Children's Mental Health: Problems and

Services

December 1986

NTIS order #PB87-207486
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Children’s Mental Health: Problems and

Services-A Background Paper, OTA-BP-H-33 (Washington, DC: U.S. Government Printing Office, December 1986).

Library of Congress Catalog Card Number 86-600539

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, DC 20402
Foreword

Within the past several

dren have been the focus of

years, several

congressional

important mental health problems of chilattention. The incidence of adolescent suicide, 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 debate on the need for an appropriateness of mental health services. This background

paper indicates that although there are no simple answers to when and what type of

mental health services are necessary, the need for a mental health system response, coordinated with activities of other service systems, seems well documented.

This background paper was requested by Senators Mark O. Hatfield and Daniel

K. Inouye through the Senate Appropriations Committee. Its development was guided

by a panel of experts chaired by Dr. Lenore Behar. The key contractor was Dr. Leonard

Saxe and his colleagues at Boston University. Key OTA staff for the background paper

were Denise Dougherty and Kerry Kemp.

 JOHN H. GIBBONS

Director

i l l
OTA Project Staff—Children’s Mental Health: Problems and Services

Roger C. Herdman, Assistant Director, OTA

Health 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, with

Theodore 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Organization of This Background Paper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Summary and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Children’s Mental Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Children’s Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Effectiveness of Mental Health Treatment and Preventive Services . . . . . . . 8

Current Federal Efforts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Part I: Earlier Evaluations and the Current Situation

Chapter 2. Earlier Evaluations and the Current Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Earlier Evaluations of Children’s Mental Health Needs and Services . . . . . . . 17

Estimates of the Prevalence of Children’s Mental Health Problems . . . . . . . 17

Recommendations About Mental Health Services for Children . . . . . . . . . . 19

The Current Availability and Use of Children’s Mental Health Services . . . 24

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

PartII: Problems

Chapter3. DSM-III Mental Disorders in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

The DSM-111 Diagnostic System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Intellectual Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Developmental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Pervasive Developmental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Specific Developmental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Behavior Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Attention Deficit Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Conduct Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Substance Abuse and Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Emotional Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Childhood Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Reactive Attachment Disorder of Infancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Psychophysiological Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Stereotyped Movement Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . ..., . . . . . 44

Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Enuresis and Encopresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Adjustment Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Chapter 4. Environmental Risk Factors and Children’s Mental Health Problems . . . . . . . 49

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Interactions Among Environmental Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . .50

Poverty and Membership in a Minority Ethnic Group . . . . . . . . . . . . . . . . . . . 50

Parental Psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Affectively Disordered Parent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Schizophrenic Parent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Alcoholic Parent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Physical Abuse and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Teenage Parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Premature Birth and Low Birthweight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Contents—continued

Page

Parental Divorce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5$

Major Physical Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Part III: Services

Chapter 5. Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Individual Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Psychodynamic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Behavioral Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Cognitive Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Group and Family Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Group Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Family Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Milieu Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Crisis Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Psychopharmacological (Drug) Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Neuroleptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Chapter 6. Treatment Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Psychiatric Hospitalization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

State and County Mental Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Private Psychiatric Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Children’s Psychiatric Hospitals and Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Chemical Dependency Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

General Hospitals With Inpatient Psychiatric Services . . . . . . . . . . . . . . . . . . 82

Residential Treatment Centers (RTCs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Day Treatment/Partial Hospitalization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Outpatient Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

CMHC Outpatient Departments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Private Outpatient Clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Private Mental Health Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Chapter 7. Treatment in Non-Mental-Health Systems, Prevention, and the Integration

of Mental Health and Other Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Children’s Mental Health Treatment in Non-Mental-Health Systems . . . . . . . 89

Treatment in the Educational System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Treatment in the General Health Care System . . . . . . . . . . . . . . . . . . . . . . . 91

Treatment in the Child Welfare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Treatment in the Juvenile Justice System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Prevention of Children’s Mental Health Problems . . . . . . . . . . . . . . . . . . . . . . . 93

Primary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Secondary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Integration of Mental Health and Other Services . . . . . . . . . . . . . . . . . . . . . . . . 96

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Part IV: Effectiveness of Services

Chapter 8. Effectiveness of Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........103

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..............103

Effectiveness of Child Psychotherapy in General and Methodological Issues 103
Contents—continued

Page

Reviews of Child Psychotherapy Outcome Research . . . . . . . . . . . . . . . . . . .104

Methodological Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .105

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...................106

Effectiveness of Specific Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..., ....106

Effectiveness of Individual Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . .......106

Effectiveness of Group Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Effectiveness of Family Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....110

Effectiveness of Crisis Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . .......111

Effectiveness of Psychopharmacological (Drug) Therapy. . ..............111

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..........113

Chapter 9. Effectiveness of Treatment and Prevention in Mental Health and Other

Settings, and Evaluating the Integration of Mental Health and

Other Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....................117

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....117

Effectiveness of Treatment in Selected Mental Health Treatment Settings ...117

Effectiveness of Psychiatric Hospitalization . . . . . . . . . . . . . . . . . . . . . ......118

Effectiveness of Residential Treatment Centers . . . . . . . . . . . . . . . . . . . . ....119

Effectiveness of Day Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ...120

Effectiveness of Treatment in Selected Non-Mental-Health Systems . .......121

Effectiveness of Treatment in the Educational System . . . . . . . . . . . . . . . ...121

Effectiveness of Treatment in the Juvenile Justice System ., .............121

Effectiveness of Selected Prevention Efforts . ............................122

Effectiveness of Selected Primary Prevention Efforts . ..................122

Effectiveness of Selected Secondary Prevention Efforts . ................125

Summary: Effectiveness of Prevention . . . . . . . . . . . . . . . . . . ............125

Evaluating the Integration of Mental Health and Other Services. . . . . . . . ...126

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............126

Part V: Current Federal Efforts

Chapter 10.Current Federal Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............131

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...131

Federal Programs That Support Mental Health and Related Services for

Children . . . . . . . . . . . . . . . . . . . . . . . . ................................131

Financing of Mental Health Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . .. ...131

Coordination of Services. . . . . . . . . . . . . . . . . . . . . . . . . . ..................140

Research and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....141

Prevention and Other Services. . . . . . . . . . . . . . . . . . . . . . .................142

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................143

Appendix 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Mental Health Services for Children: Selected Findings and Recommendations of

Past National Study Panels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Admissions of Children Under 18 Years of Age to Hospital Inpatient Psychiatric

Facilities and Residential Treatment Centers, 1970, 1975, and 1980 . . . . . . . . . . . . . . . . 25

Median Length of Stay in Hospital Inpatient Psychiatric Facilities Among Children

Under 18 Years of Age, 1970, 1975, and 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

DSM-III's Multiaxial Diagnostic Evaluation System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

vii
Contents—continued

Table No. Page

6.

7.

- 8.

9.

10.

11.

Children’s Mental Disorders Listed in DSM-III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Distribution of Full-Time Equivalent Staff Positions in Psychiatric Hospitals and

Residential Treatment Centers, 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Federal Contributions to Programs Contributing to Mental Health Services for

Children, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......132

Fiscal Year 1985 Estimated Allocation of the lo-Percent Set-Aside of the Alcohol,

Drug Abuse, and Mental Health (ADM) Block Grant for Selected States . . . . . . . . . . .134

Planned Use unselected States of Fiscal Year 1985 Set-Aside Funds for Mental

Health Services for Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. ... ... ....135

Lengths of Stay Associated With Mental Disorder Diagnosis-Related Groups (DRGs)

Ranked by Interquartile Range. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figures

Figure No

1.

2.

3.

4.

Estimated Numbers of Children Who Need and Who Receive Mental

Services, 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . 138

Page

Health

. . . . . . . . . . . . . . 5

Organization of This Background Paper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Admission Rates for Children Under 18 Years to Psychiatric Hospitals and

Residential Treatment Centers, 1970, 1975, and 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Estimated Proportions of State v. Federal and Private Expenditures for Mental

Health 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 suffering for children, difficulties for their families, and

great loss for society. Though such problems are

sometimes tragic, an even greater tragedy may be

that we currently know more about how to prevent and treat children’s mental health problems

than is reflected in the care available. This background paper was requested by the Senate Appropriations Committee through Senators Mark

O. Hatfield and Daniel K. Inouye, who expressed

special interest in learning the extent to which the

mental health field has reached a consensus on

the appropriate treatments and treatment settings

for responding to the mental health needs of our

Nation’s children. It examines the nature of children’s mental health problems, the mental health

services available to aid disturbed children, and

the Federal role in providing services.

The problems that affect children’s mental health

range from transient conditions in a child’s environment to diagnosable mental illnesses. Mental

health problems that meet the diagnostic criteria

contained in the third edition of the American

Psychiatric Association’s Diagnostic and Statistical Manual, the “DSM-III,”l are identified in this

background paper by the terms mental disorders,

diagnosable mental disorders, and DSM-III disorders. Typically, the existence of a DSM-III disorder is necessary for obtaining third-party reimbursement for mental health services. Other terms

like mental health problems and disturbed children refer in this background paper not only to

DSM-III disorders, but also to children’s mental

health problems more generally —i.e., to disturbed

self-esteem, developmental delays, and other subclinical problems that children may experience as

a result of environmental stress. Currently, services for problems other than DSM-III disorders

are seldom eligible for third-party payment.

‘At the time this background paper was being prepared, DSM111 was being revised by the American Psychiatric Association. The

new version will be known as DSM-111-R.

Interventions to prevent and treat children’s

mental health problems are as diverse as children’s

problems. This background paper considers several issues related to the provision of mental health

services for children, emphasizing in particular,

psychiatric hospitalization—the most restrictive

and costly form of treatment.

Although serious policy questions remain concerning the provision of adequate, appropriate,

and cost-effective mental health services to children, several conclusions can be drawn from this

background paper:

•

●

●

Many children do not receive the full range

of necessary and appropriate services to treat

their mental health problems effectively.

Howeverr the precise nature of the gap between what mental health services are being

provided to children and what should be provided is not clear.

A substantial theoretical and research base

suggests that, in general, mental health interventions for children are helpful, although

it is often not clear what intervention is best

for particular children with particular problems. Most important for the focus of this

paper, the effectiveness of psychiatric hospitalization for treating childhood mental disorders has not been studied systematically.

Although there seem to be shortages in all

forms of children’s mental health care, there

is a particular shortage of community-based

services, case management, and coordination

across child service systems—all of which are

necessary to provide a comprehensive and

coordinated system of mental health care

throughout the country. Models for providing community-based continuums of mental

health care exist, and preliminary evidence

suggests that such continuums can be effective; these deserve careful and large-scale

trials with systematic evaluation.

3
4

Available epidemiologic data indicate that at

least 12 percent, or 7.5 million, of the Nation’s

approximately 63 million children suffer from

emotional or other problems that warrant mental health treatment—and that figure may be as

high as 15 percent, or 9.5 million children. These

epidemiologic data, while not based on systematic, recent national studies, are widely accepted

and give some indication of the magnitude of children’s mental health care needs.

Like estimates of children’s mental health needs,

information about mental health care utilization

by children is somewhat dated. The most recent

mental health care utilization data available show

that less than 1 percent of the Nation’s children,

or 100,000 children, receive mental health treatment in a hospital or residential treatment center

(RTC) in a given year, and perhaps only 5 percent, or 2 million children, receive mental health

treatment in outpatient settings (see figure 1).

Using these data, OTA estimates that from 70 to

80 percent of children in need may not be getting

appropriate mental health services.

It is not always clear why children do not receive needed mental health services. Some children may not receive services because of the

stigma attached to having a mental disorder.

Other children may not receive services because

the services are not available in their communities. Still others may not receive services because

their families cannot afford them. Using the most

recent data available (1977), OTA estimates that

14 million of the Nation’s approximately 63 million children may not have any private health

insurance. Furthermore, the insurance that is available for mental health problems is generally restricted to treating diagnosable mental disorders,

is significantly less generous than insurance for

other disorders, and covers outpatient care less

generously than inpatient care.

To the extent that treatment decisions are based

on service system or financial considerations, inappropriate mental health care may be given.

Some children may be undertreated (e.g., be given

outpatient treatment when they require hospital

‘The most recent year for which mental health service utilization

data are available is 1980, or in some cases, 1981.

or other residential care), and some children may

be given overly intensive treatments (e.g., be

treated in a psychiatric hospital when they could

be treated without 24-hour medical supervision).

Unfortunately, the data needed to understand precisely which children and problems should be

treated in different settings have not been collected.

OTA’s finding that many children with mental health problems do not receive needed care is,

perhaps disappointingly, wholly consistent with

the findings of commissions and study groups

over the past half century. In recent years, as

knowledge of the effects of children’s mental

health problems has grown, the urgency of addressing these problems has increased. Providing

the most appropriate mental health services for

children is a daunting task. The immensity of the

difficulties, however, should not restrain specific

efforts 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 other

mentally 

disturbed

children

4.5b

Children

admitted to

inpatient

or other

residential

facilities

for mental

health

treatment

0.1

\

Children

receiving

other

mental

health

services d

?

Children in need of services Children who receive services

a

Excludes 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 million children m 1980—were /n need of mental health services (excludlng prevention) (514). Gould, Wunsch-Hltzlg, and Dohrenwend have since estimated that

11.8 percent—or 7.5 mllllon—of the Nation’s children have mental health disturbances (248). A number of factors account for differences in estimates of ch!ldren In

need 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 Report) (Washington, DC U.S. Government Print Ing Office, 1978), and J Knltzer, Unc/a/rned Ctr//dren

(Washington, DC” Children’s Defense Fund, 1982).

Total number of mentally disturbed children in need of services: President’s Commission on Mental Health, Report to the Pres/dent From the Pres/dent’s

Comm/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, and

B Dohrenwend, “Estlmattng the Prevalence of Childhood Psychopathology: A Cntlcal Review,” Journa/ of the Amer/can Academy of Ch//d Psych/a fry

20’482, 1981

Children 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 ),

DHHS Pub 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 Center

for Health Statistics, Naf/ona/ Med/ca/ Care Ut///zaorrrr and Experrd/fure Survey, Data Report No 5, “Utltlzatlon and Expenditures for Ambulatory Mental

Health 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 this

background paper and considers policy implications. The nine remaining chapters of this background paper provide additional detail on children’s mental health problems and services. The

chapters are organized in five sections (see figure

2).

Part I describes efforts to assess children’s mental health problems. Chapter 2 links conclusions

of past study commissions about the incidence and

prevalence of mental and emotional problems in

children to current estimates and notes the similarities between the current situation and what

were identified as problems decades ago.

Part II reviews children’s mental disorders and

the interrelationships of children’s mental health

problems and environmental conditions. Chapter 3 presents mental disorders in terms of the

diagnostic categories in DSM-III. Chapter 4 considers factors in a child’s family and psychosocial environment that may cause or exacerbate

certain mental health problems and that may need

to be considered in designing services.

Part 111 focuses on various approaches to treating or preventing certain children’s mental health

problems. Chapter 5 describes the primary therapies: individual psychotherapy based on psychodynamic, behavioral, and cognitive models;

group therapy; family therapy; milieu therapy;

crisis intervention; and psychopharmacological

(drug) therapy. Chapter 6 describes mental health

treatment settings, including hospital inpatient settings, RTCs, day treatment or partial hospitalization, and outpatient settings. Chapter 7 provides an overview of the mental health services

provided to children involved in the educational,

health care, child welfare, and juvenile justice systems. That chapter also describes programs aimed

at preventing mental health problems and integrating mental health with other services.

Part IV examines the effectiveness of interventions used to treat and prevent children’s mental

health problems. Chapter 8 summarizes the research on effectiveness of the specific therapies discussed in chapter 5. Chapter 9 summarizes the research on effectiveness of treatment in mental

health and other settings and the effectiveness of

prevention programs. Efforts to integrate mental

health and other services have not yet been

evaluated.

Part V analyzes the present Federal policies

aimed at alleviating children’s mental health problems. Chapter 10 describes a number of Federal

programs that have a direct or indirect effect on

children’s mental health.

SUMMARY AND POLICY IMPLICATIONS

Children’s Mental Health Problems

At least 7.5 million children in the United

States—representing approximately 12 percent of

the Nation’s 63 million children under 18—are believed to suffer from a mental health problem severe enough to require mental health treatment.

The actual number of children suffering from

mental disorders that meet the diagnostic criteria

of DSM-III is unknown, but a fairly precise estimate

will be possible with the conduct of a National

Institute of Mental Health (NIMH) epidemiologic

survey of children similar to that completed recently for adults. In addition to children who have

diagnosable mental disorders, some children are

at risk for mental suffering and disability because

of environmental risk factors such as poverty, inadequate care, parental alcoholism, or divorce.

These children may also benefit from mental

health services.

Mental health problems of children are in many

respects unlike those of adults and are much more

difficult to identify. Distinguishing between normal aspects of a child’s development and mental

health problems that may worsen if not treated

is a difficult task for parents, teachers, physicians,

and mental health care professionals.
7

4

Part 1:

Earlier Evaluations and

the Current Situation

4

Part 1:

Problems

Part Ill:

Services

I

Part IV:

Effectiveness

of 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 and

in Children Children’s Mental Health Problems

I

SOURCE Off Ice of Technology Assessment, 1986

I

Ch. 10: Current Federal Efforts

I

According to DSM-III, children maybe afflicted

by so-called childhood-onset mental disorders

(meaning the disorder is usually manifest first in

childhood) or by other disorders whose onset is

not restricted to childhood. DSM-III groups mental disorders that have their onset in childhood

by the area of functioning that is most impaired:

● intellectual disorders (mental retardation);

● developmental disorders (pervasive and specific developmental disorders);

● behavior disorders (attention deficit disorder

and conduct disorder);

● emotional disorders (anxiety disorders, other

emotional disorders of childhood or adolescence); and

● psychophysiological disorders (stereotyped

movement disorders, eating disorders, and

other disorders with physical manifestations).

Other mental disorders that affect children, but

which more commonly begin in adulthood, include organic mental disorders; substance use disorders; schizophrenic disorders; affective disorders such as major depression; adjustment

disorders; and a number of other disorders.
8

This background paper does not consider intellectual or developmental childhood-onset disorders

except as they interrelate with other problems requiring mental health services. This exclusion reflects in part the specific wording of the request

from the Senate Appropriations Committee and

in part the fact that the causes, treatment, and

treatment goals in the case of intellectual/developmental disorders differ from those associated

with other mental disorders.

For the most part, the causes of mental disorders are unknown. However, some environmental factors, particularly psychosocial ones,

pose significant risks for children’s mental health.

Environmental factors that pose risks to children’s mental health include poverty; parental

psychopathology (e.g., schizophrenia or alcoholism); maltreatment; a teenage parent; premature birth; parental divorce; and serious childhood

physical illness. These factors rarely occur in isolation and frequently interact with other aspects

of a child’s family, educational, and social environment. Although environmental factors do not

necessarily result in mental disorders that meet

the diagnostic criteria of DSM-III, they can cause

maladjustment and place a child at risk for later

and potentially more serious problems.

The consequences of mental health problems

in children can be mild and transitory or severe

and longstanding. Children with the most severe

problems may be unable to function in either their

home or school environments and may be dangerous to either themselves or others. Unresolved

problems can lead to other serious problems with

family, schools, and the criminal justice system.

Much of the interest in identifying children’s mental health problems has as its focus the understanding and prevention of disorders so as to reduce the risk of future difficulties.

Children’s Mental Health Services

Interventions to treat children’s mental health

problems are based on a variety of theories about

human development and behavior. Therapies

used with children include those which are psychodynamically based, behaviorally based, and

cognitively based, as well as those involving psychoactive medications.

Within the mental health system, a wide range

of settings has been developed to treat children’s

mental health problems. These settings —from

psychiatric hospitals to outpatient mental health

clinics—can be described as forming a continuum

of intensiveness. Mental health authorities agree

that it is desirable to provide treatment in the

“least restrictive setting” possible. Severely disturbed children sometimes need intensive and

restrictive service settings such as hospitals or

RTCs. Typically, however, intensive settings such

as these are needed only for relatively brief periods,

with followup care in less restrictive environments

such as community-based outpatient programs.

The choice of treatment and treatment setting

for each mentally disturbed child is based on several factors. Certainly, the symptoms and the

severity of the child’s disorder are primary. Other

factors that play a part in treatment decisions include the child’s developmental status, the availability of family support, social and environmental conditions, the availability of financing

for services, and the geographic availability of certain services.

Opportunities for preventing and treating children’s mental health problems arise not only in

the mental health system but within the educational, health care, child welfare, and juvenile justice systems. Models for providing mental health

services in these settings have been developed.

Programs to integrate mental health and other

services at Federal, State, and local levels have

also been developed. Such programs include individual case manager programs, with professionals to advocate for necessary and comprehensive treatment and to represent the child before

all relevant programs so that services are coordinated.

Effectiveness of Mental Health

Treatment and Preventive Services “

Clinical and policy decisions based on knowledge about the effectiveness and appropriateness

of services, rather than on their availability, would

be desirable, but drawing firm conclusions about

the effectiveness of treatment, treatment settings,

and preventive services for children’s mental
9

health problems is difficult. The research base is

limited and not methodologically rigorous.

Overall, however, OTA’s analysis indicates

that treatment is better than no treatment and that

there is substantial evidence for the effectiveness

of many specific treatments. Behavioral treatment, for example, is clearly effective for phobias

and enuresis, and cognitive-behavioral therapy is

effective for a range of disorders involving self-

-control (except aggressive behavior). Group therapy has been found to be effective with delinquent

adolescents, and family therapy appears to be effective for children with conduct disorders and

psychophysiological disorders. Psychopharmacological treatment, while not curative, has been

found to have limited effectiveness with children

with attention deficit disorder and hyperactivity

(ADD-H), depression, or enuresis, and also in

managing the behavior of children who are severely disturbed. Further, more rigorous research

may demonstrate the usefulness of several other

treatments for which there is preliminary evidence

of effectiveness.

Questions about the effectiveness of mental

health treatment in psychiatric hospitals and RTCs

are difficult to answer because of the lack of systematic research. The lack of methodologically

sound evidence for the effectiveness of mental

health treatment provided through psychiatric

hospitals and RTCs does not necessarily imply

that these treatment settings are inappropriate—

only that there is no solid evidence one way or

the other. Whether or not some mentally disturbed

children would be better off in alternative treatment settings is not known.

Available research on treatment settings does

offer some evidence to support the potential effectiveness of a system of services ranging from

outpatient community-based care to intensive

residential-based care. The long-term effectiveness

of psychiatric hospitalization and other forms of

residential treatment, for example, appears to be

related to the presence and quality of followup

care. The effectiveness of day or night hospitalization appears to be related to the inclusion of

the family in treatment plans.

Additional information about treatment effectiveness could be used to revise financial incentives—both public and private—to promote the

delivery of mental health care in the least restrictive setting possible for effective treatment, while

permitting reimbursement for the range of services necessary. Thus, a more comprehensive and

appropriate mental health treatment delivery system could be developed.

The effectiveness of prevention programs,

whether developed primarily as a mental health

intervention or designed as part of other service

systems such as schools, is supported by several

studies. Interventions to provide family support,

for example, appear to have substantial potential

to prevent and remedy a range of mental health

problems and lead to better school achievement

in children. Prevention programs in schools and

preschools and pregnancy prevention programs

for teenagers have also been found to be effective. Not only have many prevention programs

led to positive changes in social, emotional, and

academic measures, but such programs appear capable of preventing later governmental expenditures through the justice and welfare systems.

The important questions, rather than being

about the overall effectiveness of children’s mental 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 conditions?

in what settings? and

with what followup or concomitant parental, family, school, and other system; interventions?

Current Federal Efforts

State governments play the major role in providing and financing children’s mental health services, although Federal Government and private

sector roles are substantial. The Federal Government finances treatment for children’s mental disorders primarily through the Alcohol, Drug Abuse,

and Mental Health block grant, the Medicaid program, and the Civilian Health and Medical Pro-
10

gram of the Uniformed Services. These and other

financing programs also influence financing policy in the private sector.

Federal involvement in health, welfare, nutrition, and social services for children is also considerable; and Federal programs in these areas

probably have a major impact in preventing and

alleviating mental health problems, although their

actual impact is difficult to measure. However,

the lack of cohesive policies toward children, and

across service programs, may create difficulties

for those who would move public policy toward

the continuum of care that many observers conclude is needed to address children’s mental health

needs.

Past national studies have observed that few

mental health policies and programs—public or

private-appear to take into account the complexity of influences in children’s lives. Fragmentation

of treatment programs and support services has

resulted. Currently, programs at the Federal,

State, and local levels are attempting to promote

integration of services across professional, agency,

and geographic boundaries. The Federal Child and

Adolescent Service System Program, for example, provides grants to States to improve coordination among service systems, thus improving access to appropriate mental health services. The

State Comprehensive Mental Health Services Plan

Act of 1986 will institute another grant program

to assist States to develop comprehensive services for the chronically mentally ill of all ages.

The Federal Government is virtually the only

source of training and research support in the

mental health area. Despite Federal programs of

student assistance, the number of trained professionals available to deliver children’s mental

health services remains far below all estimates of

the need. Currently, about 15 percent of NIMH’s

training funds appears to be directed to training

clinicians to treat children.

A major difficulty in development of this background paper and in designing more effective children’s mental health programs was the lack of

data on many treatment regimens and service systems. Although NIMH commits approximately 20

percent of its current research budget to children’s

issues, available dollars have not kept pace with

assessments of the funds necessary. Most mental

health care interventions are appropriate for evaluation studies—and most could benefit from the

information that research provides. In addition,

basic information about the characteristics and

utilization of the contemporary mental health

service system is not available. The financial savings from a more comprehensive database are potentially enormous; the benefits to children and

society of more effective programs are incalculable.

Conclusion

OTA’s analysis suggests several needs in relation to children’s mental health problems and

services. Two needs are: a more informed estimate of the number of children who require mental health services, and a description of the availability and use of children’s mental health services.

A more immediate need is for improved delivery of mental health services to children. Clearly,

the mental health services currently available to

children are inadequate, despite a substantial theoretical and research base suggesting that mental

health interventions for children are effective.

The need for improved children’s mental health

services is not new; it has been highlighted by a

number of past national studies and commissions.

If the need is to be met, changes may be necessary in the way mental health services are conceptualized, financed, and provided. In an ideal

system, an adequate range and number of preventive, treatment, and aftercare services would be

available, particularly in the communities where

children reside, so that families and others can be

involved. Access to treatment on an outpatient

basis, and before a child develops a diagnosable

disorder, seems especially important. Access to

treatment could be facilitated by reducing restrictions on mental health benefits,

OTA found that new efforts to coordinate services between the mental health system and other

systems that children may come in contact with—

the general health care, educational, social welfare, and juvenile justice systems—are encouraging to many mental health professionals. These

new coordination programs may result in new efforts to detect and treat mental health problems.
11

Finally, additional information about the causes ety of promising approaches could greatly aid the

of mental health problems, the services available development of a system that would match the

to 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 Evaluations

and the Current Situation
Chapter 2

Earlier Evaluations and the

Current Situation
Chapter 2

Earlier Evaluations and the Current Situation

INTRODUCTION

Services for children’ with mental health problems have long been a focus of national concern.

This chapter summarizes the work of several major policy-related studies and commissions, giving

‘Throughout this background paper, the term “children” is used

to refer generally to all infants, children, and adolescents under age

18. Where necessary, further distinctions are drawn among children

of various ages and developmental stages.

their conclusions about the prevalence of mental

health problems in children and their recommendations for services. The chapter also presents

available information pertaining to trends in the

availability and use of children’s mental health

services. Although data to assess the current situation are limited, it is nevertheless clear that several key policy recommendations of past studies

and commissions have yet to be implemented.

EARLIER EVALUATIONS OF CHILDREN’S MENTAL HEALTH

NEEDS AND SERVICES

Estimates of the Prevalence of

Children’s Mental Health Problems

Estimating the prevalence of mental health problems among children is hard for several reasons.

Distinguishing between distinct mental health problems and normal changes during a child’s development, for example, is often difficult. Also, some

children without a diagnosable disorder may require mental health services because of problems

in their social and physical environment (see ch.

4). These factors complicate the task of enumerating specific disorders and identifying children

in need.

To complicate matters further, various panels

that have tried to estimate the prevalence of children’s mental health problems in the past have

varied in the age range of children and the types

of problems included in their estimates. Also, because of changes in psychiatric nomenclature, prevalence estimates used in individual studies or reports cannot be reliably replicated by subsequent

groups. Nevertheless, all of the various panels’

estimates have been roughly similar (see table 1),

and the panels have all agreed that the need for

children’s mental health services exceeds the availability of services.

Joint Commission on the Mental Health of

Children (1969)

One of the most detailed assessments of the

magnitude of children’s mental health problems

was conducted by the Joint Commission on the

Mental Health of Children (324). Established in

1965 (Public Law 89-97), the Joint Commission

on the Mental Health of Children was specifically

mandated to develop a coordinated study of the

diagnosis, prevention, and treatment of “emotional illness” in children and adolescents. An

earlier commission whose work had led to the

1963 act establishing community mental health

centers throughout the country had not dealt explicitly with children (324).

In defining and estimating the prevalence of

emotional disorders in children, the Joint Commission was hindered by a lack of specific diagnostic criteria. The Joint Commission adopted a

rather broad definition of an “emotionally disturbed child” based on its synthesis of research

and expert opinion:

. . . one whose progressive personality development is interfered with or arrested by a variety

of factors, so that he shows an impairment in the

capacity expected of him for his age and endow17
18

Table 1 .—Estimates of Children With

Mental Health Needsa

Children under 18 years of age

with mental health needs

Percent Numberb

All mentally disturbed children:

Joint Commission on the Mental

Health of Children (1969) 13.6% 8.8 million

President’s Commission on Mental

Health (1978 ) 5% to 15% 3.0 to 9.6 million

Gould, et al. (1981) . 11 .8%C 7,5 million

Severely mentally disturbed children:

National Plan for the Chronically

Mentally Ill (1980) 8% 9.1 million

Knitzer/CDF (1982) ., ., 5.0% 3 million

aEStlrnateS 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 vahdlty

of a dlagnosttc Interwew schedule for use with children In order to conduct an epldemlologlcal

study of the presence of mental disorders

bThe number of Children m need of serwces IS calculated as c1 percent Of the 1980 POPulatlOn

of 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/r

Cha//errge for the 1970’s (New York Harper & Row, 1969), President s Commission

on 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 DC

U S Government Prmtmg Office, 1978), M S Gould, R Wunsch-Hltzlg, and 8 Dohrenwend, ‘‘Estlmatmg Ihe Prevalence of Chddhood Psychopathology A Crltlcal Rewew,

Jourrra/of MeAmerlcan AcadernyofChddPsycfr/airy 20462, 1981, L Salver, “Chronic

Mental Illness m Children and Adolescents Scope of the Problem, ” paper for the National Conference on Chronic Mental Illness In Children and Adolescents, sponsored

by the American Psychiatric Asscaatlon, Dallas TX, March 1985 J Krvtzer Uflclamed

Cfuldren (Washington, OC Chddren ”s Defense Fund 1982)

ment; (1) for reasonably accurate perception of

the world around him; (2) for impulse control;

(3) for satisfying and satisfactory relations with

others; (4) for learning; or (5) for any combination of these.

Using this definition to interpret available research, the Joint Commission on the Mental Health

of Children estimated that up to 13.6 percent of

children were “emotionally disturbed. ” This included a small percentage (0.6 percent) of children

who were considered psychotic, 2 to 3 percent

who were severely disturbed, and an additional

8 to 10 percent who suffered from emotional problems serious enough to require mental health

services.

U.S. Department of Health, Education, and

Welfare: Project on the Classification of

Exceptional Children (1975)

The issues of classifying children’s mental health

problems were also of concern subsequent to the

Joint Commission’s report. In 1972, a project was

initiated by the Secretary of the U.S. Department

of Health, Education, and Welfare (DHEW), now

the U.S. Department of Health and Human Services, to consider issues in the classification of “exceptional” children, including but not limited to

those with mental health problems. Supported by

a consortium of DHEW agencies and directed by

Hobbs, the Project on the Classification of Exceptional Children brought together a group of experts to develop a better understanding of the issues involved in classification and a rationale for

policy and services for “exceptional” children.

The final report of the project cited a DHEW

Bureau of Education (298,299) estimate that there

were about 7 million children aged O to 19 in various “exceptional” categories (physically handicapped, retarded, and emotionally disturbed), but

it did not estimate prevalence for specific disabilities. Another 1 million children (2.9 percent of

children aged 10 to 17) had been in trouble with

the law in 1972, and 10 million poor and 10 million nonwhite children were also of concern to

the advisors to DHEW.

The report concluded that although there were

significant problems associated with labeling children, categorization was often necessary to establish policy and to ensure that services were delivered. The report noted, however, that the

classification of emotional disorders was particularly difficult and therefore recommended the development of multidimensional classification systems. A central feature of this recommendation

was that such systems classify disorders, rather

than children.

President’s Commission on Mental Health and

Its Task Panel on Infants, Children, and

Adolescents (1978)

The President’s Commission on Mental Health

was established in 1977 to undertake a broadbased review of national mental health needs and

to make recommendations to the President as to

how those needs might be met (514). One of the

principal “task panels” of the Commission addressed the mental health needs of children. Using

studies conducted since the time of the Joint Commission on the Mental Health of Children, this

task panel estimated that from 5 to 15 percent of

children aged 3 to 15 had handicapping mental

health problems. The panel’s lower estimate corresponds to estimates of the number of psychotic
19

and severely disturbed children; its higher estimate

corresponds to the number of children with “neuroses” and behavior problems for whom mental

health intervention may be useful.

The Commission as a whole stated that the

country’s mental health problems could not “be

defined only in terms of disabling mental illnesses

and identified psychiatric disorders. ” Mental health

problems “must include the damage to mental

health associated with unrelenting poverty and

unemployment and the institutionalized discrimination that occurs on the basis of race, sex, class,

age, and mental or physical handicaps, ” and “conditions that involve emotional or psychological

distress which do not fit conventional categories

of classification or services” (514).

Recent Estimates of the Prevalence of

Children’s Mental Health Problems

Epidemiologic research on mental health problems needed in order to estimate prevalence has

continued to develop. Over two dozen studies of

the prevalence of mental disorders in children and

adolescents have now been conducted (229,248,

389,609).

Some of the most important research on prevalence, conducted in the United Kingdom by Rutter and colleagues (562,566), is believed to be relevant to the situation in the United States. On the

basis of a convergence of identifications by mental health professionals, parents, and teachers,

Rutter estimated that 13.2 percent of children in

the United Kingdom were in need of mental health

services.

