-quality residential treatment servicesand community support mechanisms, were nec-essary components of all comprehensive mentalhealth programs.
As had the President’s Commission on MentalHealth in 1978, the Select Panel for the Promo-tion of Child Health recommended that mentalhealth services be coordinated with general healthcare. The Select Panel also recommended coordi-nation of education and social welfare programsthat serve children. Other recommendations ofthe Select Panel were that community mentalhealth programs provide services in schools, HeadStart programs, and juvenile justice institutions,and that families be involved in the delivery ofmental health services.
Knitzer/Children’s Defense Fund (1982)
Concern about the adequacy of services formentally disturbed children remained, despite theconvergence of recommendations by the JointCommission, the President’s Commission, and theSelect Panel. In 1982, the Children’s Defense Fund(CDF) published an elaborate and highly criticalstudy of how children and adolescents in need ofmental health services are treated (358). That re-port, Unclaimed Children, by Jane Knitzer, de-scribed a survey of mental health services for se-verely disturbed children and adolescents in 50States and the District of Columbia. Unlike thereports of earlier commissions and panels, theKnitzer/CDF report is based on systematicallycollected original data and is one of only a fewefforts to comprehensively assess State, as wellas Federal, programs.
The Knitzer/CDF report concluded that therewere 3 million seriously disturbed children (basedon the estimate of the President’s Commission on
24
Mental Health in 1978), but that 2 million (two-thirds) of these children were not receiving neededtreatment services. The report also suggested thatmany children who received services received in-appropriate care and that poor and minoritygroup children were most likely to receive no careor inappropriate care.
Using data from State and county hospitals,Knitzer concluded that the most restrictive andcostly level of care—inpatient hospital treatment—was also the most accessible. Although the dataKnitzer collected suggested that as many as 40 per-cent of such hospital placements were unsuitable,alternatives to hospital services for severely dis-turbed children were found to be either nonexist-ent or rudimentary in many States. One-third ofthe States responding to Knitzer’s survey indicateda need for more long- or short-term beds. Accord-ing to Knitzer (358):
. . . those States with the fewest alternatives toinpatient care were generally the ones that wantedmore beds. Those with a number of alternative
programs saw less need to fund more hospitalplacements . . .
Knitzer suggested that Federal funds had beenused disproportionately to provide medically ori-ented inpatient care, while Federal resources avail-able for community services had declined.
Responsibility for seriously disturbed children,according to Knitzer, lies with public agencies.The Knitzer/CDF report strongly recommendedincreased efforts to identify children and adoles-cents who are either in need of services or arebeing inappropriately served. It also urged thedevelopment of incentives to create a coordinatedset of services appropriate to the child. As didthe reports of each of the government panelsdescribed earlier, the Knitzer/CDF report rec-ommended increased coordination among agen-cies that deal with children, including educational,juvenile justice, and child welfare agencies. Aspecific recommendation of the report was thatADM block grant funds be targeted for children’sservices.
THE CURRENT AVAILABILITY AND USE OF CHILDREN’S MENTALHEALTH SERVICES
Despite general agreement among experts aboutthe magnitude of children’s mental health prob-lems, it is difficult to specify precisely the num-ber of children with mental health problems andthe types of services they need. The National In-stitute of Mental Health (NIMH), which recentlyconducted a nationwide study of the prevalenceof adult mental health disorders (533), plans a par-allel survey of children’s problems. At the timethis background paper was being written, NIMHwas studying the reliability and validity of the in-strument it plans to use in the survey—the Diag-nostic Interview Schedule for Children (DISC).DISC is based on the American Psychiatric Asso-ciation’s Diagnostic and Statistical Manual ofMental Disorders. The NIMH survey representsan important step toward more precise assessmentof children’s mental health problems (664).
A serious problem in attempting to assess theextent to which mental health services for chil-dren are available, and the degree to which themental health service system has changed in re-
cent years, is the lack of precise epidemiologicdata. The information available at the time thisbackground paper was being prepared was quitedated. The most recent systematically collectedinformation on inpatient, residential, and out-patient mental health care pertained to utilizationfor 1981 (665). These data do not reflect the im-pact of recent policy changes such as Medicare’sPart A prospective payment system, the limita-tion by the Civilian Health and Medical Programof the Uniformed Services on inpatient treatment,the lo-percent set-aside in the mental health por-tion of the ADM block grant, and the Child andAdolescent Service System Program (see ch. 10).Nevertheless, they do allow the identification ofseveral noteworthy trends. For the most part, thecontinuation of these trends has been confirmedby individuals consulted during the preparationof this background paper.
The most dramatic trend in recent years hasbeen a decline in the number of children treatedas inpatients in State and county mental hospi-
2 5
tals (665). This trend has been accompanied, how-ever, by increases in children’s admissions to pri-vate psychiatric hospitals and to facilities such aspsychiatric units of general hospitals, for a smallnet increase in children’s admissions to psychiatrichospitals.
In 1970, as shown in table 3, the rate of chil-dren’s admissions to private psychiatric hospitals(9.3 per 100,000 children under 18) was one-fourththe rate of children’s admissions to State andcounty mental hospitals (37.8 per 100,000 chil-dren under 18). During the 1970s, children’s ad-missions to State and county mental hospitalsdeclined 30 percent and admissions to private psy-chiatric hospitals increased almost 200 percent,so that in 1980, the latest period for which sys-tematic data are available, the rates of children’sadmissions were about the same for both typesof institutions. The rates of children’s admissionsto non-Federal general hospitals with inpatientpsychiatric services increased slightly from 63.3per 100,000 population in 1970 to 68.5 per 100,000population in 1980, for a total net increase in therate of psychiatric hospitalization of children ofabout 10 admissions per 100,000 population.There may be significant regional variations (589).
Some evidence suggests that the length of treat-ment episodes in State and county mental hospi-tals is declining, although the evidence on thelength of stay for children in private psychiatrichospitals is unclear (458,665). As can be seen in
table 4, data from NIMH indicate that the me-dian length of stay of children in State and countymental hospitals dropped from 74 days in 1970to 54 days in 1980, while the 1ength of stay in pri-vate psychiatric hospitals remained constant at36 days (665). A survey of National Associationof Private Psychiatric Hospitals members, how-ever, found that the median length of stay for chil-dren in 1985 in the private hospitals surveyed wastwice NIMH’s number for 1980 (458). Data fromNIMH indicate that the length of stay in non-Federal general hospitals with inpatient psychiatricservices increased from 9 to 17 days between 1970and 1975, then decreased to 14 days in 1980. Theevidence just cited clearly shows that general hos-pitals are used for short-term care, and the lengthof stay in State and county mental hospitals hasdeclined. It does not allow conclusions about thelength of treatment in private psychiatric hos-pitals.
As shown in table 3, NIMH data suggest thatthere has been an increase in utilization of resi-dential treatment centers for emotionally disturbedchildren (RTCs). Such facilities can provide analternative form of treatment for children who re-quire residential treatment but who do not requireconstant medical supervision (see ch. 6). Therewas a substantial increase in the number of ad-missions to RTCs between 1969 and 1981. Accord-ing to NIMH data, the rate more than doubled,from 11.4 admissions per 100,000 population un-der 18 in 1969 to 28.3 admissions per 100,000 pop-
Table 3.—Admissions of Children Under 18 Years of Age to Hospital Inpatient Psychiatric Facilities andResidential Treatment Centers, 1970, 1975, and 1980a
1970b 1975 1980C
R a t ed N u m b e r R a t ed N u m b e r R a t ed N u m b e r
Hospital inpatient facilitiesState and county mental hospitals . . . . . . . . . . . . . . . . . . . . . . 37.8 26,352 38.1 25,252 26.1 16,612Private psychiatric hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3 6,452 23.3 15,426 26.3 16,735Non-Federal general hospitals with inpatient psychiatric
services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63.3 44,135 64,4 42,690 68.5 43,595
Total hospital inpatient admissions . . . . . . . . . . . . . . . . . . . . 110.4 76,939 125.8 83,368 120.9 76,942
Residential treatment centers for emotionally disturbedchildren (RTCs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.4 7,596 18.8 12,022 28.3 17.703
alncludes new admissions and readmission during the year, SO is not an undupllcated countbData for RTCS are fOr 1%9cData for RTCS are for 1981.dRate per 1~,000 children under 18 Years of a9eelncludes St Ellzabeth’s H o s p i t a l In W a s h i n g t o n , DC
S O U R C E National Institute of Mental Health, Alcohol, Drug Abuse, and Mental Health Administration, Publlc Health Service, U S Department of Health and HumanS e r v i c e s , &fenfa/ Hea/fh, Urr/fed Stafes, 1985, C A. Taube and S A Barrett (eds ) , DHHS Pub No. (ADM) 85-1378 (Rockvilie, MD 1985), tables 221 and 23.
59-964 0 - 87 - 2
26
Table 4.—Median Length of Stay in Hospital InpatientPsychiatric Facilities Among Children Under 18
Years of Age, 1970, 1975, and 1980
Figure 3.—Admission Rates for Children Under 18Years to Psychiatric Hospitals and Residential
Treatment Centers, 1970, 1975, and 1980a
1970 1975 1980State and county mental
h o s p i t a l s . . . . , 74 days 66 days 54 daysPr ivate psychia t r ic hospi ta ls 36 days 36 days 36 daysNon-Federal general hospitals with
inpat ient psychia t r ic serv ices , 9 days 17 days 14 daysSOURCE Nat!onal lnstltute of Mental Health Alcohol, Drug Abuse and Mental Health Admms-
trallon Pubhc Health Serwce U S Department of Health and Human Serwces, Merr/a//fea/fh L/ruled Sfales 7985 C A Taube and S A Barrett (eds ) DHHS Pub No (ADM)8 5 - 1 3 7 8 (Rockwlle MD 19851
ulation under 18 in 1981. The declining use ofState and county mental hospitals and increasinguse of RTCs is shown dramatically in figure 3.
Partial hospitalization or day treatment in otherfacilities is another increasingly accepted way totreat some children. It may be appropriate forthose who require mental health care that is moreintensive than outpatient care but less intensivethan inpatient or RTC care (see ch. 6). Data onchildren’s admissions for partial hospitalizationcomparable to the data on other settings are notavailable, but the increasing use of partial hospi-talization can be inferred from NIMH’s 1983 end-of-year census data. These data indicated that20,000 individuals under 18 were receiving aplanned program of mental health treatment serv-ices generally provided in visits of 3 or more hoursto groups of patients/clients in various settings(665).
The use of outpatient treatment mental healthservices by children is difficult to determine. The1980 National Medical Care Utilization and Ex-penditures Survey found that 3.2 percent of chil-dren under 18—and 4.3 percent of all age groupscombined—had had a mental health visit in 1980,(665). Some observers have suggested that thesefigures probably underestimate the number of in-dividuals who receive outpatient mental healthtreatment and that the treatment rate for individ-uals of all ages may be as high as 6 percent (178).The 1980-82 NIMH epidemiologic catchment areasurvey of adults in urban areas found that 6 to7 percent of those surveyed had had a visit for
c
1965 1970 1975 1980Year
● State and county mental hospitalsA Private psychiatric hospitalsO Residential treatment centers for emotionally
disturbed childrenaData for residential treatment centers are for years 1969, 1975, and 1981
SOURCES 1970 to 1980 admission ratas to State and county mental hospitalsand private psychiatric hospitals. and 1969, 1975, and 1981 admis-sions for residential treatment centers National Institute of MentalHealth, Alcohol, Drug Abuse and Mental Health Administration, PubllcHealth Service, US, Department of Healfh and Human Services, Men.tal /-/ea/th United States, 1985, C.A Taube and .5A Barret t (eds.),DHHS Pub No. (ADM) 85-1378 (Rockville, MD 1985) 1969, 1975 and1 9 8 0 p o p u l a t i o n undar 18 (used to calculate admlsslon rates forresidential treatment centers) U.S. Department of Commerce, Bureauof the Census, Washington, DC, unpublished data for 1969, 1975, and1980.
a mental health problem, not necessarily a diag-nosable disorder, in the 6-month period preced-ing the survey (599). Without specifying precisepercentage increases by age, a 1985 NIMH report(665) noted that the use of outpatient mentalhealth services had greatly increased for all ages.Careful assessment of the use of mental healthservices by children awaits conduct of the NIMHepidemiologic survey of children.
27
CONCLUSION
There appears to be a significant gap betweenthe number of children identified in epidemiologicassessments as requiring mental health servicesand the number receiving services. There is gen-eral agreement that at least 12 percent of the Na-tion’s children—7.5 million—are in need of sometype of mental health treatment. Available evi-dence suggests that only a small number (fewerthan one-third) of the children who have mentalhealth problems receive treatment. An unknownnumber of other children maybe at risk for mental
health problems and in need of preventive serv-ices (see ch. 4). The problems of a lack of treat-ment and inappropriate treatment for children’smental health problems have long plagued thoseresponsible for providing services to children.Subsequent chapters of this background paper ex-amine the current state of knowledge about diag-nosable mental disorders and the environmentalrisk factors that can cause or exacerbate children’smental health problems.
Part II: Problems
Chapter 3
DSMDIII Mental Disordersin Children
Chapter 3
DSM1111Mental Disorders in Children
INTRODUCTION
The mental health problems of children existalong a continuum. This chapter describes thoseproblems which are considered mental disordersamong children, as described in the most widelyused diagnostic manual in the United States—thethird edition of the American Psychiatric Asso-ciation’s Diagnostic and Statistical Manual, bet-ter known as “DSM-111’” (19). Generally, DSM-111 defines a mental disorder as:
. . . a clinically significant behavioral or psycho-logical syndrome or pattern that occurs in an in-dividual and that is typically associated with ei-ther a painful symptom (distress) or impairmentin one or more areas of functioning (disability).
A description of the major DSM-III diagnosabledisorders in children is important to an analysisof mental health services, because these disorders
‘At the time this background paper was being prepared, the Amer-ican Psychiatric Association was revising DSM-111. The new ver-sion will be known as DSM-111-R,
THE DSM-III DNOSTIC SYSTEM
A standard diagnostic system provides clini-cians and researchers common terms with whichto identify patients and thus makes possible shar-ing of information about similar classes of patients(19). It also allows clinicians and researchers tomake use of experience with previous patients inplanning and assessing the effectiveness of men-tal health treatment.
DSM-III provides clearer, more specific criteriafor diagnoses than previous taxonomies have, andit bases the diagnoses on descriptive informationabout disorders rather than on causal factors,about which there is still disagreement. Theseaspects of DSM-III have been lauded, but criti-cisms of DSM-III have been raised as well (563).Some critics have objected to labeling children’s
make up an intellectual framework by which themental health professions understand children’smental health problems. It takes on added impor-tance, because, in most cases, an individual musthave a DSM-III diagnosable disorder to be eligi-ble for third-party reimbursement for treatment.
For most mental health problems, the etiologyis not known (19). However, many DSM-III dis-orders and other children’s mental health prob-lems are often related to environmental stressorssuch as poverty, parental divorce, and abuse andneglect. Environmental stressors that pose risksto children’s mental health are described in chapter4. Many observers believe that children exposedto such environmental stressors, in addition tochildren with diagnosable disorders, are in needof preventive or other mental health services dis-cussed in this background paper. Both social andorganic causes of mental disorders are continu-ously under investigation (668), but a comprehen-sive analysis of causation is beyond the scope ofthis background paper.
mental health problems as “mental disorders” andhave been concerned that DSM-III diagnoses wouldbe used as labels to discriminate against children(563). Other criticisms are that DSM-III does notappropriately address mental health problems thatdo not fit into specific categories and lists specificcriteria for diagnosis with little empirical basis forsome categories (563).
DSM-III has gained substantial acceptance inthe United States. Outside the United States, theninth edition of the International Classificationof Diseases (ICD-9), developed by the WorldHealth Organization, is the standard.
DSM-III differs from ICD-9 and other classifi-cation systems in several respects. Among other
33
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things, it is the first widely used system to em-ploy a multiaxial approach to the diagnostic eval-uation of patients. The purpose of the multiaxialsystem of DSM-III is to “ensure that certain in-formation that may be of value in planning treat-ment and predicting outcome for each individualis recorded” (19). DSM-III has five axes, each ofwhich refers to a specific class of information rele-vant to a patient’s mental health problems (seetable 5).
The first three axes constitute the official diag-nostic assessment. Axis I is for indicating all men-tal disorders other than those to be indicated onAxis II. Examples of Axis I disorders are anxietydisorder and major depression. Axis II is for long-standing personality disorders and specific dis-orders of development in which a child’s devel-opment lags behind that of his or her peers in aspecific area such as reading or arithmetic. A pa-tient can receive multiple Axis I or Axis II diag-noses. Thus, for example, a child could be diag-nosed as having an anxiety disorder (Axis 1) inaddition to a reading disorder (Axis II).
Axis III is used to note physical disorders orconditions that are relevant to understanding ormanaging a patient’s mental health needs. Thecondition noted can be etiologically significant(e.g., a necrologic disorder associated with de-mentia) or not. This axis would be used, for ex-ample, to indicate juvenile diabetes, an illness thatcan have implications for the management ofmental health care.
DSM-III explicitly recognizes that factors suchas environmental stress and previous adaptationcan influence the course and treatment of a men-tal health problem. A comprehensive DSM-IIIdiagnosis includes information on these factorson Axes IV and V. Axis IV is a rating of the sever-ity of any psychosocial stressors connected withthe onset of a mental disorder. Examples of suchstressors are shown in table 5.
Finally, Axis Visa rating of the patient’s high-est level of adaptive functioning, a composite ofa patient’s ability to manage social relations, oc-cupation, and leisure time. Such information isoften important in predicting the course of a dis-order and in planning treatment (19).
In classifying mental disorders, DSM-III sepa-rates the class of disorders that usually first be-
Table 5.—DSM-llI’s Multiaxial DiagnosticEvaluation System
Official DSM-III Diagnostic Evaluation (Axes I,II, and Ill)Mental Disorders a
Ib
Axis 1: All Mental Disorders Not Assigned to Axis Ii● Mental disorders not assigned to Axis II (e. g., depres-
sion, anxiety disorder, conduct disorder)● Conditions not attributable to a mental disorder that are
a focus of attention or treatment (e.g., academic problem,parent-child problem, isolated acts of child or adoles-cent antisocial behavior)
● Additional codes (e. g., unspecified mental disorder, nodiagnosis on Axis 1, no diagnosis on Axis II)
Axis II: Personality Disorders and Specific DevelopmentalDisorders
● Personality disorders (e. g., paranoid personality disorder)c
● Specific developmental disorders (e. g., developmentalreading disorder)
Physical D isorders and Condi t ionsAxis Ill: Physical Disorders and Conditions
. Any physical disorders or conditions that are potential-ly relevant to the understanding or management of theindividual (e.g., diabetes in a child with conduct disorder)
Additional Information (Axes IV and V)Axis IV: Severity of Psychosocial Stressors
● A rating on a scale of 1 (no apparent stressor) to 7 (cata-strophic stressor) of the severity of the summed effectof all of the psychosocial stressors judged to have beena significant contributor to the development or exacer-bation of the current disorder. Examples of psychoso-cial stressors that might be considered in the case ofa child or adolescent include puberty, change in resi-dence, overtly hostile relationship between parents,hostile parental behavior toward child, insufficient or in-consistent parental control, anomalous family situation(e.g., single parent, foster family), institutional rearing,school problems, legal problems, unwanted pregnancy,insufficient social or cognitive stimulation, natural ormanmade disaster, A physical disorder can also be a psy-chosocial stressor if its impact is due to its meaning tothe individual, in which case it would be noted on bothAxis Ill and Axis IV.
Axis V: Highest Level of Adaptive Functioning Past Year● A rating on a scale of 1 (superior) to 5 (poor) of an in-
dividual’s highest level of adaptive functioning (for atleast a few months) during the past year. Adaptive func-tioning is a composite of social relations, occupational/academic functioning, and use of leisure time.
aMental disorders are disorders for which the manifestations are PrimarilY be-
havioral or psychological; physical disorders are disorders for which the mani-festations are not primarily behavioral or psychological,
bA person may have multiple diagnoses on Axes I and 11—0.9., one diagnosison Axis I and one diagnosis on AxIs 11, or multiple diagnoses within Axis I orA x i s Il.
cThe diagnosis of a personality disorder is generally reserved for adults, althou9h
t h e m a n i f e s t a t i o n s o f p e r s o n a l i t y d i s o r d e r s m a y a p p e a r i n c h i l d h o o d o radolescence.
SOURCE: Adapted from American Psychiatric Association, Diagnost ic arrdStatistic/ Manua/ of &ferrta/ Disorders, 3d ed. (Washington, DC: 1980),
come evident in infants, children, or adolescentsfrom several other major classes of disorders thatare not generally restricted to children (see table6). For heuristic purposes, DSM-III groups men-tal disorders that usually manifest themselves in
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Table 6.—Children’s Mental Disorders Listed in DSM-IIIa
MENTAL DISORDERS THAT ARE USUALLY FIRST EVIDENT IN INFANCY, CHILDHOOD, OR ADOLESCENCE
Intellectual DisordersMental retardation
Mild mental retardation, moderate retardation, severe mental retardation, unspecified mental retardation
Developmental DisordersPervasive developmental disorders (PDDs)
Infantile autism (onset before 30 months of age), childhood-onset pervasive developmental disorder (onset after 30 months of age and before12 years of age)
Specific developmental disorders (SDDs) (Axis II of DSM-III)Developmental reading disorder (dyslexia), developmental arithmetic disorder, developmental language disorder (expressive type or receptive
type), developmental articulation disorder, mixed specific developmental disorder, atypical specific developmental disorder
Behavior DisordersAttention deficit disorder (ADD)
ADD with hyperactivity, ADD without hyperactivityConduct disorder
Undersocialized, aggressive; undersocialized, nonaggressive; socialized, aggressive; socialized, nonaggressive; atypical
Emotional DisordersAnxiety disorders of childhood or adolescence
Separation anxiety disorder; avoidant disorder of childhood or adolescence; overanxious disorderOther disorders of infancy, childhood, or adolescence
Reactive attachment disorder of infancy; schizoid disorder of childhood or adolescence; elective mutism; oppositional disorder; identity disorder
Physical (Psychophysiological) DisordersStereotyped movement disorders
Transient tic disorder, chronic motor tic disorder, Tourette’s disorder, atypical tic disorder, atypical stereotyped movement disorderEating disorders
Anorexia nervosa, bulimia, picaOther disorders with physical manifestations
Stuttering, enuresis (repeated involuntary voiding of urine), encopresis (repeated voluntary or involuntary defecation in Inappropriate places),sleepwalking disorder, sleep terror disorder
OTHER MENTAL DISORDERS THAT MAY AFFECT CHILDRENb
Organic disorders (e.g., delirium, dementia, alcohol intoxication, barbiturate intoxication)Substance use disorders—sometimes occur in teens
Abuse of or dependence on any of five classes of substances; alcohol, barbiturates, opioids, amphetamines, and cannabisAbuse of any of three classes of substances: cocaine, phencyclidine (PCP), and hallucinogensDependence on tobaccoOther, mixed, or unspecified substance abuse (e.g., glue sniffing)Dependence on a combina t ion o f substances (e .g . , hero in and barbiturates, amphetamines and barbiturates)
Schizophrenic disorders (e.g., disorganized, catatonic, paranoid, or undifferentiated type)—onset is usually in late adolescence or early adulthoodSchizophreniform disorderAffective disorders
Major depression (single episode, recurrent)—can occur at any age, including infancyAnxiety disorders
Phobic disorders:Social phobia—often begins in late childhood or early adolescenceSimple phobia (e.g., of animals, heights, school, water)–age at onset varies, but fear of animals almost always begins in childhood
Anxiety states:Panic disorder—often begins in late adolescenceGeneralized anxiety disorderObsessive compulsive disorder—usually beings in adolescence or early adulthood, but may begin in childhoodPost-traumatic stress disorder—can occur at any age
Somatoform disorders (e.g., somatization disorder, conversion disorder, psychogenic pain disorder, hypocondriasis)Psychosexual disorders
Gender identity disorders:TranssexualismGender identity disorder of childhoodParaphilias (e.g., exhibitionism, sexual masochism)Other psychosexual disorders (e.g., ego-dystonic homosexuality)
Factitious disordersDisorders of impulse control not elsewhere classified (e.g., kleptomania, pyromania)Adjustment disorder—may begin at any agePersonality disorders (Axis II of DSM-III)
Although the symptoms of personality disorders may manifest themselves in adolescence or earlier, the diagnosis of a personality disorder(e.g., paranoid personality disorder, schizoid personality disorder, histrionic personality disorder, antisocial personality disorder) is generallyreserved for adults. Some personality disorders in adults have a relationship to corresponding diagnostic categories for children or adolescents:
Disorders of childhoodSchizoid disorder of childhood
Personality disordersSchizoid personality disorder
Avoidant disorder of childhood Avoidant personality disorderConduct disorder (undersocialized, aggressive) Antisocial personality disorderOppositional disorder Passive-aggressive personality disorderIdentity disorder Borderline personalitv disorder
aAlth~ugh this list does include the more ~omm~n children’s mental disorders, it is not e~haljstive, F u r t h e r m o r e , only s e l e c t e d d i s o r d e r s a r e d i s c u s s e d i n t h e text
of this background paperbDisorders In these classes are primarily adult diagnoses but may occur amon9 children
SOURCE Adapted from American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3d ed (Washington, DC’ 1980)
—
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infancy, childhood, or adolescence into five gen-eral categories based on the aspect of functioningthat is most disturbed: intellectual, developmen-tal, behavioral, emotional, and physical (psycho-physiological). Examples of disorders in severalof these categories are severe mental retardation,developmental reading disorder, undersocializedaggressive conduct disorder, reactive attachmentdisorder of infancy, chronic motor tic disorder,anorexia nervosa, encopresis, and enuresis.
In addition to the class of disorders that usu-ally first become evident in children, several broadclasses of mental disorders discussed in DSM-IIImay affect children. These classes and examplesof disorders that may affect children are shownin table 6. Such disorders include substance usedisorders, affective disorders such as major de-pression, various anxiety disorders, and adjust-ment disorder. Following DSM-III's heuristic fordisorders that usually manifest themselves earlyin a person’s life, substance use disorder is dis-cussed in this background paper under behaviordisorders, and depression and anxiety disorderunder emotional disorders. Because it stemsdirectly from an environmental stressor and cantake various forms, adjustment disorder is dis-cussed separately.
Any given child may have more than one DSM-111 disorder, and disorders may involve problemsacross general categories. Furthermore, distur-bances in one area are likely to have secondary
INTELLECTUAL DISORDERS
The only DSM-III mental disorder that primar-ily involves intellectual impairment is mentalretardation, although secondary intellectual def-icits are often involved in other disorders. Inclu-sion of mental retardation as a DSM-III mentaldisorder on Axis I has provoked concern.
One critical article (563) notes that mental re-tardation is primarily defined by a lowered levelof intellectual functioning and thus differs fromother disorders, which are characterized by ab-normal types of functioning. Advocates for men-tally retarded children seek to avoid any prejudiceagainst this population stemming from the asso-
effects on other areas of functioning. Thus, forexample, a child with a specific developmental dis-order will often have problems with behavior andemotions as a result.
Patterns of disturbance vary widely across diag-nostic categories. Disturbances present differentclinical patterns, pose different consequences forchildren and their families, impinge on differentsettings in varying ways, and require differenttreatments. Furthermore, mental disorders mayvary in severity. In some cases, for example, child-hood phobias are mild and transient; childrenoften overcome such phobias in the course of de-velopment. In other cases, however, childhoodphobias involve severe impairment and interferein significant ways with a child’s development(553). Beyond a certain level, the severity of a dis-order must usually be assessed separately fromthe DSM- diagnosis.
Several children’s mental disorders within broadgeneral categories are discussed below. The dis-cussion is not exhaustive. The purpose is to givethe reader a basic understanding of the range ofchildhood disorders, along with some informa-tion on their prevalence and their consequencesfor children. Most of the childhood disorders arereviewed, but a few are omitted in the interest ofspace because they are rare, their consequencesare relatively less severe than those of other dis-orders, or because the disorders that are discussedsufficiently illustrate the broad category.
ciation of mental retardation with mental disorders(422). When mental retardation is discussed in thisbackground paper, it is because of its inclusionin DSM-111 or because many mentally retardedchildren have mental health treatment needs.
Mental retardation is defined as significantlysubnormal intellectual ability that leads to defi-cits in functioning. In DSM-III, the criterion denot-ing intellectual ability in the mentally retardedrange is a score on a standardized intelligence (IQ)test of 70 or below (although some flexibility onthe IQ is allowed). IQ tests are standardized tests
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with a mean of 100 and a standard deviation of15. A score of 70 is two standard deviations be-low the mean and places mentally retarded chil-dren in the bottom 2 percent of children intellec-tually.
There are an estimated 6 million mentally re-tarded persons in the United States; the range ofintellectual impairment in these individuals is wide.The American Association on Mental Deficiencyhas identified four broad levels of mental retarda-tion based on IQ: mild, moderate, severe, andprofound (257). These levels are intended to cor-respond to the individual’s capability for adapt-ive functioning and the degree to which trainingwill result in independent functioning. In general,the more retarded an individual is, the less inde-pendence he or she can be expected to gain fromtraining and the more supervision he or she willneed for self-care, work, and social relationships.At the extreme, profoundly retarded individualsrequire a highly structured setting with continu-ous care. With adequate training, however, manymentally retarded individuals can function inde-pendently.
Most mentally retarded children—about 80 per-cent—are mildly retarded. Approximately 12 per-cent of retarded children are moderately retarded,7 percent severely retarded, and 1 percent pro-foundly retarded (19).
Organic causation is not believed to be a fac-tor in most mental retardation. Only about 25percent of the incidence of mental retardation isattributable to organic causes (36); moderate, se-vere, and profound retardation are nearly alwaysassociated with organic brain damage. For 75 per-cent of mental retardation, almost all mildly re-tarded, however, there is no evidence of organiccausation. How this type of mental retardationis caused is not well understood, but it is thoughtto stem from environmental causes, genetic causes,or a combination of the two.
Neurologically based impairments in coordina-tion, vision, or hearing are often associated withmental retardation (19). Mentally retarded chil-dren are also three to four times more suscepti-
ble to other mental disorders than children in thegeneral population (19), especially to other dis-orders that may have a neurological basis likestereotyped movement disorder and attention def-icit disorder with hyperactivity (ADD-H) (19).They are at increased risk for problems with speech,language, and academic and social adjustment.Mental retardation can lead to stress, depression,and other emotional disturbances through severalmeans. The parents of some mentally retardedchildren may reject or overprotect them (538), ormentally retarded children may gain awarenessof their deficiencies, leading to low self-esteem anddepression (538).
Further, mental retardation limits the numberand quality of supportive relationships that chil-dren can form and limits their flexibility in solv-ing problems; as a consequence, there is an in-creased likelihood that retarded children will befrustrated and adopt poor strategies for manag-ing their lives. Institutionalized retarded childrenfrequently manifest atypically heightened levelsof dependency that are not attributable to cogni-tive level alone (730). The social environment ofretarded children is apparently critical; whetherthey are institutionalized, placed in a communitysetting, or raised at home can affect their mentaIhealth. Similarly, their mental health can be en-hanced by receiving education and training adaptedto their abilities.
Care and training of the mentally retarded isgenerally handled by a special service system sep-arate from the system that treats the emotionallyor behaviorally disturbed. Moreover, it is not gen-erally conceptualized by practitioners as mentalhealth treatment. For these reasons, interventionsspecific to mental retardation are excluded fromParts 111 and IV of this background paper. Thediscussion of disorders, environmental risk fac-tors, and services applies to mentally retardedchildren only insofar as such children have con-comitant mental health problems. Because con-comitant mental health problems are common inmentally retarded children, however, mentalhealth treatment is an important part of the serviceneeds of this population.
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DEVELOPMENTAL DISORDERS
Developmental disorders are characterized bydeviations from the normal path of child devel-opment. Such disorders can be either pervasive,affecting multiple areas of development, or spe-cific, affecting only one aspect of development.Like mental retardation, developmental disorderspose multiple problems for a child. Pervasive de-velopmental disorders (PDDs) severely limit chil-dren’s ability to function independently, while spe-cific developmental disorders (SDDSs can greatlyimpede children’s education and development ofsocial relations.
Pervasive DevelopmentalDisorders (PDDs)
Children with a PDD experience severe devia-tions from normal development in a number ofspheres. Primarily, these deviations are manifestedin cognitive and intellectual functioning, languagedevelopment, and social relationships. PDDsidentified in DSM-III are infantile autism andchildhood-onset PDD. DSM-III terms such as in-fantile autism or childhood-onset PDD have gen-erally superseded older labels such as childhoodschizophrenia or childhood psychosis.
Children with a PDD manifest a gross lack ofinterest in others and have problems relating, evento family members. They may appear obliviousto family members or caretakers walking in theroom, as if they were inanimate. They often uselanguage in bizarre ways —i.e., echoing what theyare told, using phrases with their own privatemeaning or using the pronoun “you” to refer tothemselves. Also, they often insist on the preser-vation of sameness in their environments and dis-play odd finger movements or postures. PDD chil-dren vary in terms of specific symptoms (712),but they all share marked impairment. PDDs arerelatively rare, but they affect somewhere between50,000 and 100,000 children in the United States,approximately 1 per every 1,000 children (712).
The intellectual functioning of children withPDDs varies. Many of the children with a PDDare mentally retarded, and the majority are be-low average in intelligence. In extremely rarecases, children with a PDD have brilliant isolated
skills, such as the ability to memorize train sched-ules or play musical instruments, although theymay not be toilet trained or able to use languageto communicate. The vast majority of childrenwith a PDD require special educational programs,and many parents need professional consultationor training to deal with these difficult children(712).
In most cases, parents are able to care for PDDchildren at home, although home care can becomeincreasingly difficult as the children become older(712). PDD is usually chronic, and the majorityof affected individuals are permanently unable tofunction independently. Autistic adults are foundin the same placements as adults who are men-tally retarded or schizophrenic: hospitals, long-term residential treatment centers, boarding houses,and often their families’ homes.
At one time, it was thought that the parentsof PDD children rejected them or withdrew fromthem in such a way as to lead to disturbance intheir development (58). Such ideas have gener-ally been discredited. Studies indicate that thereare no personality or other differences betweenparents of PDD children and other parents (97,424). It is now suspected that PDD is related toimpairment in neurochemistry or neuroanatomy.
Specific DevelopmentalDisorders (SDDs)
Children with SDDs have difficulty with spe-cific skills underlying learning, but their overalldevelopment is within normal ranges. DSM-IIIidentifies several types of SDDs according to theparticular skill which is impaired—e.g., develop-mental language disorders, developmental read-ing disorder (i. e., dyslexia), and developmentalarithmetic disorder (19). In children with an SDD,the development of one of these specific skills iswell below the average for the particular child’sgrade level. All SDDS combined are estimated toaffect 3 to 5 percent of the school age population(41), although as much as 10 percent of the adultpopulation is thought to have significant difficul-ties with reading, possibly related to an under-lying disorder.
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There are two forms of developmental languagedisorders: receptive type and expressive type. Inthe receptive type, children have trouble under-standing spoken language; in the expressive type,children understand what they hear and knowwhat they want to say, but have difficulty recall-ing and arranging the words necessary to speak.Developmental articulation disorder refers to pro-nunciation difficulties with English sounds suchas “s” and “th,” leading children to appear as ifthey are using “baby talk” (19). Developmentalreading disorder and developmental arithmeticdisorder are diagnosed when reading or arithmeticskills are impaired relative to expectations for achild’s age, and neither deficits in intelligence norschooling are deemed responsible.
SDD children are prone to school failure. Dif-ficulties in learning are often compounded by sec-ondary mental health problems, including schoolbehavior problems, aggression or delinquencyoutside of school, anxiety and depression, and
BEHAVIOR DISORDERS
Behavior disorders are a set of problems inwhich a child’s distress or disability is a functionof his or her overt behavior. Since the centralcharacteristics of these disorders are behaviorsthat disturb or harm others, the child’s social envi-ronment plays a large part in whether that childwill be identified as having behavior disorders andinfluences the course of these disorders. Some re-searchers and clinicians maintain that the natureof behavior disorders and the life history of af -fected children are especially dependent on thechildren’s experience with social systems,the family, neighborhood, and school.
such as
Attention Deficit Disorder (ADD)
Children with ADD are unable to maintain fo-cused activity for more than a brief period andcontinually initiate new activities. Most childrenwith ADD also suffer from hyperactivity, con-tinual movement that is especially disruptive instructured group situations like a classroom.These children are diagnosed as having ADD withhyperactivity (ADD-H). In addition, there is a 50-
poor relationships with peers (41,576). The per-ceptual skills that are essential for learning to read,spell, write, and do arithmetic may also be im-portant in social interactions and in establishingand maintaining social relationships (82,426).
