# Presentation: 698946

## The Influence of Childhood Trauma on Public Mental Health Service Use and Expenditures:  Preliminary Findings

-  James T. Yoe, Ph.D.
- Julia R. Burns, M.S.W.
- Sapna Linus, M.S.
- Mary Auslander, M.S.W.
- Paper Presented at the Fourteenth Annual Conference on State Mental Health Agency Services Research,
- Program Evaluation, and Policy
- Arlington, Virginia
- February 9, 2004

## Study Goals

- To investigate the extent to which the history of childhood trauma influences public mental health service use and expenditures for children and youth experiencing serious emotional and behavioral challenges.
- To describe and compare the demographic and functional characteristics of the children/youth in the trauma experience and non-trauma experience groups.

## Study Hypotheses

**As a result of their life experiences and lack of trauma informed service alternatives, children and youth who have experienced trauma will:**
- experience more acute mental health episodes requiring greater use of high cost psychiatric inpatient, crisis stabilization, and residential treatment services;
- require and use more public behavioral health services and supports;
- exhibit more complex clinical profiles, including greater co-occurring substance abuse, medical, and developmental challenges; more behaviors that place them at risk of harm; and experience higher levels of environmental stress and lower levels of support;
- exhibit greater functional-behavioral challenges.

## Study Sample Selection Criteria

- Sample of 492 children and adolescents enrolled in Targeted Case Management Services in FY 2000 and FY 2001
- The study sample was divided into two groups: an identified trauma experience group (n= 227) and a non-trauma experience group (n=265)
- All study participants were enrolled in targeted case management services for at least 12 months with functional/behavioral assessments completed at baseline, 6 months, and 12 months.
- All study participants were active Medicaid Service recipients with at least some behavioral health service use during FY 2000 or FY 2001.

## Study Criteria: Identification of Previous Trauma Experience

- Trauma relevant diagnosis:
- Prolonged Post Traumatic Stress
- Acute Reaction to Stress
- Child Abuse
- Child Maltreatment
- Child Sexual Abuse
- or
- Child Welfare Involvement
- Child Protective Services
- Substitute Care Services

## Study Data Sources and Measures

**Service Utilization: Medicaid Service Claims**:
- Targeted Case Management (Average Expenditures FY 2000 and FY2001)
- In-Home Behavioral Services (Average Expenditures FY 2000 and FY2001)
- Inpatient Psychiatric Hospital (Annual days spent in Inpatient Psychiatric Setting & Average expenditures FY 2000 and FY2001)
- Outpatient Clinical Services (Average Expenditures FY 2000 and FY2001)
- Medication Management (Average Expenditures FY 2000 and FY2001)
- Mental Health Medications (Average Expenditures FY 2000 and FY2001)
- Residential Treatment (Average Expenditures FY 2000 and FY2001)
- Total Behavioral Health Services (Average Expenditures FY 2000 and FY2001)

## Study Data Sources and Measures (Continued)

**Functional/Behavioral Outcomes:**
**Child and Adolescent Functional Assessment Scale (CAFAS-Hodges, 2000)**
- Assessments completed at Baseline, Six months, and 12 months
- Ratings based on 4-point scale: 30-Severe Impairment; 20-Moderate Impairment; 10-Mild Impairment; 0-Minimal or No Impairment.
- Higher scores reflect greater degree of challenge.
- Completed by case manager/clinician based on knowledge of child and family.
**CAFAS Domains:**
- School/Work
- Home
- Community
- Behavior Toward Others
- Mood/Emotions
- Self-Harmful Behavior
- Substance Use
- Thinking
- Total Youth Functioning Score

## Study Data Sources and Measures (Continued)

**Functional/Behavioral Outcomes:**
**Child and Adolescent Level of Care Utilization System (CALOCUS; Klaehn, O’Malley, Vaugan & Kroeger, 2003)**
- Assessments completed at Baseline, Six months, and 12 months
- Rating based on 5-point scale with higher scores reflecting greater degree of challenge in a particular domain.
- Assessments completed by case manager/clinician based on knowledge of child and family.
**CALOCUS Domains:**
- Risk of Harm
- Functional Status
- Co-Occurring Conditions (Co-Morbidity)
- Recovery Environment
- Environmental Stress
- Environmental Support
- Resiliency and Treatment History
- Child Acceptance and Engagement
- Caregiver Acceptance and Engagement
**Total Composite Score**