In a detailed 1981 review, Gould, et al., concluded that the percentage of children and adolescents in need of mental health services in the

United States was probably “no lower than 11.8

percent” (248). Later reviews, by Gilmore, et al.

(229), and Silver (609), concur with the 11.8-

percent figure.

Gould and her colleagues’ estimate that about

12 percent of the children in the United States—

7.5 million—are in need of mental health services seems to be one on which there is generaI concurrence. This estimate, however, reveals nothing about the severity of disturbances and levels

of care children need—distinctions that are essential for the development of comprehensive public policy.

Increasing interest is being directed to children

with severe mental health disturbances, both in

terms of identification and for developing appropriate treatment options (396). Estimates of the

number of severely disturbed children, however,

differ substantially. In comparison to the findings

of the President’s Commission on Mental Health

(514), for example, the 1980 National Plan for the

Chronically Mentally 111 (609) estimated that

about 9.1 million (8 percent) children are severely

disturbed and in need of services.

Recommendations About Mental

Health Services for Children

Concern about the inadequacy of mental health

services for children is not a recent phenomenon.

As long ago as 1909, a White House Conference

on Children recommended new programs to care

for mentally disturbed children (324). A White

House Conference in 1930 echoed the earlier recommendation and maintained that mentally disturbed children have the “right” to develop the

way other children do. A similar conclusion has

been reached by nearly every subsequent commission or panel (324). These panels and study commissions have made numerous detailed and specific recommendations conceiving policy relevant

to the mental health needs of children. Only the

flavor of their recommendations can be provided

here. Selected conclusions and recommendations

of various commissions and panels are summarized in table 2, and the work of the more recent

groups is discussed in detail below.

Joint Commission on the Mental Health of

Children (1969)

The Joint Commission on the Mental Health of

Children (324), in its 1969 report Crisis in Child

Mental Health, stated that large numbers of emotionally, physically, and socially handicapped

children did not receive necessary or appropriate

services and that the mental health service system for children and youth was wholly inadequate. Although the most disturbed and disrup-
Table 2.—Mental Health Services for Children: Selected Findings and Recommendations of

Past 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 conditions

Increase 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 Handithicket of conceptual confusions, competing Coordinate and plan services, capped Children Act

authorities, 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 the

needs 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 proery 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 coordination

groups 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 chilIittle 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 intensiveness

Increase 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 developmental problems, other preventive services for children and families,

high quality residential treatment services, and community support

mechanisms,

Develop new means of coordinating physical and mental health services, and

mental 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

adequate

Child 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 cobut also the most costly and restrictive, Coordinate juvenile justice, education, child welfare, and mental health services ordination of mental health

States 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 mental

Service systems (juvenile, educational, child wel- for children’s services, health block grant funds

fare, mental health) are uncoordinated, was set aside for children

Seriously emotionally disturbed children appear to or other underserved popbe 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 Our

CtWdren 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, DC

Chddren’s Defense Fund, 1982)
21

tive children could receive treatment services, the

Commission found that treatment provided to

them very often was inappropriate and ineffective. The Joint Commission was particularly concerned that severely disturbed children were being institutionalized in State mental hospitals and

that such facilities provided custodial rather than

treatment services for children. The Joint Commission was also concerned about the “corrosive”

effects of poverty and the fact that mental health

problems were more acute and services less available among poor children.

A principal recommendation of the Joint Commission on the Mental Health of Children was that

a child advocacy system be established to coordinate Federal, State, and local actions. The Commission believed that advocacy was essential for

development of a comprehensive network to meet

children’s mental health, physical, and social needs.

The Joint Commission also recommended the

establishment of community services that focused

on prevention and “remediation. ” Recommended

prevention services included family planning, prenatal care, and mental health services associated

with schools. Remedial mental health services,

which the Commission estimated would be required for 10 percent of children, were to be based

on children’s functional level, rather than on legal or clinical classification systems.

The Joint Commission further recommended

that children (particularly the severely handicapped) be cared for in settings that most closely

resembled normal living situations. An additional

recommendation was for increased research on

diagnosis and treatment of children’s mental health

problems. The Joint Commission believed that

both basic and applied research was essential and

suggested a variety of research priorities, both for

the National Institute of Mental Health (NIMH)

and for the National Institutes of Health.

U.S. Department of Health, Education, and

Welfare: Project on the Classification of

Exceptional Children

Perhaps because it was concerned with “exceptional” children of several kinds (handicapped,

disadvantaged, and delinquent), the Project on

the Classification of Exceptional Children was perhaps even more concerned than the Joint Commission on the Mental Health of Children with

the coordination of services across agencies and

categories of children. Thus, the Project’s final report (298,299) recommended that the U.S. Congress and the legislative bodies of each State and

community establish an agency to serve a planning and coordinating function for all programs

bearing on families and children. The Project report also suggested that at every level, citizens’

councils advise the planning agencies on program

development and agency operations. The Project

also made recommendations concerning specific

programs which might be implemented under the

purview of the legislative bodies, and noted several 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 all

children including the handicapped have access

to education, was implemented with the passage

of Public Law 94-142, the Education for All Handicapped Children Act. Public Law 94-142 also

implicitly made the public schools the primary

A number of national studies and commissions

have concluded that mental health services for children

are inadequate.
22

source of advocacy for children, another recommendation of the Project on the Classification of

Exceptional Children.

President’s Commission on Mental Health and

Its Task Panel on Infants, Children, and

Adolescents (1978)

The President’s Commission on Mental Health

(514) found that many of the Joint Commission’s

1969 recommendations had not been implemented.

Children and adolescents, the President’s Commision found, continued to receive inadequate

mental health care:

Services that reflect the unique needs of children and adolescents are frequently unavailable.

Our existing mental health services system contains too few mental health professionals and

other personnel trained to meet the special needs

of children and adolescents. Even when identified, children’s needs are too often isolated into

distinct categories, each to be addressed separately

by a different specialist. Shuttling children from

service to service, each with its own label, adds

to their confusion, increases their despair, and

sets the pattern for adult disability.

The Commission’s subtask panel on infants,

children, and adolescents recommended preventive services for all children, not only those identified as mentally disturbed. Services such as developmental assessments and access to diagnostic

mental health services, it suggested, should be incorporated within children’s general health care.

The subtask panel also recommended a network of “psychiatric, pediatric, counseling, special education and occupational training services”

for children with severe psychiatric disorders.

These services were necessary, according to the

panel, because no matter how successful prevention efforts were, some children would always require special help. The services provided, the

panel recommended, should be adapted to children’s specific needs and should include counseling with parents and others significant in a child’s

life. In addition, the panel believed, it was essential that services “respect ethnic differences. ”

The subtask panel on infants, children, and

adolescents emphasized that children’s mental

health services should be provided within a system of care that “insofar as possible maintain a

continuing relationship between child and family.” To prevent disruption in the relationship between children and their families, the panel recommended that health insurance plans eliminate

barriers to reimbursement for outpatient treatment services. The panel also recommended that

parents be involved in the development of special education and other treatment plans, especially for intensive services provided for severely

disturbed children.

Another recommendation of the subtask panel

was that children’s mental health services be organized along a continuum of intensiveness, so that

children could move along the continuum as their

needs changed. Good residential facilities specializing in the treatment of severely disturbed children and adolescents, the panel suggested, were

urgently needed. The panel supported the Joint

Commission calling for development of a better

research and evaluation base, characterizing the

tendency to reduce research funding in order to

provide treatment services as “penny wise and

pound foolish” (514). Noting that without more

research and evaluation, “the potential for waste

of resources is great, ” the panel recommended a

lo-percent set-aside of total program funds for research, demonstrations, and evaluation.

The subtask panel called the mental health system for adolescents “woefully inadequate, ” noting

that adolescents were one of the most underserved

groups in the Nation. This panel urged that services be provided to address such problems as adolescent suicide, teenage pregnancy, delinquency,

and substance abuse. The panel’s recommendations focused on development of an integrated

network of mental health services in schools, juvenile courts, neighborhood centers, and occupational training facilities.

One impact of the work of the President’s Commission was the development and enactment of

the Mental Health Systems Act. The act authorized programs to improve the delivery and coordination of services for severely emotionally disturbed children and adolescents. The act became

law in 1981, but was repealed before it became

effective and was replaced by the Alcohol, Drug

Abuse, and Mental Health (ADM) block grant

(Public Law 97-35; see ch. 10).
23

Select Panel for the Promotion

of Child Health (1981)

Established at about the same time as the President’s Commission on Mental Health was the Select Panel for the Promotion of Child Health established under Public Law 95-626. The Select

Panel had a broad mandate; it attempted to develop recommendations that:

. . . reflected] hardheaded analysis of serious

unmet needs in child and maternal health . . .

and a sober and pragmatic assessment of the capacity of our institutions to provide parents, professionals and . . . others working to improve

child health with the scientific, financial and organizational support they need.

The Select Panel reported its findings in December 1980 (595). The general recommendations of

the Panel, much like those of its predecessors, emphasized the interrelationships among services

provided by health care agencies, schools, families, and social service institutions. The Select

Panel’s analysis suggested changes to a wide range

of Federal programs affecting children. With respect to mental health needs, the Panel focused

on implementation of the Education for All Handicapped Children Act (Public Law 94-142, enacted

in 1975) and mental health service systems that

were to be affected by the Mental Health Systems

Act (enacted in 1980, but then repealed in 1981).

Public Law 94-142 mandates that handicapped

children be provided access to a free and appropriate public education. Public Law 94-142 authorizes a program for States to receive Federal

funds, but it also “guarantees” the right to education for handicapped children without regard

to the provision of Federal funds to support such

services. Although the Select Panel found that significant improvements had resulted from Public

Law 94-142, particularly in changing attitudes

about the handicapped, it was concerned that substantial variations existed across States in the

availability of services. The Panel stressed the

need for better methods of identifying and evaluating children with handicapping conditions and

more stringent requirements for delivering health

and mental health services to these children. To

ensure compliance with the law, it recommended

Federal and State monitoring, technical assistance,

and enforcement.

The Select Panel also considered the role of

community mental health centers and other mental health service systems and recommended that

these systems expand mental health services for

children. Although children’s mental health services had been mandated earlier (Part F of the 1970

Amendments to the Community Mental Health

Centers Act), direct Federal support specifically

for children’s programs had been withdrawn in

1975. The Select Panel believed that developmental assessment and other preventive services, as

well as high-quality residential treatment services

and community support mechanisms, were necessary components of all comprehensive mental

health programs.

As had the President’s Commission on Mental

Health in 1978, the Select Panel for the Promotion of Child Health recommended that mental

health services be coordinated with general health

care. The Select Panel also recommended coordination of education and social welfare programs

that serve children. Other recommendations of

the Select Panel were that community mental

health programs provide services in schools, Head

Start programs, and juvenile justice institutions,

and that families be involved in the delivery of

mental health services.

Knitzer/Children’s Defense Fund (1982)

Concern about the adequacy of services for

mentally disturbed children remained, despite the

convergence of recommendations by the Joint

Commission, the President’s Commission, and the

Select Panel. In 1982, the Children’s Defense Fund

(CDF) published an elaborate and highly critical

study of how children and adolescents in need of

mental health services are treated (358). That report, Unclaimed Children, by Jane Knitzer, described a survey of mental health services for severely disturbed children and adolescents in 50

States and the District of Columbia. Unlike the

reports of earlier commissions and panels, the

Knitzer/CDF report is based on systematically

collected original data and is one of only a few

efforts to comprehensively assess State, as well

as Federal, programs.

The Knitzer/CDF report concluded that there

were 3 million seriously disturbed children (based

on the estimate of the President’s Commission on
24

Mental Health in 1978), but that 2 million (twothirds) of these children were not receiving needed

treatment services. The report also suggested that

many children who received services received inappropriate care and that poor and minority

group children were most likely to receive no care

or inappropriate care.

Using data from State and county hospitals,

Knitzer concluded that the most restrictive and

costly level of care—inpatient hospital treatment

—was also the most accessible. Although the data

Knitzer collected suggested that as many as 40 percent of such hospital placements were unsuitable,

alternatives to hospital services for severely disturbed children were found to be either nonexistent or rudimentary in many States. One-third of

the States responding to Knitzer’s survey indicated

a need for more long- or short-term beds. According to Knitzer (358):

. . . those States with the fewest alternatives to

inpatient care were generally the ones that wanted

more beds. Those with a number of alternative

programs saw less need to fund more hospital

placements . . .

Knitzer suggested that Federal funds had been

used disproportionately to provide medically oriented inpatient care, while Federal resources available for community services had declined.

Responsibility for seriously disturbed children,

according to Knitzer, lies with public agencies.

The Knitzer/CDF report strongly recommended

increased efforts to identify children and adolescents who are either in need of services or are

being inappropriately served. It also urged the

development of incentives to create a coordinated

set of services appropriate to the child. As did

the reports of each of the government panels

described earlier, the Knitzer/CDF report recommended increased coordination among agencies that deal with children, including educational,

juvenile justice, and child welfare agencies. A

specific recommendation of the report was that

ADM block grant funds be targeted for children’s

services.

THE CURRENT AVAILABILITY AND USE OF CHILDREN’S MENTAL

HEALTH SERVICES

Despite general agreement among experts about

the magnitude of children’s mental health problems, it is difficult to specify precisely the number of children with mental health problems and

the types of services they need. The National Institute of Mental Health (NIMH), which recently

conducted a nationwide study of the prevalence

of adult mental health disorders (533), plans a parallel survey of children’s problems. At the time

this background paper was being written, NIMH

was studying the reliability and validity of the instrument it plans to use in the survey—the Diagnostic Interview Schedule for Children (DISC).

DISC is based on the American Psychiatric Association’s Diagnostic and Statistical Manual of

Mental Disorders. The NIMH survey represents

an important step toward more precise assessment

of children’s mental health problems (664).

A serious problem in attempting to assess the

extent to which mental health services for children are available, and the degree to which the

mental health service system has changed in recent years, is the lack of precise epidemiologic

data. The information available at the time this

background paper was being prepared was quite

dated. The most recent systematically collected

information on inpatient, residential, and outpatient mental health care pertained to utilization

for 1981 (665). These data do not reflect the impact of recent policy changes such as Medicare’s

Part A prospective payment system, the limitation by the Civilian Health and Medical Program

of the Uniformed Services on inpatient treatment,

the lo-percent set-aside in the mental health portion of the ADM block grant, and the Child and

Adolescent Service System Program (see ch. 10).

Nevertheless, they do allow the identification of

several noteworthy trends. For the most part, the

continuation of these trends has been confirmed

by individuals consulted during the preparation

of this background paper.

The most dramatic trend in recent years has

been a decline in the number of children treated

as inpatients in State and county mental hospi-
2 5

tals (665). This trend has been accompanied, however, by increases in children’s admissions to private psychiatric hospitals and to facilities such as

psychiatric units of general hospitals, for a small

net increase in children’s admissions to psychiatric

hospitals.

In 1970, as shown in table 3, the rate of children’s admissions to private psychiatric hospitals

(9.3 per 100,000 children under 18) was one-fourth

the rate of children’s admissions to State and

county mental hospitals (37.8 per 100,000 children under 18). During the 1970s, children’s admissions to State and county mental hospitals

declined 30 percent and admissions to private psychiatric hospitals increased almost 200 percent,

so that in 1980, the latest period for which systematic data are available, the rates of children’s

admissions were about the same for both types

of institutions. The rates of children’s admissions

to non-Federal general hospitals with inpatient

psychiatric services increased slightly from 63.3

per 100,000 population in 1970 to 68.5 per 100,000

population in 1980, for a total net increase in the

rate of psychiatric hospitalization of children of

about 10 admissions per 100,000 population.

There may be significant regional variations (589).

Some evidence suggests that the length of treatment episodes in State and county mental hospitals is declining, although the evidence on the

length of stay for children in private psychiatric

hospitals is unclear (458,665). As can be seen in

table 4, data from NIMH indicate that the median length of stay of children in State and county

mental hospitals dropped from 74 days in 1970

to 54 days in 1980, while the 1ength of stay in private psychiatric hospitals remained constant at

36 days (665). A survey of National Association

of Private Psychiatric Hospitals members, however, found that the median length of stay for children in 1985 in the private hospitals surveyed was

twice NIMH’s number for 1980 (458). Data from

NIMH indicate that the length of stay in nonFederal general hospitals with inpatient psychiatric

services increased from 9 to 17 days between 1970

and 1975, then decreased to 14 days in 1980. The

evidence just cited clearly shows that general hospitals are used for short-term care, and the length

of stay in State and county mental hospitals has

declined. It does not allow conclusions about the

length of treatment in private psychiatric hospitals.

As shown in table 3, NIMH data suggest that

there has been an increase in utilization of residential treatment centers for emotionally disturbed

children (RTCs). Such facilities can provide an

alternative form of treatment for children who require residential treatment but who do not require

constant medical supervision (see ch. 6). There

was a substantial increase in the number of admissions to RTCs between 1969 and 1981. According to NIMH data, the rate more than doubled,

from 11.4 admissions per 100,000 population under 18 in 1969 to 28.3 admissions per 100,000 popTable 3.—Admissions of Children Under 18 Years of Age to Hospital Inpatient Psychiatric Facilities and

Residential Treatment Centers, 1970, 1975, and 1980a

1970b 1975 1980C

Rat e

d Numbe r Rat e

d Numbe r Rat e

d Numbe r

Hospital inpatient facilities

State and county mental hospitals . . . . . . . . . . . . . . . . . . . . . . 37.8 26,352 38.1 25,252 26.1 16,612

Private psychiatric hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3 6,452 23.3 15,426 26.3 16,735

Non-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 disturbed

children (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 count

bData for RTCS are fOr 1%9

cData for RTCS are for 1981.

dRate per 1~,000 children under 18 Years of a9e

elncludes St Ellzabeth’s Hospital In Washington, DC

SOURCE National Institute of Mental Health, Alcohol, Drug Abuse, and Mental Health Administration, Publlc Health Service, U S Department of Health and Human

Services, &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 Inpatient

Psychiatric Facilities Among Children Under 18

Years of Age, 1970, 1975, and 1980

Figure 3.—Admission Rates for Children Under 18

Years to Psychiatric Hospitals and Residential

Treatment Centers, 1970, 1975, and 1980a

1970 1975 1980

State and county mental

hospitals ... ., 74 days 66 days 54 days

Private psychiatric hospitals 36 days 36 days 36 days

Non-Federal general hospitals with

inpatient psychiatric services , 9 days 17 days 14 days

SOURCE Nat!onal lnstltute of Mental Health Alcohol, Drug Abuse and Mental Health Admmstrallon 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)

85-1378 (Rockwlle MD 19851

ulation under 18 in 1981. The declining use of

State and county mental hospitals and increasing

use of RTCs is shown dramatically in figure 3.

Partial hospitalization or day treatment in other

facilities is another increasingly accepted way to

treat some children. It may be appropriate for

those who require mental health care that is more

intensive than outpatient care but less intensive

than inpatient or RTC care (see ch. 6). Data on

children’s admissions for partial hospitalization

comparable to the data on other settings are not

available, but the increasing use of partial hospitalization can be inferred from NIMH’s 1983 endof-year census data. These data indicated that

20,000 individuals under 18 were receiving a

planned program of mental health treatment services generally provided in visits of 3 or more hours

to groups of patients/clients in various settings

(665).

The use of outpatient treatment mental health

services by children is difficult to determine. The

1980 National Medical Care Utilization and Expenditures Survey found that 3.2 percent of children under 18—and 4.3 percent of all age groups

combined—had had a mental health visit in 1980,

(665). Some observers have suggested that these

figures probably underestimate the number of individuals who receive outpatient mental health

treatment and that the treatment rate for individuals of all ages may be as high as 6 percent (178).

The 1980-82 NIMH epidemiologic catchment area

survey of adults in urban areas found that 6 to

7 percent of those surveyed had had a visit for

c

1965 1970 1975 1980

Year

● State and county mental hospitals

A Private psychiatric hospitals

O Residential treatment centers for emotionally

disturbed children

aData for residential treatment centers are for years 1969, 1975, and 1981

SOURCES 1970 to 1980 admission ratas to State and county mental hospitals

and private psychiatric hospitals. and 1969, 1975, and 1981 admissions for residential treatment centers National Institute of Mental

Health, Alcohol, Drug Abuse and Mental Health Administration, Publlc

Health Service, US, Department of Healfh and Human Services, Men.

tal /-/ea/th United States, 1985, C.A Taube and .5A Barrett (eds.),

DHHS Pub No. (ADM) 85-1378 (Rockville, MD 1985) 1969, 1975 and

1980 population undar 18 (used to calculate admlsslon rates for

residential treatment centers) U.S. Department of Commerce, Bureau

of the Census, Washington, DC, unpublished data for 1969, 1975, and

1980.

a mental health problem, not necessarily a diagnosable disorder, in the 6-month period preceding the survey (599). Without specifying precise

percentage increases by age, a 1985 NIMH report

(665) noted that the use of outpatient mental

health services had greatly increased for all ages.

Careful assessment of the use of mental health

services by children awaits conduct of the NIMH

epidemiologic survey of children.
27

CONCLUSION

There appears to be a significant gap between

the number of children identified in epidemiologic

assessments as requiring mental health services

and the number receiving services. There is general agreement that at least 12 percent of the Nation’s children—7.5 million—are in need of some

type of mental health treatment. Available evidence suggests that only a small number (fewer

than one-third) of the children who have mental

health problems receive treatment. An unknown

number of other children maybe at risk for mental

health problems and in need of preventive services (see ch. 4). The problems of a lack of treatment and inappropriate treatment for children’s

mental health problems have long plagued those

responsible for providing services to children.

Subsequent chapters of this background paper examine the current state of knowledge about diagnosable mental disorders and the environmental

risk factors that can cause or exacerbate children’s

mental health problems.
Part II: Problems
Chapter 3

DSMDIII Mental Disorders

in Children
Chapter 3

DSM1111Mental Disorders in Children

INTRODUCTION

The mental health problems of children exist

along a continuum. This chapter describes those

problems which are considered mental disorders

among children, as described in the most widely

used diagnostic manual in the United States—the

third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, better known as “DSM-111’” (19). Generally, DSM111 defines a mental disorder as:

. . . a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment

in one or more areas of functioning (disability).

A description of the major DSM-III diagnosable

disorders in children is important to an analysis

of mental health services, because these disorders

‘At the time this background paper was being prepared, the American Psychiatric Association was revising DSM-111. The new version will be known as DSM-111-R,

THE DSM-III DNOSTIC SYSTEM

A standard diagnostic system provides clinicians and researchers common terms with which

to identify patients and thus makes possible sharing of information about similar classes of patients

(19). It also allows clinicians and researchers to

make use of experience with previous patients in

planning and assessing the effectiveness of mental health treatment.

DSM-III provides clearer, more specific criteria

for diagnoses than previous taxonomies have, and

it bases the diagnoses on descriptive information

about disorders rather than on causal factors,

about which there is still disagreement. These

aspects of DSM-III have been lauded, but criticisms of DSM-III have been raised as well (563).

Some critics have objected to labeling children’s

make up an intellectual framework by which the

mental health professions understand children’s

mental health problems. It takes on added importance, because, in most cases, an individual must

have a DSM-III diagnosable disorder to be eligible for third-party reimbursement for treatment.

For most mental health problems, the etiology

is not known (19). However, many DSM-III disorders and other children’s mental health problems are often related to environmental stressors

such as poverty, parental divorce, and abuse and

neglect. Environmental stressors that pose risks

to children’s mental health are described in chapter

4. Many observers believe that children exposed

to such environmental stressors, in addition to

children with diagnosable disorders, are in need

of preventive or other mental health services discussed in this background paper. Both social and

organic causes of mental disorders are continuously under investigation (668), but a comprehensive analysis of causation is beyond the scope of

this background paper.

mental health problems as “mental disorders” and

have been concerned that DSM-III diagnoses would

be used as labels to discriminate against children

(563). Other criticisms are that DSM-III does not

appropriately address mental health problems that

do not fit into specific categories and lists specific

criteria for diagnosis with little empirical basis for

some categories (563).

DSM-III has gained substantial acceptance in

the United States. Outside the United States, the

ninth edition of the International Classification

of Diseases (ICD-9), developed by the World

Health Organization, is the standard.

DSM-III differs from ICD-9 and other classification systems in several respects. Among other

33
34

things, it is the first widely used system to employ a multiaxial approach to the diagnostic evaluation of patients. The purpose of the multiaxial

system of DSM-III is to “ensure that certain information that may be of value in planning treatment and predicting outcome for each individual

is recorded” (19). DSM-III has five axes, each of

which refers to a specific class of information relevant to a patient’s mental health problems (see

table 5).

The first three axes constitute the official diagnostic assessment. Axis I is for indicating all mental disorders other than those to be indicated on

Axis II. Examples of Axis I disorders are anxiety

disorder and major depression. Axis II is for longstanding personality disorders and specific disorders of development in which a child’s development lags behind that of his or her peers in a

specific area such as reading or arithmetic. A patient can receive multiple Axis I or Axis II diagnoses. Thus, for example, a child could be diagnosed as having an anxiety disorder (Axis 1) in

addition to a reading disorder (Axis II).

Axis III is used to note physical disorders or

conditions that are relevant to understanding or

managing a patient’s mental health needs. The

condition noted can be etiologically significant

(e.g., a necrologic disorder associated with dementia) or not. This axis would be used, for example, to indicate juvenile diabetes, an illness that

can have implications for the management of

mental health care.

DSM-III explicitly recognizes that factors such

as environmental stress and previous adaptation

can influence the course and treatment of a mental health problem. A comprehensive DSM-III

diagnosis includes information on these factors

on Axes IV and V. Axis IV is a rating of the severity of any psychosocial stressors connected with

the onset of a mental disorder. Examples of such

stressors are shown in table 5.

Finally, Axis Visa rating of the patient’s highest level of adaptive functioning, a composite of

a patient’s ability to manage social relations, occupation, and leisure time. Such information is

often important in predicting the course of a disorder and in planning treatment (19).

In classifying mental disorders, DSM-III separates the class of disorders that usually first beTable 5.—DSM-llI’s Multiaxial Diagnostic

Evaluation System

Official DSM-III Diagnostic Evaluation (Axes I,II, and Ill)

Mental Disorders aI

b

Axis 1: All Mental Disorders Not Assigned to Axis Ii

● Mental disorders not assigned to Axis II (e. g., depression, 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 adolescent antisocial behavior)

● Additional codes (e. g., unspecified mental disorder, no

diagnosis on Axis 1, no diagnosis on Axis II)

Axis II: Personality Disorders and Specific Developmental

Disorders

● Personality disorders (e. g., paranoid personality disorder)c

● Specific developmental disorders (e. g., developmental

reading disorder)

Physical Disorders and Conditions

Axis Ill: Physical Disorders and Conditions

. Any physical disorders or conditions that are potentially relevant to the understanding or management of the

individual (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 (catastrophic stressor) of the severity of the summed effect

of all of the psychosocial stressors judged to have been

a significant contributor to the development or exacerbation of the current disorder. Examples of psychosocial stressors that might be considered in the case of

a child or adolescent include puberty, change in residence, overtly hostile relationship between parents,

hostile parental behavior toward child, insufficient or inconsistent 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 or

manmade disaster, A physical disorder can also be a psychosocial stressor if its impact is due to its meaning to

the individual, in which case it would be noted on both

Axis 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 individual’s highest level of adaptive functioning (for at

least a few months) during the past year. Adaptive functioning is a composite of social relations, occupational/

academic functioning, and use of leisure time.

aMental disorders are disorders for which the manifestations are PrimarilY behavioral or psychological; physical disorders are disorders for which the manifestations are not primarily behavioral or psychological,

bA person may have multiple diagnoses on Axes I and 11—0.9., one diagnosis

on Axis I and one diagnosis on AxIs 11, or multiple diagnoses within Axis I or

Axis Il.

cThe diagnosis of a personality disorder is generally reserved for adults, althou9h

the manifestations of personality disorders may appear in childhood or

adolescence.

SOURCE: Adapted from American Psychiatric Association, Diagnostic arrd

Statistic/ Manua/ of &ferrta/ Disorders, 3d ed. (Washington, DC: 1980),

come evident in infants, children, or adolescents

from several other major classes of disorders that

are not generally restricted to children (see table

6). For heuristic purposes, DSM-III groups mental disorders that usually manifest themselves in
35

Table 6.—Children’s Mental Disorders Listed in DSM-IIIa

MENTAL DISORDERS THAT ARE USUALLY FIRST EVIDENT IN INFANCY, CHILDHOOD, OR ADOLESCENCE

Intellectual Disorders

Mental retardation

Mild mental retardation, moderate retardation, severe mental retardation, unspecified mental retardation

Developmental Disorders

Pervasive developmental disorders (PDDs)

Infantile autism (onset before 30 months of age), childhood-onset pervasive developmental disorder (onset after 30 months of age and before

12 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 Disorders

Attention deficit disorder (ADD)

ADD with hyperactivity, ADD without hyperactivity

Conduct disorder

Undersocialized, aggressive; undersocialized, nonaggressive; socialized, aggressive; socialized, nonaggressive; atypical

Emotional Disorders

Anxiety disorders of childhood or adolescence

Separation anxiety disorder; avoidant disorder of childhood or adolescence; overanxious disorder

Other 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) Disorders

Stereotyped movement disorders

Transient tic disorder, chronic motor tic disorder, Tourette’s disorder, atypical tic disorder, atypical stereotyped movement disorder

Eating disorders

Anorexia nervosa, bulimia, pica

Other 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 cannabis

Abuse of any of three classes of substances: cocaine, phencyclidine (PCP), and hallucinogens

Dependence on tobacco

Other, mixed, or unspecified substance abuse (e.g., glue sniffing)

Dependence on a combination of substances (e.g., heroin and barbiturates, amphetamines and barbiturates)

Schizophrenic disorders (e.g., disorganized, catatonic, paranoid, or undifferentiated type)—onset is usually in late adolescence or early adulthood

Schizophreniform disorder

Affective disorders

Major depression (single episode, recurrent)—can occur at any age, including infancy

Anxiety disorders

Phobic disorders:

Social phobia—often begins in late childhood or early adolescence

Simple 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 adolescence

Generalized anxiety disorder

Obsessive compulsive disorder—usually beings in adolescence or early adulthood, but may begin in childhood

Post-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:

Transsexualism

Gender identity disorder of childhood

Paraphilias (e.g., exhibitionism, sexual masochism)

Other psychosexual disorders (e.g., ego-dystonic homosexuality)

Factitious disorders

Disorders of impulse control not elsewhere classified (e.g., kleptomania, pyromania)

Adjustment disorder—may begin at any age

Personality 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 generally

reserved for adults. Some personality disorders in adults have a relationship to corresponding diagnostic categories for children or adolescents:

Disorders of childhood

Schizoid disorder of childhood

Personality disorders

Schizoid personality disorder

Avoidant disorder of childhood Avoidant personality disorder

Conduct disorder (undersocialized, aggressive) Antisocial personality disorder

Oppositional disorder Passive-aggressive personality disorder

Identity disorder Borderline personalitv disorder

aAlth~ugh this list does include the more ~omm~n children’s mental disorders, it is not e~haljstive, Furthermore, only selected disorders are discussed in the text

of this background paper

bDisorders 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)
—

36

infancy, childhood, or adolescence into five general categories based on the aspect of functioning

that is most disturbed: intellectual, developmental, behavioral, emotional, and physical (psychophysiological). Examples of disorders in several

of these categories are severe mental retardation,

developmental reading disorder, undersocialized

aggressive conduct disorder, reactive attachment

disorder of infancy, chronic motor tic disorder,

anorexia nervosa, encopresis, and enuresis.

In addition to the class of disorders that usually first become evident in children, several broad

classes of mental disorders discussed in DSM-III

may affect children. These classes and examples

of disorders that may affect children are shown

in table 6. Such disorders include substance use

disorders, affective disorders such as major depression, various anxiety disorders, and adjustment disorder. Following DSM-III's heuristic for

disorders that usually manifest themselves early

in a person’s life, substance use disorder is discussed in this background paper under behavior

disorders, and depression and anxiety disorder

under emotional disorders. Because it stems

directly from an environmental stressor and can

take various forms, adjustment disorder is discussed separately.

Any given child may have more than one DSM111 disorder, and disorders may involve problems

across general categories. Furthermore, disturbances in one area are likely to have secondary

INTELLECTUAL DISORDERS

The only DSM-III mental disorder that primarily involves intellectual impairment is mental

retardation, although secondary intellectual deficits are often involved in other disorders. Inclusion of mental retardation as a DSM-III mental

disorder on Axis I has provoked concern.

One critical article (563) notes that mental retardation is primarily defined by a lowered level

of intellectual functioning and thus differs from

other disorders, which are characterized by abnormal types of functioning. Advocates for mentally retarded children seek to avoid any prejudice

against this population stemming from the assoeffects on other areas of functioning. Thus, for

example, a child with a specific developmental disorder will often have problems with behavior and

emotions as a result.

Patterns of disturbance vary widely across diagnostic categories. Disturbances present different

clinical patterns, pose different consequences for

children and their families, impinge on different

settings in varying ways, and require different

treatments. Furthermore, mental disorders may

vary in severity. In some cases, for example, childhood phobias are mild and transient; children

often overcome such phobias in the course of development. In other cases, however, childhood

phobias involve severe impairment and interfere

in significant ways with a child’s development

(553). Beyond a certain level, the severity of a disorder must usually be assessed separately from

the DSM- diagnosis.

Several children’s mental disorders within broad

general categories are discussed below. The discussion is not exhaustive. The purpose is to give

the reader a basic understanding of the range of

childhood disorders, along with some information on their prevalence and their consequences

for children. Most of the childhood disorders are

reviewed, but a few are omitted in the interest of

space because they are rare, their consequences

are relatively less severe than those of other disorders, or because the disorders that are discussed

sufficiently illustrate the broad category.

ciation of mental retardation with mental disorders

(422). When mental retardation is discussed in this

background paper, it is because of its inclusion

in DSM-111 or because many mentally retarded

children have mental health treatment needs.

Mental retardation is defined as significantly

subnormal intellectual ability that leads to deficits in functioning. In DSM-III, the criterion denoting intellectual ability in the mentally retarded

range is a score on a standardized intelligence (IQ)

test of 70 or below (although some flexibility on

the IQ is allowed). IQ tests are standardized tests
37

with a mean of 100 and a standard deviation of

15. A score of 70 is two standard deviations below the mean and places mentally retarded children in the bottom 2 percent of children intellectually.