In some cases, SDD children may have to en-dure the frustration and anger of parents andteachers who do not recognize their learning dis-ability or understand how to help them. In suchsituations, parents or teachers may ascribe thechild’s failure to laziness or stubbornness. In cer-tain cases, behavioral problems may partiallycause the learning difficulty (576), but in othercases, emotional or behavioral problems stemfrom the breakdown in a child’s education thatis the consequence of having a learning disorder.Such secondary effects create additional obstaclesto learning and reinforce a child’s classroom fail-ure (132). Many SDD children drop out of schoolin their teens (79).
to 80-percentSDDs (462).
overlap between ADD-H and some
Schoolchildren with ADD may have great dif-ficulty concentrating or inhibiting impulses toleave their seat and move around during classtime. They may continually call out in class orpush ahead of others in lines because they can-not tolerate waiting. Since the ability to maintainattention is essential to learning, children withADD often have serious academic problems. Fur-ther problems may arise from the stress the childand school experience in dealing with the primaryproblem. Like SDD children, ADD children suf-fer from the frustration and poor self-imagecaused by not learning, the stigma of lagging be-hind their class, and the anger and frustration ofparents and teachers. ADD children are prone toanxiety, depression, and social withdrawal (426),and typicalIy have problems developing and main-taining friendships. The severity of ADD variesgreatly across children (556). Some children areable to compensate for their difficulty with littleinterference in their lives, while others are so se-
40
verely affected that they cannot tolerate normalschool programs.
ADD children often exhibit aggressiveness orstubbornness and are prone to temper tantrums(439). Aggressiveness and impulsivity may beprimary components of ADD, or they maybe sec-ondary consequences of the frustration and hu-miliation felt by a learning-disordered or hyper-active child. In addition, aggressiveness may arisefrom the struggle with teachers trying to deal withADD children in the classroom.
An important factor in ADD is the ability ofchildren’s families and schools to tolerate andmanage their behavior (470). Although it is un-likely that social factors cause hyperactivity, neg-ative responses from the social environment towardthese children are often an additional burden.
The outcome of ADD in adolescence and adult-hood varies greatly. Some children seem to “out-grow” ADD, while others continue to suffer fromADD into adolescence and adulthood. In somecases, hyperactivity ends or attenuates in adoles-cence, but problems with distractibility or impul-sivity often remain. As they grow to be adoles-cents and adults, hyperactive children have anincreased risk of academic and behavioral prob-lems, substance abuse, school failure, and con-tact with the legal system (62,306,435,441,692).
The causes of ADD are not well understood.It was once believed that ADD stemmed fromprenatal or perinatal brain injury. But there is noevidence for the existence of brain damage amongmost affected children, and the difference betweenhyperactive and normal children in the birth proc-ess and infancy does not explain the existence ofthese disorders (556). Neurological differences be-tween hyperactive children and normal childrenare plausible, but they may not reflect pathologyso much as the general variation in cognitive abil-ities and temperament in children. Other researchhas implicated food additives, allergies, and envi-ronmental toxins as causal agents for hyperac-tivity (176,461), although such evidence is, atpresent, only suggestive.
Conduct Disorder
Children with conduct disorder exhibit a pat-tern of behavior that violates social norms, oftenharming others. Such children have a history ofeither infringement of the rights of others, or vio-lations of the law, or both. Their pattern of mis-conduct includes behaviors such as fighting, van-dalism, stealing, lying, rule-breaking, and runningaway from home. An ongoing history of misbe-havior differentiates conduct disorders from thenormal mischief of adolescence.
Conduct disorders are often first defined asproblems by the legal system. Despite some over-lap, however, conduct disorder is not the sameas “juvenile delinquency. ” Conduct disorder is apsychiatric term describing a longstanding pat-tern of misbehavior, whereas delinquency is a le-gal term applied to minors convicted of an of-fense. Many children incarcerated in juvenilejustice facilities would not be diagnosed as hav-ing conduct disorder, primarily because their be-havior does not comprise a pattern. The extentto which juvenile crime is associated with actualconduct-disordered adolescents is unknown.
Children with conduct disorders differ in thedegree to which they are socialized and capableof forming attachments to others, but there is con-troversy about whether differences in socializa-tion constitute distinct types of conduct disorders(19). Some believe that adolescents who havegood family and peer relationships, who have areasonable sense of self, and whose delinquencyprimarily reflects neighborhood and peer groupinfluence probably do not truly have a mental dis-order (9). The antisocial behavior of such adoles-cents may be largely directed at those outside theirgang or family.
Some children with conduct disorders are un-able to form friendships or extend themselves toothers in any way. These undersocialized be-havior-disordered children relate to others in ex-ploitive and egocentric ways. They are also likelyto have experienced problems with conduct froman early age, when they would normally have de-
veloped the capacity to relate to others. Conductdisorders that begin prior to age 13 are particu-larly pernicious. Early onset often leads to seri-ous consequences for both children with conductdisorders and people around them.
Although disorders of conduct are defined bya pattern of inappropriate behaviors, such dis-orders are often accompanied by considerable per-sonal suffering, and children with conduct dis-orders usually have low self-esteem, despiteoutward bravado (19). These children often ex-perience mental health problems such as depres-sion, anxiety, or substance abuse, and/or haveacademic problems (19,565). Even when they areable to form significant relationships, the relation-ships may be fraught with conflict (432). It shouldalso be noted that the occurrence of hyperactivityand conduct disorder overlaps considerably (624).
Estimates of the prevalence of conduct disordervary greatly because of the use of different defi-nitions of the disorder and different sources ofdata. In addition, the prevalence of conduct dis-order varies depending on sociological variablessuch as low income and poor housing (703). Gen-eral population surveys estimate the prevalenceat 5 to 15 percent, but such surveys often use lessstringent criteria than DSM-III (432). A furtherproblem is that such surveys fail to distinguishbetween socialized and undersocialized children(432).
The course of conduct disorder depends greatlyon social as well as individual factors (19). Gang-related delinquency, for example, depends on suchfactors as youth employment rates. Most childrenwith conduct disorders, particularly those able toform relationships, are able to stop their misbe-havior as they mature (546). Others may continueillegal behavior for financial gain, but functionadequately otherwise. Many children with con-duct disorders, however, continue their inappro-priate behavior into adulthood and maintain a lifecentered around criminal behavior. They continueto have problems with social relationships, andmany suffer in adulthood from alcoholism, drugdependence, or depression (544). These tend tobe the children whose delinquency starts early andwho have committed a greater number and vari-ety of antisocial acts (544).
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Many theories for explaining the developmentof conduct disorder implicate child-rearing prac-tices. The parents of undersocialized, aggressivechildren are believed not to have formed a lov-ing parental attachment to the infant. Many par-ents of children with conduct disorders are alco-holic or have a history of antisocial behavior(544,545). Often, children who develop conductdisorders are unwanted or unplanned. As the childmatures, parents alternate between being unin-terested in the child and being overly protective(432). Other theories suggest biological andgenetic components to undersocialized conductdisorder (544).
Substance Abuse and Dependence
Drug and alcohol abuse are sometimes viewedas diseases separate from mental health problems.In terms of etiology and implications, however,substance abuse may be similar to other mentalhealth difficulties. The implications of substanceabuse for children and adolescents are particularlysevere. Substance abuse broadly disrupts a youngperson’s functioning, can cause distress and long-term disability, and can lead to or exacerbate con-flict in family and peer relationships. Chronic drugand alcohol use can also harm academic and jobperformance. Legal problems arise both from ac-tions carried out under the influence of drugs oralcohol and from buying, possessing, and sellingdrugs or alcohol. Several substances, such as al-cohol, barbiturates and sedatives, opiates, andamphetamines, can, with frequent use, lead tochemical dependence.
Substance abuse is correlated with problemssuch as psychological distress (483), life stress(156), low school achievement (321), runningaway from home (160), parental drug use (547),and perceived lack of involvement by parents(483). Substance-abusing children are often trou-bled by anxiety and depressed moods (19). Sev-eral studies suggest that many adolescents whouse alcohol and drugs heavily were psychologi-cally disturbed as younger children (331,486,615;for conflicting evidence, 338). School learningproblems and aggressive or antisocial behavioras a child are good predictors of later drug use,especially if they are associated with difficulties
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in relationships (338). Available evidence suggeststhat interventions aimed at treating substanceabuse and dependence must also deal with themultitude of other mental health problems withwhich abusers are also afflicted (63).
Identifying substance abuse as a type of men-tal disorder is useful because it draws attentionto the mental health implications of abusing chem-ical substances. Substance abuse in adolescents,
EMOTIONAL DISORDERS
Several children’s mental disorders have theirmost noticeable effect on a child’s emotional state.The severity of children’s emotional problemsvaries widely. To represent a diagnosable men-tal disorder, however, an emotional problem mustbe accompanied by considerable impairment ofa child’s ability to function.
Anxiety Disorders
In children with anxiety disorders, excessivefearfulness and symptoms associated with fear in-terfere with a child’s functioning. Anxiety-disor-dered children may experience muscular tension,have somatic complaints without physical basis,and experience repeated nightmares. Childrenwith anxiety disorders may be preoccupied withunrealistic dangers and may avoid fear-producingsituations to the point of stubbornness or tantrums.
Anxiety disorders that are especially associatedwith childhood or adolescence include separationanxiety disorder, avoidant disorder of childhood,overanxious disorder, and certain phobic disor-ders (19). Children with separation anxiety areafraid to be away from their parents, from home,or from familiar surroundings. They avoid a va-riety of normal activities and, in some cases, re-fuse to go to school. They may cling to parentsand develop physical complaints when separationis about to occur; if separated, they become fear-ful, sometimes to the point of panic. Separationanxiety may lead children to have morbid fearsabout their parents’ death, or difficulty sleepingif family members do not stay with them. Thisdisorder often waxes and wanes during childhoodyears, usually increasing in response to stress.
however, is frequently associated with other men-tal disorders discussed in this chapter, includingconduct disorder, ADD, and SDD. Substance useand abuse by children also illustrates the complex-ity of identifying discrete mental health problemsand separating disorders from normal development.Considerable evidence suggests that substance use,and occasional abuse, is currently “a ‘normal’ de-velopmental reality” among adolescents (369).
Avoidant disorder of childhood or adolescenceis similar in many ways to separation anxiety dis-order, except that the focus of the problem is con-tact with strangers rather than separation fromloved ones. These disorders rarely last beyondadolescence.
Phobias are irrational anxiety reactions to spe-cific situations or objects leading children to avoidthese situations or objects. Common childhoodphobias include dog, school, and water phobias(553). Mild phobias are normal and occur amongalmost half of all children; they are usually out-grown. Phobias in an estimated 0.5 to 1 percentof children, however, can be intense and inter-fere with the child’s development. Children avoidthe feared object to the point of not participatingin an important activity or avoiding learning im-portant new behaviors. School phobia is perhapsthe most common childhood phobia (553) and canlead to serious educational problems (343).
Childhood Depression
“Depression” can refer to a mood, to a set ofrelated symptoms that occur together, or to acomplete psychiatric disorder with characteristicsymptoms, course, and prognosis (357). The psy-chiatric disorder includes both depressed moodand symptoms of impaired functioning such asinsomnia, loss of appetite, slowed activity andspeech, fatigue, self-reproach, diminished concen-tration, and suicidal or morbid thoughts (19),
Depression influences concentration, energylevel, and confidence; can affect physical health;and is usually associated with a perhaps unrealis-
tically pessimistic view of the world (367). Likeother emotional disorders, it has the potential toseriously impair a child’s abilities to function inschool, with peers, and with family. Depressedchildren commonly withdraw from social rela-tionships. The low self-regard, hopelessness, andhelplessness of depressed adolescents may lead tosuicide (93). The amount of mental suffering de-pressed children undergo can be considerable, al-though the degree of impairment and length ofthe depression vary considerably (19).
Many depressed children exhibit behavioralproblems that are more longstanding and morealarming to adults than their depression (95). Aconduct or learning problem may be labeled asthe chief disturbance that needs treatment, whiletheir depression is overlooked. Some theorists andresearchers have called this “masked” depression,because these behavioral difficulties, in theirability to stir up and distract the child and others,protect the child from experiencing painful, de-pressed feelings (133). Recent research, however,suggests that with careful questioning, many suchchildren with behavioral problems will reveal per-vasive problems with mood as well as behavior(102).
Depressive symptoms specific to children mayoccur, including anxiety over separation from par-ents, clinging, and refusal to go to school. De-pressed adolescents may react with sulky, angry,or aggressive behavior; problems in school; orsubstance abuse (19). Estimates of the prevalenceof childhood depression are variable as a resultof differing criteria used by researchers, differ-ences in the age of children studied, and otherdifferences among the populations examined (333).Estimates range from 0.14 percent (564) to 1.9 per-cent (332). Among children brought to psychiatricor education-related treatment centers, estimatesrange as high as 59 percent (SOS). Available re-search does not permit an overall conclusionabout the incidence and prevalence of childhooddepression or about the relationship of childhooddepression to other disorders.
The large number and range of theories sug-gesting the cause of depression are notable, Whatseems most likely is that psychological, biologi-cal, and social causal factors arise together to ini-tiate and perpetuate depression (13). Most models
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It is sometimes difficult to distinguish between commonadolescent emotional turmoil and more serious forms
of childhood depression and anxiety.
used in explaining how childhood depression de-velops are borrowed from analyses of adult de-pression. Studies assessing the applicability ofadult models to childhood depression have beenconducted only recently. For example, much evi-dence substantiates the relationship between de-pression in adults and low concentrations of cer-tain neurotransmitters (biochemical that providefor transmission of impulses across nerve cells).Several studies have found lower levels of the by-products of these neurotransmitters in the urineof children with chronic depressive disorder (428).
Even when children are not clinically depressed,persistent poor mood or symptoms such as insom-nia or poor appetite often accompany other child-hood disorders or stressful situations or events.Clinicians treating children must often attend tothe depressed mood which accompanies demorali-zation felt in the face of a number of the otherdisorders, or environmental or medical stressors.
Reactive Attachment Disorderof Infancy
Reactive attachment disorder of infancy, insome severe cases called “failure to thrive, ”denotes a syndrome in which infants who are re-ceiving inadequate care are poorly developed bothemotionally and physically. If the disorder is nottreated, it often results in severe physical compli-
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cations: malnutrition, starvation, or even death.Case studies also show that failure to thrive canlead to feeding disorders such as obsession withfood and food refusal.
Reactive attachment disorder exemplifies thecomplexity of the origins of childhood mentalhealth problems. DSM-III states: “The diagnosisof Reactive Attachment Disorder of Infancy canbe made only in the presence of clear evidenceof lack of adequate care” (19). Often, however,the disorder does not arise simply from “bad”parenting, but instead arises from a combinationof both complications in an infant’s developmentand emotional difficulties and stress affecting par-ents (153). Some parents interpret problems in an
infant’s feeding or development as rejection. If aparent, as a result, is unable to properly interpretan infant’s cues to be fed, the infant will not befed adequately, and may develop a severe reac-tive attachment disorder. Parents who have emo-tional difficulties or are burdened with stress areespecially predisposed to such a response. A pat-tern of similar breakdowns in communication be-tween infants and parents can also lead to difficul-ties developing emotional attachments betweenparents and children, and later with the child’sdeveloping appropriate autonomy. Yet reactiveattachment disorder of infancy can be “completelyreversed” by adequate care (19).
PSYCHOPHYSIOLOGICAL DISORDERS
Children’s mental disorders that involve a dis-turbance in some aspect of bodily functioningusually involve a combination of mental andphysical factors; hence, these disorders have beencalled psychophysiological disorders. Psycho-physiological disorders include stereotyped move-ment disorders, enuresis and encopresis, and eat-ing disorders. As described below, the physicalmanifestations of psychophysiological disordersare diverse. These disorders may place childrenat great risk, since they pose threats to both phys-ical and mental health.
Stereotyped Movement Disorders
Stereotyped movement disorders are thoughtto have a primary physical or neurological ba-sis. Nevertheless, such disorders are influenced bythe psychological state of the child and are some-times amenable to behavioral or psychological in-tervention.
Children with stereotyped movement disorderssuffer from tics—sudden, repetitive movementsof a particular body part. In a rare form of stereo-typed movement disorder, Tourette’s syndrome,vocal tics (short grunts, yelps, or other vocalsounds) accompany the body movements (19).Tics are generally involuntary, although they canbe suppressed temporarily through concentration
(19,598). In general, they are thought to have anorganic basis, yet stress or anticipation can in-crease their frequency (314,598). Tics may be atransient or chronic problem (19). Although 12to 24 percent of schoolchildren in surveys havereported having had tics at some time, overallprevalence is unknown because there is no infor-mation on how many children have this difficultyat any one time. Children with these disorders suf-fer considerable embarrassment and are often un-able to bring their tics under continual voluntarycontrol. These disorders sometimes disappear inadulthood, but can be lifelong.
Eating Disorders
Disorders involving eating behavior include avaried group of dysfunctions. The most commoneating disorders are anorexia nervosa and bulimia,which occur primarily in adolescents. Anorexiais characterized by a refusal to eat, leading to aloss of body weight (literally, “nervous weightloss”). The DSM-III diagnosis of anorexia nervosaapplies to those who have lost at least 25 percentof body weight. Individuals with this disorder,typically adolescent girls and young women,starve themselves because of an exaggerated fearthat they will be overweight and therefore un-attractive.
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In extreme cases, children with anorexia ner-vosa may refuse to eat altogether, even if theyare already very thin. Because of the possibilityof malnutrition, serious medical illness, or death,anorexia can have serious consequences. Psycho-logical complications such as depression and with-drawal can also result from the starvation involvedwith anorexia nervosa. These complications oftenovershadow the original psychiatric problems thatled to the eating disorder (620).
Bulimia is, in some respects, the converse ofanorexia nervosa. Bulimics, usually adolescents,consume large quantities of food in one sitting(“binge eating”). They often stop only when painor nausea is too great to continue. Often, bulimicsself-induce vomiting or use laxatives, enemas, ordiuretics to purge themselves of what they haveeaten. Because of the physical insult of this pat-tern of behavior, bulimia can be associated withphysiological disturbance. Although the preva-lence of bulimia in adolescents is unknown (19),recent surveys (271,626) indicate an incidence rateof 13 to 67 percent for self-reported binge eatingin college populations. Such data suggest that theproblem of bulimia is substantial, although it maymost frequently appear only as a transient prob-lem. Various adjustment problems often accom-pany a bulimic disorder, including depression anddifficulty with social relationships (322,335,708).
ADJUSTMENT DISORDER
For most DSM-III disorders, a cause is notspecified, because in most cases, causes of dis-orders are as yet unknown (19). Adjustment dis-order, however, refers to a pattern of emotionalor behavioral difficulties that occurs in responseto a stressful event. Stressful events can over-whelm the capacity of children to cope, leadingthem to develop disabling emotional reactions tothe stress or to develop unfortunate ways of try-ing to cope that create more problems. Stressfulevents leading to adjustment disorder could in-clude any of a variety of crises such as divorceor acute illness of a parent. Adjustment disorderoften remits without treatment, either because thestressful life event has ended or because the childand family have developed new resources equal
Perhaps the most serious eating disorder is thecoincidence of the two above disorders, which hasbeen called “bulimarexia” (64). Affecting primarilyadolescents, bulimarexia combines obsessive self-denial of food with intermittent binge eating.Casper and her colleagues (105) found that almosthalf of a sample of patients with anorexia alsosuffered from bulimia, and that these patientswere significantly more obsessional about food,more guilty, more depressed, and more likely tobe involved in compulsive stealing.
Enuresis and EncopresisEnuresis is the diagnostic term for bedwetting
and other inappropriate urination, while encopre-sis is the term for lack of control over defecation.Each of these disorders has relationships to otherdisorders as well as complicated connections tophysiology, environmental factors, and familygenetic history. In many cases, physical problemseither cause these disorders or predispose childrento them (19,596), and there is some evidence thatenuresis tends to run in families (19,33). But enu-resis and encopresis tend to occur more frequentlyin disadvantaged families (440), under stressfulconditions (19,523), and together with other dis-orders (565). Enuresis affects 5 to 15 percent of7-year-olds (565) and encopresis 1 percent of 5-year-olds (19).
to the stress. In vulnerable children and families,however, an adjustment disorder can usher inmore serious difficulties.
The main features of adjustment disorder aredepressed or anxious moods, antisocial behavior(especially in adolescents), difficulties that infantshave in their interaction with their primary care-givers, or inability to work or maintain relation-ships (19). Thus, adjustment disorder resemblespsychiatric disorders such as anxiety disorder orconduct disorder. Adjustment disorder is differen-tiated from disorders with parallel symptoms onthe basis of how long the problem has lasted andwhether or not it followed from a stressful event.The diagnosis of adjustment disorder is sometimes
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made by child clinicians because they would often or major depression which imply more pervasiverather use the more benign label of adjustment impairment.disorder than diagnoses such as conduct disorder
CONCLUSION
The five general categories of children’s men-tal disorders discussed in this chapter—intellec-tual, developmental, behavioral, emotional, andpsychophysiological—represent patterns of dys-functional adaptation in children. Although nor-mal, as well as mentally disordered, children mayexhibit symptoms of these disorders, in each case,it is the pattern of pervasive difficulty that leadsto the diagnosis. No mental disorder, howeverwell-described by current psychiatric nomencla-ture, manifests itself in parallel ways across chil-dren. Environmental risk factors, to be discussedin chapter 4, can influence both the manifestationand course of children’s mental disorders. In addi-
tion, when maladjustment of a child occurs, itdoes not necessarily take the form of mental dis-ability as defined by psychiatric nomenclature.
The diversity and complexity of children’s men-tal health problems suggests a need for treatmentapproaches differentiated according to each spe-cific child’s needs. In addition, the relationship ofmany of these problems to normal functioningsuggests a need for integrating mental health serv-ices with family and school settings in which chil-dren function. Subsequent chapters of this back-ground paper consider these topics more explicitly.
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Chapter 4
Environmental Risk Factors andChildren’s Mental Health Problems
Chapter 4
Environmental Risk Factors andChildren’s Mental Health Problems
INTRODUCTION
As described in chapter 3, diagnostic manuals,such as the American Psychiatric Association’sDiagnostic and Statistical Manual (DSM-III), de-fine mental disorders and set out criteria that mustbe met for a mental health problem to be consid-ered a disorder. In DSM-III (19), a mental healthproblem is considered a disorder only if the prob-lem is:
. . . a clinically significant behavioral or psycho-logical syndrome or pattern . . . that is typicallyassociated with a painful symptom (distress) orimpairment in one or more areas of functioning.
Although defining and establishing criteria formental disorders is useful, it can mean that chil-dren with subclinical mental health problems, orthose in danger of developing a disorder, may notbe considered to be in need of mental health serv-ices. In reality, children, particularly those ex-posed to environmental stressors, may exhibit dis-crete mental health problems. For example, a childwhose parents divorce may experience anger anddepression. Children with a major physical illnessmay experience loneliness when they cannot seetheir family and friends, Children born into orthrust into poverty may experience constant anxi-ety as a result of financial insecurity. Further,some children are exposed to multiple stressorsand so may be vulnerable to a number of mentalhealth problems.
The multiaxial system of DSM-III incorporatesenvironmental stressors on Axis IV (psychosocialstressors, including stress arising from physicalillness) (19; also see ch. 3). Because DSM-III isprimarily a manual for clinicians, however, it nec-essarily treats psychosocial stressors as additional,rather than primary, information to be used indeveloping a mental health treatment plan for apatient. Although there is disagreement about thevalue of primary prevention of mental health
problems (15), it is widely agreed that it may bepossible to address certain environmental stres-sors preventively.
This chapter describes a number of environ-mental stressors that children may be exposed to,along with the mental health problems that maybe caused or exacerbated by such stressors. Thechapter does not review every environmental fac-tor that poses a risk to children’s mental health,but it does attempt to cover the specific environ-mental, primarily psychosocial, factors that posethe greatest risk and to illustrate generally theeffect that environment can have on the devel-opment of children’s mental health problems.And, as acknowledged by DSM-III's multiaxialdiagnostic system, these environmental factorscan also affect the course of mental health prob-lems, and plans to treat such problems, Discussedare poverty; premature birth; parental psy-chopathology such as alcoholism, maltreatment,teenage parenting (a problem for both parent andchild); and parental divorce. The purposes are tofocus attention on the range of children’s mentalhealth problems that may be amenable to inter-vention, whether the intervention is designed toalleviate pain or prevent development of more se-vere problems; and to raise the issue that it seemsessential to develop policies and programs so thatthey work for the particular children who needto be helped. As discussed in chapter 2, severalnational commissions have stressed the impor-tance of attending to environmental factors in de-veloping mental health programs for children.These commissions have also made specific sug-gestions for developing such policies and pro-grams. However, it is beyond the scope of thisbackground paper to draw out fully all the im-plications of designing a mental health servicessystem so that it is responsive to all the childrenin need.
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INTERACTIONS AMONG ENVIRONMENTAL RISK FACTORS
Single environmental risk factors rarely occurin isolation. Much more common is the occur-rence of several risk factors together—often in thecontext of a broad risk factor such as low socio-economic status. Child maltreatment, for example,most often occurs in families that are disor-ganized, under high stress, and of low socioeco-nomic status (219,499,500). Parental divorce oftenresults in downward economic mobility, reloca-tion to more stressful circumstances, increased so-cial isolation, and loss of important support sys-tems (289).
For a comprehensive look at the mental healthneeds of children, it is important to consider howrisk factors interact with one another. For exam-ple, ethnicity, social class, and related variables(e.g., years of parent education) have been foundto have a powerful influence on a child’s develop-ment. They, in turn, are related to parental atti-tudes towards childrearing (360, 572); to the qual-
ity of parent-child interaction (640); to children’scognition, motivations, personality, and achieve-ment behavior (144,149,150,241,287,320,392, 732);and, of course, to the community in which a childlives and the school he or she attends.
It is also important to consider children’s dif-ficulties in the context of knowledge about nor-mal development. It is useful to describe the neg-ative effects of environmental risk factors in termsof a child’s difficulties with completing importantdevelopmental tasks. Developmental tasks are theactivities children engage in so as to advance tothe next stage of their development (e.g., becom-ing toilet-trained is a developmental task for tod-dlers; developing intense friendships with peersis a developmental task for young adolescents).A child’s failure to carry out salient developmentaltasks can appropriately be viewed as an indica-tor of maladjustment.
POVERTY AND MEMBERSHIP IN A MINORITY ETHNIC GROUP
Being poor and being a member of a minoritygroup are environmental stressors that may poserisks to children’s mental health (116). Althoughit is important to recognize that most poor andminority individuals make health adjustments(116), the relationships between these environ-mental risk factors and poor social and psycho-logical functioning is well recognized (15). In their1981 review of the epidemiologic literature on theprevalence of mental disorders in children, for ex-ample, Gould, et al. (248), noted that childrenwho were poor, black, or Spanish-speaking andliving in an urban environment had mental healthproblems at rates greater than the 11.8 percentfound in U.S. communities on average. Althoughthe relationships are correlational rather thancausal, increasing evidence about the effects ofpsychosocial stress on both physical and mentalhealth supports the view that poverty and minor-ity status pose risks for mental health (15). In addi-tion, poverty and minority status are often ac-companied by other risk factors, making children
Photo credit: New York Times/Peter Freed
Children who must live in shelters may be at increasedrisk of developing mental health problems as a resultof adverse environmental factors such as poverty,
unstable home life, and inadequate care.
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exposed to other risk factors even more vulner-able to developing mental health problems.
The relationship of socioeconomic class andethnicity to mental health takes on particularlygreat importance with evidence that povertyamong children—especially among black and His-panic children—has increased in recent years. Areport prepared by the Congressional ResearchService and the Congressional Budget Office in-dicates that in 1983 there were 13.8 million poorchildren in the United States (646). The report
PARENTAL PSYCHOPATHOLOGY
In most children’s development, the family playsa crucial role. It is perhaps not surprising, there-fore, that the presence in the family of a parentwith psychopathology increases a child’s risk ofexperiencing emotional and behavioral difficul-ties. Some of the difficulties that the children ofmentally ill parents may develop meet the criteriafor standard DSM-III psychiatric diagnoses; otherdifficulties, however, are general impairments inchildren’s social, emotional, or cognitive function-ing that do not meet the standard criteria for di-agnosable mental disorders. The relative contri-bution of genetic and environmental factors incausing the emotional and behavioral difficultiesof children with mentally ill parents is not clear.Nonetheless, the occurrence of mental illness ina parent constitutes a significant risk factor to achild’s psychological well-being.
Affectively Disordered Parent
The development of children who have a par-ent with an affective disorder, such as depressionor manic-depressive illness, has been a focus ofmuch research. Evidence about the incidence ofaffective disorders within families indicates that10 to 40 percent of the immediate relatives of af-fectively disordered individuals also develop suchdisorders (225,315,501,613,713). There is grow-ing awareness that children can manifest thesymptoms of affective illness; although manic-depression is found infrequently in children andyoung adolescents, depression does exist duringchildhood (95).
notes that child poverty rates have increasedsharply among black and Hispanic children. Cur-rently, almost half of black children in the UnitedStates live in poverty, while less than 15 percentof nonblack children are poor (117). Being poormay also mean that children will not have accessto health insurance. An estimated 15.9 millionchildren and young adults (1- to 19-year-olds)were uninsured in 1977, the last year for whichnational data are available (661a).
Considering the effects of affectively disorderedparents on their children is important, because af-fective disorders—particularly depression—arethe major form of psychopathology to which chil-dren are exposed. The incidence of diagnosabledepression in adult women has been estimated at1 to 8 percent (70), and an even higher propor-tion (20 to 25 percent) are estimated to manifestmarked, untreated depressive symptoms (69). Fur-ther, the presence of infants and young childrenin the home increases the risk for depression inadult women (45,695).
In children of affectively ill parents, DSM-IIIdisorders as diverse as depression, separationanxiety, attention deficit disorder, personality dis-turbances, and conduct disorder have been iden-tified (371,560,697). The overall prevalence of di-agnosable mental disorders in these children hasbeen found to be in the vicinity of 40 percent(428,467,477). Although the rates found in vari-ous studies are not directly comparable (becauseof the use of different diagnostic criteria), the sim-ilar direction of results confirms that the childrenof affectively ill parents have a higher incidenceof depression and other problems than the chil-dren of normal parents.
Parental depression and mania seem to have aparticularly marked effect on cognitive and emo-tional development during infancy and early child-hood (115,218,571,696,725). Studies comparingthe effects of maternal depression with those ofschizophrenia (572), and the effects of maternal“psychological unavailability,” often a result of
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depression, with those of physical abuse and ne-glect (162) for example, indicate that a mother’saffective illness has a particularly pathogenic ef-fect on a child’s early development. In one study,children of psychologically unavailable mothersevidenced striking declines in functioning in everyimportant area of development from birth to 2years (162). As a group, these children appearedeven more impaired than children exposed tophysical abuse and neglect.
In middle childhood, children of affectively dis-ordered parents often experience difficulty in im-portant developmental tasks. Such children havebeen found to exhibit problems in meeting normsof school and classroom behavior (192,688); pooracademic performance (550,551); and difficultywith peers, especially in terms of aggressive be-havior (689).
As adolescents, the children of affectively dis-ordered parents often experience difficulties thatare more severe than those of other children.Garmezy and Devine (221) found, for example,that children of depressed mothers drop out ofjunior high school at more than twice the rate ofcontrols (22 v. 10 percent).
Studies of children of parents with affective im-pairments have looked almost exclusively at moth-ers; therefore it is difficult to draw conclusionsabout children of fathers with affective impairments.
Schizophrenic Parent
A parent with schizophrenia, a debilitating andoften chronic mental disorder, places a child atserious risk for developing mental health prob-lems. Persons who are schizophrenic are plaguedby hallucinations, delusions, or other thought dis-turbances. Children of schizophrenic parents havebeen shown to have a risk of developing schizo-phrenia 10 times greater than that of the offspringof nonschizophrenic parents (246). In general,these children also have more difficulties duringchildhood than do children of nonschizophrenicparents (682). This observation holds true evenin the case of children who have not spent themajority of their childhoods living with the schizo-phrenic parent.
Prior to birth, the children of a schizophrenicmother may already have experienced more ad-verse circumstances than the children of nonschiz-ophrenic mothers. The pregnancies and deliver-ies of schizophrenic mothers are more frequentlyaccompanied by complications than those of non-schizophrenic mothers (430,431,571,720), andsuch complications are frequently related to chil-dren’s developmental problems. Some research-ers have found the increased pregnancy and birthcomplications of schizophrenic mothers to beassociated with the low socioeconomic status thatoften accompanies schizophrenia (571), whileothers have found them to be independent (720).
In infancy and early childhood, children of aschizophrenic parent often exhibit a number ofmental health difficulties. Such children oftenscore lower than other children on measures ofcognitive, linguistic, and psychomotor function-ing, and they evidence deficiencies in adaptive be-havior and emotional attachment (571). Theseproblems can be exacerbated by the severity andchronicity of the illness and the low socioeco-nomic status typically associated with schizophre-nia (571,572).
During the preschool and early elementary schoolyears, children of a schizophrenic parent gener-ally do not exhibit severe behavior problems. Dur-ing middle childhood, however, evidence of seri-ous social and academic difficulties emerge whenthese children are compared to the children ofnonschizophrenic parents. Children of schizophren-ics are rated by teachers and by peers as less com-petent than other children (550). These lower rat-ings of competence seem to stem from a perceptionof these children as more aggressive, impulsive,and disruptive (431,687). Furthermore, childrenof schizophrenics seem to have serious difficul-ties in terms of intellectual functioning. In com-parison to the children of nonschizophrenic par-ents, they tend to have lower grades (551), lowerIQ scores (431,460,717), and less scholastic moti-vation (316). In addition, these children have beenfound to exhibit more attentional dysfunction(460), more emotional instability (316,683), anda greater amount of psychological disturbance ingeneral (718).
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In most studies on the development of childrenof schizophrenics, subjects have not yet reachedthe age at which schizophrenia becomes manifest(i.e., the early twenties). Nonetheless, they al-ready appear vulnerable. Although epidemiologicresearch suggests that only 10 percent of the chil-dren of schizophrenics themselves develop schizo-phrenia in adulthood, one study found that 75percent of these high-risk children develop someform of psychiatric disturbance (295).
The relative contributions of genetic and envi-ronmental factors in schizophrenia are not known.It is also unclear whether the negative psychologi-cal impact of having a schizophrenic parent is dueto the features of the disorder, to factors relatedto mental illness generally (e.g., severity and chro-nicity), or to the lower socioeconomic status thatusually accompanies this major form of psycho-pathology.
Alcoholic Parent
Alcoholism is one of our Nation’s most serioushealth problems (648,581), and the prevalence ofalcoholism and alcohol abuse among adult menand women (up to 15 percent) suggests that paren-tal alcoholism is one of the most common haz-ards to children’s mental health. Abuse of illegaldrugs by parents has also been implicated in theetiology of drug abuse by children (668a), but hasnot been subject to as much analysis as has paren-tal alcohol abuse.
Approximately 6.6 million children under theage of 18 in the United States are estimated to havean alcoholic parent (559). That alcoholism mayhave serious negative effects on child-rearing andfamily relations is suggested by the well-docu-mented harmful consequences of alcoholism tohealth, productivity, and other aspects of adultfunctioning (see 648). Alcoholism can disable par-ents from caring for their children effectively, and
it is associated with a number of other familyproblems that place children at risk of mental ill-ness. Such problems include family disorganiza-tion and divorce, violence, and life changes suchas job loss and frequent moves.
One of the earliest consequences of parental al-coholism is the exposure of the fetus to alcohol(l). Evidence suggests that alcoholic mothers haveincreased risk of complications in pregnancy andof having children who develop health problemssuch as physical anomalies (e. g., heart defects)and disturbances to physical growth (165). De-velopment of fetal alcohol syndrome, with a com-bination of birth defects, deficiency in growth,and deficits in development, is rare (165), but thedevelopment of fetal alcohol effects maybe morecommon.
The disinhibiting effect of alcohol suggests thatalcoholism may be associated with child abuse,although literature examining this relationship isequivocal (165,166). Some researchers find in-creased prevalence of alcoholism among childabusers, others find no relationship, while stillothers find that psychosocial disorders in general,including alcoholism, are associated with childabuse.
Only a few studies have examined the effect ofparental alcoholism on children’s development,despite frequent clinical suggestions about thedamaging effects of family alcoholism on a child’spersonality and family relationships (685). Somestudies have identified children of alcoholics asmore susceptible than other children to a rangeof psychological, educational, and social prob-lems including “emotional disturbance, ” hyper-activity, legal problems and drug abuse as adoles-cents, and a variety of behavioral problems andpsychiatric disorders (165,166). However, it is dif-ficult to rule out the possibility that related fac-tors such as socioeconomic status or family dis-organization are producing these effects.
MALTREATMENT
Recent estimates suggest that each year over 1 jury, sexual abuse, neglect and failure to provide,million children experience some type of maltreat- and emotional mistreatment. An estimated 100,000ment (662). “Maltreatment” includes physical in- to 200,000 children each year experience physi-
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cal abuse, 60,000 to 100,000 experience sexualabuse, and over 700,000 children are neglected(57). Although there are no estimates of the prev-alence of emotional maltreatment, it is logical toassume that emotional maltreatment accompaniesother forms of maltreatment and that there isanother unknown number of children who experi-ence emotional maltreatment alone. Maltreatedchildren are often exposed to more than one typeof maltreatment (162,231,284). Furthermore, mal-treatment often consists of more than a single epi-sode; studies suggest that approximately half ofmaltreated children have experienced previousabuse (159,282,377,610,737).