## Study Data Sources and Measures (Continued)

**Child & Adolescent Characteristics**:
- Child Age at Baseline
- Diagnostic Category – (Conduct – Behavioral Disorders vs Emotional-Mood Disorders)
- Child Gender

## Full Study Sample Characteristics N=492

**Gender: ****	****	****	****	**69%** **Male
**Age:  **Average Age  12.19 Years: Range: 6 to 18 Years
**Diagnostic Category:**
** **Behavioral/Conduct Related Disorders	 41.5%
** **Emotional/Mood Related Disorders	 58.5%
**Baseline Level of Functional Challenge**
- Average CAFAS Youth Score at Baseline: 	  87.42
**Inpatient Psychiatric Hospitalizations**
- Percent Hospitalized	**	****	****  **26.6%
- Annual Days Hospitalized	 	  12.57

## Sample Characteristics: Comparison of Trauma and Non-Trauma Groups

- 				 **Trauma****	****	****Non-Trauma**
**Gender**
**	**Female		   32.6%		      29.8%
- 	Male			   67.4%	     	      70.2%
**Age at Baseline *****	****	****   **11.78 Years	      12.54 Years
**Psychiatric Hospitalizations**
**	**Percent Hospitalized *	    31.3%		       22.6%
- 	Annual Days Hospitalized *	    15.81		        9.34
**Diagnostic Category**
**	**Conduct/Behavioral	    40.5%**	****	****       **42.3%
- 	Emotional/Mood Related	    59.5%		       57.7%
**Level of Functional Challenge**
**	**Total Youth Score (Baseline)	     88.15		       86.79
**	**

- * p<.05

## Comparison of Behavioral/Functional Profiles Between Trauma and Non-Trauma Groups: CALOCUS Subscales

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- + Groups differ significantly, p<.05

## Comparison of Behavioral/Functional Profiles Between Trauma and Non-Trauma Groups: CAFAS Subscales

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- + Groups differ significantly, p<.05

## Annual Medicaid Expenditure Measures

- Based on average per child expenditures for two year period: Fiscal Years 2000 and 2001;
- Includes: all behavioral health service expenditures:
- Targeted Case Management;
- In-home Behavioral Services;
- Inpatient Psychiatric Hospital;
- Residential Treatment;
- Outpatient-Clinical Services;
- Medication Management Services;
- Mental Health Pharmacy;
- Day Treatment;
- Home-based Family Services:
- Substance Abuse Treatment;
- Community Support Services;
- Total Behavioral Health Expenditures

## Annual Expenditure Analysis Issues

**Analysis Issues & Challenges**
- For a number of service categories, the sample includes many children with no service use and no expenditures;
- Sample includes children who had some service expenditures in FY 2000 or FY 2001 but may include children with no expenditures in a particular service area for a given year;
- Sample may include small numbers of children with extremely high expenditures (outliers);
- These issues result in extremely skewed – non-normal distributions for expenditure variables.
**Statistical Approach**
- Construct average per child, two-year expenditure variables for each service category & total expenditures;
- Construct per child service use variables for each service category.  A child was counted as using a service if they used any amount of a particular service in either FY2000 or FY2001;
- Used log-normal transformation to normalize service expenditure distributions;
- Student T-Tests conducted on log-transformed variables to assess expenditure differences between Trauma and Non-Trauma groups**.**