There are an estimated 6 million mentally retarded persons in the United States; the range of

intellectual impairment in these individuals is wide.

The American Association on Mental Deficiency

has identified four broad levels of mental retardation based on IQ: mild, moderate, severe, and

profound (257). These levels are intended to correspond to the individual’s capability for adaptive functioning and the degree to which training

will result in independent functioning. In general,

the more retarded an individual is, the less independence he or she can be expected to gain from

training and the more supervision he or she will

need for self-care, work, and social relationships.

At the extreme, profoundly retarded individuals

require a highly structured setting with continuous care. With adequate training, however, many

mentally retarded individuals can function independently.

Most mentally retarded children—about 80 percent—are mildly retarded. Approximately 12 percent of retarded children are moderately retarded,

7 percent severely retarded, and 1 percent profoundly retarded (19).

Organic causation is not believed to be a factor in most mental retardation. Only about 25

percent of the incidence of mental retardation is

attributable to organic causes (36); moderate, severe, and profound retardation are nearly always

associated with organic brain damage. For 75 percent of mental retardation, almost all mildly retarded, however, there is no evidence of organic

causation. How this type of mental retardation

is caused is not well understood, but it is thought

to stem from environmental causes, genetic causes,

or a combination of the two.

Neurologically based impairments in coordination, vision, or hearing are often associated with

mental retardation (19). Mentally retarded children are also three to four times more susceptible to other mental disorders than children in the

general population (19), especially to other disorders that may have a neurological basis like

stereotyped movement disorder and attention deficit 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 several

means. The parents of some mentally retarded

children may reject or overprotect them (538), or

mentally retarded children may gain awareness

of their deficiencies, leading to low self-esteem and

depression (538).

Further, mental retardation limits the number

and quality of supportive relationships that children can form and limits their flexibility in solving problems; as a consequence, there is an increased likelihood that retarded children will be

frustrated and adopt poor strategies for managing their lives. Institutionalized retarded children

frequently manifest atypically heightened levels

of dependency that are not attributable to cognitive level alone (730). The social environment of

retarded children is apparently critical; whether

they are institutionalized, placed in a community

setting, or raised at home can affect their mentaI

health. Similarly, their mental health can be enhanced by receiving education and training adapted

to their abilities.

Care and training of the mentally retarded is

generally handled by a special service system separate from the system that treats the emotionally

or behaviorally disturbed. Moreover, it is not generally conceptualized by practitioners as mental

health treatment. For these reasons, interventions

specific to mental retardation are excluded from

Parts 111 and IV of this background paper. The

discussion of disorders, environmental risk factors, and services applies to mentally retarded

children only insofar as such children have concomitant mental health problems. Because concomitant mental health problems are common in

mentally retarded children, however, mental

health treatment is an important part of the service

needs of this population.
38

DEVELOPMENTAL DISORDERS

Developmental disorders are characterized by

deviations from the normal path of child development. Such disorders can be either pervasive,

affecting multiple areas of development, or specific, affecting only one aspect of development.

Like mental retardation, developmental disorders

pose multiple problems for a child. Pervasive developmental disorders (PDDs) severely limit children’s ability to function independently, while specific developmental disorders (SDDSs can greatly

impede children’s education and development of

social relations.

Pervasive Developmental

Disorders (PDDs)

Children with a PDD experience severe deviations from normal development in a number of

spheres. Primarily, these deviations are manifested

in cognitive and intellectual functioning, language

development, and social relationships. PDDs

identified in DSM-III are infantile autism and

childhood-onset PDD. DSM-III terms such as infantile autism or childhood-onset PDD have generally superseded older labels such as childhood

schizophrenia or childhood psychosis.

Children with a PDD manifest a gross lack of

interest in others and have problems relating, even

to family members. They may appear oblivious

to family members or caretakers walking in the

room, as if they were inanimate. They often use

language in bizarre ways—i.e., echoing what they

are told, using phrases with their own private

meaning or using the pronoun “you” to refer to

themselves. Also, they often insist on the preservation of sameness in their environments and display odd finger movements or postures. PDD children vary in terms of specific symptoms (712),

but they all share marked impairment. PDDs are

relatively rare, but they affect somewhere between

50,000 and 100,000 children in the United States,

approximately 1 per every 1,000 children (712).

The intellectual functioning of children with

PDDs varies. Many of the children with a PDD

are mentally retarded, and the majority are below average in intelligence. In extremely rare

cases, children with a PDD have brilliant isolated

skills, such as the ability to memorize train schedules or play musical instruments, although they

may not be toilet trained or able to use language

to communicate. The vast majority of children

with a PDD require special educational programs,

and many parents need professional consultation

or training to deal with these difficult children

(712).

In most cases, parents are able to care for PDD

children at home, although home care can become

increasingly difficult as the children become older

(712). PDD is usually chronic, and the majority

of affected individuals are permanently unable to

function independently. Autistic adults are found

in the same placements as adults who are mentally retarded or schizophrenic: hospitals, longterm residential treatment centers, boarding houses,

and often their families’ homes.

At one time, it was thought that the parents

of PDD children rejected them or withdrew from

them in such a way as to lead to disturbance in

their development (58). Such ideas have generally been discredited. Studies indicate that there

are no personality or other differences between

parents of PDD children and other parents (97,

424). It is now suspected that PDD is related to

impairment in neurochemistry or neuroanatomy.

Specific Developmental

Disorders (SDDs)

Children with SDDs have difficulty with specific skills underlying learning, but their overall

development is within normal ranges. DSM-III

identifies several types of SDDs according to the

particular skill which is impaired—e.g., developmental language disorders, developmental reading disorder (i. e., dyslexia), and developmental

arithmetic disorder (19). In children with an SDD,

the development of one of these specific skills is

well below the average for the particular child’s

grade level. All SDDS combined are estimated to

affect 3 to 5 percent of the school age population

(41), although as much as 10 percent of the adult

population is thought to have significant difficulties with reading, possibly related to an underlying disorder.
39

There are two forms of developmental language

disorders: receptive type and expressive type. In

the receptive type, children have trouble understanding spoken language; in the expressive type,

children understand what they hear and know

what they want to say, but have difficulty recalling and arranging the words necessary to speak.

Developmental articulation disorder refers to pronunciation difficulties with English sounds such

as “s” and “th,” leading children to appear as if

they are using “baby talk” (19). Developmental

reading disorder and developmental arithmetic

disorder are diagnosed when reading or arithmetic

skills are impaired relative to expectations for a

child’s age, and neither deficits in intelligence nor

schooling are deemed responsible.

SDD children are prone to school failure. Difficulties in learning are often compounded by secondary mental health problems, including school

behavior problems, aggression or delinquency

outside of school, anxiety and depression, and

BEHAVIOR DISORDERS

Behavior disorders are a set of problems in

which a child’s distress or disability is a function

of his or her overt behavior. Since the central

characteristics of these disorders are behaviors

that disturb or harm others, the child’s social environment plays a large part in whether that child

will be identified as having behavior disorders and

influences the course of these disorders. Some researchers and clinicians maintain that the nature

of behavior disorders and the life history of af -

fected children are especially dependent on the

children’s experience with social systems,

the family, neighborhood, and school.

such as

Attention Deficit Disorder (ADD)

Children with ADD are unable to maintain focused activity for more than a brief period and

continually initiate new activities. Most children

with ADD also suffer from hyperactivity, continual movement that is especially disruptive in

structured group situations like a classroom.

These children are diagnosed as having ADD with

hyperactivity (ADD-H). In addition, there is a 50-

poor relationships with peers (41,576). The perceptual skills that are essential for learning to read,

spell, write, and do arithmetic may also be important in social interactions and in establishing

and maintaining social relationships (82,426).

In some cases, SDD children may have to endure the frustration and anger of parents and

teachers who do not recognize their learning disability or understand how to help them. In such

situations, parents or teachers may ascribe the

child’s failure to laziness or stubbornness. In certain cases, behavioral problems may partially

cause the learning difficulty (576), but in other

cases, emotional or behavioral problems stem

from the breakdown in a child’s education that

is the consequence of having a learning disorder.

Such secondary effects create additional obstacles

to learning and reinforce a child’s classroom failure (132). Many SDD children drop out of school

in their teens (79).

to 80-percent

SDDs (462).

overlap between ADD-H and some

Schoolchildren with ADD may have great difficulty concentrating or inhibiting impulses to

leave their seat and move around during class

time. They may continually call out in class or

push ahead of others in lines because they cannot tolerate waiting. Since the ability to maintain

attention is essential to learning, children with

ADD often have serious academic problems. Further problems may arise from the stress the child

and school experience in dealing with the primary

problem. Like SDD children, ADD children suffer from the frustration and poor self-image

caused by not learning, the stigma of lagging behind their class, and the anger and frustration of

parents and teachers. ADD children are prone to

anxiety, depression, and social withdrawal (426),

and typicalIy have problems developing and maintaining friendships. The severity of ADD varies

greatly across children (556). Some children are

able to compensate for their difficulty with little

interference in their lives, while others are so se-
40

verely affected that they cannot tolerate normal

school programs.

ADD children often exhibit aggressiveness or

stubbornness and are prone to temper tantrums

(439). Aggressiveness and impulsivity may be

primary components of ADD, or they maybe secondary consequences of the frustration and humiliation felt by a learning-disordered or hyperactive child. In addition, aggressiveness may arise

from the struggle with teachers trying to deal with

ADD children in the classroom.

An important factor in ADD is the ability of

children’s families and schools to tolerate and

manage their behavior (470). Although it is unlikely that social factors cause hyperactivity, negative responses from the social environment toward

these children are often an additional burden.

The outcome of ADD in adolescence and adulthood varies greatly. Some children seem to “outgrow” ADD, while others continue to suffer from

ADD into adolescence and adulthood. In some

cases, hyperactivity ends or attenuates in adolescence, but problems with distractibility or impulsivity often remain. As they grow to be adolescents and adults, hyperactive children have an

increased risk of academic and behavioral problems, substance abuse, school failure, and contact with the legal system (62,306,435,441,692).

The causes of ADD are not well understood.

It was once believed that ADD stemmed from

prenatal or perinatal brain injury. But there is no

evidence for the existence of brain damage among

most affected children, and the difference between

hyperactive and normal children in the birth process and infancy does not explain the existence of

these disorders (556). Neurological differences between hyperactive children and normal children

are plausible, but they may not reflect pathology

so much as the general variation in cognitive abilities and temperament in children. Other research

has implicated food additives, allergies, and environmental toxins as causal agents for hyperactivity (176,461), although such evidence is, at

present, only suggestive.

Conduct Disorder

Children with conduct disorder exhibit a pattern of behavior that violates social norms, often

harming others. Such children have a history of

either infringement of the rights of others, or violations of the law, or both. Their pattern of misconduct includes behaviors such as fighting, vandalism, stealing, lying, rule-breaking, and running

away from home. An ongoing history of misbehavior differentiates conduct disorders from the

normal mischief of adolescence.

Conduct disorders are often first defined as

problems by the legal system. Despite some overlap, however, conduct disorder is not the same

as “juvenile delinquency. ” Conduct disorder is a

psychiatric term describing a longstanding pattern of misbehavior, whereas delinquency is a legal term applied to minors convicted of an offense. Many children incarcerated in juvenile

justice facilities would not be diagnosed as having conduct disorder, primarily because their behavior does not comprise a pattern. The extent

to which juvenile crime is associated with actual

conduct-disordered adolescents is unknown.

Children with conduct disorders differ in the

degree to which they are socialized and capable

of forming attachments to others, but there is controversy about whether differences in socialization constitute distinct types of conduct disorders

(19). Some believe that adolescents who have

good family and peer relationships, who have a

reasonable sense of self, and whose delinquency

primarily reflects neighborhood and peer group

influence probably do not truly have a mental disorder (9). The antisocial behavior of such adolescents may be largely directed at those outside their

gang or family.

Some children with conduct disorders are unable to form friendships or extend themselves to

others in any way. These undersocialized behavior-disordered children relate to others in exploitive and egocentric ways. They are also likely

to have experienced problems with conduct from

an early age, when they would normally have de-
veloped the capacity to relate to others. Conduct

disorders that begin prior to age 13 are particularly pernicious. Early onset often leads to serious consequences for both children with conduct

disorders and people around them.

Although disorders of conduct are defined by

a pattern of inappropriate behaviors, such disorders are often accompanied by considerable personal suffering, and children with conduct disorders usually have low self-esteem, despite

outward bravado (19). These children often experience mental health problems such as depression, anxiety, or substance abuse, and/or have

academic problems (19,565). Even when they are

able to form significant relationships, the relationships may be fraught with conflict (432). It should

also be noted that the occurrence of hyperactivity

and conduct disorder overlaps considerably (624).

Estimates of the prevalence of conduct disorder

vary greatly because of the use of different definitions of the disorder and different sources of

data. In addition, the prevalence of conduct disorder varies depending on sociological variables

such as low income and poor housing (703). General population surveys estimate the prevalence

at 5 to 15 percent, but such surveys often use less

stringent criteria than DSM-III (432). A further

problem is that such surveys fail to distinguish

between socialized and undersocialized children

(432).

The course of conduct disorder depends greatly

on social as well as individual factors (19). Gangrelated delinquency, for example, depends on such

factors as youth employment rates. Most children

with conduct disorders, particularly those able to

form relationships, are able to stop their misbehavior as they mature (546). Others may continue

illegal behavior for financial gain, but function

adequately otherwise. Many children with conduct disorders, however, continue their inappropriate behavior into adulthood and maintain a life

centered around criminal behavior. They continue

to have problems with social relationships, and

many suffer in adulthood from alcoholism, drug

dependence, or depression (544). These tend to

be the children whose delinquency starts early and

who have committed a greater number and variety of antisocial acts (544).

41

Many theories for explaining the development

of conduct disorder implicate child-rearing practices. The parents of undersocialized, aggressive

children are believed not to have formed a loving parental attachment to the infant. Many parents of children with conduct disorders are alcoholic or have a history of antisocial behavior

(544,545). Often, children who develop conduct

disorders are unwanted or unplanned. As the child

matures, parents alternate between being uninterested in the child and being overly protective

(432). Other theories suggest biological and

genetic components to undersocialized conduct

disorder (544).

Substance Abuse and Dependence

Drug and alcohol abuse are sometimes viewed

as diseases separate from mental health problems.

In terms of etiology and implications, however,

substance abuse may be similar to other mental

health difficulties. The implications of substance

abuse for children and adolescents are particularly

severe. Substance abuse broadly disrupts a young

person’s functioning, can cause distress and longterm disability, and can lead to or exacerbate conflict in family and peer relationships. Chronic drug

and alcohol use can also harm academic and job

performance. Legal problems arise both from actions carried out under the influence of drugs or

alcohol and from buying, possessing, and selling

drugs or alcohol. Several substances, such as alcohol, barbiturates and sedatives, opiates, and

amphetamines, can, with frequent use, lead to

chemical dependence.

Substance abuse is correlated with problems

such as psychological distress (483), life stress

(156), low school achievement (321), running

away from home (160), parental drug use (547),

and perceived lack of involvement by parents

(483). Substance-abusing children are often troubled by anxiety and depressed moods (19). Several studies suggest that many adolescents who

use alcohol and drugs heavily were psychologically disturbed as younger children (331,486,615;

for conflicting evidence, 338). School learning

problems and aggressive or antisocial behavior

as a child are good predictors of later drug use,

especially if they are associated with difficulties
42

in relationships (338). Available evidence suggests

that interventions aimed at treating substance

abuse and dependence must also deal with the

multitude of other mental health problems with

which abusers are also afflicted (63).

Identifying substance abuse as a type of mental disorder is useful because it draws attention

to the mental health implications of abusing chemical substances. Substance abuse in adolescents,

EMOTIONAL DISORDERS

Several children’s mental disorders have their

most noticeable effect on a child’s emotional state.

The severity of children’s emotional problems

varies widely. To represent a diagnosable mental disorder, however, an emotional problem must

be accompanied by considerable impairment of

a child’s ability to function.

Anxiety Disorders

In children with anxiety disorders, excessive

fearfulness and symptoms associated with fear interfere with a child’s functioning. Anxiety-disordered children may experience muscular tension,

have somatic complaints without physical basis,

and experience repeated nightmares. Children

with anxiety disorders may be preoccupied with

unrealistic dangers and may avoid fear-producing

situations to the point of stubbornness or tantrums.

Anxiety disorders that are especially associated

with childhood or adolescence include separation

anxiety disorder, avoidant disorder of childhood,

overanxious disorder, and certain phobic disorders (19). Children with separation anxiety are

afraid to be away from their parents, from home,

or from familiar surroundings. They avoid a variety of normal activities and, in some cases, refuse to go to school. They may cling to parents

and develop physical complaints when separation

is about to occur; if separated, they become fearful, sometimes to the point of panic. Separation

anxiety may lead children to have morbid fears

about their parents’ death, or difficulty sleeping

if family members do not stay with them. This

disorder often waxes and wanes during childhood

years, usually increasing in response to stress.

however, is frequently associated with other mental disorders discussed in this chapter, including

conduct disorder, ADD, and SDD. Substance use

and abuse by children also illustrates the complexity of identifying discrete mental health problems

and separating disorders from normal development.

Considerable evidence suggests that substance use,

and occasional abuse, is currently “a ‘normal’ developmental reality” among adolescents (369).

Avoidant disorder of childhood or adolescence

is similar in many ways to separation anxiety disorder, except that the focus of the problem is contact with strangers rather than separation from

loved ones. These disorders rarely last beyond

adolescence.

Phobias are irrational anxiety reactions to specific situations or objects leading children to avoid

these situations or objects. Common childhood

phobias include dog, school, and water phobias

(553). Mild phobias are normal and occur among

almost half of all children; they are usually outgrown. Phobias in an estimated 0.5 to 1 percent

of children, however, can be intense and interfere with the child’s development. Children avoid

the feared object to the point of not participating

in an important activity or avoiding learning important new behaviors. School phobia is perhaps

the most common childhood phobia (553) and can

lead to serious educational problems (343).

Childhood Depression

“Depression” can refer to a mood, to a set of

related symptoms that occur together, or to a

complete psychiatric disorder with characteristic

symptoms, course, and prognosis (357). The psychiatric disorder includes both depressed mood

and symptoms of impaired functioning such as

insomnia, loss of appetite, slowed activity and

speech, fatigue, self-reproach, diminished concentration, and suicidal or morbid thoughts (19),

Depression influences concentration, energy

level, and confidence; can affect physical health;

and is usually associated with a perhaps unrealis-
tically pessimistic view of the world (367). Like

other emotional disorders, it has the potential to

seriously impair a child’s abilities to function in

school, with peers, and with family. Depressed

children commonly withdraw from social relationships. The low self-regard, hopelessness, and

helplessness of depressed adolescents may lead to

suicide (93). The amount of mental suffering depressed children undergo can be considerable, although the degree of impairment and length of

the depression vary considerably (19).

Many depressed children exhibit behavioral

problems that are more longstanding and more

alarming to adults than their depression (95). A

conduct or learning problem may be labeled as

the chief disturbance that needs treatment, while

their depression is overlooked. Some theorists and

researchers have called this “masked” depression,

because these behavioral difficulties, in their

ability to stir up and distract the child and others,

protect the child from experiencing painful, depressed feelings (133). Recent research, however,

suggests that with careful questioning, many such

children with behavioral problems will reveal pervasive problems with mood as well as behavior

(102).

Depressive symptoms specific to children may

occur, including anxiety over separation from parents, clinging, and refusal to go to school. Depressed adolescents may react with sulky, angry,

or aggressive behavior; problems in school; or

substance abuse (19). Estimates of the prevalence

of childhood depression are variable as a result

of differing criteria used by researchers, differences in the age of children studied, and other

differences among the populations examined (333).

Estimates range from 0.14 percent (564) to 1.9 percent (332). Among children brought to psychiatric

or education-related treatment centers, estimates

range as high as 59 percent (SOS). Available research does not permit an overall conclusion

about the incidence and prevalence of childhood

depression or about the relationship of childhood

depression to other disorders.

The large number and range of theories suggesting the cause of depression are notable, What

seems most likely is that psychological, biological, and social causal factors arise together to initiate and perpetuate depression (13). Most models

Photo credit OTA

It is sometimes difficult to distinguish between common

adolescent emotional turmoil and more serious forms

of childhood depression and anxiety.

used in explaining how childhood depression develops are borrowed from analyses of adult depression. Studies assessing the applicability of

adult models to childhood depression have been

conducted only recently. For example, much evidence substantiates the relationship between depression in adults and low concentrations of certain neurotransmitters (biochemical that provide

for transmission of impulses across nerve cells).

Several studies have found lower levels of the byproducts of these neurotransmitters in the urine

of children with chronic depressive disorder (428).

Even when children are not clinically depressed,

persistent poor mood or symptoms such as insomnia or poor appetite often accompany other childhood disorders or stressful situations or events.

Clinicians treating children must often attend to

the depressed mood which accompanies demoralization felt in the face of a number of the other

disorders, or environmental or medical stressors.

Reactive Attachment Disorder

of Infancy

Reactive attachment disorder of infancy, in

some severe cases called “failure to thrive, ”

denotes a syndrome in which infants who are receiving inadequate care are poorly developed both

emotionally and physically. If the disorder is not

treated, it often results in severe physical compli-
44

cations: malnutrition, starvation, or even death.

Case studies also show that failure to thrive can

lead to feeding disorders such as obsession with

food and food refusal.

Reactive attachment disorder exemplifies the

complexity of the origins of childhood mental

health problems. DSM-III states: “The diagnosis

of Reactive Attachment Disorder of Infancy can

be made only in the presence of clear evidence

of lack of adequate care” (19). Often, however,

the disorder does not arise simply from “bad”

parenting, but instead arises from a combination

of both complications in an infant’s development

and emotional difficulties and stress affecting parents (153). Some parents interpret problems in an

infant’s feeding or development as rejection. If a

parent, as a result, is unable to properly interpret

an infant’s cues to be fed, the infant will not be

fed adequately, and may develop a severe reactive attachment disorder. Parents who have emotional difficulties or are burdened with stress are

especially predisposed to such a response. A pattern of similar breakdowns in communication between infants and parents can also lead to difficulties developing emotional attachments between

parents and children, and later with the child’s

developing appropriate autonomy. Yet reactive

attachment disorder of infancy can be “completely

reversed” by adequate care (19).

PSYCHOPHYSIOLOGICAL DISORDERS

Children’s mental disorders that involve a disturbance in some aspect of bodily functioning

usually involve a combination of mental and

physical factors; hence, these disorders have been

called psychophysiological disorders. Psychophysiological disorders include stereotyped movement disorders, enuresis and encopresis, and eating disorders. As described below, the physical

manifestations of psychophysiological disorders

are diverse. These disorders may place children

at great risk, since they pose threats to both physical and mental health.

Stereotyped Movement Disorders

Stereotyped movement disorders are thought

to have a primary physical or neurological basis. Nevertheless, such disorders are influenced by

the psychological state of the child and are sometimes amenable to behavioral or psychological intervention.

Children with stereotyped movement disorders

suffer from tics—sudden, repetitive movements

of a particular body part. In a rare form of stereotyped movement disorder, Tourette’s syndrome,

vocal tics (short grunts, yelps, or other vocal

sounds) accompany the body movements (19).

Tics are generally involuntary, although they can

be suppressed temporarily through concentration

(19,598). In general, they are thought to have an

organic basis, yet stress or anticipation can increase their frequency (314,598). Tics may be a

transient or chronic problem (19). Although 12

to 24 percent of schoolchildren in surveys have

reported having had tics at some time, overall

prevalence is unknown because there is no information on how many children have this difficulty

at any one time. Children with these disorders suffer considerable embarrassment and are often unable to bring their tics under continual voluntary

control. These disorders sometimes disappear in

adulthood, but can be lifelong.

Eating Disorders

Disorders involving eating behavior include a

varied group of dysfunctions. The most common

eating disorders are anorexia nervosa and bulimia,

which occur primarily in adolescents. Anorexia

is characterized by a refusal to eat, leading to a

loss of body weight (literally, “nervous weight

loss”). The DSM-III diagnosis of anorexia nervosa

applies to those who have lost at least 25 percent

of body weight. Individuals with this disorder,

typically adolescent girls and young women,

starve themselves because of an exaggerated fear

that they will be overweight and therefore unattractive.
45

In extreme cases, children with anorexia nervosa may refuse to eat altogether, even if they

are already very thin. Because of the possibility

of malnutrition, serious medical illness, or death,

anorexia can have serious consequences. Psychological complications such as depression and withdrawal can also result from the starvation involved

with anorexia nervosa. These complications often

overshadow the original psychiatric problems that

led to the eating disorder (620).

Bulimia is, in some respects, the converse of

anorexia nervosa. Bulimics, usually adolescents,

consume large quantities of food in one sitting

(“binge eating”). They often stop only when pain

or nausea is too great to continue. Often, bulimics

self-induce vomiting or use laxatives, enemas, or

diuretics to purge themselves of what they have

eaten. Because of the physical insult of this pattern of behavior, bulimia can be associated with

physiological disturbance. Although the prevalence of bulimia in adolescents is unknown (19),

recent surveys (271,626) indicate an incidence rate

of 13 to 67 percent for self-reported binge eating

in college populations. Such data suggest that the

problem of bulimia is substantial, although it may

most frequently appear only as a transient problem. Various adjustment problems often accompany a bulimic disorder, including depression and

difficulty with social relationships (322,335,708).

ADJUSTMENT DISORDER

For most DSM-III disorders, a cause is not

specified, because in most cases, causes of disorders are as yet unknown (19). Adjustment disorder, however, refers to a pattern of emotional

or behavioral difficulties that occurs in response

to a stressful event. Stressful events can overwhelm the capacity of children to cope, leading

them to develop disabling emotional reactions to

the stress or to develop unfortunate ways of trying to cope that create more problems. Stressful

events leading to adjustment disorder could include any of a variety of crises such as divorce

or acute illness of a parent. Adjustment disorder

often remits without treatment, either because the

stressful life event has ended or because the child

and family have developed new resources equal

Perhaps the most serious eating disorder is the

coincidence of the two above disorders, which has

been called “bulimarexia” (64). Affecting primarily

adolescents, bulimarexia combines obsessive selfdenial of food with intermittent binge eating.

Casper and her colleagues (105) found that almost

half of a sample of patients with anorexia also

suffered from bulimia, and that these patients

were significantly more obsessional about food,

more guilty, more depressed, and more likely to

be involved in compulsive stealing.

Enuresis and Encopresis

Enuresis is the diagnostic term for bedwetting

and other inappropriate urination, while encopresis is the term for lack of control over defecation.

Each of these disorders has relationships to other

disorders as well as complicated connections to

physiology, environmental factors, and family

genetic history. In many cases, physical problems

either cause these disorders or predispose children

to them (19,596), and there is some evidence that

enuresis tends to run in families (19,33). But enuresis and encopresis tend to occur more frequently

in disadvantaged families (440), under stressful

conditions (19,523), and together with other disorders (565). Enuresis affects 5 to 15 percent of

7-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 in

more serious difficulties.

The main features of adjustment disorder are

depressed or anxious moods, antisocial behavior

(especially in adolescents), difficulties that infants

have in their interaction with their primary caregivers, or inability to work or maintain relationships (19). Thus, adjustment disorder resembles

psychiatric disorders such as anxiety disorder or

conduct disorder. Adjustment disorder is differentiated from disorders with parallel symptoms on

the basis of how long the problem has lasted and

whether or not it followed from a stressful event.

The diagnosis of adjustment disorder is sometimes
46

made by child clinicians because they would often or major depression which imply more pervasive

rather use the more benign label of adjustment impairment.

disorder than diagnoses such as conduct disorder

CONCLUSION

The five general categories of children’s mental disorders discussed in this chapter—intellectual, developmental, behavioral, emotional, and

psychophysiological—represent patterns of dysfunctional adaptation in children. Although normal, as well as mentally disordered, children may

exhibit symptoms of these disorders, in each case,

it is the pattern of pervasive difficulty that leads

to the diagnosis. No mental disorder, however

well-described by current psychiatric nomenclature, manifests itself in parallel ways across children. Environmental risk factors, to be discussed

in chapter 4, can influence both the manifestation

and course of children’s mental disorders. In addition, when maladjustment of a child occurs, it

does not necessarily take the form of mental disability as defined by psychiatric nomenclature.

The diversity and complexity of children’s mental health problems suggests a need for treatment

approaches differentiated according to each specific child’s needs. In addition, the relationship of

many of these problems to normal functioning

suggests a need for integrating mental health services with family and school settings in which children function. Subsequent chapters of this background paper consider these topics more explicitly.
——

Chapter 4

Environmental Risk Factors and

Children’s Mental Health Problems
Chapter 4

Environmental Risk Factors and

Children’s Mental Health Problems

INTRODUCTION

As described in chapter 3, diagnostic manuals,

such as the American Psychiatric Association’s

Diagnostic and Statistical Manual (DSM-III), define mental disorders and set out criteria that must

be met for a mental health problem to be considered a disorder. In DSM-III (19), a mental health

problem is considered a disorder only if the problem is:

. . . a clinically significant behavioral or psychological syndrome or pattern . . . that is typically

associated with a painful symptom (distress) or

impairment in one or more areas of functioning.

Although defining and establishing criteria for

mental disorders is useful, it can mean that children with subclinical mental health problems, or

those in danger of developing a disorder, may not

be considered to be in need of mental health services. In reality, children, particularly those exposed to environmental stressors, may exhibit discrete mental health problems. For example, a child

whose parents divorce may experience anger and

depression. Children with a major physical illness

may experience loneliness when they cannot see

their family and friends, Children born into or

thrust into poverty may experience constant anxiety as a result of financial insecurity. Further,

some children are exposed to multiple stressors

and so may be vulnerable to a number of mental

health problems.

The multiaxial system of DSM-III incorporates

environmental stressors on Axis IV (psychosocial

stressors, including stress arising from physical

illness) (19; also see ch. 3). Because DSM-III is

primarily a manual for clinicians, however, it necessarily treats psychosocial stressors as additional,

rather than primary, information to be used in

developing a mental health treatment plan for a

patient. Although there is disagreement about the

value of primary prevention of mental health

problems (15), it is widely agreed that it may be

possible to address certain environmental stressors preventively.

This chapter describes a number of environmental stressors that children may be exposed to,

along with the mental health problems that may

be caused or exacerbated by such stressors. The

chapter does not review every environmental factor that poses a risk to children’s mental health,

but it does attempt to cover the specific environmental, primarily psychosocial, factors that pose

the greatest risk and to illustrate generally the

effect that environment can have on the development of children’s mental health problems.

And, as acknowledged by DSM-III's multiaxial

diagnostic system, these environmental factors

can also affect the course of mental health problems, and plans to treat such problems, Discussed

are poverty; premature birth; parental psychopathology such as alcoholism, maltreatment,

teenage parenting (a problem for both parent and

child); and parental divorce. The purposes are to

focus attention on the range of children’s mental

health problems that may be amenable to intervention, whether the intervention is designed to

alleviate pain or prevent development of more severe problems; and to raise the issue that it seems

essential to develop policies and programs so that

they work for the particular children who need

to be helped. As discussed in chapter 2, several

national commissions have stressed the importance of attending to environmental factors in developing mental health programs for children.

These commissions have also made specific suggestions for developing such policies and programs. However, it is beyond the scope of this

background paper to draw out fully all the implications of designing a mental health services

system so that it is responsive to all the children

in need.

49
—

50

INTERACTIONS AMONG ENVIRONMENTAL RISK FACTORS

Single environmental risk factors rarely occur

in isolation. Much more common is the occurrence of several risk factors together—often in the

context of a broad risk factor such as low socioeconomic status. Child maltreatment, for example,

most often occurs in families that are disorganized, under high stress, and of low socioeconomic status (219,499,500). Parental divorce often

results in downward economic mobility, relocation to more stressful circumstances, increased social isolation, and loss of important support systems (289).

For a comprehensive look at the mental health

needs of children, it is important to consider how

risk factors interact with one another. For example, ethnicity, social class, and related variables

(e.g., years of parent education) have been found

to have a powerful influence on a child’s development. They, in turn, are related to parental attitudes towards childrearing (360, 572); to the quality of parent-child interaction (640); to children’s

cognition, motivations, personality, and achievement behavior (144,149,150,241,287,320,392, 732);

and, of course, to the community in which a child

lives and the school he or she attends.

It is also important to consider children’s difficulties in the context of knowledge about normal development. It is useful to describe the negative effects of environmental risk factors in terms

of a child’s difficulties with completing important

developmental tasks. Developmental tasks are the

activities children engage in so as to advance to

the next stage of their development (e.g., becoming toilet-trained is a developmental task for toddlers; developing intense friendships with peers

is a developmental task for young adolescents).

A child’s failure to carry out salient developmental

tasks can appropriately be viewed as an indicator of maladjustment.

POVERTY AND MEMBERSHIP IN A MINORITY ETHNIC GROUP

Being poor and being a member of a minority

group are environmental stressors that may pose

risks to children’s mental health (116). Although

it is important to recognize that most poor and

minority individuals make health adjustments

(116), the relationships between these environmental risk factors and poor social and psychological functioning is well recognized (15). In their

1981 review of the epidemiologic literature on the

prevalence of mental disorders in children, for example, Gould, et al. (248), noted that children

who were poor, black, or Spanish-speaking and

living in an urban environment had mental health

problems at rates greater than the 11.8 percent

found in U.S. communities on average. Although

the relationships are correlational rather than

causal, increasing evidence about the effects of

psychosocial stress on both physical and mental

health supports the view that poverty and minority status pose risks for mental health (15). In addition, poverty and minority status are often accompanied by other risk factors, making children

Photo credit: New York Times/Peter Freed

Children who must live in shelters may be at increased

risk of developing mental health problems as a result

of adverse environmental factors such as poverty,

unstable home life, and inadequate care.
51

exposed to other risk factors even more vulnerable to developing mental health problems.

The relationship of socioeconomic class and

ethnicity to mental health takes on particularly

great importance with evidence that poverty

among children—especially among black and Hispanic children—has increased in recent years. A

report prepared by the Congressional Research

Service and the Congressional Budget Office indicates that in 1983 there were 13.8 million poor

children in the United States (646). The report

PARENTAL PSYCHOPATHOLOGY

In most children’s development, the family plays

a crucial role. It is perhaps not surprising, therefore, that the presence in the family of a parent

with psychopathology increases a child’s risk of

experiencing emotional and behavioral difficulties. Some of the difficulties that the children of

mentally ill parents may develop meet the criteria

for standard DSM-III psychiatric diagnoses; other

difficulties, however, are general impairments in

children’s social, emotional, or cognitive functioning that do not meet the standard criteria for diagnosable mental disorders. The relative contribution of genetic and environmental factors in

causing the emotional and behavioral difficulties

of children with mentally ill parents is not clear.