Maltreatment has long been thought to consti-tute a significant risk factor for children’s devel-opment. Recent clinical and empirical investiga-tions of maltreated children substantiate thisassumption. The quality of available researchvaries (see 3); however, the research suggests thatmaltreated children are at high risk for physical,cognitive, behavioral, and emotional difficulties.Recent research and theorizing about maltreat-ment, although inadequate (see 729), documentsthe cognitive and social-emotional problems ofmaltreated children.
Physical Abuse and Neglect
Physical abuse and neglect are believed to causeintellectual and cognitive deficits, specifically low-ered IQ scores that are frequently in the mentallyretarded range. Clinical investigations of physi-cally maltreated infants and children report thatlarge numbers of these children are functioningat diminished cognitive and intellectual levels. Re-search suggests that 33 to 57 percent of physicallyabused and neglected infants and children haveIQ scores below 85 (168,413,416,448).
Physically abused and neglected infants havebeen shown to have diminished performance onIQ tests and other developmental measures com-pared to a retrospective control group (23,146,194,256,366). Comparison group studies of thecognitive and academic functioning of preschoolersand older children have frequently found thatabused and neglected children perform at signifi-cantly lower levels than similar, nonmaltreatedchildren (39,194,212,302,344,502). However, most
of these studies are correlational, and it is possi-ble that at least some children maybe targets ofabuse because of cognitive deficits.
In early and middle childhood, maltreated chil-dren exhibit several signs of social and emotionalmaladjustment. As preschoolers, maltreated chil-dren exhibit more adjustment problems and be-havioral symptoms indicative of pathology (163,502). They are also described as more aggressive,especially in response to frustration (283). Asschool-aged children, they frequently have im-paired self-concepts and display heightened levelsof aggression, both with peers and in the classroom(66,302,534,535). There is also limited evidenceof self-destructive behaviors in these children, in-cluding suicide attempts, threats and gestures, andself-mutilative behavior (255). Finally, in their in-teraction with adult strangers, maltreated childrenare found to be more dependent and imitativethan other children, and to exhibit less motiva-tion to shape their own lives and make their owndecisions (2). It has been hypothesized that thesetendencies negatively affect maltreated children’sability to cope with the important developmen-tal tasks of entry into school and effective func-tioning in the classroom.
That physical abuse and neglect causes at leastsome such deficits in development is supportedby studies that compared maltreated children tocontrol groups that are similar on important dem-ographic and socioeconomic variables. The useof a matched, nonmaltreated control group is par-ticularly important, since abuse and neglect oftenoccur in the context of other risk factors such ashigh-stress environments and reduced socioeco-nomic status (222,228,499). Studies using controlgroups suggest that maltreatment causes cogni-tive deficits, in terms of both performance on IQtests and academic functioning in school.
Studies using comparison groups also substan-tiate clinical observations that a significant degreeof social and emotional maladaptation resultsfrom a history of physical maltreatment. As in-fants and toddlers, physically maltreated childrenare often insecurely attached to their caregivers(162,584), a factor that has been related to socialand emotional difficulties throughout early child-hood (385,421,623). In interactions with care-givers, physically maltreated infants and toddlers
frequently exhibit withdrawal; inconsistency andunpredictability in affective communication; alack of pleasure; indiscriminate attachment (214);and high levels of frustration, noncompliance, andaggression (162).
Although the relationship between cognitiveperformance and emotional difficulties in physi-cally abused children is not clear, emotional andbehavioral problems exhibited by maltreated chil-dren have been well documented. Clinical reportsof physically maltreated infants and children de-scribe a heterogeneous group of behavioral andemotional difficulties. These include severe anxi-ety, withdrawal, apathy in social interactions, andhypervigilance and “frozen watchfulness” in re-gard to the social environment (217,414,415,479,634). In addition, these children are described asaggressive, oppositional, impulsive, provocative,and limit-testing (254,414,415). They exhibit a va-riety of other behavioral symptoms (e.g., hyper-activity, sleep disturbances, and socially inap-propriate behavior), as well as significant sadness,low self-esteem, and self-depreciating behaviors(254,414,415).
Sexual Abuse
It has been estimated that 60,000 to 100,000children are sexually abused in the United Statesevery year (659), although some observers believethat available estimates probably represent onlya small percentage of actual cases (18). This be-lief is supported by surveys of adults in which 15to 34 percent report having been sexually vic-timized as children (191). In general, girls are sex-ually abused more frequently than boys, and theoffender is often a family member, particularlya father or stepfather (122,191,453). Much less isknown about the effects of sexual abuse on achild’s mental health than is known about the ef-fects of physical abuse and neglect. Nonetheless,
TEENAGE PARENTING
Adolescent parenthood has received increasingattention in recent years as the perception of thefrequency and magnitude of this phenomenon has
psychological and psychiatric literature stronglysuggest that the experience of sexual victimizationin childhood has serious deleterious psychologi-cal effects, both short and long term.
One study of the short-term effects of sexualabuse in children (12) found that all of the affectedchildren and adolescents were symptomatic andin need of mental health attention. The degree ofpathology ranged from mild to severe (e.g., anxi-ety and sleep disturbances, suicidal ideation, ad-justment reactions, psychoses). In general, emo-tional disturbance was greater when the child wasfemale, was unsupported by a close adult, hadbeen molested by a father and/or by more thanone relative, and had been genitally molested.Severity of disturbance was associated both withlongstanding abuse that began in early childhoodand with sexual abuse in adolescence, even iflimited to only one incident.
One review of the literature indicates that sex-ually abused children and adolescents suffer fromproblems with sexual adjustment, interpersonalrelationships, and educational functioning (452).The review suggests that when no disclosure oreffective intervention occurs, difficulties can per-sist into adulthood. The most prominent effectsof child sexual abuse found in adult populationsare disturbed self-esteem and an inability to de-velop trust in intimate relationships (191).
Unfortunately, available research does not al-low us to determine the degree to which theseemotional and other psychological difficulties aredue to sexual abuse or to other factors in the envi-ronment. Features of sexual abuse that seem moststrongly related to negative psychological impactinclude the nature of the offense, the degree towhich the offender is known, the use of force, andthe age of the offender (190,227,373). Increasedpublic recognition of problems engendered by sex-ual abuse is leading to better identification of thepsychological effects and implications for treatment.
grown. Of the over 3 million live births that oc-cur annually in the United States, approximately600,000 are to adolescent girls between 15 and 19
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adolescents from poor families (200). The vastmajority of teenage mothers are unwed at the timeof conception (465,726); in 1980 to 1981, onlyone-third of teenage mothers were married beforethe birth of their first child (466). The proportionof children born to unwed mothers has doubledsince the early 1960s, and unwed mothers todayare less likely to marry after the birth of a childthan were unwed mothers in prior decades (466).The unwed mothers who do marry are more likelyto divorce (213,393,578).
Teenage pregnancy and childbearing are asso-ciated with heightened medical risks to bothmother and child. In girls younger than 15 years,in particular, there is a reduced likelihood of re-ceiving adequate prenatal care, and an increasedprobability of morbidity and mortality in the off-spring and toxemia in the mother (76,446,558).Offspring of teenage mothers have a greater prob-ability of being premature and of low birthweightthan those born to older mothers (427). In addi-tion, there is an increased incidence of neurolog-ical abnormalities in the infants of teenage moth-ers (73,123,188). Teenage mother-infant dyads arecharacterized by less than optimal behaviors;these are often found to be associated with lowerscores on tests of the infant’s motor and mentaldevelopment (183,409,573).
Cognitive deficits and diminished academic per-formance have been found in the preschool andschool-aged children of teenage mothers. Childrenborn to teenage mothers have been found to per-form more poorly than other children on stand-ardized IQ and achievement tests and on assess-ments of preparation for school (52,213,409). Inone study, first-grade children who were born toadolescents were rated by their teachers as “lesslikely to adapt to school, ” a variable that corre-lates strongly with psychiatric symptoms in theteenage years (339).
In assessing the impact of low parental age onchildren’s development, it is important to note theinfluence of other environmental factors. Themost important of these are low socioeconomicstatus and marital instability. Both social dis-advantage and marital instability have powerfuleffects on the development of children, independ-ent of the effects attributable to maternal age.
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Substantial evidence suggests that many of thenegative effects of teenage parenting are only min-imally related to the mother’s age at birth, andare instead a function of the parent’s reducededucational achievement and low socioeconomicstatus (35). Adolescent mothers have been foundto have relatively limited knowledge and unrealis-tic expectations about child development (142).Some research indicates an association between
adolescent parenting and child abuse (401,608,617). In general, better outcomes on a range ofindicators (e.g., cognitive skills) are found foradolescent mothers and their children who are re-ceiving more support either from the children’sfather or from the mother’s family compared withthose in which the mother is the sole, full-timecaretaker (213).
PREMATURE BIRTH AND LOW BIRTHWEIGHT
Premature birth (defined as gestational age ofless than 37 weeks) and low birthweight (weightless than 2,500 grams) have potentially broad ef-fects on mental health functioning. The incidenceof prematurity is higher among infants born tomothers of low socioeconomic status than amongother infants (478,541) and is approximately 10percent for white infants and 20 percent for blackinfants (403).
The strong association of socioeconomic sta-tus and race with prematurity and low birthweightis probably due in part to the association of thesevariables with other important factors affectingneonatal status—e. g., the age of the mother, themother’s previous pregnancy history, and theavailability of prenatal care for mother and in-fant (391). Given the associations between pre-terrn birth and social and economic circumstances,it is often difficult to separate the effects ofprematurity from effects related to the correlatesof premature birth (e.g., social and economic cir-cumstances and other illnesses in the child). More-over, the developmental outcome of prematureinfants is being affected by medical advances thatincrease the survival rate of smaller and youngerinfants (210).
At present, prematurely born infants are likelyto experience some difficulties in several domainsof functioning, including social, environmental,linguistic, physical, and cognitive areas. One ofthe earliest difficulties to appear is disturbed in-teractions between mothers and preterm infants.These disturbances constitute a pattern of the in-fant showing less responsiveness, less positive af-fect, and more aversion behaviors than full-terminfants and the mother showing more than the
Photo credit: March of Dimes -
Premature birth and low birthweight have potentiallybroad effects on mental health functioning.
usual degree of activity and stimulating behaviors(80,130,145,179,180,181,182). This imbalance fre-quently results in a vicious cycle, as increasedactivity on the part of the mother leads to less in-fant responsiveness, and this, in turn, results inmore active maternal behavior. In general, pre-
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term infant-mother dyads have fewer positive in-teractions than their full-term counterparts, andthis difference may increase over the first year oflife (130). In normal populations, the quality ofearly social interactions has frequently been asso-ciated with both early and late social, emotional,and cognitive competence. Similarly, it has beenfound that the less optimal social interactions ex-perienced by preterm infants are related to poorersocial, emotional, and cognitive functioning inearly childhood (46,181,186,642).
The incidence of the most severe problems asso-ciated with premature birth—e.g., cerebral palsy,severe mental retardation, brain damage, epi-lepsy, and vision and hearing defects (99)–hasdeclined over the last few decades because of im-proved prenatal monitoring and medical technol-ogy (see 635). Nevertheless, infants and childrenborn prematurely are found to display poorer out-comes than full-term infants and children on a va-riety of developmental indices. Preterm infantshave been found to perform more poorly thanfull-term infants on measures of cognitive, lan-guage, and motor development in infancy, includ-ing an early assessment of IQ known as the Bay-ley Scales of Infant Development (80,84,130,185,195). These problems are especially common inpreterm infants of very low birthweight (i.e., lessthan 1,500 grams). Similarly, toddlers and pre-schoolers born prematurely tend to perform atlower levels than full-term toddlers and childrenon tests of cognitive competence (184,185,195,307,607,642). Again, these differences are muchmore marked for those born at very low birth-weights. In addition to exhibiting lowered cogni-tive competence, preschoolers born prematurelyhave been found to display more behavioral symp-toms suggestive of minimal brain dysfunction
(e.g., hyperactivity, distractibility, short attentionspan, irritability, impulsiveness, specific fears, andunclear speech); less social maturity; and inferiorlanguage production (184,185,186,642).
For many children born prematurely, develop-mental delays shown in infancy and early child-hood are mild and decrease with age. Some ef-fects of prematurity, however, do not fully emergeuntil the school-age years. These effects frequentlytake the form of specific cognitive deficits in termsof visuomotor and other perceptual-motor skills(100,307,607). Patterns of specific impairment inperceptual-motor functioning (in the context ofnormal language performance) are suggestive oflearning disabilities (607). In general, childrenborn prematurely have been observed to showpoorer school performance than other children(124,140,204,273), although recent research sug-gests that these differences in long-term outcomemay be more related to socioeconomic status thanto prematurity (138,148).
In samples of abused and neglected infants andchildren, preterms are frequently overrepresented(34,168,199,355,583). To the extent that pretermsare in greater danger of being abused, they areat risk for experiencing cognitive, social, and emo-tional difficulties associated with maltreatmentdetailed above, The cause of the relationship be-tween prematurity and maltreatment is unclear.Factors in the infant, the parent, and the environ-ment, as well as the effects of early separation ofpreterm infants from their parents, have all beensuggested as leading to abuse. It seems likely,however, that none of these factors alone explainsthe link between prematurity and child maltreat-ment and, instead, that each contributes to pro-duce a cumulative effect (417).
PARENTAL DIVORCE
Parental divorce can have serious consequences parental separation or divorce. From 1970 tofor children’s mental health and has increasingly 1981, the percentage of single-parent families inbeen recognized as an important mental health the United States increased from 12 to 20 percentrisk factor. The increasing recognition of its ef- of households (652). Furthermore, recent estimatesfects is not surprising, given recent increases in suggest that nearly half of the children born inthe numbers of children under 18 who are living the 1970s and 1980s will spend a portion of theirin single-parent households, usually as a result of childhood living in a single-parent home (236).
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The initial period following separation or di-vorce is one of severe stress and disorganizationfor the entire family. During this time, childrenoften exhibit a variety of behavior problems, in-cluding oppositional, aggressive behavior (291,292,293); and depressive reactions and develop-mental delays (676,677,678,679,680). These prob-lems often occur in children who have had noprior history of psychological difficulty or treat-ment. Moreover, the problems extend into manyparts of children’s lives—family relationships,school functioning and academic performance,and relationships with friends. Children fromdivorced families are more likely than intact-family children to have been referred for psycho-logical treatment (28,265). In addition, childrenfrom divorced families have been found to scoresignificantly lower on IQ tests (292), evidencepoorer work styles (288), and demonstrate gen-erally lower academic and classroom competence(265).
Many studies report that the various behaviorproblems exhibited by children immediately af-
MAJOR PHYSICAL ILLNESS
As a result of improvements in the quality ofmedical treatment, many more children with maj-or chronic illnesses are surviving today who inthe past would have died. Although not strictlyenvironmental factors, major physical illnesses arestressful experiences that affect mental health.Chronic diseases that children are now living withand that have demonstrated effects on mentalhealth include cancer (364), cystic fibrosis (151),and chronic renal failure (705). Burn or accidentvictims and children with congenital abnormal-ities are also afflicted with mental health prob-lems. Chronic medical conditions that lead to rela-tively little physical disability, such as epilepsyand diabetes, are also of concern in this context,because these chronic conditions can frequentlyhave greater emotional consequences than con-ditions which are medically more threatening.
In recent years, it has been recognized that theexperience of a major or chronic illness involvescomplicated psychological and social stresses.Several surveys have found that chronically ill
ter divorce tend to abate without treatment in the2 years following divorce, especially among girls(294). However, this outcome varies and seemsto be related to several mediating variables suchas the amount of parental conflict after the di-vorce. One recent study, using a large, randomlyselected sample of children, found that the effectsof divorce did not evaporate after 1 to 2 years(266). When compared with intact-family chil-dren, children from divorced households (particu-larly boys) were found to experience a variety ofacademic, social, mental health, and physicalhealth problems even 5 to 6 years after divorce.
Factors that can either accentuate or amelioratethe negative effects of divorce include the child’srelationship with the noncustodial parent, parentadjustment, parents’ postdivorce relationship, thechild’s predivorce adjustment and temperament,the sex and age of the child, and extrafamilial sup-port systems (28). Research varies in the degreeto which it has successfully separated the impactof divorce from the impact of other mediatingvariables (28,169,265,294,370).
children are at greater risk for developing be-havioral or emotional problems than are healthychildren (74,425,511,593), although such effectshave not been found for all categories of chronicdisease (155,633).
The diagnosis of a serious childhood illness canhave devastating psychological effects on childrenand families, even where survival rates and othertreatment prospects are good. Children face anxi-ety over the cause of the illness, its course andprognosis, and the threat it presents to the in-tegrity of their body. They often develop feelingsthat they are defective and different from theirfriends, and react with shame and lowered self--esteem. To manage the disturbing feelings, theymay deny their illness or develop a sense that partsof their body are alien and separate from them-selves, which makes it more difficult to face thereality of their illness (32).
A second source of stress is the effect of the con-dition itself (705). Experiencing constant pain or
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severe physical limitations is extremely stressful.Furthermore, a medical condition can limit chil-dren’s functioning in areas that are especially crit-ical to their stage of development (423,705). Pro-longed confinement to bed, for example, interfereswith young children’s developmental need formovement to explore the world and test theirabilities.
An additional source of stress faced by chron-ically ill children is the difficulty of undergoingdiagnosis and treatment. Many techniques usedto diagnose and treat illness are uncomfortable,painful, immobilizing, or defacing. Needles todraw blood, biopsies, radioisotopic preparations,and other diagnostic procedures are often morefrightening and painful to children than the slowcourse of a disease. Many treatments of severediseases (e.g., chemotherapy or radiation therapy)have painful and debilitating side effects. Treat-ments such as dialysis, which must be continuedindefinitely, place enormous psychological de-mands on children. Furthermore, treatment oftenforces children to spend long periods of time ina hospital, separated from their parents and friends.
For some children, the greatest stress arises af-ter they return from the hospital. Anxiety remainsabout the risk that their illness will recur, theirbody integrity, and their ongoing chances for sur-vival. For children with some conditions, stressis increased because not much is known abouttheir prognosis other than that they are at in-creased risk for having another episode of the dis-ease (364). Children with major and chronic ill-nesses may have physical impairment remainingfrom their illness or from invasive treatment ofthe illness—either concrete disabilities such as theloss of a limb or more unpredictable problemssuch as suppression of the immune system. On-going treatment regimens, which often involvefrequent medication or other treatment, disruptnormal school, peer, and family activities of chil-dren. Treatment often continues to be painful orlead to physical changes. Children must rejointheir classroom and peer groups while still cop-ing with the feeling that they are different and,
in many cases, appearing different from other chil-dren. The siblings of a sick child may also sufferpsychologically because of the illness; they oftenexperience guilt over being well while their brotheror sister is ill and jealousy over all the resourcesand attention devoted to the sick one (152,154,364). Medical conditions and treatments also in-terfere directly with children’s development, sothat they may fall behind in intellectual, emo-tional, and social development.
The requirements of managing a chronic illnessoften conflict with the developmental or psycho-logical needs of children. For example, chronic ill-ness forces adolescents to be more dependent ontheir parents at a time when they need to developindependence. It may lead children to feel bothresponsible for what happens in the family andguilty over the family’s distress. Often the fam-ily exacerbates these problems by being overpro-tective. In general, normal development is mademore difficult, because illness necessarily placeschildren in a more dependent, child-like position.Children’s prospects for the future can be dimin-ished, partly because their illness impairs theirabilities, but also because of prejudice againstthem in school or at jobs. There is also often prej-udice against recovered patients who try to ob-tain life and health insurance. Several studies havefound consequences for adaptation, especially insocial relationships, for adults who have had achronic childhood medical condition (71,237,474).An additional complication is that mental andphysical health are closely intertwined; emotionalor behavioral problems often exacerbate physi-cal problems. This is true for almost any disease,but especially so for conditions such as asthmain which emotional arousal can stimulate physi-cal symptoms.
Success in coping with a chronic medical con-dition seems to be related to such factors as thespecific course of the medical illness (when it oc-curs in life, how long it lasts, number of relapses,etc. ) and the ability of the family, physician, andothers to be supportive (364).
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CONCLUSION
A number of biological and psychosocial fac-tors can pose risks to children’s mental health.This chapter has examined a number of the moresevere environmental risk factors for children—poverty, minority ethnic status, parental psycho-pathology, physical or other maltreatment, ateenage parent, premature birth and low birth-weight, parental divorce, and serious childhoodillness. The evidence on many of these factors andtheir direct relation to children’s mental healthproblems is sometimes unclear, primarily becausechildren exposed to one risk factor may be ex-posed to others as well.
Consideration of environmental risk factors isimportant to an examination of children’s men-
tal health problems and services. As is acknowl-edged in diagnostic manuals such as DSM-III,knowledge of a child’s physical health status andpsychosocial environment is important to devel-oping an effective mental health treatment plan.For policy purposes, it can be important to knowthat children’s mental health problems are notlimited to mental disorders, and that it may bepossible to prevent development of some mentalhealth problems by reducing certain risk factors(e.g., poverty) and ameliorating the effects ofothers.
Part Ill: Services
Chapter 5
Therapies
Chapter 5
Therapies
INTRODUCTION
The specific techniques used to treat childrenwith mental health problems vary depending onthe nature and severity of a child’s problems, theorientation of mental health professionals, and theresources available to finance and house treatmentservices. Although some treatment methods havebeen devised especially for children, most areadaptations of procedures used with adults.
This chapter describes the principal treatmentmethods currently used with children by mentalhealth professionals:
INDIVIDUAL THERAPY
The paradigm for mental health treatment hastraditionally been individual therapy—the one-on-one encounter of a therapist and a patient.Over the past 50 years, there have developed alarge number of individually based therapies basedon theories as disparate as psychoanalysis andoperant conditioning. Each theory has spawnedvarious approaches to individual therapy thathave been adapted for use with children.
Three broad categories of treatment approachesused
1.
2.
3.
with individual children are described below:
psychodynamic therapy, which focuses onthe development of insight;behavioral therapy, which is based on be-havioral learning theories and relies on posi-tive and negative reinforcements to createchanges in behavior; andcognitive therapy, which is based on cogni-tive learning theories and trains individualsto use new patterns of thinking.
Each of these approaches, though developed todeal with individual patients, can also be used aspart of group and family therapy. Furthermore,although psychodynamic, behavioral, and cog-nitive therapy are based on distinct theories, inpractice, many clinicians use an eclectic therapeu-tic approach.
. individual therapy,● group and family therapy,● milieu therapy,• crisis intervention, and● psychopharmacological (drug) therapy.
In practice, most of these techniques are usedin combination with one another.
Psychodynamic Therapy
All forms of therapy for children involve bring-ing about changes in their cognition, emotions,and behavior (260). What distinguishes psycho-dynamic approaches is their emphasis on cogni-tion and emotions and the concomitant idea thatchanges in these two realms will be followed bychanges in behavior. When psychodynamic ap-proaches are used with children, they often in-volve elements that are usually not emphasizedwith adults and that blur distinctions betweenpsychodynamic and other therapeutic approacheswith children. These include clarification of con-scious feelings and thoughts and aid in the de-velopment of alternative problem-solving andcoping strategies. The accentuation of these tech-niques in work with children reflects children’searly stage of cognitive and psychosocial devel-opment.
Psychodynamic therapy with children is usu-ally accompanied by other interventions. Mostoften it is accompanied by therapy with the child’sparents. The involvement of individuals in thechild’s environment reflects the fact that childrenare more dependent than adults and less able tochange their environmental conditions.
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Psychodynamic child therapy requires consid-erable resources. A highly trained clinician mustprovide the therapy, several individuals in thechild’s environment need to be involved, and fre-quent therapy sessions may be needed. Psycho-dynamic child therapy usually involves once- ortwice-weekly meetings between therapist andchild. There is no predetermined length of treat-ment, and treatment can last from a few weeksto a few years (9). Because of the resources needed,it is probably more typical that individual ther-apy with children is psychodynamically informedrather than a pure instance of the psychodynamicmodel.
A number of mechanisms are thought to ac-count for therapeutic change in psychodynamicchild therapy. An emphasis on one mechanismor another may depend on a child’s age, the child’srelevant strengths and weaknesses, and the sever-ity of the child’s problem (207).
IEmotional expression by the child and the label-
ing of emotions by the therapist are primary mech-~ anisms in psychodynamic therapy. The expres-
sion of feelings is thought to aid the child byproviding him or her with an opportunity forcatharsis. The labeling of feelings by the therapistis believed to enable the child to place the feel-ings in context, thereby reducing his or her senseof being overwhelmed. The therapist’s interven-tion is also thought to help the child understandthe connections between thoughts, feelings, andbehaviors. The goal is to replace the acting-outof conflicts with feeling, thinking, and verbali-zation.
Psychodynamic therapy is also hypothesized toaid in the development of ego structure (i. e., asense of self), which is particularly important forchildren whose problems began early and wholack self-esteem and impulse control (361). Inaddition, psychodynamic therapy can provide achild with a “corrective emotional experience. ”This occurs because the child’s usual expectations(e.g., rejection or punishment) are not met, andeventually the “automatic” connections betweenfeelings (e.g., between anger and guilt) no longeroccur. Finally, psychodynamic therapy is believedto produce change because it instills hope in thechild and fosters the belief that the important peo-ple in his or her life are caring and concerned.
Photo credit Charter Colonial
In play therapy, problems are approached throughgames in order to put children at ease.
Despite a well-described theory of the mecha-nisms of psychodynamic therapy, there are fewempirical data to guide decisions about whichmechanisms should be emphasized in the treat-ment of specific problems and particular types ofchildren, Substantial clinical literature suggeststhat an insight-oriented approach that focuses onwidening children’s understanding is most appli-cable for children with relatively good function-ing and circumscribed internal conflicts. Childrenwith major developmental problems and limitedintrospective abilities are probably better servedwith an approach that stresses problem-solvingskills (207,272,481,537).
Psychodynamic therapy is contraindicated insituations in which the parents are unwilling tosupport the treatment and situations in which theproblem is best addressed by altering a child’senvironment (via the family or school). It is alsocontraindicated for children who do not have theability to form a working relationship with a ther-apist (274).
Behavioral Therapy
Behavioral therapy was developed more re-cently than psychodynamic therapy, but it is morewidely applied in treating children (553). Be-havioral therapy assumes that a child learns per-sistent pathological behavior from his or her ex-
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perience with the social environment. Therapistsusing behavioral techniques systematically ana-lyze the child’s problem and environment andidentify the specific behaviors to be modified. Aspart of the assessment, frequency counts ofmaladaptive behaviors may be carefully collected,along with data on the situation within which themaladaptive behavior occurs. Then specific be-havioral techniques are applied in an effort tochange specific problem behaviors.
Models of Learning on Which BehavioralTherapies Are Based
Several models of learning underlie behavioraltherapy methods. The most commonly appliedmodel is operant conditioning. This model as-sumes that learning results from the consequencesof behavior (611). Behavior that leads to reward-ing consequences is said to be positively reinforcedand, as a consequence, is presumed to increase,while behavior that leads to unrewarding or pun-ishing consequences is presumed to decrease. Inbehavioral therapy based on operant condition-ing, adaptive behavior is explicitly rewarded,while maladaptive behavior is either explicitly notrewarded, leads to a delay in reward, or is pun-ished. Thus, for example, children who haveproblems with aggression and who learn to in-teract appropriately with classmates may receivespecial rewards. Some residential treatment set-tings use “token economies” in which children“earn” tokens that are redeemable for privileges.
A second model for behavioral therapy is re-ciprocal inhibition (716). This model holds thatchildren “learn” an inappropriate, anxious re-action (e. g., a phobia) to an aspect of the envi-ronment. Behavioral therapy based on the recip-rocal inhibition model usually involves trainingpatients in systematic desensitization—i .e., sub-stituting relaxation or other appropriate behaviorsto break the patient’s association between a fearedobject and an inappropriate reaction (37).
A third paradigm, sociaol modeling or observa-tional learning (37), is an elaboration of operantconditioning (252). According to this paradigm,an individual learns new behavior by observinganother person successfully carrying out the newbehavior and being rewarded for it. For example,
observing another child approach a dog could beused to help a child patient overcome a dogphobia.
Applications of Behavioral Therapies
Behavioral therapies are applied in the treat-ment of children with specific intellectual anddevelopmental disorders, behavior disorders,emotional disorders, and psychophysiological dis-orders.
Intellectual and Developmental Disorders.—In the case of mental retardation or pervasive de-velopment disorders (PDDs), behavioral therapyis not intended as a “cure. ” It has been used, how-ever, as a major tool for training severely dis-turbed children to communicate with others andto develop self-care skills (252). Children aretrained to use language (305), to develop house-hold skills like telling time and counting change,and to develop social and educational skills. Be-havioral methods are sometimes prescribed as spe-cific, intensive, time-limited procedures, but moreoften they are integrated into a treatment setting’sprogram. For example, meals can be used as partof a behavioral treatment program to teach chil-dren to make requests (252). Operant condition-ing relying on positive reinforcement has been themainstay of this training.
Behavioral therapy has often been used in seek-ing to limit tantrums, self-mutilation, and otherself-destructive behaviors in children with PDDs(410). Punishment is used occasionally (e.g., theuse of electric shock to stop head-banging), al-though considerable public and scientific con-troversy exists about the side effects and ethicsof using punishment with children (641).
Behavior Disorders.—A number of behavioraltechniques have been developed for treating chil-dren with attention deficit disorder with hyper-activity (ADD-H) (129). The contingency manage-ment approach requires that parents and teachersuse a structured system of rewards contingent onappropriate, attentive behavior by the children.
Behavioral therapy is frequently used with con-duct-disordered children in residential juvenile jus-tice facilities. The focus is on improving delin-quent children’s social or educational skills, while
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decreasing delinquent behavior within the residen-tial setting (252). Operant conditioning is the pri-mary technique, and token economies are usedfrequently, but techniques such as behavioral con-tracting are also employed (591).
Emotional Disorders. —Behavioral techniqueshave a long history of use in treating children’sphobias—a subset of anxiety disorders. Whetherdesensitization, modeling, or other techniques areemployed, most seek to reduce children’s anxietyso that they will approach (physically or symbol-ically) and eventually confront the feared object.Behavioral techniques have not been extensivelydeveloped for treatment of emotional disordersother than anxiety.
Psychophysiological Disorders. -Most psycho-physiological symptoms are believed to be amena-ble to behavioral treatment. Therapists haveadapted behavioral techniques such as relaxationtraining, self-control training, and operant con-ditioning to teach children with stereotyped move-
1 ment disorders to have greater control over their
I bodies.I The use of operant conditioning techniques is
especially common with enuretic and encopreticchildren. One such technique, the bell-and-padtechnique, for example, places a special device onan enuretic child’s bed that sounds a wake-upalarm on contact with a child’s urine, teaching thechild to associate sleeping with continence (450).Operant conditioning techniques have also beenused to treat patients with eating disorders suchas anorexia nervosa.
Parent Training in Behavioral Therapy .—Train-ing parents to use behavioral techniques with theirchildren is increasingly favored and has great po-tential for expansion (251). The application of be-havioral techniques by parents has an inherentlogic in that parents are responsible for their chil-dren and can be directly involved as soon as aproblem is identified. It is also an important ap-proach to consider in light of resource constraintsand the desirable policy of providing treatmentfor disturbed children in the least restrictive envi-ronment. For some children, a home environmentin which the parents apply behavioral techniquescan replace the behaviorally programmed envi-ronments of residential treatment settings such as
psychiatric hospitals and residential treatmentcenters (RTCs). For the implementation of many be-havioral techniques, fairly little training is needed.
Many parents of severely disturbed childrenhave received training in operant conditioning andother behavioral management techniques used inresidential treatment settings (398,585). Parentsof children with some of the less severe psy-chophysiological problems have also receivedtraining in behavioral techniques, including forexample, the bell-and-pad treatment for enuresis.The most common application of parent trainingis, by far, to childhood behavior problems. Theseproblems can range from tantrums in a toddler,to disruptive classroom behavior (27), to adoles-cent delinquency. Parents are also reported tohave conducted successful behavioral treatmentsfor school phobia (285) and night-time fears (251,343).
A frequent combination of behavioral proce-dures taught to parents includes:
1.
2.
3.
providing positive reinforcement for appro-priate behaviors (usually in the form of at-tention or praise);avoiding inadvertent reinforcement (e.g.,negative attention) for disruptive behaviorthat is not severe (“extinction”); andsegregating children by themselves for moresevere disruptive behavior (554).
The use of behavioral contracts is encouraged insome families with conduct-disordered children(252).
Although the techniques of behavioral therapyare relatively simple, especially compared to thoseof other individual psychotherapies, the analysisof a child’s behavior is usually complex, especiallywhen there are multiple dysfunctions. In addition,designing reinforcement schedules and redesign-ing a child’s environment can be more complexthan mere description would suggest.
Parents can learn appropriate behavioral tech-niques from self-help manuals (487), as well asdirectly from professionals (429). Self-helpmanuals vary in their quality and their ground-ing in empirical evidence (235). Since self-helptechniques are largely out of the hands of profes-sionals once the books are written and distributed,
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little is known about the extent, manner, and ef-fectiveness of their use.
Cognitive Therapy
Clinical and research findings indicate thatthinking processes of disturbed children are differ-ent from those of other children (399,674). Suchfindings have led to cognitive treatment modali-ties that attempt to alter the way disturbed chil-dren think about their behavior and their envi-ronments. Although the way in which cognitiveinterventions attempt to change thinking variesgreatly, two broad classes of cognitive interven-tions can be identified. One class of cognitive in-terventions tries to alter the thinking that takesplace during a child’s troublesome behavior—e.g.,by having impulsive, distractible children verballydescribe their actions to themselves as they dothem (433). The other class of cognitive interven-tions tries to influence how children think aboutthemselves and others.
Cognitive interventions are used to help chil-dren with many types of problems: behavior,learning, emotional, and social problems. Onecognitive method derived from theories aboutneuropsychological functions (399) trains childrento use speech as a tool to slow down and focustheir learning and behavior (433). Other cogni-tive interventions train children in such aspectsof learning as the amount of time used to respondto a question (436), the visual scanning of educa-tional material, question-asking strategies (143),and analytic abilities (164). Peers and adults whouse effective strategies are often used as models.
GROUP AND FAMILY THERAPY
Group and family therapeutic approaches arerooted, in part, in theories of individual behavior.They are also based on distinct theories of peerand family relations. Because of the importanceof peers and family members or other adults ina child’s life, group and family therapy are oftenused to treat children with mental health prob-lems. The purpose of group therapy is not sim-ply to reduce the cost of treatment by providingtreatment to several children simultaneously.
For emotionally disordered children with pho-bias, therapists have used behavioral models com-bined with cognitive training to demonstrate thata feared object or situation can be confronted(351). In addition, various cognitively based train-ing programs have been used to teach emotion-ally disordered children to solve interpersonalproblems more effectively. Other cognitive train-ing programs aim to improve young people’s abil-ity to understand and think through social situa-tions (their “social cognition”) (643). Suchcognitive training may include procedures thatteach children the consequences of their behaviorfor others (621), or train them to take the perspec-tive of others—and to know thereby what behav-ior would be best in the relationship (643). Theremay be a significant educational component tothese cognitive interventions. For example, somelearning groups offer children concrete informa-tion about how to improve their social skills (376).Some cognitively based training has focused ontraining delinquent adolescents the skills neces-sary to manage group living or a job interview(574).
Cognitive methods are also used with familiesof disturbed children. For example, some ther-apists have taught social problem-solving skillsto families, especially families of behavior-dis-ordered children (16,347).
In summary, cognitive therapeutic interven-tions have wide applicability. Cognitive ap-proaches are incorporated in many therapies, andalthough cognitive approaches require trainedmental health professionals, they can be adaptedin many settings.
Rather, the goal is to treat aspects of a child’sproblem which involve interaction with peers andsignificant adults.
Group Therapy
Although group therapy incorporates elementsof other treatments, it is nevertheless a distincttreatment modality. The effectiveness of grouptherapy is thought to arise from interpersonal
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processes within the therapeutic group (722).Therapeutic groups are believed to develop an in-digenous “culture” (507) and to allow individualsto develop new ways of relating. The strengthsof one child become a model for other children,while the entire group can help an individual childaddress a weakness (230).
The therapist’s task in group therapy is to helpthe group develop helping capacities and to per-form organizing and caretaking functions withinthe group (582). Children in group psychother-apy are a heterogeneous population, and psycho-therap y groups are not usually targeted to a par-ticular disorder; most groups aim to addressproblems in relationships and identity that cutacross disorders. Group therapy is thought to beparticularly useful for children experiencing dif-ficulties in peer relationships.
Group psychotherapy for children is adaptedto the developmental level of the group. Therapygroups for young children are usually organizedaround group play and activity-oriented social be-havior, while adolescent therapy groups rely moreheavily on discussion. Particularly for adoles-cents, the structure of group therapy depends onthe level of social relationships among groupmembers.
