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National estimates of child mental health difficulties and service use: A public health approach. Anna K. Falkenstern Maternal and Child Health Leadership Development Team April 1, 2005. Objectives. To frame children’s mental health (MH) problems as a public health issue

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National estimates of child mental health difficulties and service use:

A public health approach

Anna K. Falkenstern

Maternal and Child Health Leadership Development Team

April 1, 2005

objectives
Objectives
  • To frame children’s mental health (MH) problems as a public health issue
  • To describe the strengths and challenges of studying child psychiatric epidemiology
  • To examine the prevalence of child MH difficulties in major sociodemographic subgroups
  • To describe use of MH services among children with MH difficulties in a national sample
statement of the problem
Statement of the problem
  • One in five children meet criteria for a mental health (MH) disorder
  • 5% experience serious functional impairment
  • MH disorders often undetected and untreated
  • “No other illnesses damage so many children so seriously”-National Advisory MH Council’s Workgroup on Child and Adolescent MH
impact of unmet mh needs
Impact of unmet MH needs
  • Impaired functioning with family, school and peers
    • School drop out
    • Criminal activity
    • Suicide
    • Long-term MH and substance abuse problems
  • Additional social costs
    • Hospital and medical expenditures
    • Lost productivity
psychiatric epidemiology challenges
Psychiatric epidemiology: Challenges
  • Population-based measurement of MH
    • Time
    • Cost
    • Measurement error
    • Symptoms versus diagnosis
  • Lack of national epidemiological data
    • Limited to clinic-based or community samples
measuring child mh problems challenges
Measuring child MH problems: Challenges
  • Varying rates of childhood development
  • Criteria based on adults
  • Parental recognition and perceived burden
  • Stigma and fears about labeling
  • Multiple services and settings
child mh and public policy
Child MH and public policy
  • US Surgeon General’s Children MH Action Agenda (2000): Increase access and coordination of quality MH services
  • President’s New Freedom Commission on Mental Health (2003): Eliminate disparities in the use of MH services
  • National health surveys may provide useful data for developing policies to improve services
methods
Methods
  • National Health Interview Survey (NHIS)
    • Annual, nationally representative
    • Civilian, noninstitutionalized U.S. population
    • In-personinterviews with a knowledgeable adult family member, usually a parent
  • Study sample:
    • Children 4-17 years of age
    • 2001-2003 NHIS child sample n=28,476
conceptual framework
Conceptual framework*

Predisposing

Factors

Biology

Demographic

Health beliefs

Need

Mental health

difficulties

External

Environment

Physical

Social

Political

Economic

Health care

system

Policy

Resources

Organization

Enabling

Resources

Family

Community

Use of health

Services

Mental health

services

*Adapted from Anderson (1995)

independent variables
Independent variables
  • Predisposing factors: Demographics
    • Age
    • Sex
    • Race/ethnicity
  • Enabling resources: Health insurance
    • None, public, private insurance
need mh difficulties
Need: MH difficulties
  • Question from the Strengths and Difficulties Questionnaire (Goodman, 1994)

“Overall, do you think that (sample child) has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?”

  • Response categories-Severe, definite, minor, or no difficulties
outcome mh service use
Outcome: MH service use
  • MH professional
  • General doctor
  • Special Education
estimation and analysis procedures
Estimation and analysis procedures
  • Sample data weighted
  • Standard errors calculated with SUDAAN
  • Chi square tests and pairwise t tests
  • Odds ratios adjusted for confounders
  • Results are preliminary-please do not cite
prevalence of mh difficulties
Prevalence of MH difficulties

Overall: 5% of children (2.8 million) had definite/severe difficulties

Age: Percentage of children with difficulties increased with age

Sex: Boys were twice as likely as girls to have difficulties (6.6% vs. 3.5%)

prevalence of mh difficulties1
Prevalence of MH difficulties

Race/ethnicity: Hispanic children were less likely to have reports of difficulties than NH white or NH black children

Health insurance: Children with public health insurance were more likely to have difficulties than uninsured children or children with private insurance

mh service use among children with mh difficulties
MH service use among childrenwith MH difficulties
  • 62% used at least one type of MH service:
    • 45% had contact with a MH professional
    • 39% had contact with a general doctor
    • 28% received special education
  • Use of services varied by sociodemographic factors
adjusted 1 odds ratio of use of mh services age
Adjusted1 odds ratio of use of MH services: Age

1Adjusted for child’s sex, race/ethnicity, family structure, health insurance, and residential location

adjusted 1 odds ratio of use of mh services sex
Adjusted1 odds ratio of use of MH services: Sex

1Adjusted for child’s age, race/ethnicity, family structure, health insurance, and residential location

adjusted 1 odds ratio of use of mh services race ethnicity
Adjusted1 odds ratio of use of MH services: Race/ethnicity

NH – non-Hispanic

1Adjusted for child’s sex, age, family structure, health insurance, and residential location

adjusted 1 odds ratio of use of mh services health insurance
Adjusted1 odds ratio of use of MH services: Health insurance

1Adjusted for child’s sex, age, race/ethnicity, family structure, and residential location

social work role
Social work role

Multi-level Interventions:

  • Micro: Individual and family practice
    • Case management and psychotherapy
    • Focus on prevention and early identification
  • Macro: Policy development and advocacy
    • Mental health parity and coordination of services
    • Coordination of systems of care
    • Integration of policy, research, and practice
study limitations
Study limitations
  • Based on parental report at a single point in time
  • Measures based on single questions
  • Only current health insurance was assessed
  • Institutionalized population not included
conclusion key points
Conclusion: Key points
  • A substantial portion of children with MH difficulties do not receive MH services
  • Independent differences in MH service use by health insurance, age, sex, and race/ethnicity
  • Public health insurance and school services reduce barriers to MH care
  • National epidemiological data can inform MH policy analysis and planning
additional information
Additional Information
  • The National Health Interview Survey (NHIS): http://www.cdc.gov/nchs/nhis.htm
  • Strengths and Difficulties Questionnaire: www.sdqinfo.com
  • America's Children, a publication of the Federal Interagency Forum on Child and Family Statistics: http://childstats.gov
acknowledgements
Acknowledgements
  • Patricia Pastor, PhD, Cynthia Reuben, MA, and Susan Lukacs, MD, National Center for Health Statistics, Centers for Disease Control and Prevention