Nonetheless, the occurrence of mental illness in

a parent constitutes a significant risk factor to a

child’s psychological well-being.

Affectively Disordered Parent

The development of children who have a parent with an affective disorder, such as depression

or manic-depressive illness, has been a focus of

much research. Evidence about the incidence of

affective disorders within families indicates that

10 to 40 percent of the immediate relatives of affectively disordered individuals also develop such

disorders (225,315,501,613,713). There is growing awareness that children can manifest the

symptoms of affective illness; although manicdepression is found infrequently in children and

young adolescents, depression does exist during

childhood (95).

notes that child poverty rates have increased

sharply among black and Hispanic children. Currently, almost half of black children in the United

States live in poverty, while less than 15 percent

of nonblack children are poor (117). Being poor

may also mean that children will not have access

to health insurance. An estimated 15.9 million

children and young adults (1- to 19-year-olds)

were uninsured in 1977, the last year for which

national data are available (661a).

Considering the effects of affectively disordered

parents on their children is important, because affective disorders—particularly depression—are

the major form of psychopathology to which children are exposed. The incidence of diagnosable

depression in adult women has been estimated at

1 to 8 percent (70), and an even higher proportion (20 to 25 percent) are estimated to manifest

marked, untreated depressive symptoms (69). Further, the presence of infants and young children

in the home increases the risk for depression in

adult women (45,695).

In children of affectively ill parents, DSM-III

disorders as diverse as depression, separation

anxiety, attention deficit disorder, personality disturbances, and conduct disorder have been identified (371,560,697). The overall prevalence of diagnosable mental disorders in these children has

been found to be in the vicinity of 40 percent

(428,467,477). Although the rates found in various studies are not directly comparable (because

of the use of different diagnostic criteria), the similar direction of results confirms that the children

of affectively ill parents have a higher incidence

of depression and other problems than the children of normal parents.

Parental depression and mania seem to have a

particularly marked effect on cognitive and emotional development during infancy and early childhood (115,218,571,696,725). Studies comparing

the effects of maternal depression with those of

schizophrenia (572), and the effects of maternal

“psychological unavailability,” often a result of
52

depression, with those of physical abuse and neglect (162) for example, indicate that a mother’s

affective illness has a particularly pathogenic effect on a child’s early development. In one study,

children of psychologically unavailable mothers

evidenced striking declines in functioning in every

important area of development from birth to 2

years (162). As a group, these children appeared

even more impaired than children exposed to

physical abuse and neglect.

In middle childhood, children of affectively disordered parents often experience difficulty in important developmental tasks. Such children have

been found to exhibit problems in meeting norms

of school and classroom behavior (192,688); poor

academic performance (550,551); and difficulty

with peers, especially in terms of aggressive behavior (689).

As adolescents, the children of affectively disordered parents often experience difficulties that

are more severe than those of other children.

Garmezy and Devine (221) found, for example,

that children of depressed mothers drop out of

junior high school at more than twice the rate of

controls (22 v. 10 percent).

Studies of children of parents with affective impairments have looked almost exclusively at mothers; therefore it is difficult to draw conclusions

about children of fathers with affective impairments.

Schizophrenic Parent

A parent with schizophrenia, a debilitating and

often chronic mental disorder, places a child at

serious risk for developing mental health problems. Persons who are schizophrenic are plagued

by hallucinations, delusions, or other thought disturbances. Children of schizophrenic parents have

been shown to have a risk of developing schizophrenia 10 times greater than that of the offspring

of nonschizophrenic parents (246). In general,

these children also have more difficulties during

childhood than do children of nonschizophrenic

parents (682). This observation holds true even

in the case of children who have not spent the

majority of their childhoods living with the schizophrenic parent.

Prior to birth, the children of a schizophrenic

mother may already have experienced more adverse circumstances than the children of nonschizophrenic mothers. The pregnancies and deliveries of schizophrenic mothers are more frequently

accompanied by complications than those of nonschizophrenic mothers (430,431,571,720), and

such complications are frequently related to children’s developmental problems. Some researchers have found the increased pregnancy and birth

complications of schizophrenic mothers to be

associated with the low socioeconomic status that

often accompanies schizophrenia (571), while

others have found them to be independent (720).

In infancy and early childhood, children of a

schizophrenic parent often exhibit a number of

mental health difficulties. Such children often

score lower than other children on measures of

cognitive, linguistic, and psychomotor functioning, and they evidence deficiencies in adaptive behavior and emotional attachment (571). These

problems can be exacerbated by the severity and

chronicity of the illness and the low socioeconomic status typically associated with schizophrenia (571,572).

During the preschool and early elementary school

years, children of a schizophrenic parent generally do not exhibit severe behavior problems. During middle childhood, however, evidence of serious social and academic difficulties emerge when

these children are compared to the children of

nonschizophrenic parents. Children of schizophrenics are rated by teachers and by peers as less competent than other children (550). These lower ratings of competence seem to stem from a perception

of these children as more aggressive, impulsive,

and disruptive (431,687). Furthermore, children

of schizophrenics seem to have serious difficulties in terms of intellectual functioning. In comparison to the children of nonschizophrenic parents, they tend to have lower grades (551), lower

IQ scores (431,460,717), and less scholastic motivation (316). In addition, these children have been

found to exhibit more attentional dysfunction

(460), more emotional instability (316,683), and

a greater amount of psychological disturbance in

general (718).
53

In most studies on the development of children

of schizophrenics, subjects have not yet reached

the age at which schizophrenia becomes manifest

(i.e., the early twenties). Nonetheless, they already appear vulnerable. Although epidemiologic

research suggests that only 10 percent of the children of schizophrenics themselves develop schizophrenia in adulthood, one study found that 75

percent of these high-risk children develop some

form of psychiatric disturbance (295).

The relative contributions of genetic and environmental factors in schizophrenia are not known.

It is also unclear whether the negative psychological impact of having a schizophrenic parent is due

to the features of the disorder, to factors related

to mental illness generally (e.g., severity and chronicity), or to the lower socioeconomic status that

usually accompanies this major form of psychopathology.

Alcoholic Parent

Alcoholism is one of our Nation’s most serious

health problems (648,581), and the prevalence of

alcoholism and alcohol abuse among adult men

and women (up to 15 percent) suggests that parental alcoholism is one of the most common hazards to children’s mental health. Abuse of illegal

drugs by parents has also been implicated in the

etiology of drug abuse by children (668a), but has

not been subject to as much analysis as has parental alcohol abuse.

Approximately 6.6 million children under the

age of 18 in the United States are estimated to have

an alcoholic parent (559). That alcoholism may

have serious negative effects on child-rearing and

family relations is suggested by the well-documented harmful consequences of alcoholism to

health, productivity, and other aspects of adult

functioning (see 648). Alcoholism can disable parents from caring for their children effectively, and

it is associated with a number of other family

problems that place children at risk of mental illness. Such problems include family disorganization and divorce, violence, and life changes such

as job loss and frequent moves.

One of the earliest consequences of parental alcoholism is the exposure of the fetus to alcohol

(l). Evidence suggests that alcoholic mothers have

increased risk of complications in pregnancy and

of having children who develop health problems

such as physical anomalies (e. g., heart defects)

and disturbances to physical growth (165). Development of fetal alcohol syndrome, with a combination of birth defects, deficiency in growth,

and deficits in development, is rare (165), but the

development of fetal alcohol effects maybe more

common.

The disinhibiting effect of alcohol suggests that

alcoholism may be associated with child abuse,

although literature examining this relationship is

equivocal (165,166). Some researchers find increased prevalence of alcoholism among child

abusers, others find no relationship, while still

others find that psychosocial disorders in general,

including alcoholism, are associated with child

abuse.

Only a few studies have examined the effect of

parental alcoholism on children’s development,

despite frequent clinical suggestions about the

damaging effects of family alcoholism on a child’s

personality and family relationships (685). Some

studies have identified children of alcoholics as

more susceptible than other children to a range

of psychological, educational, and social problems including “emotional disturbance, ” hyperactivity, legal problems and drug abuse as adolescents, and a variety of behavioral problems and

psychiatric disorders (165,166). However, it is difficult to rule out the possibility that related factors such as socioeconomic status or family disorganization 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 100,000

ment (662). “Maltreatment” includes physical in- to 200,000 children each year experience physi-
54

cal abuse, 60,000 to 100,000 experience sexual

abuse, and over 700,000 children are neglected

(57). Although there are no estimates of the prevalence of emotional maltreatment, it is logical to

assume that emotional maltreatment accompanies

other forms of maltreatment and that there is

another unknown number of children who experience emotional maltreatment alone. Maltreated

children are often exposed to more than one type

of maltreatment (162,231,284). Furthermore, maltreatment often consists of more than a single episode; studies suggest that approximately half of

maltreated children have experienced previous

abuse (159,282,377,610,737).

Maltreatment has long been thought to constitute a significant risk factor for children’s development. Recent clinical and empirical investigations of maltreated children substantiate this

assumption. The quality of available research

varies (see 3); however, the research suggests that

maltreated children are at high risk for physical,

cognitive, behavioral, and emotional difficulties.

Recent research and theorizing about maltreatment, although inadequate (see 729), documents

the cognitive and social-emotional problems of

maltreated children.

Physical Abuse and Neglect

Physical abuse and neglect are believed to cause

intellectual and cognitive deficits, specifically lowered IQ scores that are frequently in the mentally

retarded range. Clinical investigations of physically maltreated infants and children report that

large numbers of these children are functioning

at diminished cognitive and intellectual levels. Research suggests that 33 to 57 percent of physically

abused and neglected infants and children have

IQ scores below 85 (168,413,416,448).

Physically abused and neglected infants have

been shown to have diminished performance on

IQ tests and other developmental measures compared to a retrospective control group (23,146,

194,256,366). Comparison group studies of the

cognitive and academic functioning of preschoolers

and older children have frequently found that

abused and neglected children perform at significantly lower levels than similar, nonmaltreated

children (39,194,212,302,344,502). However, most

of these studies are correlational, and it is possible that at least some children maybe targets of

abuse because of cognitive deficits.

In early and middle childhood, maltreated children exhibit several signs of social and emotional

maladjustment. As preschoolers, maltreated children exhibit more adjustment problems and behavioral symptoms indicative of pathology (163,

502). They are also described as more aggressive,

especially in response to frustration (283). As

school-aged children, they frequently have impaired self-concepts and display heightened levels

of aggression, both with peers and in the classroom

(66,302,534,535). There is also limited evidence

of self-destructive behaviors in these children, including suicide attempts, threats and gestures, and

self-mutilative behavior (255). Finally, in their interaction with adult strangers, maltreated children

are found to be more dependent and imitative

than other children, and to exhibit less motivation to shape their own lives and make their own

decisions (2). It has been hypothesized that these

tendencies negatively affect maltreated children’s

ability to cope with the important developmental tasks of entry into school and effective functioning in the classroom.

That physical abuse and neglect causes at least

some such deficits in development is supported

by studies that compared maltreated children to

control groups that are similar on important demographic and socioeconomic variables. The use

of a matched, nonmaltreated control group is particularly important, since abuse and neglect often

occur in the context of other risk factors such as

high-stress environments and reduced socioeconomic status (222,228,499). Studies using control

groups suggest that maltreatment causes cognitive deficits, in terms of both performance on IQ

tests and academic functioning in school.

Studies using comparison groups also substantiate clinical observations that a significant degree

of social and emotional maladaptation results

from a history of physical maltreatment. As infants and toddlers, physically maltreated children

are often insecurely attached to their caregivers

(162,584), a factor that has been related to social

and emotional difficulties throughout early childhood (385,421,623). In interactions with caregivers, physically maltreated infants and toddlers
frequently exhibit withdrawal; inconsistency and

unpredictability in affective communication; a

lack of pleasure; indiscriminate attachment (214);

and high levels of frustration, noncompliance, and

aggression (162).

Although the relationship between cognitive

performance and emotional difficulties in physically abused children is not clear, emotional and

behavioral problems exhibited by maltreated children have been well documented. Clinical reports

of physically maltreated infants and children describe a heterogeneous group of behavioral and

emotional difficulties. These include severe anxiety, withdrawal, apathy in social interactions, and

hypervigilance and “frozen watchfulness” in regard to the social environment (217,414,415,479,

634). In addition, these children are described as

aggressive, oppositional, impulsive, provocative,

and limit-testing (254,414,415). They exhibit a variety of other behavioral symptoms (e.g., hyperactivity, sleep disturbances, and socially inappropriate 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 100,000

children are sexually abused in the United States

every year (659), although some observers believe

that available estimates probably represent only

a small percentage of actual cases (18). This belief is supported by surveys of adults in which 15

to 34 percent report having been sexually victimized as children (191). In general, girls are sexually abused more frequently than boys, and the

offender is often a family member, particularly

a father or stepfather (122,191,453). Much less is

known about the effects of sexual abuse on a

child’s mental health than is known about the effects of physical abuse and neglect. Nonetheless,

TEENAGE PARENTING

Adolescent parenthood has received increasing

attention in recent years as the perception of the

frequency and magnitude of this phenomenon has

psychological and psychiatric literature strongly

suggest that the experience of sexual victimization

in childhood has serious deleterious psychological effects, both short and long term.

One study of the short-term effects of sexual

abuse in children (12) found that all of the affected

children and adolescents were symptomatic and

in need of mental health attention. The degree of

pathology ranged from mild to severe (e.g., anxiety and sleep disturbances, suicidal ideation, adjustment reactions, psychoses). In general, emotional disturbance was greater when the child was

female, was unsupported by a close adult, had

been molested by a father and/or by more than

one relative, and had been genitally molested.

Severity of disturbance was associated both with

longstanding abuse that began in early childhood

and with sexual abuse in adolescence, even if

limited to only one incident.

One review of the literature indicates that sexually abused children and adolescents suffer from

problems with sexual adjustment, interpersonal

relationships, and educational functioning (452).

The review suggests that when no disclosure or

effective intervention occurs, difficulties can persist into adulthood. The most prominent effects

of child sexual abuse found in adult populations

are disturbed self-esteem and an inability to develop trust in intimate relationships (191).

Unfortunately, available research does not allow us to determine the degree to which these

emotional and other psychological difficulties are

due to sexual abuse or to other factors in the environment. Features of sexual abuse that seem most

strongly related to negative psychological impact

include the nature of the offense, the degree to

which the offender is known, the use of force, and

the age of the offender (190,227,373). Increased

public recognition of problems engendered by sexual abuse is leading to better identification of the

psychological effects and implications for treatment.

grown. Of the over 3 million live births that occur annually in the United States, approximately

600,000 are to adolescent girls between 15 and 19
56

adolescents from poor families (200). The vast

majority of teenage mothers are unwed at the time

of conception (465,726); in 1980 to 1981, only

one-third of teenage mothers were married before

the birth of their first child (466). The proportion

of children born to unwed mothers has doubled

since the early 1960s, and unwed mothers today

are less likely to marry after the birth of a child

than were unwed mothers in prior decades (466).

The unwed mothers who do marry are more likely

to divorce (213,393,578).

Teenage pregnancy and childbearing are associated with heightened medical risks to both

mother and child. In girls younger than 15 years,

in particular, there is a reduced likelihood of receiving adequate prenatal care, and an increased

probability of morbidity and mortality in the offspring and toxemia in the mother (76,446,558).

Offspring of teenage mothers have a greater probability of being premature and of low birthweight

than those born to older mothers (427). In addition, there is an increased incidence of neurological abnormalities in the infants of teenage mothers (73,123,188). Teenage mother-infant dyads are

characterized by less than optimal behaviors;

these are often found to be associated with lower

scores on tests of the infant’s motor and mental

development (183,409,573).

Cognitive deficits and diminished academic performance have been found in the preschool and

school-aged children of teenage mothers. Children

born to teenage mothers have been found to perform more poorly than other children on standardized IQ and achievement tests and on assessments of preparation for school (52,213,409). In

one study, first-grade children who were born to

adolescents were rated by their teachers as “less

likely to adapt to school, ” a variable that correlates strongly with psychiatric symptoms in the

teenage years (339).

In assessing the impact of low parental age on

children’s development, it is important to note the

influence of other environmental factors. The

most important of these are low socioeconomic

status and marital instability. Both social disadvantage and marital instability have powerful

effects on the development of children, independent of the effects attributable to maternal age.
57

Substantial evidence suggests that many of the

negative effects of teenage parenting are only minimally related to the mother’s age at birth, and

are instead a function of the parent’s reduced

educational achievement and low socioeconomic

status (35). Adolescent mothers have been found

to have relatively limited knowledge and unrealistic 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 of

indicators (e.g., cognitive skills) are found for

adolescent mothers and their children who are receiving more support either from the children’s

father or from the mother’s family compared with

those in which the mother is the sole, full-time

caretaker (213).

PREMATURE BIRTH AND LOW BIRTHWEIGHT

Premature birth (defined as gestational age of

less than 37 weeks) and low birthweight (weight

less than 2,500 grams) have potentially broad effects on mental health functioning. The incidence

of prematurity is higher among infants born to

mothers of low socioeconomic status than among

other infants (478,541) and is approximately 10

percent for white infants and 20 percent for black

infants (403).

The strong association of socioeconomic status and race with prematurity and low birthweight

is probably due in part to the association of these

variables with other important factors affecting

neonatal status—e. g., the age of the mother, the

mother’s previous pregnancy history, and the

availability of prenatal care for mother and infant (391). Given the associations between preterrn birth and social and economic circumstances,

it is often difficult to separate the effects of

prematurity from effects related to the correlates

of premature birth (e.g., social and economic circumstances and other illnesses in the child). Moreover, the developmental outcome of premature

infants is being affected by medical advances that

increase the survival rate of smaller and younger

infants (210).

At present, prematurely born infants are likely

to experience some difficulties in several domains

of functioning, including social, environmental,

linguistic, physical, and cognitive areas. One of

the earliest difficulties to appear is disturbed interactions between mothers and preterm infants.

These disturbances constitute a pattern of the infant showing less responsiveness, less positive affect, and more aversion behaviors than full-term

infants and the mother showing more than the

Photo credit: March of Dimes -

Premature birth and low birthweight have potentially

broad effects on mental health functioning.

usual degree of activity and stimulating behaviors

(80,130,145,179,180,181,182). This imbalance frequently results in a vicious cycle, as increased

activity on the part of the mother leads to less infant responsiveness, and this, in turn, results in

more active maternal behavior. In general, pre59-964 0 - 87 - 3
58

term infant-mother dyads have fewer positive interactions than their full-term counterparts, and

this difference may increase over the first year of

life (130). In normal populations, the quality of

early social interactions has frequently been associated with both early and late social, emotional,

and cognitive competence. Similarly, it has been

found that the less optimal social interactions experienced by preterm infants are related to poorer

social, emotional, and cognitive functioning in

early childhood (46,181,186,642).

The incidence of the most severe problems associated with premature birth—e.g., cerebral palsy,

severe mental retardation, brain damage, epilepsy, and vision and hearing defects (99)–has

declined over the last few decades because of improved prenatal monitoring and medical technology (see 635). Nevertheless, infants and children

born prematurely are found to display poorer outcomes than full-term infants and children on a variety of developmental indices. Preterm infants

have been found to perform more poorly than

full-term infants on measures of cognitive, language, and motor development in infancy, including an early assessment of IQ known as the Bayley Scales of Infant Development (80,84,130,185,

195). These problems are especially common in

preterm infants of very low birthweight (i.e., less

than 1,500 grams). Similarly, toddlers and preschoolers born prematurely tend to perform at

lower levels than full-term toddlers and children

on tests of cognitive competence (184,185,195,

307,607,642). Again, these differences are much

more marked for those born at very low birthweights. In addition to exhibiting lowered cognitive competence, preschoolers born prematurely

have been found to display more behavioral symptoms suggestive of minimal brain dysfunction

(e.g., hyperactivity, distractibility, short attention

span, irritability, impulsiveness, specific fears, and

unclear speech); less social maturity; and inferior

language production (184,185,186,642).

For many children born prematurely, developmental delays shown in infancy and early childhood are mild and decrease with age. Some effects of prematurity, however, do not fully emerge

until the school-age years. These effects frequently

take the form of specific cognitive deficits in terms

of visuomotor and other perceptual-motor skills

(100,307,607). Patterns of specific impairment in

perceptual-motor functioning (in the context of

normal language performance) are suggestive of

learning disabilities (607). In general, children

born prematurely have been observed to show

poorer school performance than other children

(124,140,204,273), although recent research suggests that these differences in long-term outcome

may be more related to socioeconomic status than

to prematurity (138,148).

In samples of abused and neglected infants and

children, preterms are frequently overrepresented

(34,168,199,355,583). To the extent that preterms

are in greater danger of being abused, they are

at risk for experiencing cognitive, social, and emotional difficulties associated with maltreatment

detailed above, The cause of the relationship between prematurity and maltreatment is unclear.

Factors in the infant, the parent, and the environment, as well as the effects of early separation of

preterm infants from their parents, have all been

suggested as leading to abuse. It seems likely,

however, that none of these factors alone explains

the link between prematurity and child maltreatment and, instead, that each contributes to produce a cumulative effect (417).

PARENTAL DIVORCE

Parental divorce can have serious consequences parental separation or divorce. From 1970 to

for children’s mental health and has increasingly 1981, the percentage of single-parent families in

been recognized as an important mental health the United States increased from 12 to 20 percent

risk factor. The increasing recognition of its ef- of households (652). Furthermore, recent estimates

fects is not surprising, given recent increases in suggest that nearly half of the children born in

the numbers of children under 18 who are living the 1970s and 1980s will spend a portion of their

in single-parent households, usually as a result of childhood living in a single-parent home (236).
59

The initial period following separation or divorce is one of severe stress and disorganization

for the entire family. During this time, children

often exhibit a variety of behavior problems, including oppositional, aggressive behavior (291,

292,293); and depressive reactions and developmental delays (676,677,678,679,680). These problems often occur in children who have had no

prior history of psychological difficulty or treatment. Moreover, the problems extend into many

parts of children’s lives—family relationships,

school functioning and academic performance,

and relationships with friends. Children from

divorced families are more likely than intactfamily children to have been referred for psychological treatment (28,265). In addition, children

from divorced families have been found to score

significantly lower on IQ tests (292), evidence

poorer work styles (288), and demonstrate generally lower academic and classroom competence

(265).

Many studies report that the various behavior

problems exhibited by children immediately afMAJOR PHYSICAL ILLNESS

As a result of improvements in the quality of

medical treatment, many more children with major chronic illnesses are surviving today who in

the past would have died. Although not strictly

environmental factors, major physical illnesses are

stressful experiences that affect mental health.

Chronic diseases that children are now living with

and that have demonstrated effects on mental

health include cancer (364), cystic fibrosis (151),

and chronic renal failure (705). Burn or accident

victims and children with congenital abnormalities are also afflicted with mental health problems. Chronic medical conditions that lead to relatively little physical disability, such as epilepsy

and diabetes, are also of concern in this context,

because these chronic conditions can frequently

have greater emotional consequences than conditions which are medically more threatening.

In recent years, it has been recognized that the

experience of a major or chronic illness involves

complicated psychological and social stresses.

Several surveys have found that chronically ill

ter divorce tend to abate without treatment in the

2 years following divorce, especially among girls

(294). However, this outcome varies and seems

to be related to several mediating variables such

as the amount of parental conflict after the divorce. One recent study, using a large, randomly

selected sample of children, found that the effects

of divorce did not evaporate after 1 to 2 years

(266). When compared with intact-family children, children from divorced households (particularly boys) were found to experience a variety of

academic, social, mental health, and physical

health problems even 5 to 6 years after divorce.

Factors that can either accentuate or ameliorate

the negative effects of divorce include the child’s

relationship with the noncustodial parent, parent

adjustment, parents’ postdivorce relationship, the

child’s predivorce adjustment and temperament,

the sex and age of the child, and extrafamilial support systems (28). Research varies in the degree

to which it has successfully separated the impact

of divorce from the impact of other mediating

variables (28,169,265,294,370).

children are at greater risk for developing behavioral or emotional problems than are healthy

children (74,425,511,593), although such effects

have not been found for all categories of chronic

disease (155,633).

The diagnosis of a serious childhood illness can

have devastating psychological effects on children

and families, even where survival rates and other

treatment prospects are good. Children face anxiety over the cause of the illness, its course and

prognosis, and the threat it presents to the integrity of their body. They often develop feelings

that they are defective and different from their

friends, and react with shame and lowered self-

-esteem. To manage the disturbing feelings, they

may deny their illness or develop a sense that parts

of their body are alien and separate from themselves, which makes it more difficult to face the

reality of their illness (32).

A second source of stress is the effect of the condition itself (705). Experiencing constant pain or
60

severe physical limitations is extremely stressful.

Furthermore, a medical condition can limit children’s functioning in areas that are especially critical to their stage of development (423,705). Prolonged confinement to bed, for example, interferes

with young children’s developmental need for

movement to explore the world and test their

abilities.

An additional source of stress faced by chronically ill children is the difficulty of undergoing

diagnosis and treatment. Many techniques used

to diagnose and treat illness are uncomfortable,

painful, immobilizing, or defacing. Needles to

draw blood, biopsies, radioisotopic preparations,

and other diagnostic procedures are often more

frightening and painful to children than the slow

course of a disease. Many treatments of severe

diseases (e.g., chemotherapy or radiation therapy)

have painful and debilitating side effects. Treatments such as dialysis, which must be continued

indefinitely, place enormous psychological demands on children. Furthermore, treatment often

forces children to spend long periods of time in

a hospital, separated from their parents and friends.

For some children, the greatest stress arises after they return from the hospital. Anxiety remains

about the risk that their illness will recur, their

body integrity, and their ongoing chances for survival. For children with some conditions, stress

is increased because not much is known about

their prognosis other than that they are at increased risk for having another episode of the disease (364). Children with major and chronic illnesses may have physical impairment remaining

from their illness or from invasive treatment of

the illness—either concrete disabilities such as the

loss of a limb or more unpredictable problems

such as suppression of the immune system. Ongoing treatment regimens, which often involve

frequent medication or other treatment, disrupt

normal school, peer, and family activities of children. Treatment often continues to be painful or

lead to physical changes. Children must rejoin

their classroom and peer groups while still coping with the feeling that they are different and,

in many cases, appearing different from other children. The siblings of a sick child may also suffer

psychologically because of the illness; they often

experience guilt over being well while their brother

or sister is ill and jealousy over all the resources

and attention devoted to the sick one (152,154,

364). Medical conditions and treatments also interfere directly with children’s development, so

that they may fall behind in intellectual, emotional, and social development.

The requirements of managing a chronic illness

often conflict with the developmental or psychological needs of children. For example, chronic illness forces adolescents to be more dependent on

their parents at a time when they need to develop

independence. It may lead children to feel both

responsible for what happens in the family and

guilty over the family’s distress. Often the family exacerbates these problems by being overprotective. In general, normal development is made

more difficult, because illness necessarily places

children in a more dependent, child-like position.

Children’s prospects for the future can be diminished, partly because their illness impairs their

abilities, but also because of prejudice against

them in school or at jobs. There is also often prejudice against recovered patients who try to obtain life and health insurance. Several studies have

found consequences for adaptation, especially in

social relationships, for adults who have had a

chronic childhood medical condition (71,237,474).

An additional complication is that mental and

physical health are closely intertwined; emotional

or behavioral problems often exacerbate physical problems. This is true for almost any disease,

but especially so for conditions such as asthma

in which emotional arousal can stimulate physical symptoms.

Success in coping with a chronic medical condition seems to be related to such factors as the

specific course of the medical illness (when it occurs in life, how long it lasts, number of relapses,

etc. ) and the ability of the family, physician, and

others to be supportive (364).
61

CONCLUSION

A number of biological and psychosocial factors can pose risks to children’s mental health.

This chapter has examined a number of the more

severe environmental risk factors for children—

poverty, minority ethnic status, parental psychopathology, physical or other maltreatment, a

teenage parent, premature birth and low birthweight, parental divorce, and serious childhood

illness. The evidence on many of these factors and

their direct relation to children’s mental health

problems is sometimes unclear, primarily because

children exposed to one risk factor may be exposed to others as well.

Consideration of environmental risk factors is

important to an examination of children’s mental health problems and services. As is acknowledged in diagnostic manuals such as DSM-III,

knowledge of a child’s physical health status and

psychosocial environment is important to developing an effective mental health treatment plan.

For policy purposes, it can be important to know

that children’s mental health problems are not

limited to mental disorders, and that it may be

possible to prevent development of some mental

health problems by reducing certain risk factors

(e.g., poverty) and ameliorating the effects of

others.
Part Ill: Services
Chapter 5

Therapies
Chapter 5

Therapies

INTRODUCTION

The specific techniques used to treat children

with mental health problems vary depending on

the nature and severity of a child’s problems, the

orientation of mental health professionals, and the

resources available to finance and house treatment

services. Although some treatment methods have

been devised especially for children, most are

adaptations of procedures used with adults.

This chapter describes the principal treatment

methods currently used with children by mental

health professionals:

INDIVIDUAL THERAPY

The paradigm for mental health treatment has

traditionally been individual therapy—the oneon-one encounter of a therapist and a patient.

Over the past 50 years, there have developed a

large number of individually based therapies based

on theories as disparate as psychoanalysis and

operant conditioning. Each theory has spawned

various approaches to individual therapy that

have been adapted for use with children.

Three broad categories of treatment approaches

used

1.

2.

3.

with individual children are described below:

psychodynamic therapy, which focuses on

the development of insight;

behavioral therapy, which is based on behavioral learning theories and relies on positive and negative reinforcements to create

changes in behavior; and

cognitive therapy, which is based on cognitive learning theories and trains individuals

to use new patterns of thinking.

Each of these approaches, though developed to

deal with individual patients, can also be used as

part of group and family therapy. Furthermore,

although psychodynamic, behavioral, and cognitive therapy are based on distinct theories, in

practice, many clinicians use an eclectic therapeutic approach.

. individual therapy,

● group and family therapy,

● milieu therapy,

• crisis intervention, and

● psychopharmacological (drug) therapy.

In practice, most of these techniques are used

in combination with one another.

Psychodynamic Therapy

All forms of therapy for children involve bringing about changes in their cognition, emotions,

and behavior (260). What distinguishes psychodynamic approaches is their emphasis on cognition and emotions and the concomitant idea that

changes in these two realms will be followed by

changes in behavior. When psychodynamic approaches are used with children, they often involve elements that are usually not emphasized

with adults and that blur distinctions between

psychodynamic and other therapeutic approaches

with children. These include clarification of conscious feelings and thoughts and aid in the development of alternative problem-solving and

coping strategies. The accentuation of these techniques in work with children reflects children’s

early stage of cognitive and psychosocial development.

Psychodynamic therapy with children is usually accompanied by other interventions. Most

often it is accompanied by therapy with the child’s

parents. The involvement of individuals in the

child’s environment reflects the fact that children

are more dependent than adults and less able to

change their environmental conditions.

67
68

Psychodynamic child therapy requires considerable resources. A highly trained clinician must

provide the therapy, several individuals in the

child’s environment need to be involved, and frequent therapy sessions may be needed. Psychodynamic child therapy usually involves once- or

twice-weekly meetings between therapist and

child. There is no predetermined length of treatment, and treatment can last from a few weeks

to a few years (9). Because of the resources needed,

it is probably more typical that individual therapy with children is psychodynamically informed

rather than a pure instance of the psychodynamic

model.

A number of mechanisms are thought to account for therapeutic change in psychodynamic

child therapy. An emphasis on one mechanism

or another may depend on a child’s age, the child’s

relevant strengths and weaknesses, and the severity of the child’s problem (207).

I

Emotional expression by the child and the labeling of emotions by the therapist are primary mech-

~ anisms in psychodynamic therapy. The expression of feelings is thought to aid the child by

providing him or her with an opportunity for

catharsis. The labeling of feelings by the therapist

is believed to enable the child to place the feelings in context, thereby reducing his or her sense

of being overwhelmed. The therapist’s intervention is also thought to help the child understand

the connections between thoughts, feelings, and

behaviors. The goal is to replace the acting-out

of conflicts with feeling, thinking, and verbalization.

Psychodynamic therapy is also hypothesized to

aid in the development of ego structure (i. e., a

sense of self), which is particularly important for

children whose problems began early and who

lack self-esteem and impulse control (361). In

addition, psychodynamic therapy can provide a

child with a “corrective emotional experience. ”

This occurs because the child’s usual expectations

(e.g., rejection or punishment) are not met, and

eventually the “automatic” connections between

feelings (e.g., between anger and guilt) no longer

occur. Finally, psychodynamic therapy is believed

to produce change because it instills hope in the

child and fosters the belief that the important people in his or her life are caring and concerned.

Photo credit Charter Colonial

In play therapy, problems are approached through

games in order to put children at ease.

Despite a well-described theory of the mechanisms of psychodynamic therapy, there are few

empirical data to guide decisions about which

mechanisms should be emphasized in the treatment of specific problems and particular types of

children, Substantial clinical literature suggests

that an insight-oriented approach that focuses on

widening children’s understanding is most applicable for children with relatively good functioning and circumscribed internal conflicts. Children

with major developmental problems and limited

introspective abilities are probably better served

with an approach that stresses problem-solving

skills (207,272,481,537).

Psychodynamic therapy is contraindicated in

situations in which the parents are unwilling to

support the treatment and situations in which the

problem is best addressed by altering a child’s

environment (via the family or school). It is also

contraindicated for children who do not have the

ability to form a working relationship with a therapist (274).

Behavioral Therapy

Behavioral therapy was developed more recently than psychodynamic therapy, but it is more

widely applied in treating children (553). Behavioral therapy assumes that a child learns persistent pathological behavior from his or her ex-
69

perience with the social environment. Therapists

using behavioral techniques systematically analyze the child’s problem and environment and

identify the specific behaviors to be modified. As

part of the assessment, frequency counts of

maladaptive behaviors may be carefully collected,

along with data on the situation within which the

maladaptive behavior occurs. Then specific behavioral techniques are applied in an effort to

change specific problem behaviors.