Group therapy is not always conducted bygroup therapy specialists. It is sometimes providedby therapists of various orientations (e.g., be-havioral and cognitive), Therapists who do notspecialize in group therapy typically consider thedynamics of the group less central than otherprocesses. For example, a behavioral therapistmay intend group therapy primarily to providemutual reinforcement for improved behavior orpeer modeling (342), Group psychotherapy isoften provided as an adjunct to other modalities,particularly individual psychotherapy or familytherapy.
Family Therapy
Although most child therapists point to the im-portance of the family in understanding and treat-ing children, family therapists are distinguishedby their unique way of reconceptualizing a set ofsymptoms. For family therapists, problems do notlie within the child (as suggested by traditional
psychiatric diagnosis), but are manifestations ofdisturbed interactions within a family. A child’ssymptom is viewed as an indicator of larger familyproblems and as a response that serves a func-tion for the entire family. Thus, for example, achild’s symptom can deflect attention away frommore fundamental difficulties such as strife in theparents’ relationship (402,442). Because of itsfunctional and protective role, the symptom is re-inforcing to the family, and families are psycho-logically invested in maintaining it. Althoughfamily therapy does not necessarily involve thepresence of every family member at each session(67), family therapists believe that a child cannotchange if the family does not change as well(203,442).
Several models have evolved within familytherapy, and each offers different techniques forintervening to produce change. Zimmerman andSims (736) describe three models: dynamic, sys-tems, and behavioral.
Dynamic models for family therapy are char-acterized by their reliance on insight as the mainmethod of producing change. Frequently, the fo-cus of insight is on pathological patterns of func-tioning that are carried from the parents’ own pastinto the present family situation. These patternsmay involve conflicts over autonomy and depen-dency (704), developmental failures that haveoccurred over generations and are being “pro-jected” onto a child in the current family (612),or situations in which a child’s symptom repre-sents an “invisible loyalty” to transgenerationalthemes (65). Insight into the way in which pat-terns from the past affect the present is believedto produce growth in all family members, allow-ing the child to give up the symptomatic behavior.
Systems models for family therapy encompassa diverse group of theorists and techniques. Onesuch model is structural family therapy, an ap-proach most closely associated with Minuchin(443,445). Structural family therapy is aimed atchanging the family’s psychosocial organizationwith the expectation that this will produce a changein the experiences of individual members. Fam-ily structure, according to Minuchin, is the “in-visible set of functional demands that organizesthe way in which family members interact” (442).Aspects of family structure that maintain or are
73
the result of dysfunction include family bound-aries, alignments, and the balance of power. Forexample, Minuchin (442) notes that families withan anorectic child are frequently characterized byenmeshed relationships, restrictions on individ-ual autonomy, and lack of conflict resolution.Therapy involves firming up the boundaries be-tween the parental and child subsystems, break-ing the facade of mutual agreement between thespouses, and helping them to negotiate conflict.This approach does not preclude separate medi-cal attention for the anorectic child. It does, how-ever, propose that the family, rather than thechild, is the matrix within which change mustoccur.
A related systems model is strategic family ther-apy (171, 172,269,270,684). Strategic family ther-apists accept the idea that an individual’s symptomserves the function of stabilizing and maintain-ing a balance in the family system. Their approachin therapy, however, is to focus largely on thesymptom itself. Specific techniques are used to re-
MILIEU THERAPY
Milieu therapy involves utilizing daily living ina therapeutic setting to teach patients social andeducational skills, to explore patients’ emotionallife and patterns in relating to others, and to pro-vide patients with ongoing support.
The setting in which milieu therapy is providedis either a hospital, an RTC, or a day treatmentcenter. Every aspect of daily life in this setting isshaped to contribute to a child’s recovery. Suchdisparate areas of life as a child’s evening routineor how he or she reacts to conflict with anotherchild become opportunities for professional andother staff to intervene and help a child learn moreadaptive behavior.
Interventions in milieu therapy can be as pro-saic as teaching children to replace rough physi-cal contact with a special handshake or as pro-found as pointing out a parallel between children’s
veal the changeability of the symptom and tomake the previously covert functions and controlof the symptom more overt and obvious to allfamily members. Strategic family therapy doesnot rely on insight to produce change, and thecourse of treatment is frequently brief (736).
A third model of family therapy is behavioralfamily treatment developed by Patterson (487,490,497). Designed for use with families of con-duct-disordered children, Patterson’s approach isbased on the observation that parents of thesechildren tend to reinforce the occurrence of ag-gressive behavior and discourage the occurrenceof prosocial behaviors (491,492). Parents aretrained in the techniques of social-learning-basedchild management. Through exposure to pro-grammed texts and participation in a parent train-ing group, parents are taught to define, track, andrecord both deviant and prosocial behaviors intheir children and to devise behavioral contractswhich specify the consequences of specific be-haviors at home.
reaction to the staff and their relationship to theirfamily (639). In many therapeutic milieus, the in-tensive therapeutic relationships that develop withseveral different staff are thought to give childrena chance to re-create and then work out a numberof interpersonal difficulties. Behavioral programsare often used as the basis of milieu therapy.
Milieu treatment also includes the group pro-grams used to meet some of the children’s needsfor education, recreation, and a sense of commu-nity. For example, community meetings are heldto review events within the hospital and exploretheir relationship to patients’ difficulties, Groupsled by professional staff in art therapy, music ther-apy, and recreation may allow patients to expressfeelings about their predicament and, at the sametime, learn better ways to adapt.
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CRISIS INTERVENTION
Crisis intervention is an outpatient treatmentbased on clinical and other evidence that a ma-jor upheaval in a child’s life, such as the loss ofa family member, can pose an acute threat to thechild’s mental health (388). Unlike several otherapproaches, crisis intervention programs often in-tervene within children’s homes. Crisis interven-tion is sometimes used as an alternative to hospi-talization for acute mental health problems. Themajor goal is to help children and families returnto their previous level of functioning. Crisis in-tervention is usually completed within 6 weeksand often within days (388), but it is often fol-lowed by other outpatient treatment.
Crisis intervention techniques emphasize prac-tical steps to defuse threatening situations and toprovide family members with coping resources.Specific contracts and emergency plans, for ex-ample, are made with family members to lowerthe level of tension. Suicide prevention is a focusof intervention when necessary, and crisis inter-
vention services are typically offered intensivelyon an as-needed, off-hours basis. Often, a crisisintervention specialist arranges for additionalemergency services, such as emergency caretak-ing for children to relieve some of the stress onan acutely disturbed parent.
Crisis intervention with children necessarily in-volves the family; a tenet of the approach is thatparents must be helped to develop coping skillsnecessary to manage in a crisis. The Homebuildersprogram exemplifies a crisis intervention modelthat works within children’s homes (350). Home-builders staff begin by uncovering the nature ofthe family crisis from all viewpoints, defusing ten-sion by letting family members vent their frus-trations and concern, and helping the family de-velop alternative behavioral, cognitive, andemotional means to deal with the critical prob-lem. After the initial intervention(s), contact ismaintained until clients are referred to and thenreceive continuing services.
PSYCHOPHARMACOLOGICAL (DRUG) THERAPY
Psychoactive medication is a small but grow-ing modality of treatment for children’s mentalhealth disorders. Although widely used withadults, psychoactive medication has only recentlybeen regularly prescribed for children.
The range of children’s mental health problemsfor which drugs have been prescribed has in-creased over the last decade. Yet psychopharma-cological treatment is not regarded as a panaceafor the treatment of any disorder, and there ap-pears to be consensus on the necessity of com-bining drugs with other treatments.
Stimulants
ADD is one of the few childhood syndromescommonly treated with drugs. The drugs usedusually are stimulants, including methylphenidate(Ritalin®) and dextroamphetamine (Dexedrine@).Even though ADD children are generally over-active, stimulant drugs act to increase their atten-
tion span. The mechanism underlying the effectsof stimulant drugs is not well understood; the bestunderstanding is that such drugs stimulate areasof the brain responsible for maintaining arousaland focusing on specific functions (121). Drugtreatment alone is rarely sufficient, and psycho-logical interventions with the child, family, and/or his school environment are usually combinedwith medication (577).
Neuroleptics
Some children with severely disabling disorders—autism, brain injury, mental retardation—exhibit behaviors that are dangerous to themselvesor others. They may, for example, hit other chil-dren or destroy furniture when they become ex-cited. Some may develop disabling preoccupa-tions or harmful delusional ideas. Usually,attempts will be made to control their behaviorwithout the use of medication, but in some cases,
75
neuroleptics —also known as antipsychotic medi-cation—will be used.
Neuroleptics may significantly reduce hyper-activity, aggressiveness, and agitation in severelyimpaired children (89). It should be noted, how-ever, that neuroleptic medication is used not asa treatment to reverse severe disorders, but ratheras a means of reducing troublesome symptomsassociated with a disorder. Trifluoperazine(Stelazine”) and haloperidol (Haldol®) appear tobe the two neuroleptics of choice (89) for such ap-plications, partly because they have fewer seda-tive effects than other neuroleptics. Recent re-search (89) has demonstrated that haloperidolreduces stereotyped movements, hyperactivity,deficits in attention, and difficult behaviors in au-tistic children, and can also be associated with anincrease in intellectual functioning. Neurolepticshave little or no direct effect on symptoms suchas difficulties in relating to others, although theymay have an indirect effect on social functioningby reducing symptoms like agitation. Typically,neuroleptics are used as adjuncts to intensive psy-chotherapy and other treatments (89).
One concern about most neuroleptics is theirsedative effect. Neuroleptics sometimes affect cog-nitive functions necessary for relating to others,
CONCLUSION
The mental health treatments outlined in thischapter are based on diverse theories of children’sactions, reactions, and mental disturbances. Somemental health treatments used for children havebeen developed in response to particular child-hood problems, but the majority are adaptationsof treatments used for adults and based on gen-eral theories of behavior. There is substantial var-
for learning, and for carrying on daily life–allfunctions that clinicians aim to increase in severelydisabled children. Major tranquilizers can also re-duce a child’s motivation. Furthermore, the sideeffects of tranquilizers can be very uncomforta-ble and sometimes are a source of impairment.Possible side effects include a continuously drymouth, tremors, and cardiovascular changes.With prolonged use, antipsychotic medicationscan lead to tardive dyskinesia —an often irrevers-ible movement disorder characterized by uncon-trollable repetitive movements of the tongue, lips,head, or neck.
Antidepressants
Antidepressant treatment of childhood depres-sion began in the 1960s (333), but it has not re-ceived widespread clinical application. With re-cent increased interest in childhood depression,research is being conducted on the use of anti-depressant medication, especially the tricyclicantidepressants widely used with adults. Drugshave also been used to treat some specific child-hood anxiety disorders, although most of thesedisorders are considered best treated psychologi-cally rather than with drugs (121).
iation in treatment practice based on differingtheoretical orientation. Analyzing treatments interms of their psychodynamic, behavioral, andcognitive assumptions is useful in understandinghow treatment decisions are made, although inpractice, a number of approaches may be used.The effectiveness of mental health treatments usedwith children is considered in chapter 8.
Chapter 6
Treatment Settings
Chapter 6
Treatment Settings
INTRODUCTION
The settings in which mental health treatmentfor children is provided greatly influence the in-tensity of the treatment, the resources required,and the treatment experience of children and theirfamilies. This chapter describes treatment settingsin the mental health service system: hospitals, resi-dential treatment centers (RTCs), day treatmentprograms, and outpatient settings such as com-munity mental health centers (CMHCs). Mentalhealth services in non-mental-health settings, pre-ventive services, and the integration of mentalhealth and other services are described in chap-ter 7.
Following Wilson and Lyman (709), mentalhealth settings can be conceptualized as forminga continuum from most to least intensive. At oneend of the continuum is inpatient hospital treat-ment, which involves 24-hour-a-day care, oftenfor extended periods of time. At the other end ofthe continuum is outpatient treatment which mayinvolve only 1 or 2 hours a week, or less, some-times for only a few weeks.
More intensive mental health treatment settingsare designed to treat children with more severeproblems. Such problems can be either acute, suchas suicidal behavior, or chronic, such as infan-tile autism. In many cases, factors other than theseverity of a child’s mental problem may indicatethe selection of a relatively intensive setting. More
PSYCHIATRIC HOSPITALIZATION
The most intensive and restrictive type of chil-dren’s mental health treatment is psychiatric hos-pitalization. Children’s psychiatric hospitalizationtakes place in various types of facilities—in free-standing psychiatric hospitals for people of all
intensive settings may be chosen, for example,when children’s support systems are insufficient,their home environment is deleterious, or othertreatment resources are lacking (457). More in-tensive settings are also chosen when children maybe dangerous to themselves or others.
Intensive menial health treatment settings tendto be restrictive, and this fact necessitates specialconsiderations. Federal legislation such as the Edu-cation for All Handicapped Children Act (PublicLaw 94-142) and judicial decisions such as WillieM. v. Hunt (see 50) have codified the principlethat children should receive appropriate servicesin the “least restrictive setting” possible. No pre-cise legal meaning of least restrictive setting isavailable (353), however, and available researchdoes not allow a systematic evaluation of whetherthe principle is applied appropriately. Conse-quently, which mental health treatment settingoffers appropriate care while still being least re-strictive is a matter of clinical judgment influencedby the availability of resources. When optimal oreven adequate treatment settings are not availableor accessible, the quality of care or the principleof providing care in the least restrictive setting,or both, have to be compromised. Details ontrends in the availability and utilization of men-tal health treatment facilities are provided in chap-ter 2.
ages (both State and county mental hospitals andprivate psychiatric hospitals), separate children’shospitals or units, chemical dependency units,and, most frequently, in psychiatric units of gen-eral hospitals.
79
80
Photo credit: Children’s Center, San Antonio, Texas
Private psychiatric hospitals generally offer moretreatment by psychiatrists than do other mental
health settings.
Psychiatric hospitals—regardless of whetherthey are public or private—are medical facilitiesthat must be licensed as hospitals according toState law (531). Many of these institutions are alsoaccredited as hospitals by the Joint Commissionon the Accreditation of Hospitals.
Psychiatric hospitals place disturbed childrenin an entirely new environment. For the periodof a child’s institutionalization, the hospital mustprovide not only for the child’s psychiatric care,but also for his or her food, lodging, medical care,recreational needs and, in some cases, education.A host of interventions are used by treatmentstaff, depending on the hospital. Most hospitalsoffer individual psychotherapy, family therapy,and group therapy. In addition, medication isused as deemed appropriate. Milieu therapy iscentral to most psychiatric hospitals, since the 24-hour-a-day environment allows staff to structurethe daily life of the ward (activities, interactions
with patients and staff, etc. ) to help patients ob-tain emotional support, learn more adaptive be-haviors, and so forth, Many hospital environ-ments also incorporate behavioral interventions.
State and County Mental Hospitals
States and counties provide inpatient psychia-tric care to children as part of the public mentalhealth care system, so a substantial number ofchildren’s psychiatric beds are in public psychiatrichospitals. States and counties in which it has beenrecognized that children should be treated differ-ently from adults have begun to open up sepa-rate psychiatric hospital programs solely for chil-dren. In 1983, there were 30 such facilities in theUnited States (667). Some child psychiatric in-patient units are an organizational component ofCMHCs. Care is generally provided on a reduced-fee basis for those who cannot pay the standardcharges, and public sources provide most of therevenues for State and county mental hospitals(667).
During the past 20 years, the number of chil-dren treated as inpatients in State and countymental hospitals has declined considerably (724;also see ch. 2) as a result of the reinstitutionali-zation movement (405). In the vast majority ofStates, the number of psychiatric beds for chil-dren is quite small, and public psychiatric units
Photo credit Department of Health and Human Services,Natlonal Institute of Mental Health
The Dix Building is the child and adolescent treatmentfacility of St. Elizabeth’s Hospital, the public mental
hospital in Washington, DC.
81
are constrained by a lack of fiscal resources. Per-haps as a result, their staffs are less well-trainedthan the staffs at private facilities (see table 7).
Private Psychiatric Hospitals
Private psychiatric hospitals are owned and ad-ministered by various organizations, includingprivate corporations, universities, and religiousorganizations. The majority are for profit (667).As noted in chapter 2, the mental health servicesthat private hospitals are providing for childrenare increasing. Typically, private hospitals havemore resources to devote to treatment than dopublic hospitals; consequently, private hospitalstend to provide more hours of ancillary treatmentper week per patient, a higher staff-to-patient ra-tio, and a greater number and level of experienceof professional treatment staff.
Private psychiatric hospitalization is the mostexpensive of the common forms of children’s men-tal health treatment. As of 1986, daily chargeswere about $375 for a child and about $325 foran adolescent (457). This expense reflects not onlythe cost of 24-hour institutional care, but also thehigh cost of medically oriented services (245,587).Reduced-cost or charity treatment in private psy-chiatric hospitals is provided for only a few cases.
Children’s Psychiatric Hospitalsand Units
Children’s psychiatric hospitals and units canbe categorized by the duration of treatment theyprovide (161). Short-term, acute care psychiatrichospitals or units provide intensive treatment forchildren in crisis situations when their ability to[unction deteriorates substantially or they presenta danger to themselves or others. Treatment gen-erally lasts no more than 60 days. Short-term psy-chiatric children’s hospital programs offer an alter-native environment for disturbed children whoseusual environments have rapidly become unableto contain and care for them (60,724). The intentis to treat the most severe and threatening symp-toms, help children regain their ability to cope,and prepare them for more long-term, less inten-sive treatment in another setting.
Intermediate-term psychiatric hospitals for chil-dren represent the vast majority of children’s in-patient psychiatric facilities. Intermediate-term fa-cilities treat children for periods ranging fromabout 60 days to about 2 years. Interventions insuch facilities are intended to help children makeextensive changes in their functioning and ofteninvolve significant therapeutic intervention withfamilies.
Table 7.— Distribution of Full-Time Equivalent Staff Positions in Psychiatric Hospitalsand Residential Treatment Centers, 1982
State and county Private psychiatric RTCs for emotionallymental hospitalsa hospitals a disturbed children
Staff discipline Number Percent Number Percent Number Percent
Patient care staff . . . . . . . . . . . . . . . . . . . . .Professional patient care staff . . . . . . .
Psychiatrists. . . . . . . . . . . . . . . . . . . . .Other physicians . . . . . . . . . . . . . . . . .Psychologists (M.A. and above) . . . .Social workers . . . . . . . . . . . . . . . . . . .Registered nurses . . . . . . . . . . . . . . . .Other mental health professionals
(B.A. and above) . . . . . . . . . . . . . . . .Physical health professionals
and assistants . . . . . . . . . . . . . . . . .Other mental health workers
(less than B. A.) . . . . . . . . . . . . . . . . . . .Administrative, clerical, and
maintenance staff . . . . . . . . . . . . . . . . . .
Total staff . . . . . . . . . . . . . . . . . . . . . . . . .
124,16448,224
3,8662,0123,1966,276
15,613
65.30/o25.3
2.01.11.73.38.2
24,08817,408
1,466225
1,0301,7745,705
63,1 0/0
45.73.80.62.74.7
15.0
16,31110,901
15338
6042,100
477
72.50/o48.5
0.70.22.79.32.1
9,179 4.8 5,629 14.8 6,948 30.9
8,082 4.2 1,579 4.1 581 2.6
75,940 40.0 6,680 17.4 5,410 24.0
6,183 27.566,102 34.7 14,057 36.9
1000/0190,266 100% 38,145 22,494 100%aidult and children’s facilities comb!ned
SOURCE” National Institute of Mental Health, Alcohol, Drug Abuse, and Mental Health Administration, Publlc Health Service, U.S Department of Health and HumanServices, Mental Hea/th, Un/ted States, 1985, C A. Taube and S A Barrett (eds.) (Rockville, MD: 1985)
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Long-term children’s psychiatric hospital units,treating children 2 years or longer, are the leastcommon. Children in long-term facilities are con-sidered chronically disturbed with limited capacityfor independence and for maintaining relation-ships. Many of these children cannot be placedin the community.
Chemical Dependency Units
Chemical dependency units can be either pub-lic or private, and can be either freestanding orpart of a general hospital. Such units specializein treating substance abuse and dependence, rang-ing from alcoholism and alcohol abuse to depen-dence on use of illicit drugs such as heroin andcocaine. Substance abuse is a DSM-III disorder(see ch. 3), and many private insurers offer re-imbursement for its treatment in psychiatric in-patient units. Treatment in some units is especiallyadapted to the problems of adolescents and/or thetypes of substances abused by adolescents (709).
General Hospitals With InpatientPsychiatric Services
General hospitals offer a substantial amount ofchildren’s mental health care. Many general hos-
pitals have established separate psychiatric unitswith treatment programs resembling those of free-standing psychiatric hospitals (60). Psychiatricunits in general hospitals tend more often thanpsychiatric hospitals to focus on short-term, acutecare, lasting from a few days to a few weeks ormonths. In comparison with psychiatric hospitals,psychiatric units of general hospitals also tend tohave a somewhat greater proportion of psychia-tric patients who have a concomitant medicalproblem or a psychophysiological disorder, sincethe general hospital can provide both psychiatricand medical care (60).
Under some conditions, general hospitals admitpsychiatric patients to medical wards. In suchcases, one or two psychiatric patients may beplaced in rooms with medical patients. It is diffi-cult to determine the frequency of such treatment.Critics argue that this form of hospitalization al-lows assessment of psychiatric problems at best(161) and is probably appropriate only in crisissituations when other resources are not available.
RESIDENTIAL TREATMENT CENTERS
RTCs, as the term is used in this backgroundpaper and elsewhere, are 24-hour care settings thatprovide a mental health treatment program formentally disturbed children but are not licensedas hospitals (531).
RTCs range from highly structured institutionsthat follow something resembling a medical modeland function somewhat like psychiatric hospitalsto less medically oriented institutions that aresometimes hard to distinguish from halfway houses,group homes, and foster care homes (531). Incomparison to RTCs, psychiatric hospitals tendto have a greater mix of professionals and greaterinvolvement by psychiatrists and psychiatricnurses (see table 7). Furthermore, psychiatric hos-pitals may often admit certain children whomRTCs might not admit—in particular, children
who are highly aggressive, suicidal, or overtlypsychotic (with delusions or hallucinations) (60,411,724). It is becoming more common for hos-pitals and RTCs to be operated by the same orga-nization and to exist side by side on the samegrounds (see ch. 10)
The size of RTCs, in terms of numbers of pa-tients, ranges from a few children to hundreds.According to 1981 data, about 75 percent of theunder-21-year-old patients treated by RTCs areadolescents 12 to 17 years old; approximately 19percent are 6 to 11 years old; less than 1 percentare 5 years of age or less (724).
The intensity of treatment provided in RTCsranges from the provision of virtually every serv-ice possible to only custodial care. Like psychiatric
83
Photo credit” Horizon, a division of Shadow Mountain Institute
RTCs are 24-hour-care settings that provide a mentalhealth treatment program for mentally disturbed children
but are not licensed as psychiatric hospitals.
hospitals, RTCs place disturbed children in an en-tirely new environment and are responsible forall aspects of care. RTCs employ most of the ther-apies discussed in chapter 5. Milieu therapy is alsocentral to RTC treatment.
The length of stay in an RTC ranges from daysto a year or more. Most RTCs, over 80 percent,treat children for a period ranging from severalmonths to 2 years (724). The goal in these settingsis to return children to the community after ex-tensive efforts to increase their level of daily func-tioning. A smaller percentage of RTCs, less than15 percent according to Young (724), treat chil-dren for more than 2 years on the average. RTCsthat provide long-term care primarily serve severelydisturbed children (e.g., those with infantile au-tism, more severe mental retardation, neurologi-cal disorders). In these settings, it is recognizedthat patients will not “recover” from their condi-tions, nor ever approach normal development.
The goal in these RTCs is to enable severely dis-turbed children to attain the highest level of de-velopment possible, to allow these children toeventually return to the community.
One noteworthy model of RTC treatment (alsoextended to day treatment) is called Project-Re-ED, described originally as a “project for the re-education of emotionally disturbed children” (300).Although Re-ED programs are generally residen-tial, much of their work is based on what Hobbscalled “ecological strategies’ ’—changing a child’smental health problem by working both with thechild and the family and community from whichthe child comes.
Re-ED programs approach children’s mentalhealth problems as the result of unhealthy inter-action between children and their environmentsand intervene accordingly. Approximately one-third of Re-ED staff work full-time with parents,teachers, and other community members to helpthem change their interactions with the child be-ing treated at Re-ED. Staff may advise parents,for example, on strategies to help their childrenmaintain self-centered, or collaborate with teachersin designing a program for a child who is return-ing to a school in the community. Almost all chil-dren in Re-ED programs return home for weekendsto maintain their contact with family and com-munity.
At Re-ED residences, “teacher-counselors” workto bolster children’s academic competence andemotional well-being. Academic progress is seenas a key step in reducing mental health problemsand promoting the child’s return to the commu-nity. Re-ED also emphasizes milieu therapy, withone-on-one intervention between staff and childtaking place mainly in the context of the milieu,and little or no individual therapy. The positiveemotional experiences of daily life at a Re-ED pro-gram are thought to form a large part of thetreatment.
DAY TREATMENT/PARTIAL HOSPITALIZATIONSome children do not need 24-hour treatment is used as a followup to psychiatric hospitaliza-
but do require more intensive treatment than 1 tion or RTC treatment, when a child may noor 2 hours a week of therapy. Day treatment often longer need 24-hour care but is not yet ready to
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cope with a regular classroom. Day treatment pro-grams provide extended treatment, available fora number of hours daily, and can provide a rangeof therapies that are not available at clinics. Someprograms provide treatment to children before orafter regular school hours, while other programsprovide education to children whose troubles pre-vent them from attending school.
Some day treatment programs are designed ac-cording to an educational model. These programs,sometimes called psychoeducational day treat-ment programs, operate more like schools thanother day treatment centers but incorporate atherapeutic component within the educationalprogram. Their curriculums in many cases areadapted from regular school curriculums, but in-clude special approaches to address the almostuniversal learning problems of mentally disor-dered children. Like psychiatric hospitals andRTCs, day treatment centers offer the kind of ex-
OUTPATIENT SETTINGS
Outpatient treatment settings are by far themost prevalent settings used for children’s men-tal health treatment. CMHC outpatient depart-ments, private outpatient clinics, and private men-tal health practices are described below. Most ofthe treatment modalities discussed in chapter 5,from individual psychotherapy to group and fam-ily therapy, can be provided in these settings.
CMHC Outpatient Departments
Initially established by the Federal Governmentthrough the Community Mental Health CentersAct of 1963, CMHCs were intended to providecomprehensive mental health services to all theresidents of a catchment area regardless of theirability to pay. The mental health services pro-vided by CMHCs include treatment, prevention,and consultation and education services, but out-patient treatment is by far the most common.
CMHC care is provided to adults (619), butmost centers also provide some children’s serv-ices. Some CMHCs have incorporated previouslyestablished child guidance clinics, while othershave established new child treatment services.
tensive daily environment in which milieu ther-apy can be done. Model day treatment programsalso include mental health components involvingindividual therapy, group therapies, family ther-apy, vocational counseling, and other vocationalprograms. They also provide other educationaland recreational activities designed to further thedevelopment of adolescents in a less treatment-oriented fashion.
Partial hospitalization is the use of a psychiatrichospital setting for less than 24-hour-a-day carefor given patients. For example, some childrenmight need the treatment offered in the hospitalsetting during the day but be able to return homein the evening. The treatment program for thosechildren would be identical to the daytime treat-ment program of the inpatient children. In effect,this is day treatment applied in a psychiatric hos-pital setting.
CMHCs use virtually all treatment modalities, in-cluding psychodynamic psychotherapy, behaviortherapy, cognitive therapy, psychosocial interven-tions, parent guidance, family therapy, and psy-chopharmacological (drug) therapy. For the ma-jority of children, more than one modality oftreatment is provided simultaneously (363), usu-ally including one or more interventions directlywith the child plus work with important adultsin the child’s life.
Despite the intentions of the 1963 law, a net-work of CMHCs never developed as a nationwidemental health care system. Furthermore, accord-ing to some observers (619), the network that diddevelop slighted the needs of children for severalyears. Few CMHCs included children’s serviceswhen they were established, and in those that didestablish child services, the resources available forsuch services were often too low. The number ofstaff devoted to children was small, and the levelof training of the staff in child mental health waspoor (9,11, 55,514). The situation improved some-what in the 1970s; according to a 1981 surveyfrom the National Institute of Mental Health(NIMH), approximately 17 percent of the resources
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of CMHCs were devoted to children’s mentalhealth care (665).
In 1981, direct Federal support for CMHCs waswithdrawn. Federal funds began to be providedto CMHCs indirectly via the States through theblock grant mechanism (see ch. 10).
Private Outpatient Clinics
In addition to CMHCs, many private clinicsprovide outpatient treatment to mentally disturbedchildren. The services that private clinics provideresemble CMHC outpatient services in manyways, although private clinics vary more in size,scope, and treatment philosophy. Unlike mostCMHCs, private clinics do not have the respon-sibility to provide for all the mental health treat-ment needs of a given community. Many closelyadhere to the philosophy of the individuals ad-ministering the clinic. Some private clinics arenonprofit and have sliding scales for payment(e.g., Family Service Association centers), whileothers provide services only at standard fees.
CONCLUSION
Mental health treatment settings that provideservices to children are diverse, ranging from hos-pital and RTC settings to day treatment centersto outpatient settings. They can be arranged alonga rough continuum according to their intensive-ness. Even within a type of setting, settings varyin their form of administration (public versus pri-vate), cost, type of children served, duration oftreatment, and philosophy of treatment.
The need for availability of a diversity of set-tings to treat the range of children’s mental healthproblems has been repeatedly emphasized. For ex-ample, the President’s Commission on MentalHealth (514) recommended both an increase in thenumber of hospital and RTC facilities for seriouslydisturbed children and an expansion in the avail-ability of community-based mental health care ofall types (e.g., hospital, RTC, outpatient) for allchildren.
Some clinics were established as child guidanceclinics prior to the development of CMHCs andhave not been absorbed into CMHCs.
Private Mental Health Practices
Many mental health professionals provide out-patient child mental health care in private prac-tice. The number of children seen by private prac-titioners is not known, but it is believed to belower than the need. Private mental health carepractitioners include psychiatrists, psychologists,clinical social workers, psychiatric nurses, andmental health counselors who have met Statelicensing standards. In form and method, privatepractice resembles outpatient treatment in orga-nizational settings. However, private practitionersgenerally charge fees affordable only by familieswith middle incomes and above, and then oftenonly with help from insurance. With widespreadavailability of health insurance, some private careis accessible to most families, but insurance pol-icies vary greatly in their coverage of outpatientmental health care (374).
One factor contributing to the need for a diver-sity of mental health treatment settings is thedesirability of providing appropriately intensivemental health treatment in the least restrictive set-ting possible. It is easier to strike a balance be-tween intensiveness and restrictiveness when treat-ment settings are available that cover the rangeof these dimensions. For children who need moreintensive treatment than can be provided in weeklyoffice visits but who can still live at home, themost appropriate setting—if it is available—maybe a day treatment program.
Another factor that underlies the need for mul-tiple mental health treatment settings is the factthat many children, especially those who are se-verely disturbed, require either concurrent or con-secutive treatment from more than one setting.For example, some children who go to an out-patient clinic once a week for psychotherapy to
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address specific emotional issues might also ben-efit from participation in day treatment to learndaily living skills. Or children discharged froma psychiatric hospital may live, initially, in a lessintensive RTC and later receive psychotherapy asan outpatient in the community.
The variety of mental health treatment settingsdescribed in this chapter does not imply that allchildren have access to the full range of possiblesettings. Although many different models havebeen developed, the number of settings available
is much more limited. The overall number of men-tal health treatment facilities is fairly small. Fur-thermore, access to some settings is limited bycost. Many families cannot afford the costs oftreatment in private psychiatric hospitals or RTCsor through private practices. The number of treat-ment openings for children in public psychiatrichospitals, RTCs, and day treatment centers isseverely limited, and the development of childoutpatient treatment in CMHCs has not beencomprehensive.
Chapter 7
Treatment in Non-Mental-HealthSystems, Prevention, and theIntegration of Mental Health
and Other Services
Chapter 7
Treatment in Non-Mental-Health Systems,Prevention, and the Integration of Mental
Health and Other Services
INTRODUCTION
Mental health treatment, it is widely agreed,should take place in the context of a child’s life.Children are uniquely dependent on their families,schools, and communities, and are continually af-fected by these influences. Disturbed children aremore likely than other children to fail in school,to manifest a variety of medical problems, andto be involved with the criminal justice system.As a result, children’s mental health problems areoften first identified in settings such as schools,physicians’ offices, and juvenile courts. These set-tings, along with others, provide important men-tal health treatment sources.
Understanding how treatment services are of-fered in non-mental-health contexts, such as theeducational, health care, welfare, and juvenile jus-
tice systems, is essential for developing public pol-icy. The interrelationship between mental healthand other service systems provides opportunitiesto identify children in difficulty, to provide in-terventions at the site where mental health prob-lems are identified, and to offer programs to pre-vent mental health problems. Currently, however,there is relatively little integration among men-tal health and other systems. This chapter con-siders needs for and provision of mental healthservices across various non-mental-health systems.It describes a number of programs and projectsin the educational system, the health care system,the child welfare system, and the juvenile justicesystem, along with the development of integratedservice systems.
CHILDREN’S MENTAL HEALTH TREATMENTNON-MENTAL-HEALTH SYSTEMS
Treatment in the Educational System
The importance of dealing with children’s men-tal health problems in the educational system haslong been recognized (see 602). Mental healthproblems interfere with a child’s ability to learnand to manage in the social world of the school.Moreover, mental health problems are likely tohave a great effect at school simply because ofthe number of hours that children spend there andthe importance of education to their lives. Manychildren can receive an adequate education onlyif their mental health needs have been met.
Schools deal with the mental health needs ofchildren in a variety of ways (157), but the po-tential of the educational system in meeting chil-
dren’s mental
IN
health needs has not been fully real-ized. A tradition of referring children from schoolsto mental health treatment settings dates back tothe child guidance clinics of the 1920s and 1930s.Some schools have their own mental health pro-fessionals, such as school psychologists and so-cial workers, who provide mental health treat-ment within the school and provide consultationto other school staff (see 372). Other schools relymore heavily on external mental health profes-sionals and a variety of referral resources. A sub-specialty of education, special education, was spe-cifically developed to serve the educational needsof children with learning disabilities and psycho-logical and physical handicaps. Because of thedifficulties involved in innovation in public schools
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(407) and the difficulty of collaboration betweenthe educational system and mental health system(437), mental health interventions in schools havenot been widely implemented. Nevertheless, therehas been substantial experimentation with suchinterventions. Experimental programs have pro-vided extra classroom interventions for hyperac-tive children, learning-disordered children, con-duct-disordered children, anxious (withdrawn)children, or heterogeneous groups of disturbedchildren. These experimental programs in schoolshave involved various therapeutic approaches.Behavioral interventions have been used exten-sively since the 1960s, and the use of cognitiveinterventions such as self-control and social skillstraining has been increasing. These interventionshave been implemented by both teachers andmental health professionals.
The Education for All Handicapped ChildrenAct (Public Law 94-142) requires that an educa-tion be provided to all physically and mentallyhandicapped children. For each handicappedchild, the necessary educational and related serv-ices to enable the child to obtain an educationmust also be provided. The law requires the de-velopment of an individualized education pro-gram that specifies those educational and relatedservices for each child. There has been some dis-pute over what a “related service” is and whethermental health treatments such as psychotherapyfall within that definition. There is a growing con-sensus that mental health treatments are relatedservices, and this view has been supported by sev-eral court decisions (e.g., Papacoda v. State ofConnecticut, 528 F. Supp. 68 [D. Corm. 1981],In the matter of the “A” Family, 602 P. 2d 157[Mont. 1979]), cited in 358).
Who is to provide and who is to pay for educa-tional and mental health services for disturbedchildren under Public Law 94-142 has been un-clear. In some States, schools themselves offerpsychological services, although school person-nel providing such services often have less clini-cal training than out-of-school providers. Whenmental health services are provided in nonschoolsettings, it is often unclear whether the responsi-bility for payment rests with the schools or with
Photo credit: Very Special Arts
In general, mental health professionals believe that theleast restrictive setting is most appropriate for treatingchildren. Here, the educational system offers a valuablenon-mental-health setting in which to treat children.
the parents. This is especially unclear when thenecessary related service is a residential treatment.In 1984, 4 million students aged 3 to 21 receivedservices under Public Law 94-142. The numberof handicapped children receiving mental healthservices is not known.
The Federal contribution to activities mandatedby Public Law 94-142 is relatively small: $1.07billion in fiscal year 1984, 25 percent of which wasset aside for administrative and other supportservices, including “related health services” (657).Essentially, however, services for handicappedchildren are mandated, but resources are not pro-vided to implement them. It is not known whatportion of funds for psychological and mentalhealth were spent for psychological services. Astudy to assess amounts spent by educationalagencies on all related services, including psycho-logical services, is due to be completed in fiscalyear 1987 (656). The form that implementationof Public Law 94-142 should take is still being de-termined in a number of States, and responsibili-ties across education departments, mental healthdepartments, and other service systems are stillbeing considered.