## Comparison of Mental Health Service Use Between Trauma and Non-Trauma Groups

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## Comparison of Average Medicaid Service Expenditures per Youth between Trauma and Non-Trauma Groups For FY2000 & FY 2001

|      Service Area | Trauma  
(N=227) |    Non-Trauma (N=265) |     Full Sample
(N=492) |
| --- | --- | --- | --- |
| Targeted Case Management ** | $3437.97 | $2958.43 | $3182.35 |
| Outpatient Clinical Services | $312.71 | $308.98 | $310.45 |
| Day Treatment  | $5565.12 | $3230.74 | $4527.61 |
| Medication Management * | $700.86 | $671.07 | $686.69 |
| Behavioral Health Medication  | $1339.08 | $1440.74 | $1393.94 |
| Crisis Intervention Services * | $1455.20 | $1126.45 | $1298.03 |
| Substance Abuse Treatment  | $446.50 | $385.98 | $414.39 |
| Inpatient Psychiatric * | $38,369.32 | $32,398.09 | $35,635.40 |
| Residential Treatment ** | $19,119.09 | $14,387.47 | $16,991.69 |
| Home Based Services | $2230.11 | $2101.18 | $2170.17 |
| In-Home Behavioral Health Services | $6283.61 | $6261.97 | $6272.51 |
| Community Support Services | $751.47 | $711.13 | $731.97 |
| Total Behavioral Health Expenditures  **
* p<.05; ** p<.01 | $29,129.97 | $20,331.84 | $24,431.59
 |

## Summary of Results

**Service Use and Expenditures:**
**	****Children and youth who have experienced trauma:**
- Had significantly higher mental health service expenditures overall;
- Were more likely to use and received more high-end mental health services, including: inpatient psychiatric hospitalization, residential treatment, and crisis intervention services at higher cost;
- Used more Targeted Case Management services at higher cost; and
- Were more likely to use and received more outpatient-clinical and medication management services at higher cost;
- 		**Than children and youth without a trauma history**** **
- The groups did not differ in service use and expenditures in the following service categories
- Substance Abuse Tx Services
- Home-Based Family Services
- Day Treatment
- Community Support Services
- Behavioral Health Pharmacy
- In-Home Behavioral Health Services

## Summary of Results (Continued)

**Study Sample Differences: Child Descriptive and Behavioral/Functional Characteristics**
**	****Children and youth who have experienced trauma were:**
- younger;
- rated at significantly higher Risk of Harm (as measured by the CALOCUS);
- less likely to experience serious co-occurring (medical, substance use, or developmental) challenges (as measured by the CALOCUS) (likely due to younger age and higher substance use in non-trauma group);
- more likely to experience higher-levels of environmental stress and have fewer supports;
- Rated as having greater challenges in engaging and working with their case manager;
- More likely to have challenging to engage caregivers; and
- Less likely to experience challenges with substance use (likely due to younger age of trauma group)
- 		 **Than children and youth without a trauma history **
- The groups (trauma, non-trauma) were not found to differ in their overall level of functional challenges as measured by the CAFAS Total Youth Score or on any of the CAFAS functional domains other than substance use.
- The groups did not differ in level of challenges experienced in overall functioning or resiliency & treatment history as measured by the CALOCUS.

## Study Limitations and Next Steps

**Study Limitations**
- Included only behavioral health related Medicaid expenditures;
- Focus on high-end user sample of children in Targeted Case Management limits generalizability of findings beyond this Group;
- Indirect means of trauma identification based on diagnostic and child welfare involvement likely over identifies trauma and does not allow for examination of the type and nature of traumatic experiences encountered by the Trauma group.
**Next Steps**
- Incorporate all Medicaid health-related and child welfare related service claims to better assess overall public treatment costs;
- Develop models to assess predictors of high service use and costs;
- Examine behavioral-functional change overtime for Trauma vs Non-Trauma identified groups.
- Examine change in service use and expenditures for Trauma versus Non-Trauma groups over three years.

## Study Conclusions

- The results of this study indicate that children who experience trauma are more likely to use and use more public mental health services overall, and more restrictive and high-cost system services, including: inpatient hospitalization, residential treatment and crisis intervention services.
- These findings suggest that when service systems do not appropriately assess, identify, and effectively address the underlying trauma-related needs of these children and families, the result is greater use of expensive and often ineffective services that are likely to be overwhelming to the child and family, lead to re-traumatizing experiences for the child, and may contribute to poor treatment outcomes.