Models of Learning on Which Behavioral

Therapies Are Based

Several models of learning underlie behavioral

therapy methods. The most commonly applied

model is operant conditioning. This model assumes that learning results from the consequences

of behavior (611). Behavior that leads to rewarding consequences is said to be positively reinforced

and, as a consequence, is presumed to increase,

while behavior that leads to unrewarding or punishing consequences is presumed to decrease. In

behavioral therapy based on operant conditioning, adaptive behavior is explicitly rewarded,

while maladaptive behavior is either explicitly not

rewarded, leads to a delay in reward, or is punished. Thus, for example, children who have

problems with aggression and who learn to interact appropriately with classmates may receive

special rewards. Some residential treatment settings use “token economies” in which children

“earn” tokens that are redeemable for privileges.

A second model for behavioral therapy is reciprocal inhibition (716). This model holds that

children “learn” an inappropriate, anxious reaction (e. g., a phobia) to an aspect of the environment. Behavioral therapy based on the reciprocal inhibition model usually involves training

patients in systematic desensitization—i .e., substituting relaxation or other appropriate behaviors

to break the patient’s association between a feared

object and an inappropriate reaction (37).

A third paradigm, sociaol modeling or observational learning (37), is an elaboration of operant

conditioning (252). According to this paradigm,

an individual learns new behavior by observing

another person successfully carrying out the new

behavior and being rewarded for it. For example,

observing another child approach a dog could be

used to help a child patient overcome a dog

phobia.

Applications of Behavioral Therapies

Behavioral therapies are applied in the treatment of children with specific intellectual and

developmental disorders, behavior disorders,

emotional disorders, and psychophysiological disorders.

Intellectual and Developmental Disorders.—

In the case of mental retardation or pervasive development disorders (PDDs), behavioral therapy

is not intended as a “cure. ” It has been used, however, as a major tool for training severely disturbed children to communicate with others and

to develop self-care skills (252). Children are

trained to use language (305), to develop household skills like telling time and counting change,

and to develop social and educational skills. Behavioral methods are sometimes prescribed as specific, intensive, time-limited procedures, but more

often they are integrated into a treatment setting’s

program. For example, meals can be used as part

of a behavioral treatment program to teach children to make requests (252). Operant conditioning relying on positive reinforcement has been the

mainstay of this training.

Behavioral therapy has often been used in seeking to limit tantrums, self-mutilation, and other

self-destructive behaviors in children with PDDs

(410). Punishment is used occasionally (e.g., the

use of electric shock to stop head-banging), although considerable public and scientific controversy exists about the side effects and ethics

of using punishment with children (641).

Behavior Disorders.—A number of behavioral

techniques have been developed for treating children with attention deficit disorder with hyperactivity (ADD-H) (129). The contingency management approach requires that parents and teachers

use a structured system of rewards contingent on

appropriate, attentive behavior by the children.

Behavioral therapy is frequently used with conduct-disordered children in residential juvenile justice facilities. The focus is on improving delinquent children’s social or educational skills, while
70

decreasing delinquent behavior within the residential setting (252). Operant conditioning is the primary technique, and token economies are used

frequently, but techniques such as behavioral contracting are also employed (591).

Emotional Disorders. —Behavioral techniques

have a long history of use in treating children’s

phobias—a subset of anxiety disorders. Whether

desensitization, modeling, or other techniques are

employed, most seek to reduce children’s anxiety

so that they will approach (physically or symbolically) and eventually confront the feared object.

Behavioral techniques have not been extensively

developed for treatment of emotional disorders

other than anxiety.

Psychophysiological Disorders. -Most psychophysiological symptoms are believed to be amenable to behavioral treatment. Therapists have

adapted behavioral techniques such as relaxation

training, self-control training, and operant conditioning to teach children with stereotyped move1 ment disorders to have greater control over their

I bodies.

I The use of operant conditioning techniques is

especially common with enuretic and encopretic

children. One such technique, the bell-and-pad

technique, for example, places a special device on

an enuretic child’s bed that sounds a wake-up

alarm on contact with a child’s urine, teaching the

child to associate sleeping with continence (450).

Operant conditioning techniques have also been

used to treat patients with eating disorders such

as anorexia nervosa.

Parent Training in Behavioral Therapy .—Training parents to use behavioral techniques with their

children is increasingly favored and has great potential for expansion (251). The application of behavioral techniques by parents has an inherent

logic in that parents are responsible for their children and can be directly involved as soon as a

problem is identified. It is also an important approach to consider in light of resource constraints

and the desirable policy of providing treatment

for disturbed children in the least restrictive environment. For some children, a home environment

in which the parents apply behavioral techniques

can replace the behaviorally programmed environments of residential treatment settings such as

psychiatric hospitals and residential treatment

centers (RTCs). For the implementation of many behavioral techniques, fairly little training is needed.

Many parents of severely disturbed children

have received training in operant conditioning and

other behavioral management techniques used in

residential treatment settings (398,585). Parents

of children with some of the less severe psychophysiological problems have also received

training in behavioral techniques, including for

example, the bell-and-pad treatment for enuresis.

The most common application of parent training

is, by far, to childhood behavior problems. These

problems can range from tantrums in a toddler,

to disruptive classroom behavior (27), to adolescent delinquency. Parents are also reported to

have conducted successful behavioral treatments

for school phobia (285) and night-time fears (251,

343).

A frequent combination of behavioral procedures taught to parents includes:

1.

2.

3.

providing positive reinforcement for appropriate behaviors (usually in the form of attention or praise);

avoiding inadvertent reinforcement (e.g.,

negative attention) for disruptive behavior

that is not severe (“extinction”); and

segregating children by themselves for more

severe disruptive behavior (554).

The use of behavioral contracts is encouraged in

some families with conduct-disordered children

(252).

Although the techniques of behavioral therapy

are relatively simple, especially compared to those

of other individual psychotherapies, the analysis

of a child’s behavior is usually complex, especially

when there are multiple dysfunctions. In addition,

designing reinforcement schedules and redesigning a child’s environment can be more complex

than mere description would suggest.

Parents can learn appropriate behavioral techniques from self-help manuals (487), as well as

directly from professionals (429). Self-help

manuals vary in their quality and their grounding in empirical evidence (235). Since self-help

techniques are largely out of the hands of professionals once the books are written and distributed,
71

little is known about the extent, manner, and effectiveness of their use.

Cognitive Therapy

Clinical and research findings indicate that

thinking processes of disturbed children are different from those of other children (399,674). Such

findings have led to cognitive treatment modalities that attempt to alter the way disturbed children think about their behavior and their environments. Although the way in which cognitive

interventions attempt to change thinking varies

greatly, two broad classes of cognitive interventions can be identified. One class of cognitive interventions tries to alter the thinking that takes

place during a child’s troublesome behavior—e.g.,

by having impulsive, distractible children verbally

describe their actions to themselves as they do

them (433). The other class of cognitive interventions tries to influence how children think about

themselves and others.

Cognitive interventions are used to help children with many types of problems: behavior,

learning, emotional, and social problems. One

cognitive method derived from theories about

neuropsychological functions (399) trains children

to use speech as a tool to slow down and focus

their learning and behavior (433). Other cognitive interventions train children in such aspects

of learning as the amount of time used to respond

to a question (436), the visual scanning of educational material, question-asking strategies (143),

and analytic abilities (164). Peers and adults who

use effective strategies are often used as models.

GROUP AND FAMILY THERAPY

Group and family therapeutic approaches are

rooted, in part, in theories of individual behavior.

They are also based on distinct theories of peer

and family relations. Because of the importance

of peers and family members or other adults in

a child’s life, group and family therapy are often

used to treat children with mental health problems. The purpose of group therapy is not simply to reduce the cost of treatment by providing

treatment to several children simultaneously.

For emotionally disordered children with phobias, therapists have used behavioral models combined with cognitive training to demonstrate that

a feared object or situation can be confronted

(351). In addition, various cognitively based training programs have been used to teach emotionally disordered children to solve interpersonal

problems more effectively. Other cognitive training programs aim to improve young people’s ability to understand and think through social situations (their “social cognition”) (643). Such

cognitive training may include procedures that

teach children the consequences of their behavior

for others (621), or train them to take the perspective of others—and to know thereby what behavior would be best in the relationship (643). There

may be a significant educational component to

these cognitive interventions. For example, some

learning groups offer children concrete information about how to improve their social skills (376).

Some cognitively based training has focused on

training delinquent adolescents the skills necessary to manage group living or a job interview

(574).

Cognitive methods are also used with families

of disturbed children. For example, some therapists have taught social problem-solving skills

to families, especially families of behavior-disordered children (16,347).

In summary, cognitive therapeutic interventions have wide applicability. Cognitive approaches are incorporated in many therapies, and

although cognitive approaches require trained

mental health professionals, they can be adapted

in many settings.

Rather, the goal is to treat aspects of a child’s

problem which involve interaction with peers and

significant adults.

Group Therapy

Although group therapy incorporates elements

of other treatments, it is nevertheless a distinct

treatment modality. The effectiveness of group

therapy is thought to arise from interpersonal
72

processes within the therapeutic group (722).

Therapeutic groups are believed to develop an indigenous “culture” (507) and to allow individuals

to develop new ways of relating. The strengths

of one child become a model for other children,

while the entire group can help an individual child

address a weakness (230).

The therapist’s task in group therapy is to help

the group develop helping capacities and to perform organizing and caretaking functions within

the group (582). Children in group psychotherapy are a heterogeneous population, and psychotherapy groups are not usually targeted to a particular disorder; most groups aim to address

problems in relationships and identity that cut

across disorders. Group therapy is thought to be

particularly useful for children experiencing difficulties in peer relationships.

Group psychotherapy for children is adapted

to the developmental level of the group. Therapy

groups for young children are usually organized

around group play and activity-oriented social behavior, while adolescent therapy groups rely more

heavily on discussion. Particularly for adolescents, the structure of group therapy depends on

the level of social relationships among group

members.

Group therapy is not always conducted by

group therapy specialists. It is sometimes provided

by therapists of various orientations (e.g., behavioral and cognitive), Therapists who do not

specialize in group therapy typically consider the

dynamics of the group less central than other

processes. For example, a behavioral therapist

may intend group therapy primarily to provide

mutual reinforcement for improved behavior or

peer modeling (342), Group psychotherapy is

often provided as an adjunct to other modalities,

particularly individual psychotherapy or family

therapy.

Family Therapy

Although most child therapists point to the importance of the family in understanding and treating children, family therapists are distinguished

by their unique way of reconceptualizing a set of

symptoms. For family therapists, problems do not

lie within the child (as suggested by traditional

psychiatric diagnosis), but are manifestations of

disturbed interactions within a family. A child’s

symptom is viewed as an indicator of larger family

problems and as a response that serves a function for the entire family. Thus, for example, a

child’s symptom can deflect attention away from

more fundamental difficulties such as strife in the

parents’ relationship (402,442). Because of its

functional and protective role, the symptom is reinforcing to the family, and families are psychologically invested in maintaining it. Although

family therapy does not necessarily involve the

presence of every family member at each session

(67), family therapists believe that a child cannot

change if the family does not change as well

(203,442).

Several models have evolved within family

therapy, and each offers different techniques for

intervening to produce change. Zimmerman and

Sims (736) describe three models: dynamic, systems, and behavioral.

Dynamic models for family therapy are characterized by their reliance on insight as the main

method of producing change. Frequently, the focus of insight is on pathological patterns of functioning that are carried from the parents’ own past

into the present family situation. These patterns

may involve conflicts over autonomy and dependency (704), developmental failures that have

occurred over generations and are being “projected” onto a child in the current family (612),

or situations in which a child’s symptom represents an “invisible loyalty” to transgenerational

themes (65). Insight into the way in which patterns from the past affect the present is believed

to produce growth in all family members, allowing the child to give up the symptomatic behavior.

Systems models for family therapy encompass

a diverse group of theorists and techniques. One

such model is structural family therapy, an approach most closely associated with Minuchin

(443,445). Structural family therapy is aimed at

changing the family’s psychosocial organization

with the expectation that this will produce a change

in the experiences of individual members. Family structure, according to Minuchin, is the “invisible set of functional demands that organizes

the way in which family members interact” (442).

Aspects of family structure that maintain or are
73

the result of dysfunction include family boundaries, alignments, and the balance of power. For

example, Minuchin (442) notes that families with

an anorectic child are frequently characterized by

enmeshed relationships, restrictions on individual autonomy, and lack of conflict resolution.

Therapy involves firming up the boundaries between the parental and child subsystems, breaking the facade of mutual agreement between the

spouses, and helping them to negotiate conflict.

This approach does not preclude separate medical attention for the anorectic child. It does, however, propose that the family, rather than the

child, is the matrix within which change must

occur.

A related systems model is strategic family therapy (171, 172,269,270,684). Strategic family therapists accept the idea that an individual’s symptom

serves the function of stabilizing and maintaining a balance in the family system. Their approach

in therapy, however, is to focus largely on the

symptom itself. Specific techniques are used to reMILIEU THERAPY

Milieu therapy involves utilizing daily living in

a therapeutic setting to teach patients social and

educational skills, to explore patients’ emotional

life and patterns in relating to others, and to provide patients with ongoing support.

The setting in which milieu therapy is provided

is either a hospital, an RTC, or a day treatment

center. Every aspect of daily life in this setting is

shaped to contribute to a child’s recovery. Such

disparate areas of life as a child’s evening routine

or how he or she reacts to conflict with another

child become opportunities for professional and

other staff to intervene and help a child learn more

adaptive behavior.

Interventions in milieu therapy can be as prosaic as teaching children to replace rough physical contact with a special handshake or as profound as pointing out a parallel between children’s

veal the changeability of the symptom and to

make the previously covert functions and control

of the symptom more overt and obvious to all

family members. Strategic family therapy does

not rely on insight to produce change, and the

course of treatment is frequently brief (736).

A third model of family therapy is behavioral

family treatment developed by Patterson (487,

490,497). Designed for use with families of conduct-disordered children, Patterson’s approach is

based on the observation that parents of these

children tend to reinforce the occurrence of aggressive behavior and discourage the occurrence

of prosocial behaviors (491,492). Parents are

trained in the techniques of social-learning-based

child management. Through exposure to programmed texts and participation in a parent training group, parents are taught to define, track, and

record both deviant and prosocial behaviors in

their children and to devise behavioral contracts

which specify the consequences of specific behaviors at home.

reaction to the staff and their relationship to their

family (639). In many therapeutic milieus, the intensive therapeutic relationships that develop with

several different staff are thought to give children

a chance to re-create and then work out a number

of interpersonal difficulties. Behavioral programs

are often used as the basis of milieu therapy.

Milieu treatment also includes the group programs used to meet some of the children’s needs

for education, recreation, and a sense of community. For example, community meetings are held

to review events within the hospital and explore

their relationship to patients’ difficulties, Groups

led by professional staff in art therapy, music therapy, and recreation may allow patients to express

feelings about their predicament and, at the same

time, learn better ways to adapt.
74

CRISIS INTERVENTION

Crisis intervention is an outpatient treatment

based on clinical and other evidence that a major upheaval in a child’s life, such as the loss of

a family member, can pose an acute threat to the

child’s mental health (388). Unlike several other

approaches, crisis intervention programs often intervene within children’s homes. Crisis intervention is sometimes used as an alternative to hospitalization for acute mental health problems. The

major goal is to help children and families return

to their previous level of functioning. Crisis intervention is usually completed within 6 weeks

and often within days (388), but it is often followed by other outpatient treatment.

Crisis intervention techniques emphasize practical steps to defuse threatening situations and to

provide family members with coping resources.

Specific contracts and emergency plans, for example, are made with family members to lower

the level of tension. Suicide prevention is a focus

of intervention when necessary, and crisis intervention services are typically offered intensively

on an as-needed, off-hours basis. Often, a crisis

intervention specialist arranges for additional

emergency services, such as emergency caretaking for children to relieve some of the stress on

an acutely disturbed parent.

Crisis intervention with children necessarily involves the family; a tenet of the approach is that

parents must be helped to develop coping skills

necessary to manage in a crisis. The Homebuilders

program exemplifies a crisis intervention model

that works within children’s homes (350). Homebuilders staff begin by uncovering the nature of

the family crisis from all viewpoints, defusing tension by letting family members vent their frustrations and concern, and helping the family develop alternative behavioral, cognitive, and

emotional means to deal with the critical problem. After the initial intervention(s), contact is

maintained until clients are referred to and then

receive continuing services.

PSYCHOPHARMACOLOGICAL (DRUG) THERAPY

Psychoactive medication is a small but growing modality of treatment for children’s mental

health disorders. Although widely used with

adults, psychoactive medication has only recently

been regularly prescribed for children.

The range of children’s mental health problems

for which drugs have been prescribed has increased over the last decade. Yet psychopharmacological treatment is not regarded as a panacea

for the treatment of any disorder, and there appears to be consensus on the necessity of combining drugs with other treatments.

Stimulants

ADD is one of the few childhood syndromes

commonly treated with drugs. The drugs used

usually are stimulants, including methylphenidate

(Ritalin®) and dextroamphetamine (Dexedrine@

).

Even though ADD children are generally overactive, stimulant drugs act to increase their attention span. The mechanism underlying the effects

of stimulant drugs is not well understood; the best

understanding is that such drugs stimulate areas

of the brain responsible for maintaining arousal

and focusing on specific functions (121). Drug

treatment alone is rarely sufficient, and psychological interventions with the child, family, and/

or his school environment are usually combined

with medication (577).

Neuroleptics

Some children with severely disabling disorders

—autism, brain injury, mental retardation—

exhibit behaviors that are dangerous to themselves

or others. They may, for example, hit other children or destroy furniture when they become excited. Some may develop disabling preoccupations or harmful delusional ideas. Usually,

attempts will be made to control their behavior

without the use of medication, but in some cases,
75

neuroleptics —also known as antipsychotic medication—will be used.

Neuroleptics may significantly reduce hyperactivity, aggressiveness, and agitation in severely

impaired children (89). It should be noted, however, that neuroleptic medication is used not as

a treatment to reverse severe disorders, but rather

as a means of reducing troublesome symptoms

associated with a disorder. Trifluoperazine

(Stelazine”) and haloperidol (Haldol®) appear to

be the two neuroleptics of choice (89) for such applications, partly because they have fewer sedative effects than other neuroleptics. Recent research (89) has demonstrated that haloperidol

reduces stereotyped movements, hyperactivity,

deficits in attention, and difficult behaviors in autistic children, and can also be associated with an

increase in intellectual functioning. Neuroleptics

have little or no direct effect on symptoms such

as difficulties in relating to others, although they

may have an indirect effect on social functioning

by reducing symptoms like agitation. Typically,

neuroleptics are used as adjuncts to intensive psychotherapy and other treatments (89).

One concern about most neuroleptics is their

sedative effect. Neuroleptics sometimes affect cognitive functions necessary for relating to others,

CONCLUSION

The mental health treatments outlined in this

chapter are based on diverse theories of children’s

actions, reactions, and mental disturbances. Some

mental health treatments used for children have

been developed in response to particular childhood problems, but the majority are adaptations

of treatments used for adults and based on general theories of behavior. There is substantial varfor learning, and for carrying on daily life–all

functions that clinicians aim to increase in severely

disabled children. Major tranquilizers can also reduce a child’s motivation. Furthermore, the side

effects of tranquilizers can be very uncomfortable and sometimes are a source of impairment.

Possible side effects include a continuously dry

mouth, tremors, and cardiovascular changes.

With prolonged use, antipsychotic medications

can lead to tardive dyskinesia —an often irreversible movement disorder characterized by uncontrollable repetitive movements of the tongue, lips,

head, or neck.

Antidepressants

Antidepressant treatment of childhood depression began in the 1960s (333), but it has not received widespread clinical application. With recent increased interest in childhood depression,

research is being conducted on the use of antidepressant medication, especially the tricyclic

antidepressants widely used with adults. Drugs

have also been used to treat some specific childhood anxiety disorders, although most of these

disorders are considered best treated psychologically rather than with drugs (121).

iation in treatment practice based on differing

theoretical orientation. Analyzing treatments in

terms of their psychodynamic, behavioral, and

cognitive assumptions is useful in understanding

how treatment decisions are made, although in

practice, a number of approaches may be used.

The effectiveness of mental health treatments used

with children is considered in chapter 8.
Chapter 6

Treatment Settings
Chapter 6

Treatment Settings

INTRODUCTION

The settings in which mental health treatment

for children is provided greatly influence the intensity of the treatment, the resources required,

and the treatment experience of children and their

families. This chapter describes treatment settings

in the mental health service system: hospitals, residential treatment centers (RTCs), day treatment

programs, and outpatient settings such as community mental health centers (CMHCs). Mental

health services in non-mental-health settings, preventive services, and the integration of mental

health and other services are described in chapter 7.

Following Wilson and Lyman (709), mental

health settings can be conceptualized as forming

a continuum from most to least intensive. At one

end of the continuum is inpatient hospital treatment, which involves 24-hour-a-day care, often

for extended periods of time. At the other end of

the continuum is outpatient treatment which may

involve only 1 or 2 hours a week, or less, sometimes for only a few weeks.

More intensive mental health treatment settings

are designed to treat children with more severe

problems. Such problems can be either acute, such

as suicidal behavior, or chronic, such as infantile autism. In many cases, factors other than the

severity of a child’s mental problem may indicate

the selection of a relatively intensive setting. More

PSYCHIATRIC HOSPITALIZATION

The most intensive and restrictive type of children’s mental health treatment is psychiatric hospitalization. Children’s psychiatric hospitalization

takes place in various types of facilities—in freestanding 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 other

treatment resources are lacking (457). More intensive settings are also chosen when children may

be dangerous to themselves or others.

Intensive menial health treatment settings tend

to be restrictive, and this fact necessitates special

considerations. Federal legislation such as the Education for All Handicapped Children Act (Public

Law 94-142) and judicial decisions such as Willie

M. v. Hunt (see 50) have codified the principle

that children should receive appropriate services

in the “least restrictive setting” possible. No precise legal meaning of least restrictive setting is

available (353), however, and available research

does not allow a systematic evaluation of whether

the principle is applied appropriately. Consequently, which mental health treatment setting

offers appropriate care while still being least restrictive is a matter of clinical judgment influenced

by the availability of resources. When optimal or

even adequate treatment settings are not available

or accessible, the quality of care or the principle

of providing care in the least restrictive setting,

or both, have to be compromised. Details on

trends in the availability and utilization of mental health treatment facilities are provided in chapter 2.

ages (both State and county mental hospitals and

private psychiatric hospitals), separate children’s

hospitals or units, chemical dependency units,

and, most frequently, in psychiatric units of general hospitals.

79
80

Photo credit: Children’s Center, San Antonio, Texas

Private psychiatric hospitals generally offer more

treatment by psychiatrists than do other mental

health settings.

Psychiatric hospitals—regardless of whether

they are public or private—are medical facilities

that must be licensed as hospitals according to

State law (531). Many of these institutions are also

accredited as hospitals by the Joint Commission

on the Accreditation of Hospitals.

Psychiatric hospitals place disturbed children

in an entirely new environment. For the period

of a child’s institutionalization, the hospital must

provide 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 treatment

staff, depending on the hospital. Most hospitals

offer individual psychotherapy, family therapy,

and group therapy. In addition, medication is

used as deemed appropriate. Milieu therapy is

central to most psychiatric hospitals, since the 24-

hour-a-day environment allows staff to structure

the daily life of the ward (activities, interactions

with patients and staff, etc. ) to help patients obtain emotional support, learn more adaptive behaviors, and so forth, Many hospital environments also incorporate behavioral interventions.

State and County Mental Hospitals

States and counties provide inpatient psychiatric care to children as part of the public mental

health care system, so a substantial number of

children’s psychiatric beds are in public psychiatric

hospitals. States and counties in which it has been

recognized that children should be treated differently from adults have begun to open up separate psychiatric hospital programs solely for children. In 1983, there were 30 such facilities in the

United States (667). Some child psychiatric inpatient units are an organizational component of

CMHCs. Care is generally provided on a reducedfee basis for those who cannot pay the standard

charges, and public sources provide most of the

revenues for State and county mental hospitals

(667).

During the past 20 years, the number of children treated as inpatients in State and county

mental hospitals has declined considerably (724;

also see ch. 2) as a result of the reinstitutionalization movement (405). In the vast majority of

States, the number of psychiatric beds for children 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 treatment

facility of St. Elizabeth’s Hospital, the public mental

hospital in Washington, DC.
81

are constrained by a lack of fiscal resources. Perhaps as a result, their staffs are less well-trained

than the staffs at private facilities (see table 7).

Private Psychiatric Hospitals

Private psychiatric hospitals are owned and administered by various organizations, including

private corporations, universities, and religious

organizations. The majority are for profit (667).

As noted in chapter 2, the mental health services

that private hospitals are providing for children

are increasing. Typically, private hospitals have

more resources to devote to treatment than do

public hospitals; consequently, private hospitals

tend to provide more hours of ancillary treatment

per week per patient, a higher staff-to-patient ratio, and a greater number and level of experience

of professional treatment staff.

Private psychiatric hospitalization is the most

expensive of the common forms of children’s mental health treatment. As of 1986, daily charges

were about $375 for a child and about $325 for

an adolescent (457). This expense reflects not only

the cost of 24-hour institutional care, but also the

high cost of medically oriented services (245,587).

Reduced-cost or charity treatment in private psychiatric hospitals is provided for only a few cases.

Children’s Psychiatric Hospitals

and Units

Children’s psychiatric hospitals and units can

be categorized by the duration of treatment they

provide (161). Short-term, acute care psychiatric

hospitals or units provide intensive treatment for

children in crisis situations when their ability to

[unction deteriorates substantially or they present

a danger to themselves or others. Treatment generally lasts no more than 60 days. Short-term psychiatric children’s hospital programs offer an alternative environment for disturbed children whose

usual environments have rapidly become unable

to contain and care for them (60,724). The intent

is to treat the most severe and threatening symptoms, help children regain their ability to cope,

and prepare them for more long-term, less intensive treatment in another setting.

Intermediate-term psychiatric hospitals for children represent the vast majority of children’s inpatient psychiatric facilities. Intermediate-term facilities treat children for periods ranging from

about 60 days to about 2 years. Interventions in

such facilities are intended to help children make

extensive changes in their functioning and often

involve significant therapeutic intervention with

families.

Table 7.— Distribution of Full-Time Equivalent Staff Positions in Psychiatric Hospitals

and Residential Treatment Centers, 1982

State and county Private psychiatric RTCs for emotionally

mental hospitalsa

hospitals adisturbed 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 . . . . . . . . . . . . . . . . . . . . . . . . .

124,164

48,224

3,866

2,012

3,196

6,276

15,613

65.30/o

25.3

2.0

1.1

1.7

3.3

8.2

24,088

17,408

1,466

225

1,030

1,774

5,705

63,1 0/0

45.7

3.8

0.6

2.7

4.7

15.0

16,311

10,901

153

38

604

2,100

477

72.50/o

48.5

0.7

0.2

2.7

9.3

2.1

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

66,102 34.7 14,057 36.9 6,183 27.5

190,266 100% 38,145 1000/0 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 Human

Services, Mental Hea/th, Un/ted States, 1985, C A. Taube and S A Barrett (eds.) (Rockville, MD: 1985)
82

Long-term children’s psychiatric hospital units,

treating children 2 years or longer, are the least

common. Children in long-term facilities are considered chronically disturbed with limited capacity

for independence and for maintaining relationships. Many of these children cannot be placed

in the community.

Chemical Dependency Units

Chemical dependency units can be either public or private, and can be either freestanding or

part of a general hospital. Such units specialize

in treating substance abuse and dependence, ranging from alcoholism and alcohol abuse to dependence on use of illicit drugs such as heroin and

cocaine. Substance abuse is a DSM-III disorder

(see ch. 3), and many private insurers offer reimbursement for its treatment in psychiatric inpatient units. Treatment in some units is especially

adapted to the problems of adolescents and/or the

types of substances abused by adolescents (709).

General Hospitals With Inpatient

Psychiatric Services

General hospitals offer a substantial amount of

children’s mental health care. Many general hospitals have established separate psychiatric units

with treatment programs resembling those of freestanding psychiatric hospitals (60). Psychiatric

units in general hospitals tend more often than

psychiatric hospitals to focus on short-term, acute

care, lasting from a few days to a few weeks or

months. In comparison with psychiatric hospitals,

psychiatric units of general hospitals also tend to

have a somewhat greater proportion of psychiatric patients who have a concomitant medical

problem or a psychophysiological disorder, since

the general hospital can provide both psychiatric

and medical care (60).

Under some conditions, general hospitals admit

psychiatric patients to medical wards. In such

cases, one or two psychiatric patients may be

placed in rooms with medical patients. It is difficult to determine the frequency of such treatment.

Critics argue that this form of hospitalization allows assessment of psychiatric problems at best

(161) and is probably appropriate only in crisis

situations when other resources are not available.

RESIDENTIAL TREATMENT CENTERS

RTCs, as the term is used in this background

paper and elsewhere, are 24-hour care settings that

provide a mental health treatment program for

mentally disturbed children but are not licensed

as hospitals (531).

RTCs range from highly structured institutions

that follow something resembling a medical model

and function somewhat like psychiatric hospitals

to less medically oriented institutions that are

sometimes hard to distinguish from halfway houses,

group homes, and foster care homes (531). In

comparison to RTCs, psychiatric hospitals tend

to have a greater mix of professionals and greater

involvement by psychiatrists and psychiatric

nurses (see table 7). Furthermore, psychiatric hospitals may often admit certain children whom

RTCs might not admit—in particular, children

who are highly aggressive, suicidal, or overtly

psychotic (with delusions or hallucinations) (60,

411,724). It is becoming more common for hospitals and RTCs to be operated by the same organization and to exist side by side on the same

grounds (see ch. 10)

The size of RTCs, in terms of numbers of patients, ranges from a few children to hundreds.

According to 1981 data, about 75 percent of the

under-21-year-old patients treated by RTCs are

adolescents 12 to 17 years old; approximately 19

percent are 6 to 11 years old; less than 1 percent

are 5 years of age or less (724).

The intensity of treatment provided in RTCs

ranges from the provision of virtually every service 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 mental

health treatment program for mentally disturbed children

but are not licensed as psychiatric hospitals.

hospitals, RTCs place disturbed children in an entirely new environment and are responsible for

all aspects of care. RTCs employ most of the therapies discussed in chapter 5. Milieu therapy is also

central to RTC treatment.

The length of stay in an RTC ranges from days

to a year or more. Most RTCs, over 80 percent,

treat children for a period ranging from several

months to 2 years (724). The goal in these settings

is to return children to the community after extensive efforts to increase their level of daily functioning. A smaller percentage of RTCs, less than

15 percent according to Young (724), treat children for more than 2 years on the average. RTCs

that provide long-term care primarily serve severely

disturbed children (e.g., those with infantile autism, more severe mental retardation, neurological disorders). In these settings, it is recognized

that patients will not “recover” from their conditions, nor ever approach normal development.

The goal in these RTCs is to enable severely disturbed children to attain the highest level of development possible, to allow these children to

eventually return to the community.

One noteworthy model of RTC treatment (also

extended to day treatment) is called Project-ReED, described originally as a “project for the reeducation of emotionally disturbed children” (300).

Although Re-ED programs are generally residential, much of their work is based on what Hobbs

called “ecological strategies’ ’—changing a child’s

mental health problem by working both with the

child and the family and community from which

the child comes.

Re-ED programs approach children’s mental

health problems as the result of unhealthy interaction between children and their environments

and intervene accordingly. Approximately onethird of Re-ED staff work full-time with parents,

teachers, and other community members to help

them change their interactions with the child being treated at Re-ED. Staff may advise parents,

for example, on strategies to help their children

maintain self-centered, or collaborate with teachers

in designing a program for a child who is returning to a school in the community. Almost all children in Re-ED programs return home for weekends

to maintain their contact with family and community.

At Re-ED residences, “teacher-counselors” work

to bolster children’s academic competence and

emotional well-being. Academic progress is seen

as a key step in reducing mental health problems

and promoting the child’s return to the community. Re-ED also emphasizes milieu therapy, with

one-on-one intervention between staff and child

taking place mainly in the context of the milieu,

and little or no individual therapy. The positive

emotional experiences of daily life at a Re-ED program are thought to form a large part of the

treatment.

DAY TREATMENT/PARTIAL HOSPITALIZATION

Some children do not need 24-hour treatment is used as a followup to psychiatric hospitalizabut do require more intensive treatment than 1 tion or RTC treatment, when a child may no

or 2 hours a week of therapy. Day treatment often longer need 24-hour care but is not yet ready to
84

cope with a regular classroom. Day treatment programs provide extended treatment, available for

a number of hours daily, and can provide a range

of therapies that are not available at clinics. Some

programs provide treatment to children before or

after regular school hours, while other programs

provide education to children whose troubles prevent them from attending school.

Some day treatment programs are designed according to an educational model. These programs,

sometimes called psychoeducational day treatment programs, operate more like schools than

other day treatment centers but incorporate a

therapeutic component within the educational

program. Their curriculums in many cases are

adapted from regular school curriculums, but include special approaches to address the almost

universal learning problems of mentally disordered children. Like psychiatric hospitals and

RTCs, day treatment centers offer the kind of exOUTPATIENT SETTINGS

Outpatient treatment settings are by far the

most prevalent settings used for children’s mental health treatment. CMHC outpatient departments, private outpatient clinics, and private mental health practices are described below. Most of

the treatment modalities discussed in chapter 5,

from individual psychotherapy to group and family therapy, can be provided in these settings.

CMHC Outpatient Departments

Initially established by the Federal Government

through the Community Mental Health Centers

Act of 1963, CMHCs were intended to provide

comprehensive mental health services to all the

residents of a catchment area regardless of their

ability to pay. The mental health services provided by CMHCs include treatment, prevention,

and consultation and education services, but outpatient treatment is by far the most common.

CMHC care is provided to adults (619), but

most centers also provide some children’s services. Some CMHCs have incorporated previously

established child guidance clinics, while others

have established new child treatment services.

tensive daily environment in which milieu therapy can be done. Model day treatment programs

also include mental health components involving

individual therapy, group therapies, family therapy, vocational counseling, and other vocational

programs. They also provide other educational

and recreational activities designed to further the

development of adolescents in a less treatmentoriented fashion.

Partial hospitalization is the use of a psychiatric

hospital setting for less than 24-hour-a-day care

for given patients. For example, some children

might need the treatment offered in the hospital

setting during the day but be able to return home

in the evening. The treatment program for those

children would be identical to the daytime treatment program of the inpatient children. In effect,

this is day treatment applied in a psychiatric hospital setting.

CMHCs use virtually all treatment modalities, including psychodynamic psychotherapy, behavior

therapy, cognitive therapy, psychosocial interventions, parent guidance, family therapy, and psychopharmacological (drug) therapy. For the majority of children, more than one modality of

treatment is provided simultaneously (363), usually including one or more interventions directly

with the child plus work with important adults

in the child’s life.