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Treatment in the GeneralHealth Care System
Increasing evidence suggests that many chil-dren’s mental health problems are seen by physi-cians in the course of delivering primary healthcare; but surveys differ on the extent to whichoffice-based primary care physicians see and rec-ognize mental health problems in children. In tworecent surveys by Goldberg, et al., pediatriciansreported that approximatelys percent of the chil-dren they saw had a mental health problem (239,240). Schurman and colleagues, using data fromthe National Ambulatory Medical Care Survey,found that about 11 percent of office visits to pedi-atricians and about 12 percent to family practi-tioners were by children with psychiatric disorders(588).
In Goldberg, et al.’s investigation, the majorityof troubled children visited their physician’s of-fice because of a physical complaint, and theirmental health problems were uncovered duringthe course of visits for other problems. Pediatri-cians often treated the mental health problemsthemselves, providing supportive counseling, prac-tical advice or, less frequently, medication (239).Approximately 50 percent of the pediatricians inGoldberg, et al.’s samples (239,240) referred trou-bled children to a mental health professional,
Some observers are concerned about the levelof mental health knowledge of many primary carephysicians (239,240). Furthermore, although pri-mary care physicians and mental health profes-sionals may see child patients concurrently, theirefforts are not always coordinated.
Two options open to many primary health careproviders are obtaining mental health training(e.g., 85) and consulting with mental health spe-cialists (543). The logic behind increasing the men-tal health skills of primary care providers is thatthey are likely to be the first professionals con-sulted regarding developmental and psychologi-cal problems of young children (504).
In addition to mental health consultation andmental health training for primary care providers,early intervention programs have been developedin primary medical care settings for children suf-fering from a number of childhood problems (536).
Prevention efforts have been used to help physi-cally ill pediatric patients manage their illnesseswithout undue mental health consequences (323).Systematic mental health interventions in physi-cal health care settings remain exceptional, how-ever. Only in settings such as health maintenanceorganizations might mental health referrals andinterventions be commonplace.
Evidence for the susceptibility of chronically illand physically disabled children to mental healthproblems was noted in chapter 4. The prevalenceof mental health problems seen by medical spe-cialists in medical inpatient units is probably high.
Treatment in the ChildWelfare System
The child welfare system is involved with a sub-stantial number of children who have serious prob-lems. Child welfare systems intervene in cases ofparental abuse and neglect and in other situationsin which parental care is lacking (e. g., during aparent’s illness).
Treatment Needs for Children in Foster Care
A major form of intervention by child welfareauthorities is foster placement. The child welfaresystem places an estimated 120,000 children peryear in some form of foster care, usually withina home or institutional setting (48). There has beenlittle research to ascertain what portion of thispopulation enters foster placement with mentalhealth needs.
Children generally enter the foster care systemfrom family situations with problems includingchild maltreatment, parental psychopathology,and parental substance abuse—all of which arerisk factors for mental health problems (see ch.4). Only a small percentage of children have beenplaced in foster care because of their own behavioror disability (108). When placed in foster care,children suffer the trauma of separation from theiroriginal families (205). Many children who wouldbe diagnosed as having psychological problemsby mental health professionals are not recognizedas having such problems by foster care placementagencies and staff (205). For the most part, thesechildren are not placed in environments capable
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of providing appropriate care for psychologicalproblems (205).
Frank’s study of treatment needs for childrenin foster care found that children involved in long-term foster care typically had severe psychoso-cial problems (205), both at the point of entry intofoster care and 5 years later. Children who wererated at a level of medium to low functioning atentry into foster care slipped significantly to thelower level after the 5-year period. Frank foundthat 85 percent (composite percentage) of the sam-ple of children in long-term foster care receivedinadequate treatment (apart from the quality ofchild care).
Several State studies suggest that the prevalenceand severity of emotional disturbance is associ-ated with the number of placements a child hasexperienced (108). Long-term and repetitive fos-ter care placement, therefore, are likely to repre-sent both sources and symptoms of problems forchildren with mental health needs. Yet child wel-fare agencies often have neither the money northe experienced staff to provide mental healthservices, and coordination between welfare andmental health agencies is rare (358).
Alternatives to the usual pattern of foster place-ments are discussed below. These alternatives aretherapeutic foster care, respite care, and care ingroup homes. Efforts to prevent the need for fos-ter placement by enhancing parents’ abilities tocare for their children are discussed later in thischapter.
Therapeutic Foster Care
Mentally disturbed children who might other-wise be referred to psychiatric hospitals or resi-dential treatment centers (RTCs) are sometimesplaced in alternative family settings (83). Al-though separating a child from his or her parentsis a significant intervention, therapeutic foster careis considered less intensive than treatment in apsychiatric hospital or RTC.
Well-run therapeutic foster care programs care-fully select foster parents to take disturbed chil-dren into their homes for a finite period of time.These foster parents are generally expected to pro-vide some therapeutic work and are typically paidmore than other foster parents. Such parents, who
vary in their experience with mental health treat-ment, undergo training prior to therapeutic fos-ter care placement. Professionals involved withfoster care programs supervise and support thefoster parents, arrange for other care needs of thedisturbed children in foster care, and provideemergency professional care for foster childrenwhen needed.
The range of the intensiveness of treatmentwithin therapeutic foster care programs is substan-tial, and the more intensive levels require moretreatment-specific training, greater involvementof foster parents, and greater availability of ad-junct services. In many States, different levels oftherapeutic foster care are available to cover arange of impairment in children.
Children in therapeutic foster care usually re-ceive mental health treatment beyond therapeu-tic foster care. The nature of this other treatmentdepends on the particular child’s needs and theavailability of local resources. Thus, for exam-ple, one child in therapeutic foster care may re-ceive outpatient psychotherapy, while anothermay attend a day treatment program.
Respite Care
Respite care, a service related to foster care, in-volves placing children in homes with caring adultsas an emergency intervention. Respite care pro-vides children in need with a temporary protectedenvironment. Such care may be necessary becauseof a crisis such as the emotional breakdown ofparents or escalating conflict between children andother family members. Shelter from a crisis maybe provided for several days or up to severalweeks, until the child can return home or be placedin another appropriate setting.
Group Home Care
Group home care is similar to therapeutic fos-ter care, except that a number of children (usu-ally 10 to 12) are placed in a home at one time(709). Group homes are typically administered bysocial service agencies, which employ staff to livein the home or work there in shifts. Group homesusually have a somewhat more structured treat-ment program than therapeutic foster homes.Placement in group homes can last anywhere from
1 month to several years, and commonly includesconcurrent treatment in a mental health setting.
Treatment in the JuvenileJustice System
The juvenile justice system is a potentially ma-jor site for provision of mental health care to dis-turbed children and adolescents. By DSM-III cri-teria (see ch. 3), juvenile offenders with a historyof behaviors such as fighting, stealing, lying, andrunning away from home would be diagnosed ashaving a conduct disorder. Often, however, themental disorders of juvenile offenders are not for-mally diagnosed, and the number of juveniles whohave mental disorders in addition to criminal orstatus offenses (offenses that are criminal only be-cause the offender is a juvenile, e.g., truancy, run-ning away from home) is not actually known.
The proportion of children and adolescents inthe juvenile justice system who are regarded asmentally disordered or as having mental healthproblems obviously depends on what criteria areused to define mental disorders and mental healthproblems (601,723). Whether a child’s problemsare dealt with in the mental health system or inthe juvenile justice system often appears to de-pend less on characteristics of the child than onhow a particular behavior is defined (i.e., as asymptom or as a violation of the law) and on thesystem within a State or region for assigning serv-ice responsibility.
Coordinated interventions in which both themental health and the juvenile justice system are
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involved are rare (395). Mental health agenciesare often reluctant or unable to take responsibil-ity for intervention with juvenile offenders be-cause of the danger and disruptiveness these chil-dren and adolescents present, and the juvenilejustice system is often unable to treat the mentalhealth problems of these youths. Many mentallydisordered children have contact with both themental health and juvenile justice systems, oftenmoving back and forth between the systems. Fre-quently, children who are sent from one systemto the other are those for whom original inter-ventions have failed or been exhausted (395,723).The frequent and rapid transferring of these “turn-stile” children (276) sometimes causes problemsitself.
There are several models of coordinated men-tal health and juvenile justice interventions (601).A number of special mental health programs haveorganizational connections to State and countygovernments and provide comprehensive servicesto disturbed juvenile offenders (49,304,395,723).In some instances, States contract with privatemental health agencies to provide services to chil-dren who come in contact with the juvenile jus-tice system in specific geographic areas (395).Other programs provide mental health consulta-tion directly to juvenile justice facilities (395,601).Case management (discussed below) has been usedto resolve some of the problems of trying to servedisturbed children who are wards of the juvenilejustice system, but the use of case managementin the juvenile justice system is infrequent (49).
PREVENTION OF CHILDREN’S MENTAL HEALTH PROBLEMS
A number of strategies are used to prevent be- mental health problems in the population and tohavioral, social, emotional, and academic difficul- reduce the need for more intensive and costlyties in children. Primary prevention strategies are treatment services such as psychiatric hospitali-aimed at reducing the incidence of new cases of zation or other residential treatment (98).mental health problems; secondary prevention ef-forts are directed at reducing the severity and du- Primary Preventionration of disorders through early identification,diagnosis, and treatment (see 98). In practice, Primary prevention efforts are frequently di-however, primary and secondary prevention often rected at parents and educators. Sometimes theyoverlap. The common objective underlying all are aimed at the parents of children who are atprevention efforts is to reduce the incidence of high risk. To treat high-risk infants, for example,
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programs train parents in different techniques forstimulating and giving attention to the infant.Other similar primary prevention interventionshave been developed for particular groups (e.g.,poor women) and teenage mothers (187,525).
Primary prevention methods have also been de-vised for the parents whose children are notknown to be at high risk. Such methods includetraining manuals to help instruct parents in child-management techniques (e.g., 40,429,497), educa-tional videotapes for inexperienced mothers (78),and parent education groups such as Parent Ef-fectiveness Training (242,243). Although popu-lar, some of these methods have been criticizedfor not meeting the needs of low-income families(110).
In school settings, primary prevention effortsinclude alcohol education programs in elementaryschools (380) and mental health consultation serv-ices provided to teachers (see 408). Such effortsalso include programs aimed at decreasing spe-cific behaviors that are thought to predispose chil-dren to later problems in school adjustment. Forexample, one program employed intensive train-ing in interpersonal, cognitive problem-solving forkindergarten children in the hopes of decreasinginhibited and impulsive behavior and enhancingsocial problem-solving skills (621).
Head Start and similar preschool child devel-opment programs are examples of an ongoing ef-fort at primary prevention. Head Start was estab-lished as a national program in 1965 to provideenriched early childhood education for low-in-come children. Head Start also provides a rangeof other services, including health, nutrition, andsocial services. The program emphasizes parentand community involvement in the developmentand operation of the program, a feature that hasproved effective (see ch. 9). However, Head Starthas been criticized for devoting few resources andlittle attention to mental health services (308).
Somewhat different from other primary preven-tion programs are family support programs. Inrecent years, the importance of families for chil-dren’s mental health has been widely acknowl-edged (290). Although families are often viewedas the primary contributors to mental illness inchildren, they are increasingly recognized as a
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Photo credit: March of Dimes
Physically disabled children may be susceptible tomental health problems.
principal source of mental health and adaptation(693).
The idea of supporting families is not new, butthe growth of a family support movement as adistinct and important aspect of children’s men-tal health services is a fairly recent phenomenon(326,693). The family support movement can besaid to be integrative in that it focuses on the needsand linkages between children, families, commu-nities, and broader social systems. According toWeiss (693) and others (594), the family supportmovement evolved in part from early interven-tion and prevention programs such as Head Start,The finding that the most effective of these pro-grams were those that actively involved parents—and the related idea that children at risk needan intervention approach that encompasses morethan educational enrichment—pointed to the fam-ily as a necessary focus of intervention.
More recently, the family support movementhas gained impetus from research underscoring
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the importance of quality parent-child interactionsin promoting children’s social, emotional, andcognitive competence (e. g., 623). The develop-ment of family support programs has also beensupported by recent trends in the delivery of so-cial services. Such trends include increasing em-phasis on the promotion of health and the pre-vention of illness, the use of self-help and mutualaid groups, and access and coordination of serv-ices through information and referral systems(334,693).
Finally, the family support movement is a re-sponse to the stresses faced by contemporaryAmerican families. Such stresses include demo-graphic trends (e.g., increases in the numbers ofsingle-parent and dual-career households) as wellas broad social forces such as unemployment, eco-nomic uncertainty, and increased mobility andisolation of families.
The family support movement represents a di-verse array of services and programs that shareunderlying assumptions and conceptual emphasesmore than a particular format or structure. Fam-ily support services range from a center-based pro-gram resembling traditional mental health serv-ice to practices such as corporate flexitime anddaycare.
Family support programs are characterized bytheir focus on family strengths rather than defi-cits; their recognition that parents need and wantinformation and support in carrying out theirroles; an attempt to empower families and fosterself-reliance; and their emphasis on the relation-ship not only between children and parents, butalso between families and the sources of supportin their communities.
According to Weiss (693), the dimensions onwhich family support programs vary include thetype of family served (e.g., new families, single-parent families, families with special needs); serv-ice delivery mechanisms (e.g., newsletters, homevisits, parent groups); program goals (e.g., childabuse prevention, home and school linkages, par-ent and child education); program settings (e.g.,mental health centers, schools, churches, drop-in centers); staff composition (e.g., mental healthand health professionals, educators, volunteers);and funding sources (private and public).
Two examples of family support programs arethe Yale Child Welfare Research Program (594)and the Family Support Center Program (see 202).The Yale Child Welfare Research Program is dif-ferent from other programs in that it is univer-sity based and includes outcome research as oneof its major components. The Yale program istypical of family support interventions, however,in that it employs a multidisciplinary teamworkapproach focused on the social and emotional ad-justment of all family members. The goal of theYale program’s interventions is to enhance par-ent’s ability to perform their caregiving roles andto solve their own life problems. Interventions areaimed at impoverished families considered at riskby virtue of the chronic stresses and limited re-sources associated with reduced socioeconomicstatus. Families receive home visits, pediatric care,daycare, developmental examinations, and psy-chological services as needed, and services are pro-vided over a 2*/z-year period for each family. Ina recent 10-year followup of the original programparticipants and an equivalent group of controlfamilies, the Yale program’s interventions werefound to have both positive and long-lasting ef-fects (see ch. 9).
The Family Support Center Program is designedto reduce the incidence of child maltreatment inat-risk families by providing parents with supportand guidance in a series of steps that emphasizeprogressively greater peer support and progres-sively less staff involvement. As parents advancein the program, they move from receiving directstaff support and consultation, to attending a“family school” with their children, to participat-ing in a neighborhood support group. An evalu-ation of a Family Support Center Program (25,202) is discussed in chapter 9.
Secondary Prevention
Secondary prevention efforts for children whohave begun to show signs of behavioral difficul-ties have been implemented in both home andschool settings. Some secondary prevention ef-forts are aimed at training parents to deal directly
with their children’s problems. In one program(317,318), parents were taught to use behavioralmethods to modify a range of behaviors in their
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preschool children at home (e.g., reducing aggres-sion and tantrums, and increasing eye contact, im-itation, and vocalization). This program also in-volved parents in health-center-based activities inwhich they observed and were instructed in teach-ing activities aimed at enhancing their children’sprosocial behavior and language skills.
One of the most extensively implemented andwell-researched school-based secondary preven-tion programs is the Primary Mental Health Proj-ect (PMHP) of Cowen, et al. (128). This programwas developed to remediate children’s problemsin the primary grades, a goal based on observa-tions that early school problems frequently per-sist or increase over time and that they lead to
more serious mental health problems later in life(126,128). PMHP involves the delivery of individ-ually based, remedial efforts to grade-school chil-dren who have been identified as having behavioraland academic difficulties (e.g., acting-out, with-drawal, and learning problems). Teacher aidesmeet with children on a regular basis during theschool year, and individual goals are modifiedaccording to the child’s changing needs. Addition-ally, mental health professionals serve as consul-tants to teachers and other school personnel. ThePMHP model has been widely disseminated, andprograms have operated in over 200 schoolsthroughout the country (125).
INTEGRATION OF MENTAL HEALTH AND OTHER SERVICES
As described in this chapter, the treatment andprevention of children’s mental health problemsoccurs in a variety of settings—educational andother—outside the mental health care system. Inaddressing children’s needs, therefore, it is impor-tant to consider the integration of mental healthservices with other services. Given the diverse set-tings in which children’s mental health care is pro-vided, it is perhaps not surprising that fragmen-tation of services is often reported (324,359).
Isaacs (310,311) has reviewed various methodsof integrating systems, both at the level of entiresystems or programs and at the level of individ-ual children. State departments can cooperate atthe administrative level to develop policy deci-sions together, to initiate programs jointly, or toshare management and support services. Serviceprograms can include staff from all systems. Atthe level of the individual child, agencies can col-laborate on most stages of the treatment process,from case finding and evaluation to followup. Al-though each agency provides specialized services,staff from different services can collaborate inperiodic case conferences, case teams, or case con-sultation.
According to Isaacs (312), a number of princi-ples should undergird the organization of the chil-dren’s mental health system. One is that children’smental health services should be integrated with
services that address a child’s physical, mental,social, and intellectual needs while recognizing thedevelopmental stages of the child and the needsof different groups of children and adolescents.Another principle is that services should be co-ordinated, with a single agency given responsi-bility for developing and coordinating the systemof care at both local and State levels. Yet anotherimportant principle is that services should be de-livered to the extent possible within the child’snormal environment (i.e., home, school, healthcare setting), and, if such is not possible, withinthe least restrictive environment. Finally, earlyidentification of problems should be promotedand the system of care should support a child’sright to develop in a nurturing environment withpositive adult relationships.
One important concept in the integration ofchildren’s services is that of the case manager orcase advocate (359). A case manager or advocateis an individual or team, usually in the mentalhealth system, who assumes responsibility for en-suring that the appropriate combination of serv-ices from all service systems is provided to a cli-ent. Case managers are conversant with the lawsentitling children to services, such as Public Law94-142, and ensure their application in individ-ual cases by advocating on the child’s behalf inschool, in court, or within the mental health treat-ment program itself (359). They can maintain the
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push for treatment within systems that are some-times overwhelmed, disinclined to treat difficultchildren, and entangled in bureaucratic difficul-ties (359).
One of the most sophisticated models of casemanagement has been developed by North Caro-lina. In this model, case managers are responsi-ble for seeing that all facets of a child’s evaluationand treatment are carried out. They continuallyreview the treatment plan and monitor its imple-mentation; one of their responsibilities is seeingto it that the disturbed child receives treatmentin the least restrictive setting possible (5o). In someinstances, case managers locate and arrange forservices outside the mental health system, suchas homemaking systems for beleaguered mothers,that are nonetheless crucial to the stability of adisturbed child’s family. In addition, they arrangefor the adult service systems to continue care forchildren in need who are about to turn 18 (50).
CONCLUSION
The educational system, the general health caresystem, the child welfare system, and the juve-nile justice system present important opportuni-ties to identify and help troubled children. Yet evi-dence suggests that the mental health problemsof children involved with these systems are oftenpoorly treated or not treated at all (358,595,645).
The variety of mental health programs poten-tially available to children would appear to re-quire that such services be integrated across mo-
At present, the integration of mental health andother children’s services is probably more of anideal than a reality. In a review of State adminis-trative structures for provision of coordinatedservices, Isaacs (313) concluded that despite anumber of models, implementation of coordina-tion plans often depends on the efforts of indi-vidual staff members, rather than on establishedsystems and structures. In addition, Isaacs (313)found that even in States attempting coordinationbetween the mental health system and other agen-cies, State education and health departments,which have the most frequent contact with chil-dren, were almost always excluded from coordi-nation programs. The Federal Child and Adoles-cent Service System Program, described in chapter10 of this background paper, was established in1984 to help State mental health agencies coordi-nate care for one segment of the population ofchildren with mental health problems—those whoare severely emotionally disturbed.
dalities, providers, settings, and systems althoughin many cases there may be few services to inte-grate. The variety of mental health programs alsosuggests that evaluation of any one interventionprogram is likely to yield an incomplete pictureof the nature and effectiveness of children’s men-tal health care. Variables such as coordination ofprograms should be taken into account in theassessment of that care.
Part IV: Effectiveness of Services
Chapter 8
Effectiveness of Therapies
Chapter 8
Effectiveness of Therapies
INTRODUCTION
Although the scientific evaluation literature onchild treatment is inadequate to answer many pol-icy questions, an increasing amount of researchon the effectiveness of children’s mental healthtreatment is available. The fundamental conclu-sion that professional mental health treatmentleads to significantly better outcomes than notreatment across age groups is supported by a sub-stantial research base on the effectiveness of men-tal health treatment in general (38,484,616,647).Children’s mental health treatments cannot bedirectly equated with treatments for adults (8),but general research tests some of the fundamen-tal assumptions of treatment. Furthermore, thereis an extensive theoretical rationale concerningtreatment for children’s mental disorders (see ch.5). In many cases, such theory and data are sup-portive of child treatment interventions, even inthe absence of applied research.
To assess current scientific understanding ofwhat is known about the effectiveness of mentalhealth intervention for children, this chapter firstdiscusses reviews of the research that consider theeffectiveness of psychotherapies for children ingeneral. Available reviews of psychotherapy out-come research differ in the range of therapies theyinclude within their purview-some includingstudies of family therapies, for example, and
others not; some including studies of group ther-apy and others limited to studies of individualtherapy. By including studies of a variety of mo-dalities, these reviews analyze the question ofwhether therapy in general can be effective withtroubled children. This question is important be-cause, currently, it is therapy in general that isreimbursed, not particular therapies.
The second part of this chapter examines re-search on the effectiveness of specific therapies de-scribed in chapter 5: behavioral therapy, cogni-tive therapy, group therapy, family therapy, crisisintervention, and psychopharmacological (drug)therapy.
It should probably be noted that for the mostpart the scientific literature contains evaluationsof the effectiveness of therapies for mental dis-orders (see ch. 3) rather than subclinical mentalhealth problems (see ch. 4); consequently, it is theeffectiveness of therapies for diagnosable disorderswhich is reviewed in this chapter. Some servicesfor subclinical mental health problems come underthe rubric of prevention and mental health inter-ventions in non-mental-health settings such asschools, homes, and the juvenile justice system;the effectiveness of such services is reviewed inchapter 9.
EFFECTIVENESS OF CHILD PSYCHOTHERAPY INGENERAL AND METHODOLOGICAL ISSUES
Nearly 30 years separate the first review of child lel an improved methodological soundness in thepsychotherapy outcome research (382) from the studies reviewed. Later reviews also indicate that,most recent (104). Not surprisingly, the latest re- in general, treatment for children’s mental healthviews of child psychotherapy outcome research problems is more effective than no treatment.in general have shown greater methodological so- However, methodological problems persist, andphistication, incorporating the more rigorous the conclusions of the reviews should be viewedmeta-analytic techniques (387,552,616) to paral- somewhat cautiously.
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104
Reviews of Child PsychotherapyOutcome Research
Levitt (1957, 1963)
The first major efforts to assess children’s men-tal health treatment were Levitt’s (382,383) re-views of child psychotherapy outcome research.Levitt aggregated across available studies the per-centages of children who were judged to have im-proved following treatment. Since most of thesestudies did not include control groups, he com-pared the aggregate percentage of treated childrenwho improved to the aggregate percentage of un-treated children who improved (derived from twostudies).
In his 1957 review (382), Levitt concluded thatan estimated 67 percent of treated children hadimproved at the close of treatment and that 78percent of treated children had improved at fol-lowup; Levitt also found, however, that 72.5 per-cent of untreated children had improved. Theseobservations suggested that, in general, child psy-chotherapy for mental health problems did nothave an advantage over no treatment. Levitt’s1963 update (383) yielded similar results. Levittwrote:
. . . the inescapable conclusion is that availableevaluation studies do not furnish a reasonablebasis for the hypothesis that psychotherapy fa-cilitates recovery from emotional illness in chil-dren.
Levitt’s conclusion can be criticized on severalgrounds. Levitt’s estimate of the improvement inuntreated children might not have been valid.Levitt derived the estimate of “improvement with-out treatment” from two studies with question-able methodology (43); and these studies mightnot have been comparable on several grounds toother treatment outcome studies (280). Further-more, most of the untreated children were chil-dren who received a diagnostic assessment but didnot continue with psychotherapy. There mighthave been systematic differences, aside from treat-ment, between these children and the treated chil-dren. The children who did not receive psycho-therapy after diagnosis might have had a greaterability to cope, found other help for their prob-lems, or found the diagnostic contact sufficienttreatment (43,106,280). It is also possible that the
children in the untreated control groups receivedmental health treatment somewhere other than atthe study site.
Even if Levitt’s analytic methods were not sus-pect, the studies he reviewed might not be repre-sentative of the current state of child psychother-apy. The studies he reviewed were done in the1930s, 1940s, and 1950s. Therapy techniques inthose years differed in many ways from later tech-niques, and the populations studied might havebeen different from current clinical populations(43). Furthermore, the methods used in psycho-therapy outcome studies in those years were primi-tive in comparison to contemporary methods.
Tramontana (1980)
In a review of the literature on the effective-ness of psychotherapy for adolescents, Tramon-tana (637) derived estimates of percentage im-proved similar to Levitt’s. Overall, including bothindividual and group therapy, Tramontana founda median positive outcome rate of 75 percent withpsychotherapy and 39 percent without psycho-therapy. He questioned the meaningfulness ofthese figures, however, since the outcomes wereso variable across studies—reflecting the varietyof factors that influence adolescent therapy out-come. Most of the studies Tramontana reviewedlooked at group therapy. Two of them are dis-cussed further below in conjunction with a dis-cussion of group therapy for adolescents.
Smith, Glass, and Miller (1980)
Smith, Glass, and Miller (616) examined 500controlled studies in their 1980 meta-analysis ofpsychotherapy. This review was distinguished byits inclusion of controlled studies only and by itstaking into account differences in the strength ofthe treatment effect (effect size) across studies.Critics of the review claim that it lumps togethertoo many different kinds of studies and includesstudies of poor as well as good design (174). Infact, Smith and his colleagues attempted to con-trol for this problem by classifying studies accord-ing to methodological criteria (647). Althoughmost of the studies examined treatment of adults,approximately 50 of the studies assessed treatmentof children or adolescents.
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The Smith, et al., 1980 meta-analysis found sig-nificantly better outcomes for patients who weretreated with psychotherapy than for controls. Theinvestigators concluded that the average personwho receives therapy is better off at the end ofit than 80 percent of the persons who do not.
Smith, et al., did not analyze the effectivenessof child psychotherapy separately from adult psy-chotherapy. In a correlational analysis, however,they found that patients’ age had little effect ontreatment outcome. This finding must be viewedcautiously. The treatment effects of the approxi-mately so child and adolescent studies were notanalyzed separately from the original 500 studies,and these so studies represent a subsample muchsmaller than the larger group.
Casey and Berman (1985)
Casey and Berman (104) reviewed 75 studiesof child psychotherapy outcome dating from 1952to 1983. They restricted their sample to studiesthat used a control group of untreated childrenfrom the same general population as the treatedchildren. The sample excluded studies examiningtreatment of adolescents. Behavioral therapy wasused in 56 percent of the studies Casey and Ber-man examined, cognitive-behavioral therapy in21 percent, and nonbehavioral therapy (psycho-dynamic, client-centered, mixed, and unclassifi-able) in 48 percent. (Some of the studies exam-ined more than one form of treatment, so thesefigures add to more than 100 percent. )
Using meta-analytic techniques similar to thoseused by Smith, et al. (616), Casey and Berman(104) found that, overall, the average child receiv-ing psychotherapy was better off after treatmentthan two-thirds of control children. This treat-ment effect is comparable to the treatment effectfound by Smith, et al. (616), and others review-ing adult psychotherapy. Casey and Berman foundlittle evidence either that one modality of treat-ment differed from any other in overall effective-ness, or that individual treatment differed fromgroup treatment. Surprisingly, outcomes for chil-dren whose parents were treated concurrently didnot differ from those of children whose parentswere not treated. In general, treatment had alarger effect on problems related to fear and anxi-
ety than on problems involving self-esteem, so-cial adjustment, or global adjustment. The re-search was insufficient to allow any conclusionsmatching specific treatment modalities to specificproblems or diagnoses.
In general, Casey and Berman concluded that. . . clinicians and researchers need not be hesi-
tant about defending the merits of psychotherapyfor children” (104). The conclusions of Casey andBerman must be reviewed somewhat cautiouslyhowever, since only 24 percent of the 75 studiesthey reviewed clearly used children who wereseeking treatment as subjects; most of the rest used“school children not seeking treatment” or “com-munity volunteers for special projects” who werein mental distress but who had not sought treat-ment. Thus, it is not clear how representative ofactual treatment situations their results are.
Methodological Issues
Clinicians and researchers have expressed twomajor concerns about analyses that aggregate re-sults across different types of treatment as the re-views discussed above have done. One concernis that the research base has too many deficien-cies to allow generalizations about the effective-ness of child psychotherapy. Several discussionsof the effectiveness of child psychotherapy fromLevitt (382) to Kazdin (336) detail the lack ofmethodologically sound research on the efficacyof child psychotherapy. Among the deficienciesmentioned are the absence or inadequacy of con-trol groups; inadequate or misguided measure-ment of therapeutic, intervening, and outcomevariables; lack of specific description of subjects,treatment, and outcome; heterogeneity of sub-jects; and failure to assess the effect of psychother-apy independently of other interventions (8,43,275,280,336,637).
The other major concern is that an overall esti-mate of the effectiveness of child psychotherapy
may have little relevance for clinical practice andmental health policy, because so much seems todepend on a number of mediating factors that in-fluence both children’s problems and treatments(see, e.g., 43,280,561,637). Thus, Levitt’s (382) re-view found that the percentage of child patients
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,
who improved at close of treatment ranged from43 to 86 percent across studies, while Tramon-tana’s (637) review found that the percentage im-proved ranged from 35 to 100 percent. In Caseyand Berman’s (104) review, the standard devia-tion exceeded mean effect size, an indication ofgreat variability.
The paucity of good research reflects in partthe difficulties of introducing methodological rigorto the study of child psychotherapy (8). Many de-sign features of treatment studies that would bedesirable on methodological grounds (e.g., ran-dom assignment to treatment or control groups)are rejected as infeasible logistically or question-able ethically (647,719), although there is disagree-ment about the true extent of logistical and ethi-cal problems. Another obstacle to mental healthresearch in general is the difficulty of specifyingwhat the treatment is, since psychotherapy is oftentailored to the specific theoretical orientation ofthe therapist, the personalities of the therapist andpatient, the conditions under which therapy takes
place, and, for children’s therapy, the develop-mental stage of the child.
Summary
In summary, research reviews which aggregatea variety of treatments and problems yield mixedevidence for the effectiveness of child psychother-apy. Levitt (382,383) found little difference be-tween treated and nontreated children, but thereare serious reservations about the analytic methodhe used and the studies he reviewed. Smith, et al.(616), found a positive effect of psychotherapyover all ages, with no significant correlation ofage with treatment effect; however, they did notanalyze studies of child and adolescent treatmentseparately from studies of adult treatment. Caseyand Berman (104) found that treated children hadoutcomes better than two-thirds of untreated chil-dren, but their conclusions must be tempered bythe fact that the majority of studies they revieweddid not use actual patients.
EFFECTIVENESS OF SPECIFIC THERAPIES
A refrain resembling the one familiar in adultpsychotherapy research seems even more apt forresearch in child psychotherapy (8,43,280). Theimportant question may not be about the effec-tiveness of child psychotherapy in general butabout:
1. what specific psychotherapy is effective;2. under what conditions;3. for which children;4. at which developmental level;5. with which problems;6. under what environmental conditions; and7. with which concomitant parental, family,
environmental, or systems interventions?
The following sections discuss reviews of theresearch on the effectiveness of specific psycho-therapies identified in chapter 5: behavioral ther-apy, cognitive therapy, group therapy, familytherapy, crisis intervention, and psychopharmaco-logical (drug) therapy. Although considerable re-search has been done for some treatments, suchas several types of behavior therapy and some spe-
cific pharmacological agents, no research reviewsfocus specifically on psychodynamic therapy;therefore, a discussion of the effectiveness of psy-chodynamic therapy is not included.
Effectiveness of Individual Therapy
Behavioral Therapy
Perhaps because of the specificity of behavioraltherapy, there are few assessments of the overalleffectiveness of behavioral therapy with children.Most studies have investigated the effectivenessof a given behavioral technique for a given prob-lem with a given population in a given context.An exception is Casey and Berman’s (104) calcu-lation of an overall treatment effect size across37 studies of behavioral therapy. Casey and Ber-man found that behaviorally treated children hadbetter outcomes than 96 percent of untreated chil-dren, although treated children had better out-comes than only 55 percent of untreated childrenwhen outcome measures that closely resembled
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the activities of therapy itself (e.g., the numberof positive behaviors) were omitted. Behavioraltherapy was also one of the modalities representedin the Smith, et al. (616), review.
The effectiveness of specific behavioral treat-ments for specific problems identified in chapter3 is briefly reviewed below.
Developmental Disorders.—For children withpervasive developmental disorder (PDD), be-havioral treatments have been developed both toincrease appropriate behaviors and to decreasemaladaptive behaviors (554). Reviews of the re-search have supported the effectiveness of oper-ant conditioning for teaching PDD childrenappropriate behaviors such as language and self-care and academic skills although progress is typi-cally slow (252). One difficulty with behavioraltreatments is that they often do not generalize be-yond the site of treatment. A child learning a skillin a day treatment program may not maintain thelearning at home. Although methods of address-ing this problem are being developed, furtherwork is needed.
Behavior Disorders.— Some studies of behavioralapproaches to the treatment of attention deficitdisorder with hyperactivity (ADD-H) suggest thatbehavioral approaches have had real success inreducing off-task behavior, overactivity, andother problem behaviors and in increasing atten-tion and academic performance (14,29,473). Yet
Photo credit Charter Colonlal Institute Newport News, VA
A variety of treatment modalities, including individualtherapy, are used to treat children’s mental
health problems.
other evidence raises concerns about whether be-havioral therapy’s effectiveness for ADD-H gener-alizes to settings beyond the treatment setting,about the duration of the treatment effect (556),and about the possible distracting effect of the re-wards used in behavior modification (81). Further-more, Abikoff and Gittleman (4) found that be-havioral treatment of children with ADD-H onlyreduced aggressiveness; it did not reduce atten-tion deficits, hyperactivity, or impulsivity (555).Abikoff and Gittleman’s study suggests that fur-ther evaluation is needed to understand the clini-cal usefulness of behavioral treatment of hyper-activity .
The overall effectiveness of behavior modifi-cation for children with conduct disorders is dif-ficult to assess because of the great variation inconduct-disordered behaviors (e.g., from truancyto assault), the great effect that a child’s devel-opmental level has on the types of conduct-dis-ordered behaviors exhibited, and the great vari-ation in the severity of conduct disorders. Studiesof treatment for younger, less severely disorderedchildren tends to focus on classroom interventionsand parent training programs. A number of studieshave shown that reinforcement techniques basedin the classroom and/or at home have reduceddisruptive behavior at school (27).
Parent training programs to reduce conduct-disordered behavior have helped reduce a child’sdisruptive, difficult behaviors in many families(468). In one effective parent training program(497), parents learned behavioral strategies in aparent training group and made behavioral assess-ments and changes in their parenting behavior athome, An average of 60-percent reduction in thetarget disruptive behaviors was achieved.
EmotionaI Disorders.—Research on behavioraltreatment of emotional disorders has been largelyrestricted to laboratory treatment of specific pho-bias, a subset of anxiety disorders. One recent re-view of the outcome research (252) found ampleevidence for the effectiveness of modeling proce-dures but not for reciprocal inhibition or oper-ant conditioning, for treating phobias. The effec-tiveness of modeling procedures with childrendiagnosed with other anxiety disorders has notbeen demonstrated; nor has it been shown thattreatment has a lasting effect in a child’s normal
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environment. Behavioral treatment of anxiety dis-orders is promising, but further research is neededbefore conclusions about its effectiveness can bemade with certainty.
Psychophysiological Disorders.—Evidence forthe effectiveness of behavioral treatments for psy-chophysiological disorders tends to be greaterwhen there is a behavioral component to the dis-order. Evidence for the effectiveness of behavioraltreatment of Tourette’s syndrome (598) and otherstereotyped movement disorders is limited.
Evidence for the effectiveness of various be-havioral treatments for enuresis (lack of controlover urination) is more encouraging. A numberof studies have been conducted with several ofthe behavioral treatments (147). Mowrer’s (450)bell-and-pad treatment achieved complete successin 75 percent of studied cases, although 41 per-cent relapsed when examined at followup (147).Of individuals who relapsed and were retreated,68 percent achieved lasting success. Strengthen-ing the reinforcement, self-control, or practicecomponents of the bell-and-pad treatment havebeen found to increase the success rate (147). Moststudies examining operant conditioning methodsfor treating enuresis have found evidence for thesuccess of this method as well (252).
With encopresis (lack of control over defeca-tion), operant conditioning has been successful inseveral studies, although the total number of chil-dren studied has been small (147).