Despite the intentions of the 1963 law, a network of CMHCs never developed as a nationwide

mental health care system. Furthermore, according to some observers (619), the network that did

develop slighted the needs of children for several

years. Few CMHCs included children’s services

when they were established, and in those that did

establish child services, the resources available for

such services were often too low. The number of

staff devoted to children was small, and the level

of training of the staff in child mental health was

poor (9,11, 55,514). The situation improved somewhat in the 1970s; according to a 1981 survey

from the National Institute of Mental Health

(NIMH), approximately 17 percent of the resources
85

of CMHCs were devoted to children’s mental

health care (665).

In 1981, direct Federal support for CMHCs was

withdrawn. Federal funds began to be provided

to CMHCs indirectly via the States through the

block grant mechanism (see ch. 10).

Private Outpatient Clinics

In addition to CMHCs, many private clinics

provide outpatient treatment to mentally disturbed

children. The services that private clinics provide

resemble CMHC outpatient services in many

ways, although private clinics vary more in size,

scope, and treatment philosophy. Unlike most

CMHCs, private clinics do not have the responsibility to provide for all the mental health treatment needs of a given community. Many closely

adhere to the philosophy of the individuals administering the clinic. Some private clinics are

nonprofit and have sliding scales for payment

(e.g., Family Service Association centers), while

others provide services only at standard fees.

CONCLUSION

Mental health treatment settings that provide

services to children are diverse, ranging from hospital and RTC settings to day treatment centers

to outpatient settings. They can be arranged along

a rough continuum according to their intensiveness. Even within a type of setting, settings vary

in their form of administration (public versus private), cost, type of children served, duration of

treatment, and philosophy of treatment.

The need for availability of a diversity of settings to treat the range of children’s mental health

problems has been repeatedly emphasized. For example, the President’s Commission on Mental

Health (514) recommended both an increase in the

number of hospital and RTC facilities for seriously

disturbed children and an expansion in the availability of community-based mental health care of

all types (e.g., hospital, RTC, outpatient) for all

children.

Some clinics were established as child guidance

clinics prior to the development of CMHCs and

have not been absorbed into CMHCs.

Private Mental Health Practices

Many mental health professionals provide outpatient child mental health care in private practice. The number of children seen by private practitioners is not known, but it is believed to be

lower than the need. Private mental health care

practitioners include psychiatrists, psychologists,

clinical social workers, psychiatric nurses, and

mental health counselors who have met State

licensing standards. In form and method, private

practice resembles outpatient treatment in organizational settings. However, private practitioners

generally charge fees affordable only by families

with middle incomes and above, and then often

only with help from insurance. With widespread

availability of health insurance, some private care

is accessible to most families, but insurance policies vary greatly in their coverage of outpatient

mental health care (374).

One factor contributing to the need for a diversity of mental health treatment settings is the

desirability of providing appropriately intensive

mental health treatment in the least restrictive setting possible. It is easier to strike a balance between intensiveness and restrictiveness when treatment settings are available that cover the range

of these dimensions. For children who need more

intensive treatment than can be provided in weekly

office visits but who can still live at home, the

most appropriate setting—if it is available—may

be a day treatment program.

Another factor that underlies the need for multiple mental health treatment settings is the fact

that many children, especially those who are severely disturbed, require either concurrent or consecutive treatment from more than one setting.

For example, some children who go to an outpatient clinic once a week for psychotherapy to
—

86

address specific emotional issues might also benefit from participation in day treatment to learn

daily living skills. Or children discharged from

a psychiatric hospital may live, initially, in a less

intensive RTC and later receive psychotherapy as

an outpatient in the community.

The variety of mental health treatment settings

described in this chapter does not imply that all

children have access to the full range of possible

settings. Although many different models have

been developed, the number of settings available

is much more limited. The overall number of mental health treatment facilities is fairly small. Furthermore, access to some settings is limited by

cost. Many families cannot afford the costs of

treatment in private psychiatric hospitals or RTCs

or through private practices. The number of treatment openings for children in public psychiatric

hospitals, RTCs, and day treatment centers is

severely limited, and the development of child

outpatient treatment in CMHCs has not been

comprehensive.
Chapter 7

Treatment in Non-Mental-Health

Systems, Prevention, and the

Integration 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 affected by these influences. Disturbed children are

more likely than other children to fail in school,

to manifest a variety of medical problems, and

to be involved with the criminal justice system.

As a result, children’s mental health problems are

often first identified in settings such as schools,

physicians’ offices, and juvenile courts. These settings, along with others, provide important mental health treatment sources.

Understanding how treatment services are offered in non-mental-health contexts, such as the

educational, health care, welfare, and juvenile justice systems, is essential for developing public policy. The interrelationship between mental health

and other service systems provides opportunities

to identify children in difficulty, to provide interventions at the site where mental health problems are identified, and to offer programs to prevent mental health problems. Currently, however,

there is relatively little integration among mental health and other systems. This chapter considers needs for and provision of mental health

services across various non-mental-health systems.

It describes a number of programs and projects

in the educational system, the health care system,

the child welfare system, and the juvenile justice

system, along with the development of integrated

service systems.

CHILDREN’S MENTAL HEALTH TREATMENT

NON-MENTAL-HEALTH SYSTEMS

Treatment in the Educational System

The importance of dealing with children’s mental health problems in the educational system has

long been recognized (see 602). Mental health

problems interfere with a child’s ability to learn

and to manage in the social world of the school.

Moreover, mental health problems are likely to

have a great effect at school simply because of

the number of hours that children spend there and

the importance of education to their lives. Many

children can receive an adequate education only

if their mental health needs have been met.

Schools deal with the mental health needs of

children in a variety of ways (157), but the potential of the educational system in meeting children’s mental

IN

health needs has not been fully realized. A tradition of referring children from schools

to mental health treatment settings dates back to

the child guidance clinics of the 1920s and 1930s.

Some schools have their own mental health professionals, such as school psychologists and social workers, who provide mental health treatment within the school and provide consultation

to other school staff (see 372). Other schools rely

more heavily on external mental health professionals and a variety of referral resources. A subspecialty of education, special education, was specifically developed to serve the educational needs

of children with learning disabilities and psychological and physical handicaps. Because of the

difficulties involved in innovation in public schools

89

59-964 0 - 87 - 4
90

(407) and the difficulty of collaboration between

the educational system and mental health system

(437), mental health interventions in schools have

not been widely implemented. Nevertheless, there

has been substantial experimentation with such

interventions. Experimental programs have provided extra classroom interventions for hyperactive children, learning-disordered children, conduct-disordered children, anxious (withdrawn)

children, or heterogeneous groups of disturbed

children. These experimental programs in schools

have involved various therapeutic approaches.

Behavioral interventions have been used extensively since the 1960s, and the use of cognitive

interventions such as self-control and social skills

training has been increasing. These interventions

have been implemented by both teachers and

mental health professionals.

The Education for All Handicapped Children

Act (Public Law 94-142) requires that an education be provided to all physically and mentally

handicapped children. For each handicapped

child, the necessary educational and related services to enable the child to obtain an education

must also be provided. The law requires the development of an individualized education program that specifies those educational and related

services for each child. There has been some dispute over what a “related service” is and whether

mental health treatments such as psychotherapy

fall within that definition. There is a growing consensus that mental health treatments are related

services, and this view has been supported by several court decisions (e.g., Papacoda v. State of

Connecticut, 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 educational and mental health services for disturbed

children under Public Law 94-142 has been unclear. In some States, schools themselves offer

psychological services, although school personnel providing such services often have less clinical training than out-of-school providers. When

mental health services are provided in nonschool

settings, it is often unclear whether the responsibility for payment rests with the schools or with

Photo credit: Very Special Arts

In general, mental health professionals believe that the

least restrictive setting is most appropriate for treating

children. Here, the educational system offers a valuable

non-mental-health setting in which to treat children.

the parents. This is especially unclear when the

necessary related service is a residential treatment.

In 1984, 4 million students aged 3 to 21 received

services under Public Law 94-142. The number

of handicapped children receiving mental health

services is not known.

The Federal contribution to activities mandated

by Public Law 94-142 is relatively small: $1.07

billion in fiscal year 1984, 25 percent of which was

set aside for administrative and other support

services, including “related health services” (657).

Essentially, however, services for handicapped

children are mandated, but resources are not provided to implement them. It is not known what

portion of funds for psychological and mental

health were spent for psychological services. A

study to assess amounts spent by educational

agencies on all related services, including psychological services, is due to be completed in fiscal

year 1987 (656). The form that implementation

of Public Law 94-142 should take is still being determined in a number of States, and responsibilities across education departments, mental health

departments, and other service systems are still

being considered.
91

Treatment in the General

Health Care System

Increasing evidence suggests that many children’s mental health problems are seen by physicians in the course of delivering primary health

care; but surveys differ on the extent to which

office-based primary care physicians see and recognize mental health problems in children. In two

recent surveys by Goldberg, et al., pediatricians

reported that approximatelys percent of the children they saw had a mental health problem (239,

240). Schurman and colleagues, using data from

the National Ambulatory Medical Care Survey,

found that about 11 percent of office visits to pediatricians and about 12 percent to family practitioners were by children with psychiatric disorders

(588).

In Goldberg, et al.’s investigation, the majority

of troubled children visited their physician’s office because of a physical complaint, and their

mental health problems were uncovered during

the course of visits for other problems. Pediatricians often treated the mental health problems

themselves, providing supportive counseling, practical advice or, less frequently, medication (239).

Approximately 50 percent of the pediatricians in

Goldberg, et al.’s samples (239,240) referred troubled children to a mental health professional,

Some observers are concerned about the level

of mental health knowledge of many primary care

physicians (239,240). Furthermore, although primary care physicians and mental health professionals may see child patients concurrently, their

efforts are not always coordinated.

Two options open to many primary health care

providers are obtaining mental health training

(e.g., 85) and consulting with mental health specialists (543). The logic behind increasing the mental health skills of primary care providers is that

they are likely to be the first professionals consulted regarding developmental and psychological problems of young children (504).

In addition to mental health consultation and

mental health training for primary care providers,

early intervention programs have been developed

in primary medical care settings for children suffering from a number of childhood problems (536).

Prevention efforts have been used to help physically ill pediatric patients manage their illnesses

without undue mental health consequences (323).

Systematic mental health interventions in physical health care settings remain exceptional, however. Only in settings such as health maintenance

organizations might mental health referrals and

interventions be commonplace.

Evidence for the susceptibility of chronically ill

and physically disabled children to mental health

problems was noted in chapter 4. The prevalence

of mental health problems seen by medical specialists in medical inpatient units is probably high.

Treatment in the Child

Welfare System

The child welfare system is involved with a substantial number of children who have serious problems. Child welfare systems intervene in cases of

parental abuse and neglect and in other situations

in which parental care is lacking (e. g., during a

parent’s illness).

Treatment Needs for Children in Foster Care

A major form of intervention by child welfare

authorities is foster placement. The child welfare

system places an estimated 120,000 children per

year in some form of foster care, usually within

a home or institutional setting (48). There has been

little research to ascertain what portion of this

population enters foster placement with mental

health needs.

Children generally enter the foster care system

from family situations with problems including

child maltreatment, parental psychopathology,

and parental substance abuse—all of which are

risk factors for mental health problems (see ch.

4). Only a small percentage of children have been

placed in foster care because of their own behavior

or disability (108). When placed in foster care,

children suffer the trauma of separation from their

original families (205). Many children who would

be diagnosed as having psychological problems

by mental health professionals are not recognized

as having such problems by foster care placement

agencies and staff (205). For the most part, these

children are not placed in environments capable
92

of providing appropriate care for psychological

problems (205).

Frank’s study of treatment needs for children

in foster care found that children involved in longterm foster care typically had severe psychosocial problems (205), both at the point of entry into

foster care and 5 years later. Children who were

rated at a level of medium to low functioning at

entry into foster care slipped significantly to the

lower level after the 5-year period. Frank found

that 85 percent (composite percentage) of the sample of children in long-term foster care received

inadequate treatment (apart from the quality of

child care).

Several State studies suggest that the prevalence

and severity of emotional disturbance is associated with the number of placements a child has

experienced (108). Long-term and repetitive foster care placement, therefore, are likely to represent both sources and symptoms of problems for

children with mental health needs. Yet child welfare agencies often have neither the money nor

the experienced staff to provide mental health

services, and coordination between welfare and

mental health agencies is rare (358).

Alternatives to the usual pattern of foster placements are discussed below. These alternatives are

therapeutic foster care, respite care, and care in

group homes. Efforts to prevent the need for foster placement by enhancing parents’ abilities to

care for their children are discussed later in this

chapter.

Therapeutic Foster Care

Mentally disturbed children who might otherwise be referred to psychiatric hospitals or residential treatment centers (RTCs) are sometimes

placed in alternative family settings (83). Although separating a child from his or her parents

is a significant intervention, therapeutic foster care

is considered less intensive than treatment in a

psychiatric hospital or RTC.

Well-run therapeutic foster care programs carefully select foster parents to take disturbed children into their homes for a finite period of time.

These foster parents are generally expected to provide some therapeutic work and are typically paid

more than other foster parents. Such parents, who

vary in their experience with mental health treatment, undergo training prior to therapeutic foster care placement. Professionals involved with

foster care programs supervise and support the

foster parents, arrange for other care needs of the

disturbed children in foster care, and provide

emergency professional care for foster children

when needed.

The range of the intensiveness of treatment

within therapeutic foster care programs is substantial, and the more intensive levels require more

treatment-specific training, greater involvement

of foster parents, and greater availability of adjunct services. In many States, different levels of

therapeutic foster care are available to cover a

range of impairment in children.

Children in therapeutic foster care usually receive mental health treatment beyond therapeutic foster care. The nature of this other treatment

depends on the particular child’s needs and the

availability of local resources. Thus, for example, one child in therapeutic foster care may receive outpatient psychotherapy, while another

may attend a day treatment program.

Respite Care

Respite care, a service related to foster care, involves placing children in homes with caring adults

as an emergency intervention. Respite care provides children in need with a temporary protected

environment. Such care may be necessary because

of a crisis such as the emotional breakdown of

parents or escalating conflict between children and

other family members. Shelter from a crisis may

be provided for several days or up to several

weeks, until the child can return home or be placed

in another appropriate setting.

Group Home Care

Group home care is similar to therapeutic foster care, except that a number of children (usually 10 to 12) are placed in a home at one time

(709). Group homes are typically administered by

social service agencies, which employ staff to live

in the home or work there in shifts. Group homes

usually have a somewhat more structured treatment program than therapeutic foster homes.

Placement in group homes can last anywhere from
1 month to several years, and commonly includes

concurrent treatment in a mental health setting.

Treatment in the Juvenile

Justice System

The juvenile justice system is a potentially major site for provision of mental health care to disturbed children and adolescents. By DSM-III criteria (see ch. 3), juvenile offenders with a history

of behaviors such as fighting, stealing, lying, and

running away from home would be diagnosed as

having a conduct disorder. Often, however, the

mental disorders of juvenile offenders are not formally diagnosed, and the number of juveniles who

have mental disorders in addition to criminal or

status offenses (offenses that are criminal only because the offender is a juvenile, e.g., truancy, running away from home) is not actually known.

The proportion of children and adolescents in

the juvenile justice system who are regarded as

mentally disordered or as having mental health

problems obviously depends on what criteria are

used to define mental disorders and mental health

problems (601,723). Whether a child’s problems

are dealt with in the mental health system or in

the juvenile justice system often appears to depend less on characteristics of the child than on

how a particular behavior is defined (i.e., as a

symptom or as a violation of the law) and on the

system within a State or region for assigning service responsibility.

Coordinated interventions in which both the

mental health and the juvenile justice system are

93

involved are rare (395). Mental health agencies

are often reluctant or unable to take responsibility for intervention with juvenile offenders because of the danger and disruptiveness these children and adolescents present, and the juvenile

justice system is often unable to treat the mental

health problems of these youths. Many mentally

disordered children have contact with both the

mental health and juvenile justice systems, often

moving back and forth between the systems. Frequently, children who are sent from one system

to the other are those for whom original interventions have failed or been exhausted (395,723).

The frequent and rapid transferring of these “turnstile” children (276) sometimes causes problems

itself.

There are several models of coordinated mental health and juvenile justice interventions (601).

A number of special mental health programs have

organizational connections to State and county

governments and provide comprehensive services

to disturbed juvenile offenders (49,304,395,723).

In some instances, States contract with private

mental health agencies to provide services to children who come in contact with the juvenile justice system in specific geographic areas (395).

Other programs provide mental health consultation directly to juvenile justice facilities (395,601).

Case management (discussed below) has been used

to resolve some of the problems of trying to serve

disturbed children who are wards of the juvenile

justice system, but the use of case management

in 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 to

havioral, social, emotional, and academic difficul- reduce the need for more intensive and costly

ties in children. Primary prevention strategies are treatment services such as psychiatric hospitaliaimed at reducing the incidence of new cases of zation or other residential treatment (98).

mental health problems; secondary prevention efforts are directed at reducing the severity and du- Primary Prevention

ration of disorders through early identification,

diagnosis, and treatment (see 98). In practice, Primary prevention efforts are frequently dihowever, primary and secondary prevention often rected at parents and educators. Sometimes they

overlap. The common objective underlying all are aimed at the parents of children who are at

prevention efforts is to reduce the incidence of high risk. To treat high-risk infants, for example,
94

programs train parents in different techniques for

stimulating and giving attention to the infant.

Other similar primary prevention interventions

have been developed for particular groups (e.g.,

poor women) and teenage mothers (187,525).

Primary prevention methods have also been devised for the parents whose children are not

known to be at high risk. Such methods include

training manuals to help instruct parents in childmanagement techniques (e.g., 40,429,497), educational videotapes for inexperienced mothers (78),

and parent education groups such as Parent Effectiveness Training (242,243). Although popular, some of these methods have been criticized

for not meeting the needs of low-income families

(110).

In school settings, primary prevention efforts

include alcohol education programs in elementary

schools (380) and mental health consultation services provided to teachers (see 408). Such efforts

also include programs aimed at decreasing specific behaviors that are thought to predispose children to later problems in school adjustment. For

example, one program employed intensive training in interpersonal, cognitive problem-solving for

kindergarten children in the hopes of decreasing

inhibited and impulsive behavior and enhancing

social problem-solving skills (621).

Head Start and similar preschool child development programs are examples of an ongoing effort at primary prevention. Head Start was established as a national program in 1965 to provide

enriched early childhood education for low-income children. Head Start also provides a range

of other services, including health, nutrition, and

social services. The program emphasizes parent

and community involvement in the development

and operation of the program, a feature that has

proved effective (see ch. 9). However, Head Start

has been criticized for devoting few resources and

little attention to mental health services (308).

Somewhat different from other primary prevention programs are family support programs. In

recent years, the importance of families for children’s mental health has been widely acknowledged (290). Although families are often viewed

as the primary contributors to mental illness in

children, they are increasingly recognized as a

 ‘ -

Photo credit: March of Dimes

Physically disabled children may be susceptible to

mental health problems.

principal source of mental health and adaptation

(693).

The idea of supporting families is not new, but

the growth of a family support movement as a

distinct and important aspect of children’s mental health services is a fairly recent phenomenon

(326,693). The family support movement can be

said to be integrative in that it focuses on the needs

and linkages between children, families, communities, and broader social systems. According to

Weiss (693) and others (594), the family support

movement evolved in part from early intervention and prevention programs such as Head Start,

The finding that the most effective of these programs were those that actively involved parents

—and the related idea that children at risk need

an intervention approach that encompasses more

than educational enrichment—pointed to the family as a necessary focus of intervention.

More recently, the family support movement

has gained impetus from research underscoring
95

the importance of quality parent-child interactions

in promoting children’s social, emotional, and

cognitive competence (e. g., 623). The development of family support programs has also been

supported by recent trends in the delivery of social services. Such trends include increasing emphasis on the promotion of health and the prevention of illness, the use of self-help and mutual

aid groups, and access and coordination of services through information and referral systems

(334,693).

Finally, the family support movement is a response to the stresses faced by contemporary

American families. Such stresses include demographic trends (e.g., increases in the numbers of

single-parent and dual-career households) as well

as broad social forces such as unemployment, economic uncertainty, and increased mobility and

isolation of families.

The family support movement represents a diverse array of services and programs that share

underlying assumptions and conceptual emphases

more than a particular format or structure. Family support services range from a center-based program resembling traditional mental health service to practices such as corporate flexitime and

daycare.

Family support programs are characterized by

their focus on family strengths rather than deficits; their recognition that parents need and want

information and support in carrying out their

roles; an attempt to empower families and foster

self-reliance; and their emphasis on the relationship not only between children and parents, but

also between families and the sources of support

in their communities.

According to Weiss (693), the dimensions on

which family support programs vary include the

type of family served (e.g., new families, singleparent families, families with special needs); service delivery mechanisms (e.g., newsletters, home

visits, parent groups); program goals (e.g., child

abuse prevention, home and school linkages, parent and child education); program settings (e.g.,

mental health centers, schools, churches, dropin centers); staff composition (e.g., mental health

and health professionals, educators, volunteers);

and funding sources (private and public).

Two examples of family support programs are

the Yale Child Welfare Research Program (594)

and the Family Support Center Program (see 202).

The Yale Child Welfare Research Program is different from other programs in that it is university based and includes outcome research as one

of its major components. The Yale program is

typical of family support interventions, however,

in that it employs a multidisciplinary teamwork

approach focused on the social and emotional adjustment of all family members. The goal of the

Yale program’s interventions is to enhance parent’s ability to perform their caregiving roles and

to solve their own life problems. Interventions are

aimed at impoverished families considered at risk

by virtue of the chronic stresses and limited resources associated with reduced socioeconomic

status. Families receive home visits, pediatric care,

daycare, developmental examinations, and psychological services as needed, and services are provided over a 2*/z-year period for each family. In

a recent 10-year followup of the original program

participants and an equivalent group of control

families, the Yale program’s interventions were

found to have both positive and long-lasting effects (see ch. 9).

The Family Support Center Program is designed

to reduce the incidence of child maltreatment in

at-risk families by providing parents with support

and guidance in a series of steps that emphasize

progressively greater peer support and progressively less staff involvement. As parents advance

in the program, they move from receiving direct

staff support and consultation, to attending a

“family school” with their children, to participating in a neighborhood support group. An evaluation of a Family Support Center Program (25,

202) is discussed in chapter 9.

Secondary Prevention

Secondary prevention efforts for children who

have begun to show signs of behavioral difficulties have been implemented in both home and

school settings. Some secondary prevention efforts are aimed at training parents to deal directly

with their children’s problems. In one program

(317,318), parents were taught to use behavioral

methods to modify a range of behaviors in their
96

preschool children at home (e.g., reducing aggression and tantrums, and increasing eye contact, imitation, and vocalization). This program also involved parents in health-center-based activities in

which they observed and were instructed in teaching activities aimed at enhancing their children’s

prosocial behavior and language skills.

One of the most extensively implemented and

well-researched school-based secondary prevention programs is the Primary Mental Health Project (PMHP) of Cowen, et al. (128). This program

was developed to remediate children’s problems

in the primary grades, a goal based on observations that early school problems frequently persist or increase over time and that they lead to

more serious mental health problems later in life

(126,128). PMHP involves the delivery of individually based, remedial efforts to grade-school children who have been identified as having behavioral

and academic difficulties (e.g., acting-out, withdrawal, and learning problems). Teacher aides

meet with children on a regular basis during the

school year, and individual goals are modified

according to the child’s changing needs. Additionally, mental health professionals serve as consultants to teachers and other school personnel. The

PMHP model has been widely disseminated, and

programs have operated in over 200 schools

throughout the country (125).

INTEGRATION OF MENTAL HEALTH AND OTHER SERVICES

As described in this chapter, the treatment and

prevention of children’s mental health problems

occurs in a variety of settings—educational and

other—outside the mental health care system. In

addressing children’s needs, therefore, it is important to consider the integration of mental health

services with other services. Given the diverse settings in which children’s mental health care is provided, it is perhaps not surprising that fragmentation of services is often reported (324,359).

Isaacs (310,311) has reviewed various methods

of integrating systems, both at the level of entire

systems or programs and at the level of individual children. State departments can cooperate at

the administrative level to develop policy decisions together, to initiate programs jointly, or to

share management and support services. Service

programs can include staff from all systems. At

the level of the individual child, agencies can collaborate on most stages of the treatment process,

from case finding and evaluation to followup. Although each agency provides specialized services,

staff from different services can collaborate in

periodic case conferences, case teams, or case consultation.

According to Isaacs (312), a number of principles should undergird the organization of the children’s mental health system. One is that children’s

mental health services should be integrated with

services that address a child’s physical, mental,

social, and intellectual needs while recognizing the

developmental stages of the child and the needs

of different groups of children and adolescents.

Another principle is that services should be coordinated, with a single agency given responsibility for developing and coordinating the system

of care at both local and State levels. Yet another

important principle is that services should be delivered to the extent possible within the child’s

normal environment (i.e., home, school, health

care setting), and, if such is not possible, within

the least restrictive environment. Finally, early

identification of problems should be promoted

and the system of care should support a child’s

right to develop in a nurturing environment with

positive adult relationships.

One important concept in the integration of

children’s services is that of the case manager or

case advocate (359). A case manager or advocate

is an individual or team, usually in the mental

health system, who assumes responsibility for ensuring that the appropriate combination of services from all service systems is provided to a client. Case managers are conversant with the laws

entitling children to services, such as Public Law

94-142, and ensure their application in individual cases by advocating on the child’s behalf in

school, in court, or within the mental health treatment program itself (359). They can maintain the
97

push for treatment within systems that are sometimes overwhelmed, disinclined to treat difficult

children, and entangled in bureaucratic difficulties (359).

One of the most sophisticated models of case

management has been developed by North Carolina. In this model, case managers are responsible for seeing that all facets of a child’s evaluation

and treatment are carried out. They continually

review the treatment plan and monitor its implementation; one of their responsibilities is seeing

to it that the disturbed child receives treatment

in the least restrictive setting possible (5o). In some

instances, case managers locate and arrange for

services outside the mental health system, such

as homemaking systems for beleaguered mothers,

that are nonetheless crucial to the stability of a

disturbed child’s family. In addition, they arrange

for the adult service systems to continue care for

children in need who are about to turn 18 (50).

CONCLUSION

The educational system, the general health care

system, the child welfare system, and the juvenile justice system present important opportunities to identify and help troubled children. Yet evidence suggests that the mental health problems

of children involved with these systems are often

poorly treated or not treated at all (358,595,645).

The variety of mental health programs potentially available to children would appear to require that such services be integrated across moAt present, the integration of mental health and

other children’s services is probably more of an

ideal than a reality. In a review of State administrative structures for provision of coordinated

services, Isaacs (313) concluded that despite a

number of models, implementation of coordination plans often depends on the efforts of individual staff members, rather than on established

systems and structures. In addition, Isaacs (313)

found that even in States attempting coordination

between the mental health system and other agencies, State education and health departments,

which have the most frequent contact with children, were almost always excluded from coordination programs. The Federal Child and Adolescent Service System Program, described in chapter

10 of this background paper, was established in

1984 to help State mental health agencies coordinate care for one segment of the population of

children with mental health problems—those who

are severely emotionally disturbed.

dalities, providers, settings, and systems although

in many cases there may be few services to integrate. The variety of mental health programs also

suggests that evaluation of any one intervention

program is likely to yield an incomplete picture

of the nature and effectiveness of children’s mental health care. Variables such as coordination of

programs should be taken into account in the

assessment of that care.
Part IV: Effectiveness of Services
Chapter 8

Effectiveness of Therapies
Chapter 8

Effectiveness of Therapies

INTRODUCTION

Although the scientific evaluation literature on

child treatment is inadequate to answer many policy questions, an increasing amount of research

on the effectiveness of children’s mental health

treatment is available. The fundamental conclusion that professional mental health treatment

leads to significantly better outcomes than no

treatment across age groups is supported by a substantial research base on the effectiveness of mental health treatment in general (38,484,616,647).

Children’s mental health treatments cannot be

directly equated with treatments for adults (8),

but general research tests some of the fundamental assumptions of treatment. Furthermore, there

is an extensive theoretical rationale concerning

treatment for children’s mental disorders (see ch.

5). In many cases, such theory and data are supportive of child treatment interventions, even in

the absence of applied research.

To assess current scientific understanding of

what is known about the effectiveness of mental

health intervention for children, this chapter first

discusses reviews of the research that consider the

effectiveness of psychotherapies for children in

general. Available reviews of psychotherapy outcome research differ in the range of therapies they

include within their purview-some including

studies of family therapies, for example, and

others not; some including studies of group therapy and others limited to studies of individual

therapy. By including studies of a variety of modalities, these reviews analyze the question of

whether therapy in general can be effective with

troubled children. This question is important because, currently, it is therapy in general that is

reimbursed, not particular therapies.

The second part of this chapter examines research on the effectiveness of specific therapies described in chapter 5: behavioral therapy, cognitive therapy, group therapy, family therapy, crisis

intervention, and psychopharmacological (drug)

therapy.

It should probably be noted that for the most

part the scientific literature contains evaluations

of the effectiveness of therapies for mental disorders (see ch. 3) rather than subclinical mental

health problems (see ch. 4); consequently, it is the

effectiveness of therapies for diagnosable disorders

which is reviewed in this chapter. Some services

for subclinical mental health problems come under

the rubric of prevention and mental health interventions in non-mental-health settings such as

schools, homes, and the juvenile justice system;

the effectiveness of such services is reviewed in

chapter 9.

EFFECTIVENESS OF CHILD PSYCHOTHERAPY IN

GENERAL AND METHODOLOGICAL ISSUES

Nearly 30 years separate the first review of child lel an improved methodological soundness in the

psychotherapy 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 health

views of child psychotherapy outcome research problems is more effective than no treatment.

in general have shown greater methodological so- However, methodological problems persist, and

phistication, incorporating the more rigorous the conclusions of the reviews should be viewed

meta-analytic techniques (387,552,616) to paral- somewhat cautiously.

103
104

Reviews of Child Psychotherapy

Outcome Research

Levitt (1957, 1963)

The first major efforts to assess children’s mental health treatment were Levitt’s (382,383) reviews of child psychotherapy outcome research.

Levitt aggregated across available studies the percentages of children who were judged to have improved following treatment. Since most of these

studies did not include control groups, he compared the aggregate percentage of treated children

who improved to the aggregate percentage of untreated children who improved (derived from two

studies).

In his 1957 review (382), Levitt concluded that

an estimated 67 percent of treated children had

improved at the close of treatment and that 78

percent of treated children had improved at followup; Levitt also found, however, that 72.5 percent of untreated children had improved. These

observations suggested that, in general, child psychotherapy for mental health problems did not

have an advantage over no treatment. Levitt’s

1963 update (383) yielded similar results. Levitt

wrote:

. . . the inescapable conclusion is that available

evaluation studies do not furnish a reasonable

basis for the hypothesis that psychotherapy facilitates recovery from emotional illness in children.

Levitt’s conclusion can be criticized on several

grounds. Levitt’s estimate of the improvement in

untreated children might not have been valid.

Levitt derived the estimate of “improvement without treatment” from two studies with questionable methodology (43); and these studies might

not have been comparable on several grounds to

other treatment outcome studies (280). Furthermore, most of the untreated children were children who received a diagnostic assessment but did

not continue with psychotherapy. There might

have been systematic differences, aside from treatment, between these children and the treated children. The children who did not receive psychotherapy after diagnosis might have had a greater

ability to cope, found other help for their problems, or found the diagnostic contact sufficient

treatment (43,106,280). It is also possible that the

children in the untreated control groups received

mental health treatment somewhere other than at

the study site.

Even if Levitt’s analytic methods were not suspect, the studies he reviewed might not be representative of the current state of child psychotherapy. The studies he reviewed were done in the

1930s, 1940s, and 1950s. Therapy techniques in

those years differed in many ways from later techniques, and the populations studied might have

been different from current clinical populations

(43). Furthermore, the methods used in psychotherapy outcome studies in those years were primitive in comparison to contemporary methods.

Tramontana (1980)

In a review of the literature on the effectiveness of psychotherapy for adolescents, Tramontana (637) derived estimates of percentage improved similar to Levitt’s. Overall, including both

individual and group therapy, Tramontana found

a median positive outcome rate of 75 percent with

psychotherapy and 39 percent without psychotherapy. He questioned the meaningfulness of

these figures, however, since the outcomes were

so variable across studies—reflecting the variety

of factors that influence adolescent therapy outcome. Most of the studies Tramontana reviewed

looked at group therapy. Two of them are discussed further below in conjunction with a discussion of group therapy for adolescents.

Smith, Glass, and Miller (1980)

Smith, Glass, and Miller (616) examined 500

controlled studies in their 1980 meta-analysis of

psychotherapy. This review was distinguished by

its inclusion of controlled studies only and by its

taking into account differences in the strength of

the treatment effect (effect size) across studies.

Critics of the review claim that it lumps together

too many different kinds of studies and includes

studies of poor as well as good design (174). In

fact, Smith and his colleagues attempted to control for this problem by classifying studies according to methodological criteria (647). Although

most of the studies examined treatment of adults,

approximately 50 of the studies assessed treatment

of children or adolescents.
105

The Smith, et al., 1980 meta-analysis found significantly better outcomes for patients who were

treated with psychotherapy than for controls. The

investigators concluded that the average person

who receives therapy is better off at the end of

it than 80 percent of the persons who do not.

Smith, et al., did not analyze the effectiveness

of child psychotherapy separately from adult psychotherapy. In a correlational analysis, however,

they found that patients’ age had little effect on

treatment outcome. This finding must be viewed

cautiously. The treatment effects of the approximately so child and adolescent studies were not

analyzed separately from the original 500 studies,

and these so studies represent a subsample much

smaller than the larger group.

Casey and Berman (1985)

Casey and Berman (104) reviewed 75 studies

of child psychotherapy outcome dating from 1952

to 1983. They restricted their sample to studies

that used a control group of untreated children

from the same general population as the treated

children. The sample excluded studies examining

treatment of adolescents. Behavioral therapy was

used in 56 percent of the studies Casey and Berman examined, cognitive-behavioral therapy in

21 percent, and nonbehavioral therapy (psychodynamic, client-centered, mixed, and unclassifiable) in 48 percent. (Some of the studies examined more than one form of treatment, so these

figures add to more than 100 percent. )

Using meta-analytic techniques similar to those

used by Smith, et al. (616), Casey and Berman

(104) found that, overall, the average child receiving psychotherapy was better off after treatment

than two-thirds of control children. This treatment effect is comparable to the treatment effect

found by Smith, et al. (616), and others reviewing adult psychotherapy. Casey and Berman found

little evidence either that one modality of treatment differed from any other in overall effectiveness, or that individual treatment differed from

group treatment. Surprisingly, outcomes for children whose parents were treated concurrently did

not differ from those of children whose parents

were not treated. In general, treatment had a

larger effect on problems related to fear and anxiety than on problems involving self-esteem, social adjustment, or global adjustment. The research was insufficient to allow any conclusions

matching specific treatment modalities to specific

problems or diagnoses.

In general, Casey and Berman concluded that

. . . clinicians and researchers need not be hesitant about defending the merits of psychotherapy

for children” (104). The conclusions of Casey and

Berman must be reviewed somewhat cautiously

however, since only 24 percent of the 75 studies

they reviewed clearly used children who were

seeking treatment as subjects; most of the rest used

“school children not seeking treatment” or “community volunteers for special projects” who were

in mental distress but who had not sought treatment. Thus, it is not clear how representative of

actual treatment situations their results are.

Methodological Issues

Clinicians and researchers have expressed two

major concerns about analyses that aggregate results across different types of treatment as the reviews discussed above have done. One concern

is that the research base has too many deficiencies to allow generalizations about the effectiveness of child psychotherapy. Several discussions

of the effectiveness of child psychotherapy from

Levitt (382) to Kazdin (336) detail the lack of

methodologically sound research on the efficacy

of child psychotherapy. Among the deficiencies

mentioned are the absence or inadequacy of control groups; inadequate or misguided measurement of therapeutic, intervening, and outcome

variables; lack of specific description of subjects,

treatment, and outcome; heterogeneity of subjects; and failure to assess the effect of psychotherapy independently of other interventions (8,43,

275,280,336,637).

The other major concern is that an overall estimate of the effectiveness of child psychotherapy

may have little relevance for clinical practice and

mental health policy, because so much seems to

depend on a number of mediating factors that influence both children’s problems and treatments

(see, e.g., 43,280,561,637). Thus, Levitt’s (382) review found that the percentage of child patients
106

,

who improved at close of treatment ranged from

43 to 86 percent across studies, while Tramontana’s (637) review found that the percentage improved ranged from 35 to 100 percent. In Casey

and Berman’s (104) review, the standard deviation exceeded mean effect size, an indication of

great variability.

The paucity of good research reflects in part

the difficulties of introducing methodological rigor

to the study of child psychotherapy (8). Many design features of treatment studies that would be

desirable on methodological grounds (e.g., random assignment to treatment or control groups)

are rejected as infeasible logistically or questionable ethically (647,719), although there is disagreement about the true extent of logistical and ethical problems. Another obstacle to mental health

research in general is the difficulty of specifying

what the treatment is, since psychotherapy is often

tailored to the specific theoretical orientation of

the therapist, the personalities of the therapist and

patient, the conditions under which therapy takes

place, and, for children’s therapy, the developmental stage of the child.

Summary

In summary, research reviews which aggregate

a variety of treatments and problems yield mixed

evidence for the effectiveness of child psychotherapy. Levitt (382,383) found little difference between treated and nontreated children, but there

are serious reservations about the analytic method

he used and the studies he reviewed. Smith, et al.

(616), found a positive effect of psychotherapy

over all ages, with no significant correlation of

age with treatment effect; however, they did not

analyze studies of child and adolescent treatment

separately from studies of adult treatment. Casey

and Berman (104) found that treated children had

outcomes better than two-thirds of untreated children, but their conclusions must be tempered by

the fact that the majority of studies they reviewed

did not use actual patients.

EFFECTIVENESS OF SPECIFIC THERAPIES

A refrain resembling the one familiar in adult

psychotherapy research seems even more apt for

research in child psychotherapy (8,43,280). The

important question may not be about the effectiveness of child psychotherapy in general but

about:

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; and

7. with which concomitant parental, family,

environmental, or systems interventions?

The following sections discuss reviews of the

research on the effectiveness of specific psychotherapies identified in chapter 5: behavioral therapy, cognitive therapy, group therapy, family

therapy, crisis intervention, and psychopharmacological (drug) therapy. Although considerable research has been done for some treatments, such

as several types of behavior therapy and some specific pharmacological agents, no research reviews

focus specifically on psychodynamic therapy;

therefore, a discussion of the effectiveness of psychodynamic therapy is not included.

Effectiveness of Individual Therapy

Behavioral Therapy

Perhaps because of the specificity of behavioral

therapy, there are few assessments of the overall

effectiveness of behavioral therapy with children.

Most studies have investigated the effectiveness

of a given behavioral technique for a given problem with a given population in a given context.

An exception is Casey and Berman’s (104) calculation of an overall treatment effect size across

37 studies of behavioral therapy. Casey and Berman found that behaviorally treated children had

better outcomes than 96 percent of untreated children, although treated children had better outcomes than only 55 percent of untreated children

when outcome measures that closely resembled
107

the activities of therapy itself (e.g., the number

of positive behaviors) were omitted. Behavioral

therapy was also one of the modalities represented

in the Smith, et al. (616), review.

The effectiveness of specific behavioral treatments for specific problems identified in chapter

3 is briefly reviewed below.

Developmental Disorders.—For children with

pervasive developmental disorder (PDD), behavioral treatments have been developed both to

increase appropriate behaviors and to decrease

maladaptive behaviors (554). Reviews of the research have supported the effectiveness of operant conditioning for teaching PDD children

appropriate behaviors such as language and selfcare and academic skills although progress is typically slow (252). One difficulty with behavioral

treatments is that they often do not generalize beyond the site of treatment. A child learning a skill

in a day treatment program may not maintain the

learning at home. Although methods of addressing this problem are being developed, further

work is needed.

Behavior Disorders.—Some studies of behavioral

approaches to the treatment of attention deficit

disorder with hyperactivity (ADD-H) suggest that

behavioral approaches have had real success in

reducing off-task behavior, overactivity, and

other problem behaviors and in increasing attention and academic performance (14,29,473). Yet

Photo credit Charter Colonlal Institute Newport News, VA

A variety of treatment modalities, including individual

therapy, are used to treat children’s mental

health problems.

other evidence raises concerns about whether behavioral therapy’s effectiveness for ADD-H generalizes to settings beyond the treatment setting,

about the duration of the treatment effect (556),

and about the possible distracting effect of the rewards used in behavior modification (81). Furthermore, Abikoff and Gittleman (4) found that behavioral treatment of children with ADD-H only

reduced aggressiveness; it did not reduce attention deficits, hyperactivity, or impulsivity (555).

Abikoff and Gittleman’s study suggests that further evaluation is needed to understand the clinical usefulness of behavioral treatment of hyperactivity .

The overall effectiveness of behavior modification for children with conduct disorders is difficult to assess because of the great variation in

conduct-disordered behaviors (e.g., from truancy

to assault), the great effect that a child’s developmental level has on the types of conduct-disordered behaviors exhibited, and the great variation in the severity of conduct disorders. Studies

of treatment for younger, less severely disordered

children tends to focus on classroom interventions

and parent training programs. A number of studies

have shown that reinforcement techniques based

in the classroom and/or at home have reduced

disruptive behavior at school (27).

Parent training programs to reduce conductdisordered behavior have helped reduce a child’s

disruptive, difficult behaviors in many families

(468). In one effective parent training program

(497), parents learned behavioral strategies in a

parent training group and made behavioral assessments and changes in their parenting behavior at

home, An average of 60-percent reduction in the

target disruptive behaviors was achieved.

EmotionaI Disorders.—Research on behavioral

treatment of emotional disorders has been largely

restricted to laboratory treatment of specific phobias, a subset of anxiety disorders. One recent review of the outcome research (252) found ample

evidence for the effectiveness of modeling procedures but not for reciprocal inhibition or operant conditioning, for treating phobias. The effectiveness of modeling procedures with children

diagnosed with other anxiety disorders has not

been demonstrated; nor has it been shown that

treatment has a lasting effect in a child’s normal
108

environment. Behavioral treatment of anxiety disorders is promising, but further research is needed

before conclusions about its effectiveness can be

made with certainty.

Psychophysiological Disorders.—Evidence for

the effectiveness of behavioral treatments for psychophysiological disorders tends to be greater

when there is a behavioral component to the disorder. Evidence for the effectiveness of behavioral

treatment of Tourette’s syndrome (598) and other

stereotyped movement disorders is limited.

Evidence for the effectiveness of various behavioral treatments for enuresis (lack of control

over urination) is more encouraging. A number

of studies have been conducted with several of

the behavioral treatments (147). Mowrer’s (450)

bell-and-pad treatment achieved complete success

in 75 percent of studied cases, although 41 percent relapsed when examined at followup (147).

Of individuals who relapsed and were retreated,

68 percent achieved lasting success. Strengthening the reinforcement, self-control, or practice

components of the bell-and-pad treatment have

been found to increase the success rate (147). Most

studies examining operant conditioning methods

for treating enuresis have found evidence for the

success of this method as well (252).

With encopresis (lack of control over defecation), operant conditioning has been successful in

several studies, although the total number of children studied has been small (147).

Some evidence exists for the effectiveness of

operant conditioning to promote weight gain in

patients with anorexia nervosa, but research on

behavioral treatment mostly fails to consider the

help these patients need with psychological and

social aspects of the disorder (54). Behavioral

treatment of bulimia has been studied too little

for an overall assessment to be made.

Cognitive Therapy

During the past 15 years, the amount of research evaluating cognitive therapies for children

often combined with behavioral approaches has

increased dramatically (301,341). Cognitive

models of treatment have been developed for

problems including hyperactivity and conduct disorder, which have often been considered resistant

to other treatments. Cognitive therapy and related

methods are important approaches in child treatment, because they are closely tied to theory and

research in developmental psychology; therefore,

they deserve careful assessment (336,399,510,674).

Kendall and Braswell’s (341) volume on cognitive-behavioral therapy comprehensively reviews

much of the research on this method. The review

treats separately two different forms of cognitivebehavioral therapy: self-instructional training and

problem-solving. After reviewing nearly 30 studies,

Kendall and Braswell concluded that self-instructional training has been shown to be successful

with several types of mental health problems.

Studies have shown a positive effect of treatment

on children’s fears, hyperactivity, disruptive behavior, and general self-control. Outcomes were

most successful when self-instructional training

was combined with operant conditioning, a form

of behavioral therapy.

Kendall and Braswell found that much less research has been conducted on problem-solving

cognitive approaches, yet much of the research

that has been conducted finds successful outcomes

such as decreases in disruptive behavior and increases in prosocial behavior.

Cognitive-behavioral therapies were also included in Casey and Berman’s (104) review of

child psychotherapy outcome studies. Fourteen

studies of cognitive-behavioral therapies showed

on average that treated children fared better than

81 percent of untreated children, although this figure may be invalid because of the inclusion of outcome measures resembling the therapy (e.g., cognitive functioning rather than behavior).

The conclusion that cognitive and related therapies have been shown to be effective must be

qualified in several ways. First, there are some

questions about the clinical relevance of some

studies, since many of the children have been

selected rather than randomly assigned, and many

of the outcomes have been measured by scores

on tests of cognitive functioning rather than by

changes in actual problem behavior (301,336,341).

Several studies, however, do show positive effects

with clinical populations (336,341). Second, successful outcomes do not always generalize beyond

the training situation to the classroom or home,

although studies that have included operant con-
109

ditioning methods or that have broadened the

scope of the treatment have often achieved better generalization effects (81,341). Third, aggressive behavior has been especially resistant to cognitive methods (341).

Recent research has investigated such variables

as age, developmental level, and cognitive styles

of children to help explain differences in outcome

and to help tailor cognitive therapies to the requirements of different children (81,341). In a similar vein, Kazdin (336) has noted that studies of

more intensive courses of cognitive therapy, with

greater focus on specific clinical problems, are

needed to test their clinical potential completely.

Effectiveness of Group Therapy

As noted in chapter 5, group therapy for adolescents differs from group treatment for younger

children. Child group therapy tends to rely on

group play and activities, while adolescent group

therapy is more of a “talking” therapy. The literature on each has been discussed in separate reviews. Group therapy has also been included in

reviews by Smith, et al. (616), and Casey and Berman (104).

Group Therapy With Prepubescent Children

Abramowitz (5) has reviewed the outcome research on group therapy with prepubescent children. The literature reviewed included studies

using verbal approaches (39 percent), play and

activity approaches (37 percent), and behavior

modification (24 percent). The studies focused on

treatment of immature or problem behavior, social isolation or withdrawal, poor self-concept,

or academic underachievement. Outcome measures focused chiefly on improvement in personality variables, appropriateness of behavior, interpersonal relations, and academic performance,

Abramowitz found that about one-third of the

studies demonstrated positive effects of group

therapy, one-third had a mixture of positive, negative, and null results, and one-third found no effects of treatment. The generalizability of this evidence must be questioned, however, since most

of the outcome studies in Abramowitz’s review

investigated group therapy that lasted only 10 to

15 sessions and so may not apply to therapy

which lasts longer. Many clinicians argue that a

number of initial sessions are needed for a group

to “jell” and develop sufficient intimacy for effective therapeutic work to be done (722).

Casey and Berman’s (104) review of child psychotherapy included a separate treatment effect

size for 33 studies of group treatment. Casey and

Berman found that the average child treated in

group therapy had a better outcome than 50 percent of untreated children. However, their review

does not provide information on the nature of the

group treatment; thus, it is difficult to determine

if the 33 studies reviewed by Casey and Berman

are any more representative than those reviewed

by Abramowitz. A fair conclusion is that the full

range of child group therapy has not yet been adequately assessed.

Group Therapy With Adolescents

As noted earlier in this chapter, most of the

treatment outcome studies in Tramontana’s (637)

review of adolescent therapy utilized group therapy. A1though most of the studies in the Tramontana review were methodologically flawed, two

of the studies that evaluated the effectiveness of

adolescent group therapy were relatively rigorous. In a study by Persons (503), institutionalized

delinquents of both sexes receiving a combination

of individual and group psychotherapy were compared with adolescents receiving the standard institutional regimen. The group therapy combined

directive and nondirective elements. Persons found

positive effects of treatment on anxiety, other psychopathology, academic performance, and antisocial behavior within the institution and at followup in the community. Treated youths also

showed better outcomes on measures of employment and recidivism. In a study of a similar population, Redfering (529,530) contrasted institutionalized delinquent adolescents (girls only)

receiving short-term group counseling to a nontreated group. At the end of 11 weeks of treatment, the girls in therapy had greater positive

changes in self-concept and feelings about parents

and peers. Over time, significant differences in

parental and self ratings were maintained. Also,

treated girls were released more frequently from

the institution and recommitted less frequently.
110

Effectiveness of Family Therapy

Family therapy to deal with children’s mental

health problems has gained increasing use by clinicians. Family systems theory was found to be

useful by more than 60 percent of child therapists

in a survey by Koocher and Pedulla (365). Yet

outcome studies of family therapy have rarely

been included in generic reviews of treatment such

as those by Smith, et al. (616), and Casey and Berman (104). Their lack of inclusion speaks both to

the newness of family therapy and its status as

a conceptually different form of treatment.

Gurman and Kniskern’s Overview (1978)

In the most comprehensive review of the family therapy outcome literature, Gurman and

Kniskern (267) identified over 200 outcome studies

on marital and family therapy. Most of the studies

reviewed by Gurman and Kniskern (267) did not

identify a child as the patient and will not be considered here (although therapy with parents alone

can be helpful to children). Of the studies in which

a child was identified as the patient, Gurman and

Kniskern (267) reviewed studies of behaviorally

based family treatment separately from studies of

nonbehavioral family therapies. They also treated

studies which used “no treatment” control groups

separately from those studies which did not compare families receiving family therapy to families

receiving no treatment. Gurman and Kniskern

(267) judged that most of the controlled studies

they reviewed were well designed.

In the only five studies of behavioral family

therapy with children as identified patients, and

which used control groups, those children and/or

families who received treatment had more positive outcomes than those who received no treatment. Behavioral family therapy led to improvement in the parents’ and observers’ ratings of

children in the majority of uncontrolled studies

as well.

In 60 percent of controlled studies of nonbehavioral family therapy, treatment led to more

favorable outcomes than no treatment. Because

these studies did not include long-term followup,

however, the effects of treatment over a longer

period of time are not known. Finally, in 19 uncontrolled studies of nonbehavioral family therapy in which children or adolescents were identified as the patients, 71 percent of treated children

and/or families improved, while 29 percent either

did not improve or deteriorated. In summary,

most studies reviewed in Gurman and Kniskern’s

comprehensive evaluation found that, in general,

family therapy was better than no treatment.

Questions remain, however, about the representativeness of the treatments and samples in the

studies that Gurman and Kniskern reviewed (267).

In addition, their reviews did not speak to the efficacy of family therapy for specific childhood

mental health problems.

Effectiveness of Family Therapy With

Conduct-Disordered and Delinquent Children

Some researchers have focused on the effectiveness of family therapy with specific childhood

mental health problems (268). Two prominent research groups have investigated family therapy

for conduct-disordered and delinquent children

and adolescents (268,336).

Behavioral family treatments of conduct-disordered children have been extensively investigated by Patterson and associates with over 200

families in studies spanning two decades. Patterson’s family intervention, a form of parent training based on social learning principles, has been

found to be effective in reducing aggressive and

antisocial behavior both in the home (488,493,

495,681,710) and in the classroom (496). Positive

effects have also been found in the behavior of

siblings and in the mental health of mothers of

the identified patients (493,494).

The Functional Family Therapy program of

Parsons and Alexander—a cognitive-behavioral

family treatment of delinquent adolescents—led

not only to an improvement in family interaction

(485), but also to a decrease in recidivism (16).

Improved family interaction was correlated with

declining recidivism. A followup 2% to 3 years

later revealed that siblings of the original identified patients had a reduced number of court contacts as well (356).

While family treatments of conduct-disordered

children and youths appear promising, questions

remain about the effectiveness of these models of

treatment across the broad range of children with

conduct disorders. More severely disadvantaged,
111

troubled families have been found to benefit much

less than other families from parent management

training (336). Similarly, one criticism of parsons

and Alexander’s work is that many of the families treated were of the Mormon faith, which

stresses family and community cohesiveness and

may have provided an unusual impetus for coping with problem behavior (268).

Effectiveness of Family Therapy With

Children With Psychophysiological Disorders

Minuchin and colleagues (442,443,444) have

studied the effectiveness of family therapy for children with psychophysiological disorders such as

anorexia nervosa and chronic illnesses such as

diabetes and asthma. They found improvement

both in measures of psychosocial functioning and

in measures specific to the patients’ physical problems (e.g., weight in patients with anorexia nervosa, respiratory functioning in asthmatics). In

one study, Schwartz, et al. (268), found improved

psychosocial functioning and control of eating in

bulimic children treated with family therapy. The

lack of control groups in studies of family therapy for children’s psychophysiological disorders

necessitates caution in interpreting the results, but

the achievement of therapeutic results on several

fronts with patients often considered unlikely to

improve without treatment suggests the potential

effectiveness of family therapy.

Summary: Effectiveness of Family Therapy

In general, family therapy outcome studies provide preliminary evidence for the effectiveness of

family therapy with many children and families,

despite a number of methodological limitations.

Studies with some specific populations, such as

conduct-disordered children and adolescents,

show particular promise. Further research would

be necessary to determine when family therapy

is most appropriate and to allow knowledgeable

matching between type of child, type of disorder,

and specific family therapy models and techniques.

Effectiveness of Crisis Intervention

Few studies have evaluated the outcome of crisis

intervention. Those studies that have been identified as evaluations have generally focused on

adult populations and have not isolated the effectiveness of crisis intervention for child patients.

Furthermore, methodological shortcomings limit

the conclusions that can be drawn from these

studies. Homebuilders, the program discussed in

chapters as exemplifying crisis intervention, was

evaluated only in terms of its cost-effectiveness

and success in avoiding outside placement of patients (350), not in terms of patient functioning.

Outside placement was avoided for 90 percent of

patients with an estimated cost savings of over

$3,200 per patient.

Effectiveness of Psychopharmacological

(Drug) Therapy

The effectiveness of psychopharmacological

agents in treating childhood disorders can only

meaningfully be assessed separately for each pharmacological treatment. The various classes of drug

treatment have such contrasting purposes and

therapeutic effects that it is impossible to discuss

them as a whole. In assessing these medications,

the evidence for each intended therapeutic effect

must be considered and weighed against the medications’ side effects.

Stimulants

The use of stimulant drugs to treat ADD and

ADD-H is by far the most common application

of psychopharmacological therapy in children,

and its effectiveness with children has been researched more than any other drug treatment. Researchers have differentiated the effects of stimulants on specific cognitive functions, academic

achievement, social behavior, personality variables, and mood (96). Most research has been focused on short-term effects, but medium and longterm effects of stimulants have also received attention.

Cantwell and Carlson (96) found 15 laboratory

experiments demonstrating that several different

stimulants successfully aided children with ADDH in tests of attention, impulsivity, distractibility, motor restlessness, short-term memory, and

new learning. These results, however, are not necessarily relevant outside the laboratory.

The effects of stimulants on academic achievement by hyperactive children has been assessed
112

by a number of studies. Barkley and Cunningham

(42) reviewed 120 studies of the effect of stimulant drugs on academic achievement, although

only 17 of the studies used objective academic

measures. Few positive effects of stimulants on

academic achievement were found, and those that

were found may have reflected the influence of

the drugs on school examinations and not on daily

learning. Followup studies supported these findings. Thus, there is some evidence for the effectiveness of stimulants on attention deficits, but

little evidence that the use of stimulants to treat

ADD-H is associated with academic improvement.

Teachers and parents have noted improvements

in social behavior in children treated with stimulants for hyperactive and disruptive behavior,

(121). Recent research has found parallel effects

on some symptoms of ADD-H in adolescents

(673), yet methodological difficulties and the developmental differences between adolescents and

children prevent any firm conclusions about the

effectiveness of stimulants at this time with adolescents with ADD-H.

Although stimulant drugs achieve good shortterm results in children with ADD-H, the limited

research findings regarding long-term results are

much less impressive (526). Available studies have

compared children who have been treated continuously for a number of months with children

who have had less or no drug treatment, and they

show few long-term positive effects of stimulants

(526). Some studies suggest that adolescents who

have received stimulant treatment sometime during childhood have fewer symptoms of ADD-H

than those who have not received stimulant treatment, but that they are still prone to antisocial

behavior, poor peer relationships, low self-esteem,

and academic problems (279).

Concerns about the side effects of stimulant

treatment focus on: 1) possible retardation of

physical growth (568), 2) negative effects on learning (628), 3) drug dependence or later drug abuse,

and 4) euphoriant effects. A panel appointed by

the Food and Drug Administration evaluated the

available evidence and concluded that stimulants

may have a minor suppressive effect on growth

when prescribed in the average-to-high range of

dosage. Rapoport (526) addressed the concern

about the effects of stimulants on learning and

concluded, after reviewing six studies, that stimulant drugs seem neither to enhance nor retard

learning significantly in children with ADD-H.

The connection to drug dependence and later drug

abuse and the euphoriant effects of stimulants on

children have been determined not to be problems

(121,658), although some believe that these issues

have not been settled conclusively (121).

Neuroleptics

As noted in chapter S, neuroleptic medication—

sometimes called antipsychotic medication—is

used not as a treatment to reverse a disorder, but

rather as a means of reducing troublesome symptoms associated with a disorder. Neuroleptic

medication is prescribed most frequently to control aggressive, assaultive, hyperactive, socially

inappropriate, and difficult to manage behavior

in severely impaired children, including children

with PDD and especially children with mental

retardation (39o).

The effects of neuroleptic medications with severely disturbed children have been evaluated in

a number of studies (714). Most studies have

found positive effects of neuroleptics on many

outcome measures of behavior, but as Winsberg

and Yepes (714) state, these outcomes suggest that

neuroleptics “. . . appear useful only in the management of psychotic children, making them less

withdrawn, less overactive, less anxious, less agitated and more tractable . . . .“ Two studies by

Campbell and associates (90,91) also found positive effects of neuroleptics for severely disturbed

children in a behavioral (operant) learning paradigm, probably because of their effect of reducing inappropriate responses (92).

One neuroleptic, haloperidol (Haldol”), has

been shown to be effective in reducing the tics and

other symptoms of Tourettefs syndrome, although

there are few controlled studies (598). Neuroleptics have also been used in low doses to treat

ADD-H; however, in comparative studies, stimulants have usually outperformed neuroleptics for

treatment of hyperactivity and are generally preferred clinically (714).

A number of side effects of neuroleptics have

been documented and are of concern. The sedative effect of neuroleptics appears to impair cog-
113

nitive functioning in children who are already cognitively impaired (17,75). Evidence for this effect,

however, has been limited to nonclinical populations. Other short-term side effects can include

drowsiness; blurred vision; and moderate motor

dysfunction like tremors, occasional mood changes,

and changes in urinary behavior. The long-term

side effects of most concern are medication-induced movement disorders, especially those that

emerge when the medication is stopped (22o), and,

in a few cases, tardive dyskinesia (498).

The proportion of children treated with neuroleptics who develop side effects is unknown; in

the few studies available, estimates of the prevalence of the different side effects of neuroleptics

vary widely. Conners and Werry (121) note that

most side effects are not serious, and those that

are (e. g., tardive dyskinesia) are infrequent and

occur only with high doses or prolonged use. It

appears, however, that the decision to use neuroleptics with severely disordered children must

be made judiciously and the dosage must be carefully controlled. Some side effects—especially the

general “quasi-sedative” effect (714)—have provoked concern among many professionals and

parents about the frequent use of drugs (622).

Antidepressants

Well-conducted research on the effectiveness of

antidepressant treatment of childhood depression

has increased in the past several years, but definitive information awaits the completion of more

studies. In a recent review, Puig-Antich and colleagues (518) note that none of the more rigorous studies so far have shown antidepressants to

be better than placebos across samples of depressed children, although certain subgroups of

CONCLUSION

Although methodological problems plague research on the effectiveness of children’s mental

health treatments, considerable evidence has accumulated to suggest the effectiveness of a wide

range of modalities of treatment. The most recent

review of the effectiveness of child psychotherapy in general (104) found that the average child

receiving therapy was better off after treatment

depressed children have responded to antidepressants. Such issues as appropriate dosage, effect

of a child’s developmental level, and clinical improvements due apparently to placebo effects

complicate conclusions about the effectiveness of

antidepressants 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 maybe

entirely separate from their antidepressant action,

but numerous studies have found antidepressants

to be effective in reducing, though not curing,

enuresis (527). Antidepressants are somewhat effective in treating ADD-H, but generally less effective than stimulants (528). Antidepressants

have been used successfully in combination with

psychosocial (behavioral, cognitive, and psychodynamic) treatments to treat school phobia (233),

and separation anxiety caused, according to the

investigator’s theory, by biochemical disturbances

not associated with depression (232).

Although the side effects of antidepressants can

be dangerous in some children (121), the immediate side effects (e.g., dry mouth, drowsiness,

sweating) of moderate to low doses of antidepressants mainly cause discomfort (527). In higher

dosages, antidepressant medication can have cardiovascular side effects, but these can be minimized by adhering to strict limits on dosage level

(518). Use of antidepressants with suicidally depressed children is risky, because overdoses of

these drugs are extremely toxic (527). Conners and

Werry (121) state:

. , . of all the psychotropic drugs commonly used

in children, the tricyclics call for the greatest

caution.

than two-thirds of control children, and the authors

recommend that professionals not hesitate in

defending child psychotherapy’s merits. Even this

review is limited, however, by the fact that most

studies reviewed did not use actual patients in

treatment. Many treatments, used widely for a

variety of mental health problems, have not yet

been evaluated systematically.

4
114

With respect to specific treatments, even though

an overall assessment of their effectiveness cannot yet be made, several psychosocial therapies

have shown promise in a number of studies, especially in some specific problem areas. Thus, for

example, behavioral treatment is clearly effective

for phobias and enuresis, and cognitive-behavioral

therapy is effective for a range of disorders involving self-control (except aggressive behavior).

Group therapy has been found to be effective with

delinquent adolescents, and family therapy appears

to be effective for children with conduct disorders

and psychophysiological disorders. Psychopharmacological treatment, while not curative, has

been found to have limited effectiveness with children with ADD-H, depression, or enuresis, and

also in managing the behavior of children who

are severely disturbed. Further, more rigorous research may demonstrate the usefulness of several

other treatments for which there is preliminary

evidence of effectiveness.
Chapter 9

Effectiveness of Treatment and

Prevention in Mental Health and

Other Settings, and Evaluating

the Integration of Mental Health

and Other Services
Chapter 9

Effectiveness of Treatment and Prevention

in Mental Health and Other Settings,

and Evaluating the Integration of

Mental Health and Other Services

INTRODUCTION

The effectiveness of various settings for children’s mental health treatment is of interest to

policy makers and was one of the reasons this

background paper was requested. Mental health

treatment settings vary considerably in intensiveness, restrictiveness, and cost. Therefore, it is

valuable to have systematic information about the

effectiveness of alternative settings to justify placement, reimbursement, and public policy decisions.

Similarly, evidence about the effectiveness of prevention efforts and the integration of services across

mental health and other systems is valuable.

Chapter 6 described the mental health settings

in which disturbed children receive treatment.

Such settings range from inpatient hospital settings to private mental health practices. For those

settings that provide a therapeutic milieu or engage mentally disturbed children in treatment for

substantial periods of time each week—e.g., hospitals, residential treatment centers (RTCs), and

day treatment programs—the setting itself may

have an important effect on treatment outcome.

Available outcome research on the use of these

settings for mental health treatment is reviewed

in this chapter.

Chapter 7 described broad-based interventions

to identify and treat children’s mental health problems within the educational, general health care,

child welfare, and juvenile justice systems; it also

described efforts to prevent children’s mental

health problems and to integrate mental health

and other services. Because of a lack of research,

the effectiveness of treatment in most of the nonmental-health systems cannot be evaluated. Information on outcomes in the child welfare system

(e.g., therapeutic foster homes or group homes),

for example, is insufficient to be reviewed. There

is some research on the effectiveness of interventions in the educational and juvenile justice systems, however, and that research is considered

in this chapter. Also reviewed is some of the most

rigorous research on prevention programs. There

have been very few efforts to evaluate the integration of mental health and other services generally

and no such efforts to date for children’s mental

health services. A planned evaluation of a new

Federal effort to integrate services is described in

this chapter.

EFFECTIVENESS OF TREATMENT IN SELECTED MENTAL HEALTH

TREATMENT SETTINGS

Understanding the respective roles of mental

health treatment modalities and treatment settings

in therapeutic outcome would be invaluable in designing mental health programs. Unfortunately,

the current state of research on outcomes makes

it difficult to separate effects due to particular

treatment modalities from effects due to the settings in which treatment occurs, or to no treatment. From a methodological perspective, the

principal problem is that available research has

117
118

not used control groups to compare the effectiveness of alternate settings. Disturbed children with

similar diagnoses and life circumstances have not

been randomly assigned to either a hospital, an

RTC, a community mental health center (CMHC),

or other outpatient setting giving similar treatments and the children’s treatment outcomes subsequently compared.

The effects of some treatment elements such as

intensive individual therapy may be easier to disentangle from the settings in which treatment is

given, but systematic research that attempts to do

this has not been conducted. Consequently, it is

difficult to assess the degree to which alternative

treatments or alternative settings would have

achieved similar or different therapeutic outcomes

(580).

Effectiveness of Psychiatric

Hospitalization

The most intensive, as well as costly, form of

mental health treatment involves inpatient care

in a hospital. Although psychiatric hospitals are

a type of residential treatment, the services they

provide may differ from services provided in

nonmedically focused settings such as RTCs. Consequently, a somewhat separate research literature on the effectiveness of psychiatric hospitalization for children has developed (61,245).

Blotcky, et al. (61), reviewed two dozen followup studies of mentally disturbed children under the age of 12 who had been treated in hospital inpatient and other residential psychiatric

facilities. One-fifth of the studies were prospective. One-third included adolescents as well as

children.

All of the followup studies that Blotcky and colleagues reviewed reported some positive treatment

outcomes. The studies concluded, however, that

treatment outcomes were primarily associated

with the severity of disturbance. That is, they

found that over half of the children described as

neurotic or exhibiting personality disorders demonstrated long-term positive outcomes following

inpatient treatment. More severely impaired children, diagnosed as psychotic (i.e., having disorders involving severely disturbed perceptions

of reality) or neurologically impaired, had somewhat fewer positive outcomes. Outcomes also appeared to be related to variables such as characteristics of the patient other than diagnosis (e.g.,

intelligence), family factors (parental psychopathology), and, to a lesser extent, treatment variables

(e.g., length of stay, aftercare). However, treatment courses were so variable, and periods between discharge and followup so long in most

studies reviewed, that inferences about effective

elements of inpatient and other residential treatment cannot be made. In many cases, it was impossible to determine whether the treatment setting more resembled a hospital or an RTC.

According to Blotcky, et al., because controlled

research has not been done and inpatient followup

studies have not compared results of inpatient

mental health treatment to either natural course

or outpatient treatment, it is difficult to know the

relationship between inpatient psychiatric treatment and outcomes.

Gossett, et al. (245), reviewed 22 followup

studies of mentally disturbed adolescents who had

received inpatient psychiatric treatment, and their

conclusions about the effectiveness of such treatment were similar to those of Blotcky, et al. (61).

The studies Gossett and colleagues reviewed indicated that the majority of nonpsychotic adolescents who had received inpatient treatment were

functioning at an adaptive level several years after discharge. Of psychotic adolescents who had

received inpatient treatment, only one-third were

adjusted adequately at followup. In general, the

less severe and chronic the adolescent patients’ initial problems—including level of family psychopathology—the more positive their eventual outcomes, although Gossett, et al. ’s review found that

aftercare was associated with positive outcomes.

A primary goal of developing this background

paper was to respond to questions about the effectiveness and appropriateness of psychiatric hospitalization for children and adolescents. The

methodological limitations of available studies of

inpatient psychiatric care make firm conclusions

difficult. Available studies do not clearly show

which components of hospital treatment contribute to successful outcomes. Neither do they allow conclusions about whether children treated
119

as hospital inpatients would have better, worse,

or similar outcomes with nonhospital treatment.