Some evidence exists for the effectiveness ofoperant conditioning to promote weight gain inpatients with anorexia nervosa, but research onbehavioral treatment mostly fails to consider thehelp these patients need with psychological andsocial aspects of the disorder (54). Behavioraltreatment of bulimia has been studied too littlefor an overall assessment to be made.
Cognitive Therapy
During the past 15 years, the amount of re-search evaluating cognitive therapies for childrenoften combined with behavioral approaches hasincreased dramatically (301,341). Cognitivemodels of treatment have been developed forproblems including hyperactivity and conduct dis-order, which have often been considered resistant
to other treatments. Cognitive therapy and relatedmethods are important approaches in child treat-ment, because they are closely tied to theory andresearch in developmental psychology; therefore,they deserve careful assessment (336,399,510,674).
Kendall and Braswell’s (341) volume on cogni-tive-behavioral therapy comprehensively reviewsmuch of the research on this method. The reviewtreats separately two different forms of cognitive-behavioral therapy: self-instructional training andproblem-solving. After reviewing nearly 30 studies,Kendall and Braswell concluded that self-instruc-tional training has been shown to be successfulwith several types of mental health problems.Studies have shown a positive effect of treatmenton children’s fears, hyperactivity, disruptive be-havior, and general self-control. Outcomes weremost successful when self-instructional trainingwas combined with operant conditioning, a formof behavioral therapy.
Kendall and Braswell found that much less re-search has been conducted on problem-solvingcognitive approaches, yet much of the researchthat has been conducted finds successful outcomessuch as decreases in disruptive behavior and in-creases in prosocial behavior.
Cognitive-behavioral therapies were also in-cluded in Casey and Berman’s (104) review ofchild psychotherapy outcome studies. Fourteenstudies of cognitive-behavioral therapies showedon average that treated children fared better than81 percent of untreated children, although this fig-ure may be invalid because of the inclusion of out-come measures resembling the therapy (e.g., cog-nitive functioning rather than behavior).
The conclusion that cognitive and related ther-apies have been shown to be effective must bequalified in several ways. First, there are somequestions about the clinical relevance of somestudies, since many of the children have beenselected rather than randomly assigned, and manyof the outcomes have been measured by scoreson tests of cognitive functioning rather than bychanges in actual problem behavior (301,336,341).Several studies, however, do show positive effectswith clinical populations (336,341). Second, suc-cessful outcomes do not always generalize beyondthe training situation to the classroom or home,although studies that have included operant con-
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ditioning methods or that have broadened thescope of the treatment have often achieved bet-ter generalization effects (81,341). Third, aggres-sive behavior has been especially resistant to cog-nitive methods (341).
Recent research has investigated such variablesas age, developmental level, and cognitive stylesof children to help explain differences in outcomeand to help tailor cognitive therapies to the re-quirements of different children (81,341). In a sim-ilar vein, Kazdin (336) has noted that studies ofmore intensive courses of cognitive therapy, withgreater focus on specific clinical problems, areneeded to test their clinical potential completely.
Effectiveness of Group Therapy
As noted in chapter 5, group therapy for adoles-cents differs from group treatment for youngerchildren. Child group therapy tends to rely ongroup play and activities, while adolescent grouptherapy is more of a “talking” therapy. The liter-ature on each has been discussed in separate re-views. Group therapy has also been included inreviews by Smith, et al. (616), and Casey and Ber-man (104).
Group Therapy With Prepubescent Children
Abramowitz (5) has reviewed the outcome re-search on group therapy with prepubescent chil-dren. The literature reviewed included studiesusing verbal approaches (39 percent), play andactivity approaches (37 percent), and behaviormodification (24 percent). The studies focused ontreatment of immature or problem behavior, so-cial isolation or withdrawal, poor self-concept,or academic underachievement. Outcome meas-ures focused chiefly on improvement in person-ality variables, appropriateness of behavior, in-terpersonal relations, and academic performance,Abramowitz found that about one-third of thestudies demonstrated positive effects of grouptherapy, one-third had a mixture of positive, neg-ative, and null results, and one-third found no ef-fects of treatment. The generalizability of this evi-dence must be questioned, however, since mostof the outcome studies in Abramowitz’s reviewinvestigated group therapy that lasted only 10 to15 sessions and so may not apply to therapy
which lasts longer. Many clinicians argue that anumber of initial sessions are needed for a groupto “jell” and develop sufficient intimacy for ef-fective therapeutic work to be done (722).
Casey and Berman’s (104) review of child psy-chotherapy included a separate treatment effectsize for 33 studies of group treatment. Casey andBerman found that the average child treated ingroup therapy had a better outcome than 50 per-cent of untreated children. However, their reviewdoes not provide information on the nature of thegroup treatment; thus, it is difficult to determineif the 33 studies reviewed by Casey and Bermanare any more representative than those reviewedby Abramowitz. A fair conclusion is that the fullrange of child group therapy has not yet been ade-quately assessed.
Group Therapy With Adolescents
As noted earlier in this chapter, most of thetreatment outcome studies in Tramontana’s (637)review of adolescent therapy utilized group ther-apy. A1though most of the studies in the Tramon-tana review were methodologically flawed, twoof the studies that evaluated the effectiveness ofadolescent group therapy were relatively rigor-ous. In a study by Persons (503), institutionalizeddelinquents of both sexes receiving a combinationof individual and group psychotherapy were com-pared with adolescents receiving the standard in-stitutional regimen. The group therapy combineddirective and nondirective elements. Persons foundpositive effects of treatment on anxiety, other psy-chopathology, academic performance, and anti-social behavior within the institution and at fol-lowup in the community. Treated youths alsoshowed better outcomes on measures of employ-ment and recidivism. In a study of a similar pop-ulation, Redfering (529,530) contrasted institu-tionalized delinquent adolescents (girls only)receiving short-term group counseling to a non-treated group. At the end of 11 weeks of treat-ment, the girls in therapy had greater positivechanges in self-concept and feelings about parentsand peers. Over time, significant differences inparental and self ratings were maintained. Also,treated girls were released more frequently fromthe institution and recommitted less frequently.
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Effectiveness of Family Therapy
Family therapy to deal with children’s mentalhealth problems has gained increasing use by cli-nicians. Family systems theory was found to beuseful by more than 60 percent of child therapistsin a survey by Koocher and Pedulla (365). Yetoutcome studies of family therapy have rarelybeen included in generic reviews of treatment suchas those by Smith, et al. (616), and Casey and Ber-man (104). Their lack of inclusion speaks both tothe newness of family therapy and its status asa conceptually different form of treatment.
Gurman and Kniskern’s Overview (1978)
In the most comprehensive review of the fam-ily therapy outcome literature, Gurman andKniskern (267) identified over 200 outcome studieson marital and family therapy. Most of the studiesreviewed by Gurman and Kniskern (267) did notidentify a child as the patient and will not be con-sidered here (although therapy with parents alonecan be helpful to children). Of the studies in whicha child was identified as the patient, Gurman andKniskern (267) reviewed studies of behaviorallybased family treatment separately from studies ofnonbehavioral family therapies. They also treatedstudies which used “no treatment” control groupsseparately from those studies which did not com-pare families receiving family therapy to familiesreceiving no treatment. Gurman and Kniskern(267) judged that most of the controlled studiesthey reviewed were well designed.
In the only five studies of behavioral familytherapy with children as identified patients, andwhich used control groups, those children and/orfamilies who received treatment had more posi-tive outcomes than those who received no treat-ment. Behavioral family therapy led to improve-ment in the parents’ and observers’ ratings ofchildren in the majority of uncontrolled studiesas well.
In 60 percent of controlled studies of nonbe-havioral family therapy, treatment led to morefavorable outcomes than no treatment. Becausethese studies did not include long-term followup,however, the effects of treatment over a longerperiod of time are not known. Finally, in 19 un-controlled studies of nonbehavioral family ther-apy in which children or adolescents were iden-
tified as the patients, 71 percent of treated childrenand/or families improved, while 29 percent eitherdid not improve or deteriorated. In summary,most studies reviewed in Gurman and Kniskern’scomprehensive evaluation found that, in general,family therapy was better than no treatment.Questions remain, however, about the represen-tativeness of the treatments and samples in thestudies that Gurman and Kniskern reviewed (267).In addition, their reviews did not speak to the ef-ficacy of family therapy for specific childhoodmental health problems.
Effectiveness of Family Therapy WithConduct-Disordered and Delinquent Children
Some researchers have focused on the effective-ness of family therapy with specific childhoodmental health problems (268). Two prominent re-search groups have investigated family therapyfor conduct-disordered and delinquent childrenand adolescents (268,336).
Behavioral family treatments of conduct-dis-ordered children have been extensively investi-gated by Patterson and associates with over 200families in studies spanning two decades. Patter-son’s family intervention, a form of parent train-ing based on social learning principles, has beenfound to be effective in reducing aggressive andantisocial behavior both in the home (488,493,495,681,710) and in the classroom (496). Positiveeffects have also been found in the behavior ofsiblings and in the mental health of mothers ofthe identified patients (493,494).
The Functional Family Therapy program ofParsons and Alexander—a cognitive-behavioralfamily treatment of delinquent adolescents—lednot only to an improvement in family interaction(485), but also to a decrease in recidivism (16).Improved family interaction was correlated withdeclining recidivism. A followup 2% to 3 yearslater revealed that siblings of the original identi-fied patients had a reduced number of court con-tacts as well (356).
While family treatments of conduct-disorderedchildren and youths appear promising, questionsremain about the effectiveness of these models oftreatment across the broad range of children withconduct disorders. More severely disadvantaged,
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troubled families have been found to benefit muchless than other families from parent managementtraining (336). Similarly, one criticism of parsonsand Alexander’s work is that many of the fam-ilies treated were of the Mormon faith, whichstresses family and community cohesiveness andmay have provided an unusual impetus for cop-ing with problem behavior (268).
Effectiveness of Family Therapy WithChildren With Psychophysiological Disorders
Minuchin and colleagues (442,443,444) havestudied the effectiveness of family therapy for chil-dren with psychophysiological disorders such asanorexia nervosa and chronic illnesses such asdiabetes and asthma. They found improvementboth in measures of psychosocial functioning andin measures specific to the patients’ physical prob-lems (e.g., weight in patients with anorexia ner-vosa, respiratory functioning in asthmatics). Inone study, Schwartz, et al. (268), found improvedpsychosocial functioning and control of eating inbulimic children treated with family therapy. Thelack of control groups in studies of family ther-apy for children’s psychophysiological disordersnecessitates caution in interpreting the results, butthe achievement of therapeutic results on severalfronts with patients often considered unlikely toimprove without treatment suggests the potentialeffectiveness of family therapy.
Summary: Effectiveness of Family Therapy
In general, family therapy outcome studies pro-vide preliminary evidence for the effectiveness offamily therapy with many children and families,despite a number of methodological limitations.Studies with some specific populations, such asconduct-disordered children and adolescents,show particular promise. Further research wouldbe necessary to determine when family therapyis most appropriate and to allow knowledgeablematching between type of child, type of disorder,and specific family therapy models and tech-niques.
Effectiveness of Crisis Intervention
Few studies have evaluated the outcome of crisisintervention. Those studies that have been iden-tified as evaluations have generally focused on
adult populations and have not isolated the ef-fectiveness of crisis intervention for child patients.Furthermore, methodological shortcomings limitthe conclusions that can be drawn from thesestudies. Homebuilders, the program discussed inchapters as exemplifying crisis intervention, wasevaluated only in terms of its cost-effectivenessand success in avoiding outside placement of pa-tients (350), not in terms of patient functioning.Outside placement was avoided for 90 percent ofpatients with an estimated cost savings of over$3,200 per patient.
Effectiveness of Psychopharmacological(Drug) Therapy
The effectiveness of psychopharmacologicalagents in treating childhood disorders can onlymeaningfully be assessed separately for each phar-macological treatment. The various classes of drugtreatment have such contrasting purposes andtherapeutic effects that it is impossible to discussthem as a whole. In assessing these medications,the evidence for each intended therapeutic effectmust be considered and weighed against the medi-cations’ side effects.
Stimulants
The use of stimulant drugs to treat ADD andADD-H is by far the most common applicationof psychopharmacological therapy in children,and its effectiveness with children has been re-searched more than any other drug treatment. Re-searchers have differentiated the effects of stimu-lants on specific cognitive functions, academicachievement, social behavior, personality varia-bles, and mood (96). Most research has been fo-cused on short-term effects, but medium and long-term effects of stimulants have also received at-tention.
Cantwell and Carlson (96) found 15 laboratoryexperiments demonstrating that several differentstimulants successfully aided children with ADD-H in tests of attention, impulsivity, distractibil-ity, motor restlessness, short-term memory, andnew learning. These results, however, are not nec-essarily relevant outside the laboratory.
The effects of stimulants on academic achieve-ment by hyperactive children has been assessed
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by a number of studies. Barkley and Cunningham(42) reviewed 120 studies of the effect of stimu-lant drugs on academic achievement, althoughonly 17 of the studies used objective academicmeasures. Few positive effects of stimulants onacademic achievement were found, and those thatwere found may have reflected the influence ofthe drugs on school examinations and not on dailylearning. Followup studies supported these find-ings. Thus, there is some evidence for the effec-tiveness of stimulants on attention deficits, butlittle evidence that the use of stimulants to treatADD-H is associated with academic improvement.
Teachers and parents have noted improvementsin social behavior in children treated with stimu-lants for hyperactive and disruptive behavior,(121). Recent research has found parallel effectson some symptoms of ADD-H in adolescents(673), yet methodological difficulties and the de-velopmental differences between adolescents andchildren prevent any firm conclusions about theeffectiveness of stimulants at this time with adoles-cents with ADD-H.
Although stimulant drugs achieve good short-term results in children with ADD-H, the limitedresearch findings regarding long-term results aremuch less impressive (526). Available studies havecompared children who have been treated con-tinuously for a number of months with childrenwho have had less or no drug treatment, and theyshow few long-term positive effects of stimulants(526). Some studies suggest that adolescents whohave received stimulant treatment sometime dur-ing childhood have fewer symptoms of ADD-Hthan those who have not received stimulant treat-ment, but that they are still prone to antisocialbehavior, poor peer relationships, low self-esteem,and academic problems (279).
Concerns about the side effects of stimulanttreatment focus on: 1) possible retardation ofphysical growth (568), 2) negative effects on learn-ing (628), 3) drug dependence or later drug abuse,and 4) euphoriant effects. A panel appointed bythe Food and Drug Administration evaluated theavailable evidence and concluded that stimulantsmay have a minor suppressive effect on growthwhen prescribed in the average-to-high range ofdosage. Rapoport (526) addressed the concernabout the effects of stimulants on learning and
concluded, after reviewing six studies, that stim-ulant drugs seem neither to enhance nor retardlearning significantly in children with ADD-H.The connection to drug dependence and later drugabuse and the euphoriant effects of stimulants onchildren have been determined not to be problems(121,658), although some believe that these issueshave not been settled conclusively (121).
Neuroleptics
As noted in chapter S, neuroleptic medication—sometimes called antipsychotic medication—isused not as a treatment to reverse a disorder, butrather as a means of reducing troublesome symp-toms associated with a disorder. Neurolepticmedication is prescribed most frequently to con-trol aggressive, assaultive, hyperactive, sociallyinappropriate, and difficult to manage behaviorin severely impaired children, including childrenwith PDD and especially children with mentalretardation (39o).
The effects of neuroleptic medications with se-verely disturbed children have been evaluated ina number of studies (714). Most studies havefound positive effects of neuroleptics on manyoutcome measures of behavior, but as Winsbergand Yepes (714) state, these outcomes suggest thatneuroleptics “. . . appear useful only in the man-agement of psychotic children, making them lesswithdrawn, less overactive, less anxious, less agi-tated and more tractable . . . .“ Two studies byCampbell and associates (90,91) also found posi-tive effects of neuroleptics for severely disturbedchildren in a behavioral (operant) learning para-digm, probably because of their effect of reduc-ing inappropriate responses (92).
One neuroleptic, haloperidol (Haldol”), hasbeen shown to be effective in reducing the tics andother symptoms of Tourettefs syndrome, althoughthere are few controlled studies (598). Neurolep-tics have also been used in low doses to treatADD-H; however, in comparative studies, stimu-lants have usually outperformed neuroleptics fortreatment of hyperactivity and are generally pre-ferred clinically (714).
A number of side effects of neuroleptics havebeen documented and are of concern. The seda-tive effect of neuroleptics appears to impair cog-
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nitive functioning in children who are already cog-nitively impaired (17,75). Evidence for this effect,however, has been limited to nonclinical popu-lations. Other short-term side effects can includedrowsiness; blurred vision; and moderate motordysfunction like tremors, occasional mood changes,and changes in urinary behavior. The long-termside effects of most concern are medication-in-duced movement disorders, especially those thatemerge when the medication is stopped (22o), and,in a few cases, tardive dyskinesia (498).
The proportion of children treated with neu-roleptics who develop side effects is unknown; inthe few studies available, estimates of the preva-lence of the different side effects of neurolepticsvary widely. Conners and Werry (121) note thatmost side effects are not serious, and those thatare (e. g., tardive dyskinesia) are infrequent andoccur only with high doses or prolonged use. Itappears, however, that the decision to use neu-roleptics with severely disordered children mustbe made judiciously and the dosage must be care-fully controlled. Some side effects—especially thegeneral “quasi-sedative” effect (714)—have pro-voked concern among many professionals andparents about the frequent use of drugs (622).
Antidepressants
Well-conducted research on the effectiveness ofantidepressant treatment of childhood depressionhas increased in the past several years, but defin-itive information awaits the completion of morestudies. In a recent review, Puig-Antich and col-leagues (518) note that none of the more rigor-ous studies so far have shown antidepressants tobe better than placebos across samples of de-pressed children, although certain subgroups of
CONCLUSION
Although methodological problems plague re-search on the effectiveness of children’s mentalhealth treatments, considerable evidence has accu-mulated to suggest the effectiveness of a widerange of modalities of treatment. The most recentreview of the effectiveness of child psychother-apy in general (104) found that the average childreceiving therapy was better off after treatment
depressed children have responded to antidepres-sants. Such issues as appropriate dosage, effectof a child’s developmental level, and clinical im-provements due apparently to placebo effectscomplicate conclusions about the effectiveness ofantidepressants in treating childhood depression.
In addition to being used to treat depression,antidepressants have been used to treat enuresis,ADD-H, separation anxiety, and school phobia.The antienuretic effect of antidepressants maybeentirely separate from their antidepressant action,but numerous studies have found antidepressantsto be effective in reducing, though not curing,enuresis (527). Antidepressants are somewhat ef-fective in treating ADD-H, but generally less ef-fective than stimulants (528). Antidepressantshave been used successfully in combination withpsychosocial (behavioral, cognitive, and psycho-dynamic) treatments to treat school phobia (233),and separation anxiety caused, according to theinvestigator’s theory, by biochemical disturbancesnot associated with depression (232).
Although the side effects of antidepressants canbe dangerous in some children (121), the imme-diate side effects (e.g., dry mouth, drowsiness,sweating) of moderate to low doses of antidepres-sants mainly cause discomfort (527). In higherdosages, antidepressant medication can have car-diovascular side effects, but these can be mini-mized by adhering to strict limits on dosage level(518). Use of antidepressants with suicidally de-pressed children is risky, because overdoses ofthese drugs are extremely toxic (527). Conners andWerry (121) state:
. , . of all the psychotropic drugs commonly usedin children, the tricyclics call for the greatestcaution.
than two-thirds of control children, and the authorsrecommend that professionals not hesitate indefending child psychotherapy’s merits. Even thisreview is limited, however, by the fact that moststudies reviewed did not use actual patients intreatment. Many treatments, used widely for avariety of mental health problems, have not yetbeen evaluated systematically.
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With respect to specific treatments, even thoughan overall assessment of their effectiveness can-not yet be made, several psychosocial therapieshave shown promise in a number of studies, espe-cially in some specific problem areas. Thus, forexample, behavioral treatment is clearly effectivefor phobias and enuresis, and cognitive-behavioraltherapy is effective for a range of disorders in-volving self-control (except aggressive behavior).Group therapy has been found to be effective withdelinquent adolescents, and family therapy appears
to be effective for children with conduct disordersand psychophysiological disorders. Psychophar-macological treatment, while not curative, hasbeen found to have limited effectiveness with chil-dren with ADD-H, depression, or enuresis, andalso in managing the behavior of children whoare severely disturbed. Further, more rigorous re-search may demonstrate the usefulness of severalother treatments for which there is preliminaryevidence of effectiveness.
Chapter 9
Effectiveness of Treatment andPrevention in Mental Health and
Other Settings, and Evaluatingthe Integration of Mental Health
and Other Services
Chapter 9
Effectiveness of Treatment and Preventionin Mental Health and Other Settings,
and Evaluating the Integration ofMental Health and Other Services
INTRODUCTION
The effectiveness of various settings for chil-dren’s mental health treatment is of interest topolicy makers and was one of the reasons thisbackground paper was requested. Mental healthtreatment settings vary considerably in intensive-ness, restrictiveness, and cost. Therefore, it isvaluable to have systematic information about theeffectiveness of alternative settings to justify place-ment, reimbursement, and public policy decisions.Similarly, evidence about the effectiveness of pre-vention efforts and the integration of services acrossmental health and other systems is valuable.
Chapter 6 described the mental health settingsin which disturbed children receive treatment.Such settings range from inpatient hospital set-tings to private mental health practices. For thosesettings that provide a therapeutic milieu or en-gage mentally disturbed children in treatment forsubstantial periods of time each week—e.g., hos-pitals, residential treatment centers (RTCs), andday treatment programs—the setting itself mayhave an important effect on treatment outcome.Available outcome research on the use of thesesettings for mental health treatment is reviewedin this chapter.
Chapter 7 described broad-based interventionsto identify and treat children’s mental health prob-lems within the educational, general health care,child welfare, and juvenile justice systems; it alsodescribed efforts to prevent children’s mentalhealth problems and to integrate mental healthand other services. Because of a lack of research,the effectiveness of treatment in most of the non-mental-health systems cannot be evaluated. Infor-mation on outcomes in the child welfare system(e.g., therapeutic foster homes or group homes),for example, is insufficient to be reviewed. Thereis some research on the effectiveness of interven-tions in the educational and juvenile justice sys-tems, however, and that research is consideredin this chapter. Also reviewed is some of the mostrigorous research on prevention programs. Therehave been very few efforts to evaluate the integra-tion of mental health and other services generallyand no such efforts to date for children’s mentalhealth services. A planned evaluation of a newFederal effort to integrate services is described inthis chapter.
EFFECTIVENESS OF TREATMENT IN SELECTED MENTAL HEALTHTREATMENT SETTINGS
Understanding the respective roles of mentalhealth treatment modalities and treatment settingsin therapeutic outcome would be invaluable in de-signing mental health programs. Unfortunately,the current state of research on outcomes makes
it difficult to separate effects due to particulartreatment modalities from effects due to the set-tings in which treatment occurs, or to no treat-ment. From a methodological perspective, theprincipal problem is that available research has
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not used control groups to compare the effective-ness of alternate settings. Disturbed children withsimilar diagnoses and life circumstances have notbeen randomly assigned to either a hospital, anRTC, a community mental health center (CMHC),or other outpatient setting giving similar treat-ments and the children’s treatment outcomes sub-sequently compared.
The effects of some treatment elements such asintensive individual therapy may be easier to dis-entangle from the settings in which treatment isgiven, but systematic research that attempts to dothis has not been conducted. Consequently, it isdifficult to assess the degree to which alternativetreatments or alternative settings would haveachieved similar or different therapeutic outcomes(580).
Effectiveness of PsychiatricHospitalization
The most intensive, as well as costly, form ofmental health treatment involves inpatient carein a hospital. Although psychiatric hospitals area type of residential treatment, the services theyprovide may differ from services provided innonmedically focused settings such as RTCs. Con-sequently, a somewhat separate research litera-ture on the effectiveness of psychiatric hospitali-zation for children has developed (61,245).
Blotcky, et al. (61), reviewed two dozen fol-lowup studies of mentally disturbed children un-der the age of 12 who had been treated in hospi-tal inpatient and other residential psychiatricfacilities. One-fifth of the studies were prospec-tive. One-third included adolescents as well aschildren.
All of the followup studies that Blotcky and col-leagues reviewed reported some positive treatmentoutcomes. The studies concluded, however, thattreatment outcomes were primarily associatedwith the severity of disturbance. That is, theyfound that over half of the children described asneurotic or exhibiting personality disorders dem-onstrated long-term positive outcomes followinginpatient treatment. More severely impaired chil-dren, diagnosed as psychotic (i.e., having dis-orders involving severely disturbed perceptions
of reality) or neurologically impaired, had some-what fewer positive outcomes. Outcomes also ap-peared to be related to variables such as charac-teristics of the patient other than diagnosis (e.g.,intelligence), family factors (parental psychopathol-ogy), and, to a lesser extent, treatment variables(e.g., length of stay, aftercare). However, treat-ment courses were so variable, and periods be-tween discharge and followup so long in moststudies reviewed, that inferences about effectiveelements of inpatient and other residential treat-ment cannot be made. In many cases, it was im-possible to determine whether the treatment set-ting more resembled a hospital or an RTC.
According to Blotcky, et al., because controlledresearch has not been done and inpatient followupstudies have not compared results of inpatientmental health treatment to either natural courseor outpatient treatment, it is difficult to know therelationship between inpatient psychiatric treat-ment and outcomes.
Gossett, et al. (245), reviewed 22 followupstudies of mentally disturbed adolescents who hadreceived inpatient psychiatric treatment, and theirconclusions about the effectiveness of such treat-ment were similar to those of Blotcky, et al. (61).The studies Gossett and colleagues reviewed in-dicated that the majority of nonpsychotic adoles-cents who had received inpatient treatment werefunctioning at an adaptive level several years af-ter discharge. Of psychotic adolescents who hadreceived inpatient treatment, only one-third wereadjusted adequately at followup. In general, theless severe and chronic the adolescent patients’ ini-tial problems— including level of family psycho-pathology—the more positive their eventual out-comes, although Gossett, et al. ’s review found thataftercare was associated with positive outcomes.
A primary goal of developing this backgroundpaper was to respond to questions about the ef-fectiveness and appropriateness of psychiatric hos-pitalization for children and adolescents. Themethodological limitations of available studies ofinpatient psychiatric care make firm conclusionsdifficult. Available studies do not clearly showwhich components of hospital treatment contrib-ute to successful outcomes. Neither do they al-low conclusions about whether children treated
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as hospital inpatients would have better, worse,or similar outcomes with nonhospital treatment.Because of the methodological limitations of avail-able studies, it is unclear to what extent outcomesfor mentally disturbed children treated in hospi-tals are a function of the children’s level of dis-turbance. In many cases, hospital treatment is a“last resort” for children who have been unsuc-cessfully treated in other settings. Prospective re-search controlling for patient characteristics andfamily variables has not been conducted.
Effectiveness of ResidentialTreatment Centers
There are many similarities between RTCs andchildren’s psychiatric hospitals, and the findingsabout effectiveness of RTCs are similar to thosefor psychiatric hospitals. Several studies have in-vestigated the effects of RTC treatment, chieflyon outcomes measured during or soon after treat-ment. Unfortunately, however, interpretation ofthese studies, like studies of inpatient treatment,is limited by the fact that most of the studieslacked control groups.
Whittaker and Pecora (706) reviewed eightstudies of RTC treatment. Without exception, the
Photo credit OTA
This group home serves as an intermediate step foradolescent boys who still need supervised care and
treatment before returning to their families.
studies found that the majority of children madesatisfactory adjustment while still in RTC treat-ment. Unlike the results for psychiatric hospitals,the evidence for a relationship between severityof a child’s problems at admission (or other diag-nostic variables) and posttreatment outcome wasinconclusive. Following treatment, however, theirlevel of adjustment depended on the quality ofthe posttreatment environment, the amount ofstress or social support (especially family support),quality of parent-child relationships, and familystability. Greater involvement of the family withRTC treatment and with postdischarge planningwas also associated with favorable outcomes.
Lewis, et al. (386), performed a followup studyof 51 children who had received RTC treatment.Most of these children had been considered im-proved at the time of discharge, but were ratedpoorly adjusted at later followup by independ-ent evaluators. The majority of poorly adjustedchildren had had more than two institutionalplacements following RTC treatment. Childrenwho had been older at the time of admission toRTC treatment and who had exhibited both psy-chotic and organic symptoms also tended to havepoorer outcomes as did children with disturbedparents, although Lewis, et al., point out that itis impossible to separate possible genetic contri-butions from environmental contributions to out-come. Lewis and his colleagues note that manyof the children in the study completed RTC treat-ment just prior to adolescence and suggest thatpoor outcomes for these children might have re-sulted from the turmoil of adolescence combinedwith the difficulty of being released into a stress-ful environment.
Re-ED programs area type of RTC that appearsparticularly promising (see ch. 6). In a study byWeinstein (686), data on one Re-ED program,Cumberland House, were gathered from parents,Re-ED teacher-counselors, teachers in the chil-dren’s regular class, classroom peers, referringagency staff, and from the children themselves.Weinstein’s study, considered one of the best ofthe Re-ED evaluations, found that children whohad completed the program had more positiveself-concepts, a greater sense of self-control, andbetter academic performance than a disturbed butuntreated control group. The children who had
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completed the program were rated as improvedby Re-ED staff, regular teachers, other profes-sional staff, and parents, but, curiously, not bytheir peers. Despite their apparent improvement,however, Re-ED children were rated more poorlyon most measures than a nontroubled controlgroup.
Other evaluation and followup studies of Re-ED programs have found results such as improvedacademic achievement, increased prosocial be-havior as measured by an antisocial behaviorchecklist, successful discharge of over 65 percentof residents, improved home and school relation-ships, and improved school enrollment followingtreatment, although some school problems con-tinued (606). Since the researchers’ assessmentmeasures were sensitive to a wide range of out-comes, many in the community, Weinstein’s studyprovides preliminary support for the Re-ED pro-gram model. However, only a few studies haveevaluated Re-ED outcomes, so conclusions aboutthe Re-ED program’s effectiveness ought to beviewed with caution. Long-term followup data donot yet exist, and measurement of outcome by in-dependent clinicians or other independent ob-servers is lacking.
The outcome research on RTCs, though not ex-tensive or methodologically rigorous, suggeststhat although most children treated at RTCs im-prove during treatment, their long-term outcomesmay be less positive and depend on the involve-ment of the family in treatment, the amount ofstress in the environment, and the availability ofsocial support. The implication of available re-search is that the effectiveness of RTC treatmentcannot be considered in isolation, but must beevaluated in conjunction with the quality of fol-lowup care. Another implication is that coordi-nation between RTCs, community agencies, andthe family is necessary. Although Lewis, et al.(386), suggest that the “undoing” of RTC treat-ment that can happen in the community impliesthe need for longer RTC treatment, no evidenceis available to indicate that longer RTC treatmentleads to better outcomes or that longer RTC treat-ment is superior to RTC treatment combined withadequate followup care.
Effectiveness of Day Treatment
As noted in chapter 6, day treatment is inter-mediate in intensity between outpatient and 24-hour care, as in psychiatric hospitals or RTCs.As such, it is used both as a less restrictive alter-native to inpatient treatment and as a transitionfrom inpatient to outpatient care. Although dataon the number of children in day treatment arenot available, the number of day treatment centersfor children has increased dramatically —concomi-tantly with the development of CMHCs—from10 in 1961 to over 350 in 1980 (735). Research onthe effectiveness of child day treatment has alsoincreased in recent years, corresponding to thetreatment’s greater availability, but most of it hasnot been methodologically rigorous.
Zimet and Farley (735) reviewed six followupstudies that evaluated day treatment outcomes forchildren. The day treatment programs evaluatedin the six studies relied on a variety of theoreti-cal orientations (behavioral, psychodynamic, etc. )or combinations of orientations. Zimet and Farleystate that the studies they reviewed reported “sat-isfactory adjustments” in 76 to 90 percent ofchildren receiving day treatment. “Satisfactory ad-justments” included outcomes such as improvedself-esteem, greater academic achievement, im-proved social relationships, and more appropri-ate behavior. Children in day treatment were lesslikely to be placed in inpatient settings. Youngerchildren generally made greater gains than olderchildren. Results on the effects of parental involve-ment with children in day treatment were mixed.
Friedman and Quick (208) reported a study inwhich two groups of children who did not com-plete a day treatment program (one group com-pleted over so days of treatment) were comparedto one group of children who did complete theprogram. Adolescents who had substantial in-volvement with the multimodality program thatwas studied had greater academic gains than thosewith minimal involvement. At followup, 2 yearsafter discharge from treatment, greater involve-ment with the program appeared to be associatedwith a lower probability of being a runaway orbeing institutionalized. According to Friedman
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and Quick, the group of children who droppedout of day treatment included many chronic run-aways and truants “whose behavior was veryappropriate while attending, but for whom theprogram failed to secure consistently good at-tendance. ”
of day treatment lack methodological rigor. De-finitive conclusions about the effectiveness of daytreatment, therefore, must await further investi-gations. Nevertheless, the consistency with whichpositive outcomes following day treatment havebeen reported is encouraging.
Like most treatment outcome research in thefield of children’s mental health, available studies
EFFECTIVENESS OF TREATMENT IN SELECTEDNON-MENTAL-HEALTH SYSTEMS
As noted in chapter 7, mental health treatmentis sometimes delivered in settings in the educa-tional, health care, child welfare, and juvenile jus-tice systems. A few such interventions that havebeen evaluated are discussed below. Because ofthe paucity of evaluation studies of such interven-tions, the discussion that follows is not compre-hensive.
Effectiveness of Treatment in theEducational System
A large investigation of mental health interven-tions in the school system of Newcastle-upon-Tyne in England was undertaken by Kelvin, etal. (362). Their aim was to compare the effective-ness of a range of different approaches to mentalhealth intervention in a community setting. Theinvestigators identified 574 disturbed children (2657-year-olds and 309 11-year-olds) in 12 schoolsand randomly assigned them to a no-treatmentcontrol group or to one of four treatment condi-tions: 1) child group therapy, 2) behavior mod-ification applied to entire classrooms (for olderchildren only), 3) parent guidance, and 4) a non-specific “nurturance” intervention provided byteacher-aides in school (for younger childrenonly). All the treatments except parent guidance(which took place in the home) were delivered atschool. The investigators believed that the schoolsetting allowed them a number of advantages overa clinic setting—a better grasp of the children’ssocial environment, the children’s greater familiar-ity with the setting, and more opportunity for in-volvement by teachers.
Disturbed children were identified from an in-dex based on a combination of teacher, peer, andself ratings, along with reading scores and atten-dance records. A control group of nondisturbedchildren was used for comparison purposes. Theexperimental and control groups were not entirelycomparable, however, because disturbed childrenhad a lower socioeconomic status than nondis-turbed children and also had a greater lifetime in-cidence of broken homes and health problems.
The children in the Newcastle-upon-Tyne studywere treated for anywhere from two to five schoolterms, depending on the intervention condition.Outcome was assessed at the end of treatment,and then at 18 months and 3 years after treatment.All the treatments led to improvement on at leastsome measures. In general, the group therapy andnurturance approaches led to better results for theyounger children, and the behavior modificationand group therapy were most effective for theolder children. Emotionally disordered childrentended to improve more than behavior-disorderedchildren. One important finding was that the ef-fectiveness of the behavioral intervention tendedto increase over time, suggesting a “sleeper” ef-fect of treatment. The modality of treatment wasa better predictor of success than the sheer dura-tion of treatment.
Effectiveness of Treatment in theJuvenile Justice System
A research program conducted by Massimo andShore (419,604,605) examined the effect of a“vocationally-oriented psychotherapeutic pro-
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gram” for adolescent delinquent boys. In line withthe researchers’ understanding of the specific needsof delinquents, this program offered a compre-hensive set of interventions that differed greatlyfrom the traditional clinical approach. Job coun-seling and placement was the first component in-troduced, and psychotherapeutic contact was ad-ded later; the program also included help such asremedial education and aid in managing money.
Outcomes were measured during the 10-monthtreatment period, and at 2 to 3, 5, and 10 yearslater. Treated adolescents showed improved ad-justment emotionally, academically, and voca-
tionally. Massimo and Shore’s work is often citedas a promising multi-intervention program thathas shown some success with a difficult-to-treatpopulation.
Studies of behavioral treatment for more severeconduct disorders often take place in juvenile jus-tice settings. Reviews suggest that operant be-havioral programs have led to improvement ina number of social, academic, and personal be-haviors within the treatment setting (136,170).However, there is little evidence that these be-havioral improvements carry over to behavior innatural, community environments (252).
EFFECTIVENESS OF SELECTED PREVENTION EFFORTS
In recent decades, there has been increasingacceptance and support of the concept of serv-ices to prevent mental health problems. Preven-tive mental health efforts have burgeoned and re-ceived support on many levels (Federal, State, andcommunity). A solid research base detailing theeffectiveness of prevention strategies is just begin-ning to accumulate. Several fairly rigorous out-come studies have been done, but these studiesexamine only a minority of the prevention effortsthat have been or could be undertaken. To someextent, the paucity of methodologically sound re-search on the effectiveness of prevention effortsparallels the paucity of rigorous research on theeffectiveness of children’s mental health servicesin general. In addition, however, the amount ofinformation currently available about the effec-tiveness of prevention is limited by difficulties thatare specific to prevention outcome research (e.g.,the low base rate of certain disorders in the pop-ulation, the large cost and effort involved in long-term followup studies, and the wide range of tar-get problems and interventions included in theconcept of prevention) (281). Nonetheless, avail-able research suggests that certain preventionstrategies can be quite effective, both in terms ofpreventing the development of mental disordersand in promoting mental health and adaptation.
As is noted in chapter 7, prevention programshave taken a number of forms. Such programshave been aimed at almost all of the mental health
problems that fall into the standard diagnostic cat-egories and at the problems associated with envi-ronmental risk factors. Moreover, they have oc-curred in a diverse array of settings (e.g., home,school, mental health centers) and have involvedthe participation of children and parents, as wellas whole families, classrooms, and schools. Thewide range of prevention programs which havebeen implemented and evaluated precludes an ex-haustive review of the effectiveness of all typesof prevention programs. A selected group of themore rigorous outcome studies is described below.
Effectiveness of Selected PrimaryPrevention Efforts
As noted in chapter 7, primary prevention ef-forts are aimed at reducing the incidence of men-tal health problems in children. Some of these ef-forts are directed at parents and others at children.
Parent Training Programs
Interventions aimed at reducing the interfa-ctional and developmental difficulties often asso-ciated with preterm birth and adolescent parent-ing have been well researched. One research groupthat used random selection and assignment totreatment and control conditions found that bi-weekly intervention in the form of home visits de-signed to facilitate interaction between teenagemothers and their preterm infants improved the
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Studies have shown that programs to encourage healthyparent-child interaction can promote children’s
mental health.
infants’ physical, cognitive, social, and temper-amental outcomes (187).
Teen Pregnancy Prevention Programs
Another well-researched prevention effort is“Project Redirection,” a large-scale, multisite pro-gram aimed at preventing repeat pregnancies andfostering educational and vocational attainmentin teenagers. Investigators in one study found sig-nificant beneficial effects 1 year after the inter-vention in terms of lower rates of subsequent preg-nancy and higher rates of school enrollment andemployment; however, 2 years after the interven-tion, many of the benefits were no longer appar-ent (522).
Early Education and Child DevelopmentPrograms
Among the most widely implemented and ex-tensively researched prevention efforts are theearly education intervention programs that origi-nated with Head Start in the mid-1960s. As notedin chapter 7, although these programs were notspecifically directed at preventing mental healthproblems, they have addressed the needs of chil-dren at risk for educational and adaptive failures,which have been shown to be associated with latermental health problems (127,514,546,675,699).
The history of evaluation of early educationprograms is essentially one of initial enthusiasmand excessive optimism, giving way to pessimismand a sense of failure, and ultimately arriving ata more balanced view of what these programshave and have not achieved (731,734). Earlypronouncements of the failure of early educationprograms were, in part, the result of an evalua-tion known as the “Westinghouse Report, ” whichconcluded that Head Start programs produced nolasting gains in cognitive and affective develop-ment (113). The Westinghouse Report was widelypublicized and generated questions both about thepremises of the Head Start program and the va-lidity of outcome measures.
One response to these questions was a generalreassessment of the long-term effectiveness ofearly education programs by the Consortium forLongitudinal Studies (378). This study involvedthe pooling of original data from 12 investigatorswho had independently designed and implementedevaluations of early education programs for low-income children in the 1960s. Thus, this study wasa joint evaluation of the early education programs’long-term effects. Although all of the early edu-cation programs had focused on economically dis-advantaged preschool-aged children, they differedin terms of program length, mode of intervention,and program setting (home- or center-based). Theevaluations of the programs varied in the extentto which they utilized random assignment to treat-ment and control conditions.
The study by the Consortium for LongitudinalStudies found that low-income children who hadparticipated in early education programs were sig-nificantly more likely than controls to have metschool requirements. Participants were less likelyto have been assigned to special education classesor to have been retained in a grade. Participantsalso showed higher IQ and achievement test scoresduring the first 3 or 4 years following programparticipation, although differences in IQs of pro-gram and control children were not found afterthis time. Early education was found to have hada lasting effect on attitudes towards achievement—both among the children and their parents. Spe-cifically, program children were found to have amore positive attitude towards achievement andschool than controls and their mothers were found
124
to be more satisfied with their children’s schoolperformance and to have consistently higher oc-cupational aspirations for them.
In a more recent study of the effects of preschooleducation through age 19, Berreuter-Clement, etal. (56), found, in addition to the effects on schooland attitude found in earlier studies, that by age19, the preschool group’s employment experiencewas significantly better than the experience of ano-preschool control group.
In general, the studies by the Consortium forLongitudinal Studies and Berreuter-Clement andhis colleagues suggest that early education has sig-nificant and lasting effects on children’s function-ing (378). Although the exact mechanisms bywhich the early education programs lead to posi-tive outcomes are not known, it has been sug-gested that cognitive, social, and motivational fac-tors were involved. Furthermore, the positiveeffects of early education programs have been at-tributed not only to changes produced in the chil-dren but, perhaps more importantly, to the ef-fects programs had on parents (6,10,734) andothers in the child’s environment, including sib-lings (249) and other social institutions in com-munities served by the program (77,352,469,671).Such effects illustrate the importance of provid-ing services in the context of children’s lives.
The implementation and evaluation of earlyeducation intervention projects have importantimplications for the evaluation of prevention ef-forts in general. Zigler and Berman (731) empha-size the importance of avoiding the type of over-promising that accompanied Head Start in itsearly years. Although early intervention has beenshown to result in benefits for children and fam-ilies, it is an error to assume that an early educa-tion program alone can eliminate the often per-vasive effects of social and economic disadvantage.Furthermore, these authors note, there are prob-lems associated with overstressing change in IQscore as the major criterion of the effectivenessof early education efforts. Although measures offormal cognitive ability are important, benefitsin other essential realms of functioning have re-sulted from these efforts. Zigler and Berman sug-gest broadly defined “social competence” as amore appropriate measure of outcome (733).
Family Support Programs
Much less is known about the effectiveness ofinterventions directed at supporting effective func-tioning in high-risk families than is known aboutthe effectiveness of early education and other pro-grams designed to provide cognitive stimulationto children (594). As evaluations of early educa-tion increasingly make clear, however, the mosteffective interventions are often those that activelyinvolve parents as well as children (77,250). Thisobservation suggests that family support may bea central aspect of promoting children’s mentalhealth. Because family support programs are afairly recent development, few outcome studiesof such programs are available. Evaluations oftwo family support programs described in chap-ter 7—the Yale Child Welfare Research Programand the Family Support Center Program—are re-viewed below.
The Yale Child Welfare Research Program (seech. 7) is a program aimed at enhancing the func-tioning of high-risk families. Since its inception,the program has used a matched control groupand has undergone several evaluations.
Initial evaluations of the Yale program foundthat program children (at 30 months of age)showed significantly better language developmentthan the control children; however, control groupfamilies were more likely to be self-supporting andto include a father or father-surrogate in theirhome (516). Five years later, the program fam-ilies were found to be living in improved socio-economic circumstances, and program motherswere more likely than control group mothers tobe employed and to have fewer total children(539,638). Moreover, at that time, the childrenin program families were found to have higherIQ scores, better school achievement, and betterschool attendance than a control sample (638).
The most recent evaluation of the Yale program(594) is a 10-year followup of original programparticipants and an equivalent control group ofparents and children. This evaluation found that10 years after participating in the Yale program,participating mothers were more likely than con-trol group mothers to be self-supporting, to haveachieved higher levels of education, and to havehad fewer children. They were also more likely
725
to display self-initiated involvement in their chil-dren’s schooling. The participating children, al-though they did not have significantly higher IQscores than the control group children, had bet-ter school attendance, required fewer costly spe-cial services, and showed better social and schooladjustment. In addition, the program was foundto save money; in 1 year, the 15 control groupfamilies were found to require approximately$40,000 worth of school services and extrafamilialsupport services that were not needed by the in-tervention families.
An evaluation of the Family Support CenterProgram (FSCP) (see ch. 7) compared FSCP fam-ilies with a sample of normal families (25). Itfound that FSCP families had significantly fewerincidents of child abuse, were experiencing lessstress, and had developed better parent-child in-teraction and child care conditions by the end ofthe program. Greater involvement in the programwas correlated with better outcomes. The valid-ity of the findings is limited by the lack of a con-trol group and the fact that half of the FSCP fam-ilies did not complete all three phases of theprogram. Also, many of the families participat-ing in FSCP received additional services fromother agencies during the course of the inter-vention.
Effectiveness of Selected SecondaryPrevention Efforts
The Primary Mental Health Program (PMHP)is an extensively implemented and evaluated sec-ondary prevention program (126). Although usedwith children slightly older than the children inHead Start, PMHP is similarly focused on the pre-vention of educational failure and school mal-adjustment; PMHP also shares the premise thatamelioration of early difficulties has importantpreventive implications for later mental healthproblems. Unlike Head Start, PMHP selects forthe program children who are already beginningto experience problems.
Since the program’s inception, outcome re-search has been a central component of PMHP.Several studies attest to PMHP’s effectiveness inreducing problem behaviors and enhancing com-petence in high-risk groups (128,694). Attentionhas also been paid to the long-term effects of par-ticipation in PMHP; children have been found tomaintain significant gains in adjustment for I to5 years following PMHP intervention (107,394).
In a recent 2-to 5-year followup (107), PMHPchildren were compared with a “never seen” group(children judged to be well-adjusted at the timeof initial screening) and a “least well-adjusted”group (non-PMHP children who were judged bytheir teachers to be functioning poorly). Thisstudy found that the PMHP children maintained,and in some cases solidified further, the gains inadjustment and problem reduction they had made2 to 5 years earlier. In addition, although PMHPchildren were often found to be functioning lesswell than the “never seen” children, they consist-ently appeared to be better adjusted than the “leastwell-adjusted” children. This observation suggeststhat although PMHP did not completely eradi-cate early detected difficulties, it did significantlyprevent the development of serious problems ina high-risk group. Finally, PMHP children werefound to perform in the normal range on academicachievement measures at followup, suggesting asustained and long-term benefit of the inter-vention.
Summary: Effectiveness of Prevention
Research on the outcomes of prevention pro-grams for specific mental disorders is very un-developed. There are, however, some fairly rig-orous studies on the outcomes of efforts to preventmore broadly defined maladjustment—e. g., PMHPand early education and child development pro-grams. These studies suggest that prevention, orat least reduction, of an incipient mental healthproblem is a worthwhile and attainable goal.
126
EVALUATING THE INTEGRATION OF MENTAL HEALTH ANDOTHER SERVICES
As difficult as it is, evaluating specific programsis simple compared to evaluating the effects of in-tegrating mental health and other services. In theirreview of methods for evaluating services inte-grated across systems, Morrissey, et al. (666),found little solid evidence to support the beliefof some investigators (e.g., 262) that organization-level variables predict client-level outcomes. Eval-uations of the effects of integrated services onclient-level outcomes would require the integra-tion of system, program, and client-level data;studies encompassing all three levels of data arerelatively rare in the health and welfare field (666).
At present, there are no reviews of attempts atcoordinating mental health and other service sys-
CONCLUSION
Methodologically rigorous research comparingthe effectiveness of treatment in psychiatric hos-pitals and other residential settings with similartreatment in outpatient settings is sorely lacking.Despite the limitations of available research, how-ever, certain trends in the data are suggestive—and support particular policy choices. The long-term effectiveness of psychiatric hospitalizationand other forms of RTC treatment, for example,appears to be related to the availability of socialsupport mechanisms and mental health servicesin the posttreatment environment programs. Theeffectiveness of mental health treatment in non-mental-health settings may depend on pairingtreatment with other interventions like vocationalcounseling or family support.
terns. The National Institute of Mental Health(NIMH) and grantees of NIMH’s Child and Ado-lescent Service System Program (CASSP) are be-ginning to develop criteria for evaluating CASSP,a program intended to foster collaboration andintegration among mental health and other serv-ice systems (see ch. 10). Outcome measures willinclude States’ progress toward a “minimal serv-ice set”; the extent to which parents are used asadvocates for children; declines in the number ofchildren placed out of State; and other measuresof services, leadership, advocacy, and training.However, actual child outcomes will not be partof the evaluation.
Existing models of prevention suggest that ef-fective interventions can be offered through anyof several existing systems—including the family,the schools, and health care programs. Not onlyhave many prevention programs led to positivechanges in social, emotional, and academic meas-ures, but such programs appear capable of pre-venting later governmental expenditures throughthe justice and welfare systems.
What is clear, is that much greater emphasisneeds to be placed on evaluations of mental healthservices offered in a variety of settings, includ-ing non-mental-health settings. Assessment of in-tegrated treatment systems could help policy-makers decide how to target resources.
Part V: Current Federal Efforts
Chapter 10
Current Federal Efforts
Chapter 10
Current Federal Efforts
INTRODUCTION
The complexity of children’s mental healthproblems, the diversity of mental health treat-ments, and the effectiveness, in general, of treat-ment have been documented in previous chapters.Despite an incomplete knowledge of the causesof mental health problems in children, it is clearthat much can be done to reduce the effects of suchproblems. Yet substantial data suggest that manychildren with mental disorders, and at risk of de-veloping such problems, do not have access toadequate treatment services (216,358).
This chapter examines the Federal role in pro-viding mental health services to children. Where
possible, it considers that role in the context ofthe entire mental health system—State, local, andprivate. The chapter describes specific Federal pro-grams with the greatest relevance to children’smental health services. Such programs relate tofinancing of children’s mental health treatment;coordination of mental health and other services;research and training; and prevention and otherservices. The chapter concludes that although theroles of State and local governments and the pri-vate sector in serving the mental health needs ofchildren could be usefully enhanced, greater Fed-eral involvement may also be desirable.
FEDERAL PROGRAMS THAT SUPPORT MENTAL HEALTH ANDRELATED SERVICES FOR CHILDREN
Several Federal programs affect the provisionof mental health services to children. The discus-sion in this chapter emphasizes the programs thathave the most direct influence:
●
●
●
●
the Alcohol, Drug Abuse, and Mental Health(ADM) block grant program, which providesfunds to States for community mental healthcenters (CMHCs);third-party payment programs such as Med-icaid, Medicare, and the Civilian Health andMedical Program of the Uniformed Services(CHAMPUS), which are involved, to a greateror lesser degree, in financing children’s men-tal health care;related psychological services under the Edu-cation for All Handicapped Children Act(Public Law 94-142);the Child and Adolescent Service SystemProgram (CASSP) of the National Instituteof Mental Health (NIMH), which is intendedto coordinate mental health and other serv-ices for severely mentally disturbed children;and
• NIMH training, research, and preventionprograms.
Federal contributions to these programs in 1985and, where they can be determined, estimatedamounts devoted to children’s mental health serv-ices in 1985 are shown in table 8. Because fundsfor children’s mental health are commingled withresources for adults and for alcohol, drug abuse,and other health-related programs, the preciseamount of Federal resources dedicated to chil-dren’s mental health is not reliably known. Theestimates given, therefore, should be viewed cau-tiously.
Financing of Mental Health Treatment
When considering the role of the Federal Gov-ernment in the financing of children’s mentalhealth treatment, it is important to note that men-tal health treatment (for all ages combined) isfinanced primarily by State Mental Health Agen-cies (SMHAs). In general, Federal and privatesources currently bear less of a burden, although
731
132
Table 8.—Federal Contributions to Programs Contributing to Mental Health Services for Children, 1985(dollars in millions)
Total Federal Children’s mental health portion
contribution to Percent ofmental health and Mental health portion, total mental
Federal programa other health services adults and children Amount health portion
Mental health services programs:Alcohol, Drug Abuse, and Mental Health (ADM)
block grant (1981) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10-percent set-aside for new mental health programs
for children or other undersexedpopulations (1985) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NIMH Office of State and Community Liaison. ... , . . . . . .
Child and Adolescent Service System Program(CASSP) (1984) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Third-party payment programs:Medicare (1966)e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Medicaid (1986) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS) (1986) . . . . . . . . . . . . . . . . . . . . . . .
NIMH training, research, and prevention programsg (1947h)Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Research:
Intramural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Extramural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Biometry and epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . .Prevention and special mental health . . . . . . . . . . . . . . . . . .Communication and education . . . . . . . . . . . . . . . . . . . . . . . .
Total NIMH training. research. and prevention . . . . . . . .
$ 490 $200b N AC NA
$ 10.6 to $20.0d
N A
4.7
NANA
360/o
—490
13
—200
13
4.74.7
363613 13
69,70722,854 f
NANA
NANA
NANA
1,382.7 261.0 156.6 60
31.6 31.6 4.8 15
57.498.211.524.1
2.0224.8
57.498.211.524.1
2.0224.8
5.521.7
2.410.30.2
44.9
102221431020,
aFigures in parentheses indicate fiscal year of program’s initiation.bEstimate; States have latitude to transfer limited amounts of funds across prOgram lines.C N A = Not availabledA General Accounting Office suwey of 13 States found that States planned to use from none to all of set-aside funds for children’s Services See teXt and table 9eTh e Medicare program for enhancing health care to the aged was enacted July 30, 1985, as Title XVlfl of the SOCial Security Act, and expanded to cover the disabled
beginning in July 1973, as legislated by the 1972 amendments to the Social Security Act (Public Law 92-803)fln fiscal year 1985, States paid another $18,382 million in Medicaid.gNIM1-f does not ordinarily aggregate expenditure data by age group; the figures presented here are rough estimates In addition, NIMH was reorganized ir( 1985 Pro-
gram names presented here have changed.hNIMH was created under the public Health Service Act of 1944 (42 IJ,S,C, 29o AA-3) and began functioning in late 1947
S O U R C E S : ADM block gront: R.L. Fogel, “Early Observations on States’ Plans To Provide Children’s Mental Health Services Under the ADAMH Block Grant(GAO/HRD-85-84),” letter to Senator Inouye from Human Resources Division, General Accounting Office, US. Congress, Washington, DC, July 10, 1985.NIMH: U.S. Department of Health and Human Services, Public Health Service, National Institute of Mental Heaith, Alcohol, Drug Abuse, and Mental HealthAdministration, Twe/fth Annua/ Report on the Child and Youth Activities of the National Institute of Mental Health, Federal Fiscal Year 1985, presentedto the National Advisory Mental Health Council by M.E. Fishman (Rockville, MD: March 10, 1986). Medicare: M. Gornick, J.N. Greenberg, P.. Eggers, andA. Dobson, “Twenty Years of Medicare and Medicaid: Covered Populations, Use of Benefits, and Program Expenditures,” Health Care Firrancing Review(1985 Annual Supplement) (Baltimore, MD: U.S. Department of Health and Human Services, Public Health Service, Health Care Financing Administration,December 1985) and Health Care Financing Administration, unpublished data. Medicaid: U.S. DepaRment of Health and Human Services, Health Care FinancingAdministration, Bureau of Program Operations, Grants Branch, Division of State Agency Financial Management, unpublished data pertaining to fiscal year1985 Medicaid program expenditure information, BPO-F31, Baltimore, MD, September 1986. CHAMPUS: K. Zimmerman, Statistics Branch, Information SystemsDivision, Office of CHAMPUS, personal communication, Sept. 5, 1986
comparing the treatment costs that each of thesesources pays is difficult. In the case of Medicaid,for example, the only mental health expenditureknown is that of mental hospitals. Private third-party payers prefer not to disclose what they payfor mental health services, and the amount actu-ally spent by clients themselves is not known.
being that mental health treatment for childrenis typically more complex and thus more expen-sive than treatment for adults (see, e.g., 457).
In 1980, an estimated $21 billion was spent byall sources on mental health treatment for all agegroups (277a). About half—$10 billion—of thisamount was spent for services rendered in themental health system (277a). (Most of the otherexpenditures were for treatment rendered in the
The proportion of costs specifically for chil-dren’s mental health treatment is even more dif-ficult to determine. It cannot be derived from the general health care system. ) In 1983, the yearproportion of services rendered to children for a closest to 1980 for which data are available, SMHAsnumber of reasons, perhaps the most important reported to the National Association of State
133
Mental Health Program Directors (NASMHPD)that they spent a total of $6.8 billion on mentalhealth treatment for all age groups (459). This fig-ure allows a rough estimate that more than two-thirds of expenditures for treatment in the men-tal health system are expenditures made by SMHAS(see figure 4). In turn, most of the revenues tosupport SMHAs are provided by the States: 76percent of SMHA revenues in 1983 came from theStates, 16 percent from the Federal Government,3 percent from local governments, and 5 percentfrom other sources (459).
The NASMHPD study also indicated that SMHAswhich were able to determine how much theyspent on mental health programs exclusively forchildren spent an average of 7 percent or about$9 per capita on such programs (459). For adultprograms, SMHAs spent an average of 45 per-cent of their funds, or $22 per capita. These per-centages must be viewed with caution, however,because many of the States surveyed could notdetermine the allocation of mental health fundsby age. Further, in all of the States, a substantialportion of mental health funds was spent on pro-grams for all ages combined (e.g., on State men-tal hospitals).
Alcohol, Drug Abuse, and Mental HealthBlock Grant
The ADM block grant was initiated in 1981(Public Law 97-35) as the successor to a varietyof categorical programs—most significantly pro-grams under the Community Mental Health Cen-ters Act of 1963 (Public Law 88-164). It is cur-rently the only major Federal program that providesfunds to States to support CMHCs and relatedcommunity mental health services. ADM blockgrant funds cannot be used for inpatient care.
As shown in table 8, Congress appropriated atotal of $490 million for the fiscal year 1985 ADMblock grant (considerably less than the $625 mil-lion available for categorical programs in fiscalyear 1980 (643b)). States receive a share of theADM total block grant appropriation through aformula based on population and the level of Fed-eral funds received prior to 1981. Because the for-mula combines population and prior Federal fund-ing levels, there is no direct relationship betweenthe size of the State’s population to be served and
Figure 4.-Estimated Proportions of State v. Federaland Private Expenditures for Mental Health Treatment
Provided in the Mental Health Systemto All Age Groups,a 1983
Estimated total: $10 billion
aExcludes treatment provided in other service systems (e.g., 9eneral health caresystem),
bsources of revenue for SMHAS:States . . . . . . . . . . . . . . . . . . . . . . 760/.Federal Government (e.g., Medicaid [$600 million],
Alcohol, Drug Abuse, and Mental Health (ADM)block grant [$200 million]) . . . . . . . . . . . . . . 160/0
Local governments . . . . . ., . . . . . . . . . 30/.Other sources . . . . . . . . . . . . . 50/.
cFederal Government share excludes SMHAS (See note b)
SOURCES: Estimated total: H. Harwood, D Napolltano, P Kristiansen, et al , Eco.nornic Costs to Society of A/cotro/ and Drug Abuse arrd Menta/ ///-ness: 1980 (Research Triangle Park, NC: Research Triangle Institute,June 1984); SMHAS: National Association of State Mental Health Pro-gram Directors, Funding Sources and Expenditures for State MentalHealth Agencies: Fiscal Year 1983 (Washington, DC 1985).
the block grant allocation. Rather the block grantformula tends to “reward” States that relied onFederal funds prior to 1981 and “punish” Statesthat relied to a greater extent on State funds.
For several reasons, it is difficult to determinewhat portion of ADM block grant funds serveschildren. First, the ADM block grant is segmented,with separate funding for alcohol, drug abuse, andmental health programs, and the percentage ofblock grant funds allowed to be used specificallyfor mental health services differs among States.Second, it is not known to what extent any of thethree categories of ADM block grant programs
134
has services designed specifically for children.Third, CMHCs, which receive the bulk of themental health funds, must provide specialized out-patient services for children, but there is no re-quirement that they provide a certain level of serv-ice or report how much is spent on children’streatment. This situation is different from thatunder Part F of the Community Mental HealthCenters Act of 1963, when specific funds were tar-geted for children.
In order to better address children’s needs, Con-gress amended the fiscal year 1985 ADM blockgrant to require that 10 percent of the mentalhealth portion of block grant funds be set asidefor “new programs for children and other under-served areas and populations. ” This set-aside rep-resents a partial return to the Part F targeting pol-icy and reflects a recognition by Congress thatchildren are an underserved population. Therewas some question, however, as to how effectivethis l0-percent set-aside would be in increasingthe availability of mental health treatment serv-ices for children.
To assess the impact of the set-aside, the Gen-eral Accounting Office (GAO) was requested (bySenator Daniel K. Inouye) to study how States
were spending 1985 set-aside funds. Of particu-lar concern was whether set-aside funds were be-ing directed to programs for children and whetherthese programs were actually “new” programs.
To learn how States were spending 1985 set-aside funds, GAO conducted a telephone survey(during April/May 1985) of 13 States represent-ing each of the Federal regions and approximately50 percent of the Nation’s population (see table9). Three of the 13 States, Iowa, Mississippi, andTexas, planned to spend all of the 10-percent set-aside moneys on new programs for children. Fourof the States, Kentucky, Massachusetts, Michi-gan, and Washington, had decided not to spendany of the set-aside money on new programs forchildren. New York had decided that less thanone-quarter of its total planned set-aside funds($203,000 of $1,153,000) would be directed towardnew programs for children. Pennsylvania hadmade a similar decision and allocated approxi-mately 20 percent of its set-aside ($230,000 of$1,325,000) for children’s programs. The programsfor children to be supported were diverse and in-cluded enhancing nonhospital residential care,case management, adolescent problem and sui-cide prevention, and family support (see table 10).
Table 9.—Fiscal Year 1985 Estimated Allocation of the IO-Percent Set-Aside of the Alcohol, Drug Abuse, andMental Health (ADM) Block Grant for Selected States (in thousands)’ b
Mental health Total planned Set-aside funds allocated for:
Total ADM portion of total set-aside Undersexed Target groupsaward for fiscal ADM award funds as of areas or undetermined
State year 1985 amount/percent May 1985C Children populations as of May 1985
California. . . . . . . . . . . . . . . . . . . .Colorado . . . . . . . . . . . . . . . . . . . .Florida . . . . . . . . . . . . . . . . . . . . . .lowa . . . . . . . . . . . . . . . . . . . . . . . .Kentucky . . . . . . . . . . . . . . . . . . . .Massachusetts . . . . . . . . . . . . . . .Michigan . . . . . . . . . . . . . . . . . . . .Mississippi . . . . . . . . . . . . . . . . . .New York. . . . . . . . . . . . . . . . . . . .Pennsylvania. . . . . . . . . . . . . . . . .Texas . . . . . . . . . . . . . . . . . . . . . . .Vermont. . . . . . . . . . . . . . . . . . . . .Washington. . . . . . . . . . . . . . . . . .
Total (13 States) . . . . . . . . . . . .
$48,4067,004
24,0332,9364,551
18,24015,9485,165
40,09725,11421,446
3,3138,977
$15,778 (33°/0)3,400 (49%)
12,855 (53°/0)203 (7°/0)
1,850 (41 0/0)
10,106 (55°/0)4,708 (30°/0)3,606 (70°/0)9,700 (240/o)
13,250 (53°/0)8,457 (39°/0)2,200 (66%)4,727 (53°/0)
$2,328340
1,35820
6691,011
471361
1,1531,326
846220526
$l44337
20000
361203230846
o
$225,230 $90,840 $10,629 $2,141
$l961,021
0669
1,011471
0950
1,0960
526
$5,940
$2,3280000000000
2200
$2,548aAs of May 1985.bset.aside funds are t. be used for new Programs only; therefore, amounts in this table do not represent States’ entire expenditures on either children Or other undes-
erved areas or populations.Csome States set aside more than the required 10 percent of the mental health portion of block grant funds.
SOURCE: R.L. Fogel, “Early Observations on States’ Plans To Provide Children’s Mental Health Services Under the ADAMH Block Grant (GAO/H RD-85-84),” letter toSenator Inouye from Human Resources Division, General Accounting Office, US. Congress, Washington, DC, July 10, 1985.
135
Table IO.— Planned a Use in Selected States ofFiscal Year 1985 Set-Aside Funds forMental Health Services for Childrenb
State c Services for children
California Not decidedd
Colorado Residential careFlorida Psychiatric services, summer school ses-
sion for the handicapped, outpatient,emergency, diagnostic assessment, con-sultation, case management, crisis inter-vention, adolescent problem prevention
lowa Group home services, adolescent problemprevention, family support
Kentucky None (funds will be used for other under-served areas or populations)
Massachusetts None (funds will be used for other under-served areas or populations)
Michigan None (funds will be used for other under-served areas or populations)
Mississippi Undetermined e
New York Family support, adolescent suicide preven-tion, referral
Pennsylvania Residential careTexas Services for students with drug or alcohol
problems, weapons violations, etc., serv-ices for minority inhalant abusers
Vermont Not decidedd
Washington None (funds will be used for other under-served areas or populations)
aAs of May 1985.bBlock grant set-aside funds were also permitted to be used fOr underserved
populations other than children In addition, some undersexed populations thatthe States reported were to be served (e g., the homeless chronically mentallyIll) were not targeted by age Some of these programs may address the mentalhealth needs of children.
CA sample of 13 States, representing the receipt of about half the Alcohol, DrugAbuse, and Mental Health block grant funds, were surveyed by the General Ac-counting Office
d, Not decided,, indicates that the State had not decided whether set-aside funds
were to be used for children or for other underserved areas or populations.e,, undetermined” indicates that the State had decided to uSe set-aside funds
for children and adolescents, but had not decided which services the funds wereto be used for
SOURCE R L Fogel, “Early Observations on States’ Plans To Provide Children’sMental Health Services Under the ADAMH Block Grant (GAO/H RD.85-84 ),” letter to Senator Inouye from Human Resources Division,General Accounting Off Ice, U S Congress, Washington, DC, July 10,1985
It is important to emphasize that the entireADM block grant is small in comparison to Statefunds and that the 10-percent set-aside for chil-dren and other underserved populations is takenonly from the mental health portion of the ADMblock grant. The entire 10-percent set-aside maybe less than $20 million nationwide—and only aportion of this would be directed to new programsfor children. Because there were no new funds,the set-aside requirements might mean that fundsfor new programs for children will have to betaken from other existing programs, unless Statesmake up the funds for other programs. Some
States noted that the requirement that the pro-grams for children or other underserved popula-tions be “new” did not allow for additional fundsto be allocated to already existing programs thatappeared to be effective. In response to theseproblems, Congress amended the 10 percent set-aside in fiscal year 1986 to read that 10-percentof mental health block grant funds could be usedfor “new or expanded” programs for underservedpopulations, with a “special emphasis” on chil-dren or adolescents (Public Law 99-117).
Perhaps the most important impact of the set-aside is symbolic. As States are required to re-port the amounts of ADM block grant moneyspent on new programs for children, more atten-tion may be brought to children’s mental healthproblems. Also, because funds from the ADMblock grant cannot be spent on inpatient services,the program provides an incentive for States todevelop locally based outpatient treatment pro-grams. To the extent that resources for outpatientprograms are available, early diagnosis and treat-ment for children with mental health problemsmay be more likely.
Federal Third-Party Payment Programs
The Federal Government plays a major andtrend-setting role in financing health care services.It is the largest single insurer of health care serv-ices (Medicare and partial funding of Medicaid)and has also played a leadership role in the de-velopment of health care payment systems. Theextent to which certain services and providers re-ceive reimbursement while others do not has a di-rect effect on the delivery of care (206). Tradi-tionally, coverage for mental health services hasbeen less extensive than coverage for other med-ical services (e.g., see 20,175a). Mental health cov-erage is also limited by requirements for the pres-ence of a diagnosable disorder (see ch. 3) as acondition for reimbursement.
Three key parts of the Federal health care fi-nancing system are Medicaid, Medicare, andCHAMPUS. In 1985, Medicaid served 11 million(296,297) dependent children under the age of 21,but the amount of mental health benefits providedto these children is believed to be minimal. Medi-care provides no significant funding for children’s
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mental health care, but Medicaid and other third-party payers that do fund such care are often influ-enced by Medicare’s payment policies. CHAMPUSis the largest single health insurance program inthe country, providing coverage for health serv-ices to military dependents and retirees who areunable to receive services through uniformed serv-ice medical treatment facilities. CHAMPUS spends60 percent of its mental health expenditures ontreatment for children.
Medicaid .—Medicaid represents 55 percent ofall public health funds spent on children (645) andhas the potential to meet the needs of children whoare possibly at the greatest risk for developingmental disorders, those who are in poverty andthose who are uninsured.
In general, Medicaid provides health insuranceto low-income families who meet certain categor-ical and financial criteria. These criteria, andmany of the services provided, are generally setby the States, which provide a very significantportion of the Medicaid funding. Medicaid servesapproximately 11 million children. Most impor-tant for purposes of this background paper isthat while beneficiaries may not be discriminatedagainst on the basis of diagnosis, States are freeto set limitations on Medicaid coverage for mentalhealth services (636). The percentage of Medicaidfunds devoted to mental health care is not known.GAO is conducting a national survey of the men-tal health services available under Medicaid.
Medicaid’s Early and Periodic Screening, Diag-nosis, and Treatment (EPSDT) program providesfunds to screen, diagnose, and treat children un-der 21 who are members of families designatedas “categorically needy, ” and so is a potentiallyimportant Federal initiative (434). The develop-mental assessment that is required as part ofEPSDT screening can reveal emotional difficul-ties and problems in behavior development. How-ever, because of changes in eligibility, childrenmay not be followed long enough for a develop-mental assessment to be adequate; in addition,few States deliver any substantial amount of men-tal health care through this program (358,595).
Efforts in the late 1970s to upgrade EPSDT intoa Child Health Assurance Program (CHAP), andthus to specifically require mental health assess-
ment and treatment for Medicaid-eligible children,were not successful (595).An expansion of Med-icaid eligibility passed in 1984 (Public Law 98-369)is potentially important for preventing, detecting,and treating mental health problems because itmakes additional women and children eligible formedical services. Although this expansion of eligi-bility is sometimes referred to as a “modifiedCHAP, ” it did not specifically require mentalhealth assessment and treatment for children.
In addition to the expansion of eligibility, anotherpotentially important change in the Medicaid pro-gram was incorporated in the Consolidated Omni-bus Budget Reconciliation Act (COBRA) of 1985(Public Law 99-272), which was signed into lawon April 7, 1986. Under the provisions of COBRA,States will be allowed to cover case managementservices, which were defined as those services thatassist individuals eligible under Medicaid to gainaccess to needed medical, social, educational, andother services.
It appears that Medicaid may ensure that atleast some poor people obtain mental health carewho would not otherwise do so. An analysis byTaube and Rupp (632a) found that poor and near-poor Medicaid recipients were more likely thannonrecipients to get mental health treatment. Asnoted above, States have different Medicaid eligi-bility requirements, so Taube and Rupp were ableto compare persons who were of similar socio-economic status. Taube and Rupp attribute thegreater use of mental health benefits by Medic-aid recipients to the fact that Medicaid does notallow cost-sharing (i.e., recipients are not requiredto pay any of the costs of health services). Taubeand Rupp’s finding, as well as their interpretation,is consistent with other studies which show thatthe use of mental health care is responsive to thecost of such care, although cost is not the onlyfactor which deter-mines whether people seek men-tal health care (206).
Medicare .—The Medicare program covers thecost of hospitalization, medical care, and relatedservices for most persons over age 65, persons re-ceiving social security disability insurance pay-ments for 2 years, and persons with end-stage re-nal disease. Although only a small proportion ofMedicare program funds are directly devoted to
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children (children who are disabled and depen-dents of deceased, retired, or disabled social secu-rity beneficiaries), Medicare influences health carereimbursement nationwide. Not only have a num-ber of States adopted Medicare rules for paymentof Medicaid and other insurance benefits, but non-Federal health insurance providers closely watchMedicare.
The Social Security Amendments of 1983 (Pub-lic Law 98-21) mandated that Medicare adopt aprospective payment system’ for hospitals (648,649). Children’s hospitals and psychiatric hospi-tals, along with rehabilitation and long-term carehospitals, have been temporarily exempted fromthe new payment system; however, the systemdoes apply to psychiatric services provided innonspecialized units in general hospitals.
Medicare’s prospective payment system is basedon fixed per-case payment rates for patients in 467diagnosis-related groups (DRGs), DRGs area pa-tient classification system developed at Yale forpurposes of research on health care delivery.There are nine DRGs for “mental diseases” andsix for substance abuse (see table 11).
DRG 431, “childhood mental disorders,” includesdiagnoses of childhood-onset mental disorders (seech. 3). Because many childhood diagnoses canalso be applied to adults (e. g., a problem such asattention deficit disorder, which has its onset inchildhood), DRG 431 does not apply only to chil-dren. Furthermore, DRG 431 is not the only DRGapplied to children with mental disorders. Chil-dren with mental disorders that can also receivean adult diagnosis (e. g., adolescents with drug oralcohol abuse problems) are sometimes placed inother categories. Nonetheless, DRG 431 is prob-ably the most frequently used DRG for children,and so deserves careful attention in the event aprospective payment system is considered for thechildren’s mental health care system.
Like most DRGs, DRG 431 does not differen-tiate patient episodes by problem severity, treat-ment modality and setting, or the patient’s his-tory, The Medicare payment rate for DRG 43 I
is based on an adjusted average (the geometricmean2 of lengths of stay (LOS) in the hospitalamong patients with this diagnosis. In the caseof DRG 431, this equals 15.4 days. As indicatedin table 11, however, DRG 431 is the mental dis-order DRG category with the most variation inLOS (632), with few patients being treated closeto the 15.4-day mean LOS. Approximately 25 per-cent of patients in DRG 431 have an LOS less than10 days, while 25 percent have an LOS greaterthan 75 days. Since DRG-based payment byMedicare does not take LOS into account, a hos-pital treating an individual with a childhood-onsetmental disorder for 75 days receives the sameMedicare payment as a hospital treating the in-dividual for 1 day or for 15.4 days.
Variation in LOS for DRG 431 aside, there area number of potentially serious problems con-nected with application of a DRG-based paymentsystem to children’s mental health care (581). Onebasic problem is that there is no theoretical or em-pirical evidence to indicate that the use of treat-ment resources is related to a mentally disturbedchild’s diagnosis. Systems of classifying mentaldisorders (such as the American Psychiatric Asso-ciation’s Diagnostic and Statistical Manual or theWorld Health Organization’s International Clas-sification of Diseases) indicate only the related setof conditions that have been found for a particu-lar syndrome. These systems were not designedto be used for reimbursement purposes (19) anddo not necessarily indicate the severity of a men-tal disturbance. Especially for children, mentalhealth treatment decisions may be based on thefamily’s ability to manage the child as well as onthe multiplicity of problems faced by the child.
In the absence of a direct relationship betweendiagnosis and length/intensity/cost of mentalhealth treatment, DRG-based payment will notbe likely to match a child’s need for services. Inthe short term, a mismatch between DRG-basedpayment and the cost of needed services may re-sult in some (probably the most troubled) chil-dren’s being denied services. It may also result in
‘Prospective payment, payment to health care providers basedon rates established in advance, is an alternative to retrospectivecost-based reimbursement, under which payment to providers isbased on the amount and type of services they provide (648,707).
‘Like the arithmetic mean, or average, the geometic mean is acentral value in a distribution of scores that serves as a summarymeasure of the scores. By relying on logarithms, the geometric meanhas the advantage of being less influenced by the uneven distribu-tion of scores.
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Table 11 .–Lengths of Stay Associated With Mental Disorder Diagnosis-Related Groups (DRGs)Ranked by Interquartile Range
Length of stay in days
Interquartilebrange (75th
Geometric 25th 75th percentile minusDRG meana percentile percentile 25th percentile
Childhood mental disorders (431). . . . . . . . . . . . . . . . . . . . . . 15.4 9.8 75.5 65.0Organic disturbances and mental retardation (429). . . . . . . 8.8 9.2 34.4 25.0Psychoses (430) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.8 8.7 32.7 24.0Alcohol dependence (436) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1 4.8 26.9 22.0Disorders of personality and impulse control (428). . . . . . . 8.3 4.8 25.5 20.0Depressive neuroses (426) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4 6.1 25,3 19.0Drug dependence (434). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.1 6.9 25.5 18.0Neuroses except depressive (427) . . . . . . . . . . . . . . . . . . . . . 6.9 4.8 22.4 17.0Other mental disorder diagnoses (432) . . . . . . . . . . . . . . . . . 7.2 7.7 23.0 15.0Drug use except dependence (435) . . . . . . . . . . . . . . . . . . . . 8.0 4,2 19.4 15.0Acute adjustment reaction/disturbances of psychosocial
dysfunction (425) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.8 3.3 18.3 15.0Alcohol use except dependence (437) . . . . . . . . . . . . . . . . . . 3.5 3.1 14.8 11,0Alcohol- and substance-induced organic mental
syndrome (438) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.9 3.9 15.5 11.0Substance use and substance-induced organic mental
disorder left against medical advice (433) . . . . . . . . . . . . 2.5 1.9 9.6 7.0aLike the arithmetic rnearl,oraverage, the geometric mean is acentral value in a distribution of scores that Serves aS asummav measure of the scores BY relYin9
on logarithms, the geometric mean has the advantage of being less influenced by the uneven distribution of scores.bTheinterqua~fle range is the ran~e of scores extending equa~yon both sides of the mean that covers themiddle50 percent of a distribution Of ScOreS Thus, the
interquartile range is a measure of variation, in this instance, in length of stay.
SOURCE” FromC. Taube, ES. Lee, andR.N. Forthofer, “Diagnosis.Related Groups for Mental Disorders, Alcoholism, and Drug Abuse’ Evaluation and Alternatives,”Hospital and Community Psychiatry 35(5)453-454, 1984.
unnecessary and inappropriate treatment as hos-pitals are provided an incentive to treat “simple”cases. The long-term impact on the range andquality of available services is unknown (649).
i A second critical problem with the applicationof a DRG-based payment system to children’smental health care is that the data used to calcu-late average LOS, on which DRG payment isbased, were derived from past experience in asample of adult acute care hospitals. Data reflect-ing the types of treatments given to children inspecialized psychiatric units or in psychiatric hos-pitals were not included.
Even if LOS data were available from hospitalfacilities that treat mentally disturbed children,however, there would be a serious problem inusing such data. Most health benefit programshave limitations on the type and amount of bothinpatient and outpatient treatment provided. Inaddition, most benefit programs provide moregenerous coverage for inpatient care than for out-patient, residential treatment center (RTC), or daytreatment (600).
The fundamental problem with application ofa DRG-based payment system to children’s men-tal health services is that basing payment on abroad category of diagnosis such as “childhoodmental disorders” ignores the body of literatureon the variety of treatment needs of mentally dis-turbed children. This problem exists for otherDRGs and other vulnerable populations as well(649). A DRG-based prospective payment systemmay control costs and maintain quality of carefor patients who require specific medical or sur-gical procedures (i.e., non-mental-health care),but it seems inappropriate and potentially harm-ful to apply such a DRG-based payment systemto children’s mental health care.
Civilian Health and Medical Program of theUniformed Services. —CHAMPUS is a health in-surance program administered by the U.S. Depart-ment of Defense (DOD). CHAMPUS provideshealth benefits to 6.5 million military dependentsand retirees who are unable to receive servicesthrough uniformed service medical treatment fa-cilities, and is known as one of the most gener-ous third-party payers for mental health care.
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Primarily because few uniformed service med-ical treatment facilities offer mental health serv-ices, CHAMPUS devotes a higher percentage ofits benefit payments (16 to 19 percent [643a,655];also see table 8) to mental health services than domost private insurance plans. Another reason thatCHAMPUS devotes a high percentage of its ben-efit payments to mental health services is that mil-itary families often live in areas not adequatelyserved by outpatient mental health professionals;for families in areas not served by outpatient fa-cilities, the only mental health treatment optionmay be psychiatric hospitalization, or, for chil-dren, care in an RTC. Inpatient and RTC treat-ment are typically more expensive than outpatienttreatment; and CHAMPUS spends up to 75 per-cent of its mental health benefits on inpatient andRTC treatment (548), despite the presence of anunusually rigorous peer review system which mustcertify all care (inpatient, outpatient, residential)as medically or psychologically necessary (548,549).
In their efforts to control the costs of mentalhealth care under CHAMPUS, both Congress andCHAMPUS have implemented provisions formaximum benefits for mental health care in psy-chiatric hospitals and, more recently, in RTCs.The effect of one such provision—a 60-day “cap”on inpatient psychiatric hospitalization—illustrateshow changes in reimbursement policy can changethe type of services available. This example is notdefinitive, however, because the change inCHAMPUS reimbursement policy was not intro-duced experimentally (i.e., with use of a controlgroup experiencing no changes in coverage).Thus, alternative explanations for subsequent var-iations in treatment services, such as changes intreatment philosophy, cannot be ruled out.
Under the 60-day cap, exceptional justificationof medical necessity has to be provided for psy-chiatric hospitalization longer than 60 days forboth adults and children or CHAMPUS will notpay for the care. Extension of the 60-day limit isgranted only if a patient is a danger to himself/herself or others; or if the patient has a medicalcomplication and only an inpatient hospital fa-cility can provide appropriate treatment. The capdoes not affect RTCs.
A 1985 DOD analysis of the first year’s experi-ence with the 60-day cap concluded that the 60-day limit on inpatient psychiatric hospitalizationhad resulted in a $34.2 million “cost avoidance, ”representing 22 percent of the total CHAMPUSspent for inpatient and RTC mental health carein calendar year 1983 (655). Perhaps as expected,there was a 66-percent increase in RTC admissionsin 1983, although the costs of RTC stays were notincluded in DOD’s analysis (655). The cost of in-patient care cannot be separated from the costsof RTC care in CHAMPUS’s data system. DOD’sanalysis was adjusted, however, for an estimated80,000 outpatient visits attributed to the 60-daycap.
On the basis of its 1985 analysis and subsequentmonitoring, CHAMPUS more recently estimatedthat there would be a 100-percent increase in ad-missions to RTCs between 1983 and 1986 (from425 in 1983 to about 850 in 1986 [643a]). In addi-tion, CHAMPUS reported that since the imposi-tion of the 60-day cap, there had been an increasein the number of RTCs attached to psychiatrichospitals that had applied and been approved un-der CHAMPUS (from 13 in December 1982 to 30in December 1985 [643a]). In order to provide ad-ditional long-term control over cost escalation,CHAMPUS has since developed a new policy tolimit its payments for RTC care.
As do all health care cost-containment efforts,CHAMPUS’s attempts to limit costs raise concernsabout maintaining good quality care. CHAMPUSmonitors quality through its unusually rigorouspeer review system and its approval processes(548, 549). In addition, GAO is studying meth-ods for assessing the quality of care providedunder CHAMPUS.
The Education for All Handicapped ChildrenAct (Public Law 94-142)
The Education for All Handicapped ChildrenAct (Public Law 94-142) mandates that all physi-cally and mentally handicapped children be pro-vided a free, appropriate education and the “re-lated services” necessary to obtain an education(see ch. 7). The Federal Government provides asmall amount of grant money to States to helpthem implement this law.
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There is continuing debate about whether men-tal health care is properly included under “relatedservices.” Even those who consider mental healthinterventions necessary for education disagreeabout where the responsibility for payment lies—with the school system, the welfare system, thehealth care system, or the mental health care sys-tem. There is additional concern about the costsand personnel required when residential treatmentis indicated, and about whether the school sys-tems should be required to pay for the entire costsof residential placements or only for the educa-tion-related costs (109). Evidence suggests that theservices available to mentally disturbed childrenthrough Public Law 94-142 vary considerably byState (657). When this background paper was be-ing written, a study was being conducted to de-termine what related services, including mentalhealth services, were being provided under Pub-lic Law 94-142 (666).
Coordination of Services
The State Comprehensive Mental HealthServices Plan Act of 1986 (Public Law 99-660)
In response to the perceived inadequacy andfragmentation of services for individuals who areperhaps most in need of coordinated mental healthand other system services—the chronically men-tally ill, Congress has passed legislation to en-courage a continuum of services and coordina-tion among agencies. The most recent legislationin this vein is Public Law 99-660, the State Com-prehensive Mental Health Services Plan Act of1986, passed in November 1986. This law author-izes a total of $20 million in grants to States forfiscal years 1987 and 1988 for the developmentof State comprehensive mental health servicesplans and provides direction on the content ofsuch plans. Perhaps most significant, State plansare required to provide for the establishment andimplementation of organized community-basedsystems of care for chronically mentally ill indi-viduals; and to require the provision of case man-agement to each chronically mentally ill individ-ual. The law also expands the focus of the alreadyexisting Federal Community Support Program (inNIMH) to include the homeless chronically men-tally ill.
It is too early to tell, of course, how States willrespond to the new grant program or to what ex-tent the program will affect children. An earlierprogram to encourage the integration of mentalhealth and other services for children, CASSP,was, as is described below, enthusiastically re-sponded to by States. Neither the new programnor CASSP, however, address the needs of chil-dren with mental health problems that are not yetsevere or chronic. The analysis in this backgroundpaper, like analyses of past national commissions,suggests that the needs of such children are urgent.
Child and Adolescent Service System Program
CASSP, administered by NIMH, is a direct re-sponse to the lack of coordination among the set-tings and systems providing services to childrenwith mental health problems. Modeled after theCommunity Support Program for the chronicallymentally ill, CASSP was created by Congress in1984 after repeated findings that because of a lackof coordination among systems of care, the indi-vidual programs designed to assist mentally dis-turbed children were frequently not used. Thegoal of CASSP is to ensure the availability of acomprehensive, coordinated system of care spe-cifically for severely mentally disturbed childrenand adolescents.
Several themes developed earlier in this back-ground paper point to the need for coordinatingmental health and other children’s services. Dis-turbed children often have more than one men-tal health problem (e.g., an attention deficit andreading disorder that become apparent in schoolcombined with aggressive behavior in the neigh-borhood). Many troubled children also have edu-cational, physical, legal, economic, or familyproblems in addition to their mental disturbance.Given the interactions among disturbed children’sproblems, effective intervention often requires theprovision of a variety of multiple mental healthand other services. CASSP was based on the be-lief that coordination among mental health treat-ment and other service systems is necessary to en-sure that severely disturbed children receive allthe services they need, organized into a compre-hensive treatment plan, and timed to achieve op-timal beneficial effects.
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CASSP is designed to improve States’ capaci-ties to offer aid to severely mentally disturbed chil-dren. CASSP assists States in developing systemsof care through planning grants, as well as tech-nical assistance and training. States that receiveCASSP grants are required, initially, to developa child mental health authority and to organizea “coalition” of State agencies whose work affectschildren. Once a comprehensive State-level sys-tem is developed, the goal is to replicate the co-ordination effort at local levels.
It is too early to assess the effectiveness of theCASSP grant program, but the program incor-porates a number of elements of an ideal systemthat have long been discussed. By focusing on theorganization of services, it advances the goals ofplacing children in appropriate settings and hav-ing providers make treatment decisions based onclinical needs rather than on maintaining fiscal sol-vency. CASSP is designed to help States developmechanisms which may differ across localities andavailable resources, and it appears to be an im-portant mechanism to facilitate development ofsuch locally controlled systems of care. As de-scribed in chapter 9 of this background paper,State authorities and NIMH are jointly develop-ing an evaluation of CASSP’s effects.
Research and Training
For research related to children’s mental healthand for training clinical and research professionalsin this area, the Federal Government is virtuallythe only source of funds. With few exceptions,such as the MacArthur Foundation, neither philan-thropic foundations nor individual donors sup-port research or training in the mental health field(309). SMHAs spend very little on research andtraining. Some critics charge that the funds avail-able to support mental health research are inade-quate to take advantage of “exciting” research op-portunities or even to foster rational developmentof the field (309). Research on childhood mentaldisorders is frequently used as a prime exampleof the opportunities that are missed.
Funds for research pertaining to children’s men-tal health are available primarily through NIMH.NIMH research grants are available for a rangeof disciplines, including behavioral science re-
search, clinical research, the neuroscience, phar-macological and somatic treatments, and psycho-social treatments. As shown in table 8, NIMHestimates that roughly $27.2 million was madeavailable in fiscal year 1985 for intramural andextramural research relating to children’s mentalhealth (665). This amount represents 17 percentof NIMH’s research budget (see table 8).
The main direct source of funds for trainingmental health professionals to treat children is theclinical training program of NIMH. Since 1983,congressional appropriations committees have re-quested that NIMH allocate a portion of its clini-cal training funds specifically to mental healthprofessionals who treat underserved populations,including children. Because NIMH has limitedfunds overall and commitments to continue ex-isting training grants, however, the impact on chil-dren’s mental health services has only begun tobe seen.
In fiscal year 1985, NIMH allocated approxi-mately 15 percent of its clinical training funds,or $4.8 million, to training programs dealing atleast in part with children’s mental health issues(see table 8).
A major reason for targeting NIMH clinicaltraining funds to professionals who treat childrenis that there appear to be insufficient numbers ofwell-trained professionals to meet children’s needs.According to 1976 data (109), only 10 percent ofpsychiatrists are specifically trained to treat chil-dren, and less than 1 percent of psychologists pri-marily serve children. According to NIMH data,there are approximately 3,000 child psychiatrists,5,000 clinical child psychologists, 7,000 child andfamily-oriented social workers, and 1,000 child/family-oriented mental health nurses (358). Esti-mates of the numbers of professionals needed haveconsistently been much higher.
Funds for training mental health researchers (asopposed to clinicians) are available through NIMHunder authority of the National Research Serv-ices Awards Act (Public Law 93-348). Althoughthe Institute of Medicine (309) has called for in-creased funding of research training in children’smental health, calling this a “relatively unstudiedarea, ” only $1.1 million for training researcherswas available through NIMH in fiscal year 1984(664).
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Information about the mental health trainingfunds available from agencies other than NIMHis less clear. The Education for All HandicappedChildren Act (Public Law 94-142) includes Fed-eral funding for training special education person-nel, but this training is directed at all handicappingconditions covered under the law. Although it iscertain that funds could be well used for profes-sional development in child welfare, juvenile jus-tice, and education agencies to promote the in-tegration of mental health services with theserelated services, there are currently no major Fed-eral programs to support this kind of integrativetraining.
Prevention and Other Services
A number of Federal programs provide fundsthat may be used to support delivery of mentalhealth treatment or that have a clearly positiveor preventive role in children’s mental health.These include the programs that primarily pro-vide health services, as well as those providingsocial services, nutrition assistance, and direct orindirect financial payments.
The Maternal and Child Health block grant isa Federal program that provides funds to theStates for services to mothers and children, par-ticularly in low-income families. Since adequatehealth care is vital for promoting normal andhealthy development in children, these block grantfunds can play a significant role in the preven-tion of mental illness in children. Medical careproviders who treat children who have no linkwith mental health care providers through theschools or other agencies are often the first to iden-tify emotional or psychological problems thatmay require treatment (see ch. 7).
A Federal program related to the Maternal andChild Health block grant, the Primary Care blockgrant, gives Federal funds directly to communityhealth centers for general health care services tomedically underserved populations. These generalhealth care services provide a measure of preven-tion and screening for mental health problemsaffecting children and their families, and providea point of contact with health care providers. Sim-ilarly, the Preventive Health and Health Servicesblock grant provides Federal funds to States for
a variety of preventive health programs, includ-ing home health services, rape prevention andtreatment services, and demonstration projectsspecifically designed to deter consumption of al-cohol among children and adolescents. Many ofthese programs serve an important preventionfunction for mental disorders.
Three other major Federal support programshave important effects on children’s mental health.The Title XX Social Services block grant providesfunds to States for a wide variety of social serv-ices to children and families, including day care,protective services for children, family planning,adoption, and foster care. These services haveplayed a major role in the promotion of child wel-fare. The Adoption Assistance and Child WelfareAct (Public Law 96-272) funds child welfare serv-ices, foster care, adoption assistance for hard-to-place children (including those who are emotion-ally or intellectually handicapped), and has, ingeneral, been helpful in financing support serv-ices to aid children and families in crisis. ProjectHead Start provides educational, social, health,and nutrition services to low-income preschoolchildren. The long-term effectiveness of HeadStart programs in preventing problems is now wellrecognized (728; also see ch. 9).
Among the other Federal programs that relateto children’s mental health, directly or indirectly,are funding programs designed to enable individ-uals to meet basic health, nutrition, and cost-of-living needs. Such programs include the ChildAbuse Prevention and Treatment Act programs;Victims of Crime Act programs; DevelopmentalDisabilities Assistance and Bill of Rights Act pro-grams; Family Planning programs; the FosterGrandparents Program; the Adolescent FamilyLife Program; the Food Stamp Program; the Sup-plemental Food Program for Women, Infants, andChildren; School Lunch programs; Aid to Fam-ilies with Dependent Children; SupplementalSecurity Income; Child Support Enforcement pro-grams; and income tax deductions for adoptingspecial-needs children. As part of the overall Fed-eral effort relevant to children’s mental health,these programs provide a considerable amount ofassistance. It is not clear, however, that the assis-tance provided by these programs is coordinatedso that individual children are protected. Previ-
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ous analyses (e. g., 358,595), anecdotal evidence, of CASSP and experience under the State Com-and observations of the experts consulted during prehensive Mental Health Services Plan Act willthe preparation of this background paper suggest suggest additional ways in which such coordina-that a coordinated system for providing children’s tion can be implemented.services would be helpful. Perhaps the evaluation
CONCLUSION
It is quite well estabchildren are in need ofboth to treat diagnosable
ished that a great manymental health services—e disorders and to reduce
environmental risk factors (see ch. 2). It is alsoagreed that children’s mental health services needto be based on extensive and sound research;guided by appropriately trained personnel; andsupported by sufficient funds and incentives toencourage coordination among providers, includ-ing those in non-mental-health systems.
Federal, State, local, and private contributionsto provision of mental health services are substan-tial. The gap between the need for children’s serv-ices and the availability of such services, however,implies that even these considerable efforts fallshort of bridging the gap (e.g., 358,359). The men-tal health services available for children appearto be inadequate. In addition, research on chil-dren’s mental health and illness appears to be in-adequately funded.
Although local control of service delivery is be-lieved to be optimal for the necessary case man-agement of children with problems and potentialproblems, and although the private sector couldarrange to provide more and better mental healthservices, it may be that a larger role for the Fed-eral Government is desirable. Such a role couldinclude a statement of principle for mental healthanalogous to that articulated for education in Pub-lic Law 94-142, which mandates that all childrenbe guaranteed a free, appropriate education. Itcould also include increased Federal efforts toeradicate environmental risk factors or reduce
Photo credit: OTA
their impact on children, to continue to promotecoordination of services, and to fund research andtraining in the children’s mental health field.
Appendixes
Appendix A
Workshop Participants andOther Acknowledgments
Workshop on Children’s Mental Health
Leonore Behar, ChairChief of Child Mental Health Services, North Carolina Department of Human Resources
Division
Mark BlotckyTimberlawn HospitalDallas, TXDennis D. Drotar
of Men al Health, Mental Retardation, and Substance Abuse ServicesRaleigh, NC
Judith MeyersPolicy Analyst2
Office of the Governor
Rainbow Babies and Children’s HospitalCleveland, OHSusan GoldsteinDepartment of Child and Family PsychiatryGroup Health AssociationWashington, DCErv JanssenDirector, Children’s DivisionMenninger FoundationTopeka, KSHubert E. JonesDean, School of Social WorkBoston UniversityBoston, MAPatricia KingProfessorGeorgetown Law CenterWashington, DCJane KnitzerDirector, Division of Research, Demonstrations,
and Policyl
Bank Street College of EducationNew York, NYGerald P. KoocherDepartment of PsychiatryChildren’s Hospital Medical CenterBoston, MA
Boston, MAJoseph J. PalombiFamily CounselingFairfax, VAPatricia C. PothierProfessor
Center
University of California, School of NursingSan Francisco, CAJack ShonkoffDepartment of PediatricsUniversity of MassachusettsWorcester, MAJerry WienerChairmanDepartment of Psychiatry
George Washington University Medical SchoolWashington, DCEdward ZiglerDepartment of Psychology
Yale UniversityNew Haven, CT
NIMH LiaisonMichael FishmanAssistant Director for Children and YouthNational Institute of Mental HealthRockville, MD
I F o r m e r l y w i t h t h e B u n t i n g I n s t i t u t e , R a d c l i f f e C o l l e g e , C a m b r i d g e , M A ,‘Formerly Associate Director, Bush Program in Child Development and social PoIIcy, Universit y of Michigan, Ann Arbor, MI
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148
Workshop on Children’s Mental Health Treatment Effectiveness
Anthony BroskowskiExecutive DirectorNorthside Community Mental Health CenterTampa, FLDonald CohenDirector, Child Study CenterYale UniversityNew Haven, CTJohn P. DochertyChief, Psychosocial Treatments Research Branchl
National Institute of Mental HealthRockville, MDMichael E. FishmanAssociate Director for Children and YouthNational Institute of Mental HealthRockville, MD
Alan E. KazdinProfessor of Psychiatry and PsychologyWestern Psychiatric Institute and ClinicPittsburgh, PAIra LourieDirector, Child and Adolescent Service System
ProgramNational Institute of Mental HealthRockville, MDNatalie ReatigPharmacologic and Somatic Treatments Research
BranchNational Institute of Mental HealthRockville, MD
INo longer with NIMH.
Acknowledgments
OTA would like to thank the following people for their assistance in the development of this backgroundpaper.
Richard BrunstetterNational Institute of Mental HealthRockville, MDLana BuckNational Association of Private Psychiatric
HospitalsWashington, DCBarbara BurnsNational Institute of Mental HealthRockville, MDAnne CopelandBoston UniversityBoston, MAMary CrosbyAmerican Academy of Child and Adolescent
PsychiatryWashington, DCPhyllis Old Dog CrossIndian Health ServiceRapid City, SD
Michelle FineUniversity of PennsylvaniaPhiladelphia, PAJudith GardnerBoston, MAEllen Greenberg GarrisonAmerican Psychological AssociationWashington, DCHoward GoldmanNational Institute of Mental HealthRockville, MDDennis C. HarperUniversity of IowaIowa City, IAVictor IndrisanoOffice of U.S. Rep. Edward R. RoybalWashington, DCJoseph JacobsBureau of Health Care Delivery and AssistanceU.S. Public Health Service
Felton Earls Rockville, MDWashington University School of Medicine Judith JacobsSt. Louis, MO National InstituteGlen Elliott Rockville, MDStanford UniversityStanford, CA
of Mental Health
149
Phyllis A. KatzInstitute for Research on Social ProblemsBoulder, COJudith Katz-LeavyNational Institute of Mental HealthRockville, MDSamuel C. KlagsbrunFour Winds HospitalKatohah, NYLt. Col. Melvin KolbOffice of the Civilian Health and Medical Program
of the Uniformed ServicesAurora, CORichard KrugmanNational Center for Child AbuseDenver, COSidney S. LeeMilbank Memorial FundNew York, NYBeryce W. MacLennanU.S. General Accounting OfficeWashington, DCNoel MazadeNoel Mazade & Associates, Inc.Garrett Park, MDIrving PhilipsUniversity of CaliforniaSan Francisco, CACornelia PorterOffice of Senator Daniel K. InouyeWashington, DCPaul PosnerU.S. General Accounting OfficeWashington, DCLenore RadloffNational Institute of Mental HealthRockville, MDMason RussellPolicy AnalysisBrookline, MAJack SarmanianAdult/Adolescent Counseling, Inc.Maiden, MA
Larry SilverNational Institute of Mental HealthRockville, MDMorton SilvermanNational InstituteRockville, MDCarl R. SmithIowa DepartmentDes Moines, IAAlbert J. SolnitYale UniversityNew Haven, CTFredric Solomon
of Mental Health
of Public Instruction
Institute of MedicineWashington, DCBrian StablerAmerican Psychological AssociationWashington, DCBonnie StricklandUniversity of MassachusettsAmherst, MASusan Thompson-HoffmanU.S. Department of EducationWashington, DCCarl TishlerColumbus, OHGail ToffIntergovernmental Health Policy ProjectWashington, DCJudith L. WagnerOffice of Technology AssessmentWashington, DCTed WagnerU.S. General Accounting OfficeWashington, DCKathleen WellsBellefaireCleveland, OHDiana ZuckermanSubcommittee on Intergovernmental Relations and
Human ResourcesHouse Government Operations CommitteeWashington, DC
Appendix B
List of Acronyms and Glossary of Terms
List of Acronyms
ADAMHA –Alcohol, Drug Abuse, and Mental HealthAdministration (DHHS)
ADM –Alcohol, Drug Abuse, and Mental Health(block grant)
CASSP —Child and Adolescent Service SystemProgram (NIMH)
CDF —Children’s Defense FundCHAMPUS —Civilian Health and Medical Program
CMHCCOBRA
DHEW
DHHS
DISC
DODDRGDSM-III
EPSDT
FSCPGAO
LOS
of the Uniformed Services—community mental health center—Consolidated Omnibus Budget Recon-
ciliation Act—U.S. Department of Health, Education,
and Welfare (now DHHS)—U.S. Department of Health and Human
Services—Diagnostic Interview Schedule for
Children—U.S. Department of Defense—diagnosis-related group—Diagnostic and Statistical Manual, 3rd
ed.—Early and Periodic Screening, Diagno-
sis, and Treatment program (Medicaid)—Family Support Center Program–General Accounting Office (U.S.
Congress)—length of stay
NASMHPD—Na;ional Association of State MentalHealth Program Directors
NIMH –National Institute of Mental Health(ADAMHA)
OTA –Office of Technology Assessment (U.S.Congress)
PDD —pervasive developmental disorderRTC —residential treatment center for emo-
tionally disturbed childrenSDD —specific developmental disorderSMHA —State Mental Health Agency
Glossary of TermsAdjustment disorder: A type of mental disorder
defined by DSM-III as “a maladaptive reaction toan identifiable psychosocial stressor that occurswithin three months of the onset of the stressor. ”Adjustment disorders are manifest in impaired func-tioning or in excessive reactions to the stressor,symptoms which typically remit after the stressor
ceases or, if the stressor continues, when a new levelof adaptive functioning is achieved.
Aftercare: Mental health services provided after theindividual’s initial encounter with the mental healthcare system (e. g., RTC treatment after psychiatrichospitalization).
Anorexia nervosa: A mental disorder characterized byintense fear of becoming obese, disturbance of bodyimage, significant weight loss (accounted for by noknown physical disorder), refusal to maintain aminimal normal body weight, and the absence ofmenstruation in females.
Anxiety disorders: A category of mental health dis-orders characterized by a child’s intense feelings ofapprehension, tension, or uneasiness. These feelingsmay result from the anticipation of danger, eitherinternal or external. Anxiety is manifested by phys-iological changes such as sweating, tremor, andrapid pulse. Such disorders include phobic disor-ders, obsessive compulsive disorders, and post-traumatic stress disorders, as well as “generalizedanxiety disorders. ”
Behavior disorders: A set of childhood-onset mentaldisorders characterized by behavior that disturbsor harms the patient or others and which causesdistress or disability. Such disorders include atten-tion deficit disorder and conduct disorder.
Behavioral therapy: Psychotherapy based on theassumption that a child learns persistent pathologi-cal behavior from his or her experience with thesocial environment. Therapists using behavioraltechniques systematically analyze the child’s prob-lem and environment and seek to change specificproblem behavior by altering the child’s envi-ronment.
Bulimia: A mental disorder characterized by bingeeating accompanied by an awareness that the eatingpattern is abnormal, fear of not being able to stopeating voluntarily, and depressed mood and self-deprecating thoughts following the eating binges.Binges are usually terminated temporarily by abdomi-nal pain, sleep, social interruption, or inducedvomiting.
Cognitive therapy: Psychotherapy based on a viewthat mental health problems should be treatedthrough altering the way children think about theirbehavior and their environments. Therapists at-tempt to change the thinking that takes place duringa child’s troublesome behavior and/or try to in-fluence how children think about themselves andothers.
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Community mental health centers (CMHCs): Pro-grams initially established by the Federal Govern-ment through the Community Mental Health Cen-ters Act of 1963, to provide comprehensive mentalhealth services to all residents of a specified geo-graphic area regardless of their ability to pay. Withthe passage of the Alcohol, Drug Abuse, and MentalHealth block grant, federally funded CMHCs ceasedto exist as legal entities, but Federal funds continueto be provided indirectly via State Mental HealthAgencies.
Continuum of care: A coordinated system to providecomprehensive children’s mental health care at alllevels needed.
Day treatment/partial hospitalization: Mental healthtreatment programs that provide extended care tochildren who do not need 24-hour treatment but dorequire more intensive treatment than 1 or 2 hoursa week of therapy. One form of day treatment,partial hospitalization, arranges care for childrenwho need the treatment offered in a psychiatric hos-pital during the day but are able to return home inthe evening,
Developmental disorders: A set of mental disorderscharacterized by deviations from the normal pathof child development. Such disorders may be per-vasive, thereby affecting multiple areas of develop-ment (e. g., autism), or specific, affecting only oneaspect of development (e. g., arithmetic disorder).
Diagnostic Interview Schedule for Children (DISC):A child-oriented version of the Diagnostic InterviewSchedule, a questionnaire developed for use by theNational Institute of Mental Health for its epidemio-logic catchment area survey of mental disability inadults.
Eating disorders: Psychophysiological disorders char-acterized by disturbances in eating. Such disordersinclude anorexia nervosa and bulimia.
Emotional disorders: Mental disorders characterizedby the presence of an emotional problem and con-siderable impairment of a child’s ability to function.Such disorders include anxiety and childhood de-pression.
Encopresis: A psychophysiological disorder character-ized by defecation at inappropriate times.
Enuresis: A psychophysiological disorder character-ized by involuntary bedwetting or other lack ofcontrol over urination.
Family therapy: A type of psychotherapy based on theidea that a child’s problems are manifestations ofdisturbed interactions within a family rather thanproblems that lie within the child alone. Treatmentheavily involves other family members as well asthe child (e.g., in sessions attended by the entire
family) because it is believed that a child cannotchange if the family as a whole does not change.
Group therapy: A type of psychotherapy in which thefocus is on helping individuals develop healthierways of relating to other people, although therapygroups serve other purposes.
Inpatient treatment: Provision of mental health serv-ices to persons staying in a hospital overnight.
Integration of services: The establishment of inter-relationships among mental health and other servicesystems (e. g., the educational, health care, welfare,and juvenile justice systems) so that programs toprevent mental health problems can be offered,children in need of mental health services can beidentified, and mental health treatment can be pro-vided at the site where problems are identified.
Length of stay (LOS): The number of days betweenthe date of admission to a health care facility andthe discharge date.
Mental disorder: In this background paper, any of thediagnoses classified as mental disorders by theAmerican Psychiatric Association in the Diagnos-tic and Statistical Manual of Mental Disorders(DSM-III). Generally, DSM-III defines a mental dis-order as a clinically significant behavioral or psy-chological syndrome or pattern that occurs in anindividual and that is typically associated with ei-ther a painful symptom (distress) or impairment inone or more areas of functioning (disability).
Mental health problem: In this background paper, ei-ther a mental disorder or more general subclinicalproblem affecting mental health but not meeting thecriteria for a diagnosable mental disorder.
Mental health services: Any of the wide range ofservices designed to meet mental health needs butprimarily including therapies and preventiontechniques.
Neuroleptics: Any drug (e.g., certain tranquilizers)used to reduce psychotic behavior.
Neurosis: Currently, there is no consensus in themental health field as to the definition of neurosis,and the category neuroses was not included inDSM-III although it had been included in previousDiagnostic and Statistical Manuals. The termneurosis is usually used to refer to emotionaldisorders caused by unconscious conflict and char-acterized chiefly by anxiety.
Outpatient treatment: Provision of mental healthservices on an ambulatory basis to persons who donot require 24-hour or partial hospitalization.Settings for outpatient treatment include commu-nity mental health centers and private mental healthpractices.
Primary prevention: Efforts to avert mental health
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problems altogether. For children, these effortsinclude interventions directed at parents and edu-cators.
Private psychiatric hospital: A hospital operated pri-vately by individuals, partnerships, corporations,or nonprofit organizations, primarily for the careof persons with serious mental disorders.
Psychodynamic therapy: Psychotherapy based on thetheory that changes in cognition and emotions willbe followed by changes in behavior.
Psychopharmacological therapy: Therapy involvingthe use of psychoactive medications such as stimu-lants, antidepressants, or neuroleptics.
Psychophysiological disorders: Mental health disor-ders that involve a disturbance in some aspect ofbodily functioning usually involving a combinationof mental and physical factors. Such disordersinclude stereotyped movement disorders; eatingdisorders such as anorexia and bulimia; and enuresisand encopresis.
Residential treatment center (RTC): A residential fa-cility, not licensed as a psychiatric hospital, whoseprimary purpose is the provision of individuallyplanned programs of mental health treatmentservices in conjunction with residential care forchildren and youths primarily under the age of 18.The term used by NIMH is “residential treatmentcenters for emotionally disturbed children, ” butchildren with other mental disorders are also treatedin these facilities.
Secondary prevention: Efforts to detect mental healthproblems in their early stages of development andto apply techniques to reduce the severity andduration of incipient problems.
State and county mental hospital: A psychiatric hos-pital that is under the auspices of a State or countygovernment, or operated jointly by both a State andcounty government.
State Mental Health Agencies (SMHAs): Agenciesunder the auspices of State governments, staffedthrough the State, and offering mental healthservices to State residents in need of mental healthcare. State mental health agencies may superviseState mental hospitals, CMHCs, RTCs, and/or daytreatment facilities.
Stereotyped movement disorders: Psychophysiologicaldisorders characterized by involuntary movementsof bodily parts (i. e., tics).
Substance use/abuse disorders: A set of mentaldisorders characterized by maladaptive behavioralchanges resulting from regular use of substancesthat affect the central nervous system. Substanceuse and abuse disorders are not classified as child-hood-onset mental disorders by DSM-III, butchildren can be afflicted by them.
Tertiary prevention: Attempts to arrest further dete-rioration in individuals ‘who already suffer fromsevere mental health problems (disorders).Treatment can be considered tertiary prevention.The term is not used in this background paper.
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