Because of the methodological limitations of available studies, it is unclear to what extent outcomes

for mentally disturbed children treated in hospitals are a function of the children’s level of disturbance. In many cases, hospital treatment is a

“last resort” for children who have been unsuccessfully treated in other settings. Prospective research controlling for patient characteristics and

family variables has not been conducted.

Effectiveness of Residential

Treatment Centers

There are many similarities between RTCs and

children’s psychiatric hospitals, and the findings

about effectiveness of RTCs are similar to those

for psychiatric hospitals. Several studies have investigated the effects of RTC treatment, chiefly

on outcomes measured during or soon after treatment. Unfortunately, however, interpretation of

these studies, like studies of inpatient treatment,

is limited by the fact that most of the studies

lacked control groups.

Whittaker and Pecora (706) reviewed eight

studies of RTC treatment. Without exception, the

Photo credit OTA

This group home serves as an intermediate step for

adolescent boys who still need supervised care and

treatment before returning to their families.

studies found that the majority of children made

satisfactory adjustment while still in RTC treatment. Unlike the results for psychiatric hospitals,

the evidence for a relationship between severity

of a child’s problems at admission (or other diagnostic variables) and posttreatment outcome was

inconclusive. Following treatment, however, their

level of adjustment depended on the quality of

the posttreatment environment, the amount of

stress or social support (especially family support),

quality of parent-child relationships, and family

stability. Greater involvement of the family with

RTC treatment and with postdischarge planning

was also associated with favorable outcomes.

Lewis, et al. (386), performed a followup study

of 51 children who had received RTC treatment.

Most of these children had been considered improved at the time of discharge, but were rated

poorly adjusted at later followup by independent evaluators. The majority of poorly adjusted

children had had more than two institutional

placements following RTC treatment. Children

who had been older at the time of admission to

RTC treatment and who had exhibited both psychotic and organic symptoms also tended to have

poorer outcomes as did children with disturbed

parents, although Lewis, et al., point out that it

is impossible to separate possible genetic contributions from environmental contributions to outcome. Lewis and his colleagues note that many

of the children in the study completed RTC treatment just prior to adolescence and suggest that

poor outcomes for these children might have resulted from the turmoil of adolescence combined

with the difficulty of being released into a stressful environment.

Re-ED programs area type of RTC that appears

particularly promising (see ch. 6). In a study by

Weinstein (686), data on one Re-ED program,

Cumberland House, were gathered from parents,

Re-ED teacher-counselors, teachers in the children’s regular class, classroom peers, referring

agency staff, and from the children themselves.

Weinstein’s study, considered one of the best of

the Re-ED evaluations, found that children who

had completed the program had more positive

self-concepts, a greater sense of self-control, and

better academic performance than a disturbed but

untreated control group. The children who had
120

completed the program were rated as improved

by Re-ED staff, regular teachers, other professional staff, and parents, but, curiously, not by

their peers. Despite their apparent improvement,

however, Re-ED children were rated more poorly

on most measures than a nontroubled control

group.

Other evaluation and followup studies of ReED programs have found results such as improved

academic achievement, increased prosocial behavior as measured by an antisocial behavior

checklist, successful discharge of over 65 percent

of residents, improved home and school relationships, and improved school enrollment following

treatment, although some school problems continued (606). Since the researchers’ assessment

measures were sensitive to a wide range of outcomes, many in the community, Weinstein’s study

provides preliminary support for the Re-ED program model. However, only a few studies have

evaluated Re-ED outcomes, so conclusions about

the Re-ED program’s effectiveness ought to be

viewed with caution. Long-term followup data do

not yet exist, and measurement of outcome by independent clinicians or other independent observers is lacking.

The outcome research on RTCs, though not extensive or methodologically rigorous, suggests

that although most children treated at RTCs improve during treatment, their long-term outcomes

may be less positive and depend on the involvement of the family in treatment, the amount of

stress in the environment, and the availability of

social support. The implication of available research is that the effectiveness of RTC treatment

cannot be considered in isolation, but must be

evaluated in conjunction with the quality of followup care. Another implication is that coordination between RTCs, community agencies, and

the family is necessary. Although Lewis, et al.

(386), suggest that the “undoing” of RTC treatment that can happen in the community implies

the need for longer RTC treatment, no evidence

is available to indicate that longer RTC treatment

leads to better outcomes or that longer RTC treatment is superior to RTC treatment combined with

adequate followup care.

Effectiveness of Day Treatment

As noted in chapter 6, day treatment is intermediate in intensity between outpatient and 24-

hour care, as in psychiatric hospitals or RTCs.

As such, it is used both as a less restrictive alternative to inpatient treatment and as a transition

from inpatient to outpatient care. Although data

on the number of children in day treatment are

not available, the number of day treatment centers

for children has increased dramatically —concomitantly with the development of CMHCs—from

10 in 1961 to over 350 in 1980 (735). Research on

the effectiveness of child day treatment has also

increased in recent years, corresponding to the

treatment’s greater availability, but most of it has

not been methodologically rigorous.

Zimet and Farley (735) reviewed six followup

studies that evaluated day treatment outcomes for

children. The day treatment programs evaluated

in the six studies relied on a variety of theoretical orientations (behavioral, psychodynamic, etc. )

or combinations of orientations. Zimet and Farley

state that the studies they reviewed reported “satisfactory adjustments” in 76 to 90 percent of

children receiving day treatment. “Satisfactory adjustments” included outcomes such as improved

self-esteem, greater academic achievement, improved social relationships, and more appropriate behavior. Children in day treatment were less

likely to be placed in inpatient settings. Younger

children generally made greater gains than older

children. Results on the effects of parental involvement with children in day treatment were mixed.

Friedman and Quick (208) reported a study in

which two groups of children who did not complete a day treatment program (one group completed over so days of treatment) were compared

to one group of children who did complete the

program. Adolescents who had substantial involvement with the multimodality program that

was studied had greater academic gains than those

with minimal involvement. At followup, 2 years

after discharge from treatment, greater involvement with the program appeared to be associated

with a lower probability of being a runaway or

being institutionalized. According to Friedman
127

and Quick, the group of children who dropped

out of day treatment included many chronic runaways and truants “whose behavior was very

appropriate while attending, but for whom the

program failed to secure consistently good attendance. ”

of day treatment lack methodological rigor. Definitive conclusions about the effectiveness of day

treatment, therefore, must await further investigations. Nevertheless, the consistency with which

positive outcomes following day treatment have

been reported is encouraging.

Like most treatment outcome research in the

field of children’s mental health, available studies

EFFECTIVENESS OF TREATMENT IN SELECTED

NON-MENTAL-HEALTH SYSTEMS

As noted in chapter 7, mental health treatment

is sometimes delivered in settings in the educational, health care, child welfare, and juvenile justice systems. A few such interventions that have

been evaluated are discussed below. Because of

the paucity of evaluation studies of such interventions, the discussion that follows is not comprehensive.

Effectiveness of Treatment in the

Educational System

A large investigation of mental health interventions in the school system of Newcastle-uponTyne in England was undertaken by Kelvin, et

al. (362). Their aim was to compare the effectiveness of a range of different approaches to mental

health intervention in a community setting. The

investigators identified 574 disturbed children (265

7-year-olds and 309 11-year-olds) in 12 schools

and randomly assigned them to a no-treatment

control group or to one of four treatment conditions: 1) child group therapy, 2) behavior modification applied to entire classrooms (for older

children only), 3) parent guidance, and 4) a nonspecific “nurturance” intervention provided by

teacher-aides in school (for younger children

only). All the treatments except parent guidance

(which took place in the home) were delivered at

school. The investigators believed that the school

setting allowed them a number of advantages over

a clinic setting—a better grasp of the children’s

social environment, the children’s greater familiarity with the setting, and more opportunity for involvement by teachers.

Disturbed children were identified from an index based on a combination of teacher, peer, and

self ratings, along with reading scores and attendance records. A control group of nondisturbed

children was used for comparison purposes. The

experimental and control groups were not entirely

comparable, however, because disturbed children

had a lower socioeconomic status than nondisturbed children and also had a greater lifetime incidence of broken homes and health problems.

The children in the Newcastle-upon-Tyne study

were treated for anywhere from two to five school

terms, 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 least

some measures. In general, the group therapy and

nurturance approaches led to better results for the

younger children, and the behavior modification

and group therapy were most effective for the

older children. Emotionally disordered children

tended to improve more than behavior-disordered

children. One important finding was that the effectiveness of the behavioral intervention tended

to increase over time, suggesting a “sleeper” effect of treatment. The modality of treatment was

a better predictor of success than the sheer duration of treatment.

Effectiveness of Treatment in the

Juvenile Justice System

A research program conducted by Massimo and

Shore (419,604,605) examined the effect of a

“vocationally-oriented psychotherapeutic pro59-964 0 - 87 - 5
122

gram” for adolescent delinquent boys. In line with

the researchers’ understanding of the specific needs

of delinquents, this program offered a comprehensive set of interventions that differed greatly

from the traditional clinical approach. Job counseling and placement was the first component introduced, and psychotherapeutic contact was added later; the program also included help such as

remedial education and aid in managing money.

Outcomes were measured during the 10-month

treatment period, and at 2 to 3, 5, and 10 years

later. Treated adolescents showed improved adjustment emotionally, academically, and vocationally. Massimo and Shore’s work is often cited

as a promising multi-intervention program that

has shown some success with a difficult-to-treat

population.

Studies of behavioral treatment for more severe

conduct disorders often take place in juvenile justice settings. Reviews suggest that operant behavioral programs have led to improvement in

a number of social, academic, and personal behaviors within the treatment setting (136,170).

However, there is little evidence that these behavioral improvements carry over to behavior in

natural, community environments (252).

EFFECTIVENESS OF SELECTED PREVENTION EFFORTS

In recent decades, there has been increasing

acceptance and support of the concept of services to prevent mental health problems. Preventive mental health efforts have burgeoned and received support on many levels (Federal, State, and

community). A solid research base detailing the

effectiveness of prevention strategies is just beginning to accumulate. Several fairly rigorous outcome studies have been done, but these studies

examine only a minority of the prevention efforts

that have been or could be undertaken. To some

extent, the paucity of methodologically sound research on the effectiveness of prevention efforts

parallels the paucity of rigorous research on the

effectiveness of children’s mental health services

in general. In addition, however, the amount of

information currently available about the effectiveness of prevention is limited by difficulties that

are specific to prevention outcome research (e.g.,

the low base rate of certain disorders in the population, the large cost and effort involved in longterm followup studies, and the wide range of target problems and interventions included in the

concept of prevention) (281). Nonetheless, available research suggests that certain prevention

strategies can be quite effective, both in terms of

preventing the development of mental disorders

and in promoting mental health and adaptation.

As is noted in chapter 7, prevention programs

have taken a number of forms. Such programs

have been aimed at almost all of the mental health

problems that fall into the standard diagnostic categories and at the problems associated with environmental risk factors. Moreover, they have occurred in a diverse array of settings (e.g., home,

school, mental health centers) and have involved

the participation of children and parents, as well

as whole families, classrooms, and schools. The

wide range of prevention programs which have

been implemented and evaluated precludes an exhaustive review of the effectiveness of all types

of prevention programs. A selected group of the

more rigorous outcome studies is described below.

Effectiveness of Selected Primary

Prevention Efforts

As noted in chapter 7, primary prevention efforts are aimed at reducing the incidence of mental health problems in children. Some of these efforts are directed at parents and others at children.

Parent Training Programs

Interventions aimed at reducing the interfactional and developmental difficulties often associated with preterm birth and adolescent parenting have been well researched. One research group

that used random selection and assignment to

treatment and control conditions found that biweekly intervention in the form of home visits designed to facilitate interaction between teenage

mothers and their preterm infants improved the
123

Photo credit OTA

Studies have shown that programs to encourage healthy

parent-child interaction can promote children’s

mental health.

infants’ physical, cognitive, social, and temperamental outcomes (187).

Teen Pregnancy Prevention Programs

Another well-researched prevention effort is

“Project Redirection,” a large-scale, multisite program aimed at preventing repeat pregnancies and

fostering educational and vocational attainment

in teenagers. Investigators in one study found significant beneficial effects 1 year after the intervention in terms of lower rates of subsequent pregnancy and higher rates of school enrollment and

employment; however, 2 years after the intervention, many of the benefits were no longer apparent (522).

Early Education and Child Development

Programs

Among the most widely implemented and extensively researched prevention efforts are the

early education intervention programs that originated with Head Start in the mid-1960s. As noted

in chapter 7, although these programs were not

specifically directed at preventing mental health

problems, they have addressed the needs of children at risk for educational and adaptive failures,

which have been shown to be associated with later

mental health problems (127,514,546,675,699).

The history of evaluation of early education

programs is essentially one of initial enthusiasm

and excessive optimism, giving way to pessimism

and a sense of failure, and ultimately arriving at

a more balanced view of what these programs

have and have not achieved (731,734). Early

pronouncements of the failure of early education

programs were, in part, the result of an evaluation known as the “Westinghouse Report, ” which

concluded that Head Start programs produced no

lasting gains in cognitive and affective development (113). The Westinghouse Report was widely

publicized and generated questions both about the

premises of the Head Start program and the validity of outcome measures.

One response to these questions was a general

reassessment of the long-term effectiveness of

early education programs by the Consortium for

Longitudinal Studies (378). This study involved

the pooling of original data from 12 investigators

who had independently designed and implemented

evaluations of early education programs for lowincome children in the 1960s. Thus, this study was

a joint evaluation of the early education programs’

long-term effects. Although all of the early education programs had focused on economically disadvantaged preschool-aged children, they differed

in terms of program length, mode of intervention,

and program setting (home- or center-based). The

evaluations of the programs varied in the extent

to which they utilized random assignment to treatment and control conditions.

The study by the Consortium for Longitudinal

Studies found that low-income children who had

participated in early education programs were significantly more likely than controls to have met

school requirements. Participants were less likely

to have been assigned to special education classes

or to have been retained in a grade. Participants

also showed higher IQ and achievement test scores

during the first 3 or 4 years following program

participation, although differences in IQs of program and control children were not found after

this time. Early education was found to have had

a lasting effect on attitudes towards achievement

—both among the children and their parents. Specifically, program children were found to have a

more positive attitude towards achievement and

school than controls and their mothers were found
124

to be more satisfied with their children’s school

performance and to have consistently higher occupational aspirations for them.

In a more recent study of the effects of preschool

education through age 19, Berreuter-Clement, et

al. (56), found, in addition to the effects on school

and attitude found in earlier studies, that by age

19, the preschool group’s employment experience

was significantly better than the experience of a

no-preschool control group.

In general, the studies by the Consortium for

Longitudinal Studies and Berreuter-Clement and

his colleagues suggest that early education has significant and lasting effects on children’s functioning (378). Although the exact mechanisms by

which the early education programs lead to positive outcomes are not known, it has been suggested that cognitive, social, and motivational factors were involved. Furthermore, the positive

effects of early education programs have been attributed not only to changes produced in the children but, perhaps more importantly, to the effects programs had on parents (6,10,734) and

others in the child’s environment, including siblings (249) and other social institutions in communities served by the program (77,352,469,671).

Such effects illustrate the importance of providing services in the context of children’s lives.

The implementation and evaluation of early

education intervention projects have important

implications for the evaluation of prevention efforts in general. Zigler and Berman (731) emphasize the importance of avoiding the type of overpromising that accompanied Head Start in its

early years. Although early intervention has been

shown to result in benefits for children and families, it is an error to assume that an early education program alone can eliminate the often pervasive effects of social and economic disadvantage.

Furthermore, these authors note, there are problems associated with overstressing change in IQ

score as the major criterion of the effectiveness

of early education efforts. Although measures of

formal cognitive ability are important, benefits

in other essential realms of functioning have resulted from these efforts. Zigler and Berman suggest broadly defined “social competence” as a

more appropriate measure of outcome (733).

Family Support Programs

Much less is known about the effectiveness of

interventions directed at supporting effective functioning in high-risk families than is known about

the effectiveness of early education and other programs designed to provide cognitive stimulation

to children (594). As evaluations of early education increasingly make clear, however, the most

effective interventions are often those that actively

involve parents as well as children (77,250). This

observation suggests that family support may be

a central aspect of promoting children’s mental

health. Because family support programs are a

fairly recent development, few outcome studies

of such programs are available. Evaluations of

two family support programs described in chapter 7—the Yale Child Welfare Research Program

and the Family Support Center Program—are reviewed below.

The Yale Child Welfare Research Program (see

ch. 7) is a program aimed at enhancing the functioning of high-risk families. Since its inception,

the program has used a matched control group

and has undergone several evaluations.

Initial evaluations of the Yale program found

that program children (at 30 months of age)

showed significantly better language development

than the control children; however, control group

families were more likely to be self-supporting and

to include a father or father-surrogate in their

home (516). Five years later, the program families were found to be living in improved socioeconomic circumstances, and program mothers

were more likely than control group mothers to

be employed and to have fewer total children

(539,638). Moreover, at that time, the children

in program families were found to have higher

IQ scores, better school achievement, and better

school attendance than a control sample (638).

The most recent evaluation of the Yale program

(594) is a 10-year followup of original program

participants and an equivalent control group of

parents and children. This evaluation found that

10 years after participating in the Yale program,

participating mothers were more likely than control group mothers to be self-supporting, to have

achieved higher levels of education, and to have

had fewer children. They were also more likely
725

to display self-initiated involvement in their children’s schooling. The participating children, although they did not have significantly higher IQ

scores than the control group children, had better school attendance, required fewer costly special services, and showed better social and school

adjustment. In addition, the program was found

to save money; in 1 year, the 15 control group

families were found to require approximately

$40,000 worth of school services and extrafamilial

support services that were not needed by the intervention families.

An evaluation of the Family Support Center

Program (FSCP) (see ch. 7) compared FSCP families with a sample of normal families (25). It

found that FSCP families had significantly fewer

incidents of child abuse, were experiencing less

stress, and had developed better parent-child interaction and child care conditions by the end of

the program. Greater involvement in the program

was correlated with better outcomes. The validity of the findings is limited by the lack of a control group and the fact that half of the FSCP families did not complete all three phases of the

program. Also, many of the families participating in FSCP received additional services from

other agencies during the course of the intervention.

Effectiveness of Selected Secondary

Prevention Efforts

The Primary Mental Health Program (PMHP)

is an extensively implemented and evaluated secondary prevention program (126). Although used

with children slightly older than the children in

Head Start, PMHP is similarly focused on the prevention of educational failure and school maladjustment; PMHP also shares the premise that

amelioration of early difficulties has important

preventive implications for later mental health

problems. Unlike Head Start, PMHP selects for

the program children who are already beginning

to experience problems.

Since the program’s inception, outcome research has been a central component of PMHP.

Several studies attest to PMHP’s effectiveness in

reducing problem behaviors and enhancing competence in high-risk groups (128,694). Attention

has also been paid to the long-term effects of participation in PMHP; children have been found to

maintain significant gains in adjustment for I to

5 years following PMHP intervention (107,394).

In a recent 2-to 5-year followup (107), PMHP

children were compared with a “never seen” group

(children judged to be well-adjusted at the time

of initial screening) and a “least well-adjusted”

group (non-PMHP children who were judged by

their teachers to be functioning poorly). This

study found that the PMHP children maintained,

and in some cases solidified further, the gains in

adjustment and problem reduction they had made

2 to 5 years earlier. In addition, although PMHP

children were often found to be functioning less

well than the “never seen” children, they consistently appeared to be better adjusted than the “least

well-adjusted” children. This observation suggests

that although PMHP did not completely eradicate early detected difficulties, it did significantly

prevent the development of serious problems in

a high-risk group. Finally, PMHP children were

found to perform in the normal range on academic

achievement measures at followup, suggesting a

sustained and long-term benefit of the intervention.

Summary: Effectiveness of Prevention

Research on the outcomes of prevention programs for specific mental disorders is very undeveloped. There are, however, some fairly rigorous studies on the outcomes of efforts to prevent

more broadly defined maladjustment—e. g., PMHP

and early education and child development programs. These studies suggest that prevention, or

at least reduction, of an incipient mental health

problem is a worthwhile and attainable goal.
126

EVALUATING THE INTEGRATION OF MENTAL HEALTH AND

OTHER SERVICES

As difficult as it is, evaluating specific programs

is simple compared to evaluating the effects of integrating mental health and other services. In their

review of methods for evaluating services integrated across systems, Morrissey, et al. (666),

found little solid evidence to support the belief

of some investigators (e.g., 262) that organizationlevel variables predict client-level outcomes. Evaluations of the effects of integrated services on

client-level outcomes would require the integration of system, program, and client-level data;

studies encompassing all three levels of data are

relatively rare in the health and welfare field (666).

At present, there are no reviews of attempts at

coordinating mental health and other service sysCONCLUSION

Methodologically rigorous research comparing

the effectiveness of treatment in psychiatric hospitals and other residential settings with similar

treatment in outpatient settings is sorely lacking.

Despite the limitations of available research, however, certain trends in the data are suggestive—

and support particular policy choices. The longterm effectiveness of psychiatric hospitalization

and other forms of RTC treatment, for example,

appears to be related to the availability of social

support mechanisms and mental health services

in the posttreatment environment programs. The

effectiveness of mental health treatment in nonmental-health settings may depend on pairing

treatment with other interventions like vocational

counseling or family support.

terns. The National Institute of Mental Health

(NIMH) and grantees of NIMH’s Child and Adolescent Service System Program (CASSP) are beginning to develop criteria for evaluating CASSP,

a program intended to foster collaboration and

integration among mental health and other service systems (see ch. 10). Outcome measures will

include States’ progress toward a “minimal service set”; the extent to which parents are used as

advocates for children; declines in the number of

children placed out of State; and other measures

of services, leadership, advocacy, and training.

However, actual child outcomes will not be part

of the evaluation.

Existing models of prevention suggest that effective interventions can be offered through any

of several existing systems—including the family,

the schools, and health care programs. Not only

have many prevention programs led to positive

changes in social, emotional, and academic measures, but such programs appear capable of preventing later governmental expenditures through

the justice and welfare systems.

What is clear, is that much greater emphasis

needs to be placed on evaluations of mental health

services offered in a variety of settings, including non-mental-health settings. Assessment of integrated treatment systems could help policymakers 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 health

problems, the diversity of mental health treatments, and the effectiveness, in general, of treatment have been documented in previous chapters.

Despite an incomplete knowledge of the causes

of mental health problems in children, it is clear

that much can be done to reduce the effects of such

problems. Yet substantial data suggest that many

children with mental disorders, and at risk of developing such problems, do not have access to

adequate treatment services (216,358).

This chapter examines the Federal role in providing mental health services to children. Where

possible, it considers that role in the context of

the entire mental health system—State, local, and

private. The chapter describes specific Federal programs with the greatest relevance to children’s

mental health services. Such programs relate to

financing of children’s mental health treatment;

coordination of mental health and other services;

research and training; and prevention and other

services. The chapter concludes that although the

roles of State and local governments and the private sector in serving the mental health needs of

children could be usefully enhanced, greater Federal involvement may also be desirable.

FEDERAL PROGRAMS THAT SUPPORT MENTAL HEALTH AND

RELATED SERVICES FOR CHILDREN

Several Federal programs affect the provision

of mental health services to children. The discussion in this chapter emphasizes the programs that

have the most direct influence:

●

●

●

●

the Alcohol, Drug Abuse, and Mental Health

(ADM) block grant program, which provides

funds to States for community mental health

centers (CMHCs);

third-party payment programs such as Medicaid, Medicare, and the Civilian Health and

Medical Program of the Uniformed Services

(CHAMPUS), which are involved, to a greater

or lesser degree, in financing children’s mental health care;

related psychological services under the Education for All Handicapped Children Act

(Public Law 94-142);

the Child and Adolescent Service System

Program (CASSP) of the National Institute

of Mental Health (NIMH), which is intended

to coordinate mental health and other services for severely mentally disturbed children;

and

• NIMH training, research, and prevention

programs.

Federal contributions to these programs in 1985

and, where they can be determined, estimated

amounts devoted to children’s mental health services in 1985 are shown in table 8. Because funds

for children’s mental health are commingled with

resources for adults and for alcohol, drug abuse,

and other health-related programs, the precise

amount of Federal resources dedicated to children’s mental health is not reliably known. The

estimates given, therefore, should be viewed cautiously.

Financing of Mental Health Treatment

When considering the role of the Federal Government in the financing of children’s mental

health treatment, it is important to note that mental health treatment (for all ages combined) is

financed primarily by State Mental Health Agencies (SMHAs). In general, Federal and private

sources 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 of

mental 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 undersexed

populations (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 NA

C NA

$ 10.6 to $20.0 d

N A

4.7

NA

NA

360/o

—

490

13

—

200

13

4.7

4.7

36

13 13 36

69,707

22,854f

NA

NA

NA

NA

NA

NA

1,382.7 261.0 156.6 60

31.6 31.6 4.8 15

57.4

98.2

11.5

24.1

2.0

224.8

57.4

98.2

11.5

24.1

2.0

224.8

5.5

21.7

2.4

10.3

0.2

44.9

10

22

21

43

10

, 20

aFigures in parentheses indicate fiscal year of program’s initiation.

bEstimate; States have latitude to transfer limited amounts of funds across prOgram lines.

C NA = Not available

dA 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 9

eThe 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 Program 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

SOURCES: 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 Health

Administration, Twe/fth Annua/ Report on the Child and Youth Activities of the National Institute of Mental Health, Federal Fiscal Year 1985, presented

to the National Advisory Mental Health Council by M.E. Fishman (Rockville, MD: March 10, 1986). Medicare: M. Gornick, J.N. Greenberg, P.. Eggers, and

A. 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 Financing

Administration, Bureau of Program Operations, Grants Branch, Division of State Agency Financial Management, unpublished data pertaining to fiscal year

1985 Medicaid program expenditure information, BPO-F31, Baltimore, MD, September 1986. CHAMPUS: K. Zimmerman, Statistics Branch, Information Systems

Division, Office of CHAMPUS, personal communication, Sept. 5, 1986

comparing the treatment costs that each of these

sources pays is difficult. In the case of Medicaid,

for example, the only mental health expenditure

known is that of mental hospitals. Private thirdparty payers prefer not to disclose what they pay

for mental health services, and the amount actually spent by clients themselves is not known.

being that mental health treatment for children

is typically more complex and thus more expensive than treatment for adults (see, e.g., 457).

In 1980, an estimated $21 billion was spent by

all sources on mental health treatment for all age

groups (277a). About half—$10 billion—of this

amount was spent for services rendered in the

mental health system (277a). (Most of the other

expenditures were for treatment rendered in the

The proportion of costs specifically for children’s mental health treatment is even more difficult to determine. It cannot be derived from the general health care system. ) In 1983, the year

proportion of services rendered to children for a closest to 1980 for which data are available, SMHAs

number 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 mental

health treatment for all age groups (459). This figure allows a rough estimate that more than twothirds of expenditures for treatment in the mental health system are expenditures made by SMHAS

(see figure 4). In turn, most of the revenues to

support SMHAs are provided by the States: 76

percent of SMHA revenues in 1983 came from the

States, 16 percent from the Federal Government,

3 percent from local governments, and 5 percent

from other sources (459).

The NASMHPD study also indicated that SMHAs

which were able to determine how much they

spent on mental health programs exclusively for

children spent an average of 7 percent or about

$9 per capita on such programs (459). For adult

programs, SMHAs spent an average of 45 percent of their funds, or $22 per capita. These percentages must be viewed with caution, however,

because many of the States surveyed could not

determine the allocation of mental health funds

by age. Further, in all of the States, a substantial

portion of mental health funds was spent on programs for all ages combined (e.g., on State mental hospitals).

Alcohol, Drug Abuse, and Mental Health

Block Grant

The ADM block grant was initiated in 1981

(Public Law 97-35) as the successor to a variety

of categorical programs—most significantly programs under the Community Mental Health Centers Act of 1963 (Public Law 88-164). It is currently the only major Federal program that provides

funds to States to support CMHCs and related

community mental health services. ADM block

grant funds cannot be used for inpatient care.

As shown in table 8, Congress appropriated a

total of $490 million for the fiscal year 1985 ADM

block grant (considerably less than the $625 million available for categorical programs in fiscal

year 1980 (643b)). States receive a share of the

ADM total block grant appropriation through a

formula based on population and the level of Federal funds received prior to 1981. Because the formula combines population and prior Federal funding levels, there is no direct relationship between

the size of the State’s population to be served and

Figure 4.-Estimated Proportions of State v. Federal

and Private Expenditures for Mental Health Treatment

Provided in the Mental Health System

to All Age Groups,a 1983

Estimated total: $10 billion

aExcludes treatment provided in other service systems (e.g., 9eneral health care

system),

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 Program Directors, Funding Sources and Expenditures for State Mental

Health Agencies: Fiscal Year 1983 (Washington, DC 1985).

the block grant allocation. Rather the block grant

formula tends to “reward” States that relied on

Federal funds prior to 1981 and “punish” States

that relied to a greater extent on State funds.

For several reasons, it is difficult to determine

what portion of ADM block grant funds serves

children. First, the ADM block grant is segmented,

with separate funding for alcohol, drug abuse, and

mental health programs, and the percentage of

block grant funds allowed to be used specifically

for mental health services differs among States.

Second, it is not known to what extent any of the

three categories of ADM block grant programs
134

has services designed specifically for children.

Third, CMHCs, which receive the bulk of the

mental health funds, must provide specialized outpatient services for children, but there is no requirement that they provide a certain level of service or report how much is spent on children’s

treatment. This situation is different from that

under Part F of the Community Mental Health

Centers Act of 1963, when specific funds were targeted for children.

In order to better address children’s needs, Congress amended the fiscal year 1985 ADM block

grant to require that 10 percent of the mental

health portion of block grant funds be set aside

for “new programs for children and other underserved areas and populations. ” This set-aside represents a partial return to the Part F targeting policy and reflects a recognition by Congress that

children are an underserved population. There

was some question, however, as to how effective

this l0-percent set-aside would be in increasing

the availability of mental health treatment services for children.

To assess the impact of the set-aside, the General Accounting Office (GAO) was requested (by

Senator Daniel K. Inouye) to study how States

were spending 1985 set-aside funds. Of particular concern was whether set-aside funds were being directed to programs for children and whether

these programs were actually “new” programs.

To learn how States were spending 1985 setaside funds, GAO conducted a telephone survey

(during April/May 1985) of 13 States representing each of the Federal regions and approximately

50 percent of the Nation’s population (see table

9). Three of the 13 States, Iowa, Mississippi, and

Texas, planned to spend all of the 10-percent setaside moneys on new programs for children. Four

of the States, Kentucky, Massachusetts, Michigan, and Washington, had decided not to spend

any of the set-aside money on new programs for

children. New York had decided that less than

one-quarter of its total planned set-aside funds

($203,000 of $1,153,000) would be directed toward

new programs for children. Pennsylvania had

made a similar decision and allocated approximately 20 percent of its set-aside ($230,000 of

$1,325,000) for children’s programs. The programs

for children to be supported were diverse and included enhancing nonhospital residential care,

case management, adolescent problem and suicide 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, and

Mental 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 groups

award 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) . . . . . . . . . . . .

$48,406

7,004

24,033

2,936

4,551

18,240

15,948

5,165

40,097

25,114

21,446

3,313

8,977

$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)

$2,328

340

1,358

20

669

1,011

471

361

1,153

1,326

846

220

526

$l44

337

20

0

0

0

361

203

230

846

o

$225,230 $90,840 $10,629 $2,141

$l96

1,021

0

669

1,011

471

0

950

1,096

0

526

$5,940

$2,328

0

0

0

0

0

0

0

0

0

0

220

0

$2,548

aAs 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 undeserved 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 to

Senator Inouye from Human Resources Division, General Accounting Office, US. Congress, Washington, DC, July 10, 1985.
135

Table IO.— Planneda Use in Selected States of

Fiscal Year 1985 Set-Aside Funds for

Mental Health Services for Childrenb

Statec Services for children

California Not decidedd

Colorado Residential care

Florida Psychiatric services, summer school session for the handicapped, outpatient,

emergency, diagnostic assessment, consultation, case management, crisis intervention, adolescent problem prevention

lowa Group home services, adolescent problem

prevention, family support

Kentucky None (funds will be used for other underserved areas or populations)

Massachusetts None (funds will be used for other underserved areas or populations)

Michigan None (funds will be used for other underserved areas or populations)

Mississippi Undeterminede

New York Family support, adolescent suicide prevention, referral

Pennsylvania Residential care

Texas Services for students with drug or alcohol

problems, weapons violations, etc., services for minority inhalant abusers

Vermont Not decidedd

Washington None (funds will be used for other underserved 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 that

the States reported were to be served (e g., the homeless chronically mentally

Ill) were not targeted by age Some of these programs may address the mental

health needs of children.

CA sample of 13 States, representing the receipt of about half the Alcohol, Drug

Abuse, and Mental Health block grant funds, were surveyed by the General Accounting 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 were

to be used for

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 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 entire

ADM block grant is small in comparison to State

funds and that the 10-percent set-aside for children and other underserved populations is taken

only from the mental health portion of the ADM

block grant. The entire 10-percent set-aside may

be less than $20 million nationwide—and only a

portion of this would be directed to new programs

for children. Because there were no new funds,

the set-aside requirements might mean that funds

for new programs for children will have to be

taken from other existing programs, unless States

make up the funds for other programs. Some

States noted that the requirement that the programs for children or other underserved populations be “new” did not allow for additional funds

to be allocated to already existing programs that

appeared to be effective. In response to these

problems, Congress amended the 10 percent setaside in fiscal year 1986 to read that 10-percent

of mental health block grant funds could be used

for “new or expanded” programs for underserved

populations, with a “special emphasis” on children or adolescents (Public Law 99-117).

Perhaps the most important impact of the setaside is symbolic. As States are required to report the amounts of ADM block grant money

spent on new programs for children, more attention may be brought to children’s mental health

problems. Also, because funds from the ADM

block grant cannot be spent on inpatient services,

the program provides an incentive for States to

develop locally based outpatient treatment programs. To the extent that resources for outpatient

programs are available, early diagnosis and treatment for children with mental health problems

may be more likely.

Federal Third-Party Payment Programs

The Federal Government plays a major and

trend-setting role in financing health care services.

It is the largest single insurer of health care services (Medicare and partial funding of Medicaid)

and has also played a leadership role in the development of health care payment systems. The

extent to which certain services and providers receive reimbursement while others do not has a direct effect on the delivery of care (206). Traditionally, coverage for mental health services has

been less extensive than coverage for other medical services (e.g., see 20,175a). Mental health coverage is also limited by requirements for the presence of a diagnosable disorder (see ch. 3) as a

condition for reimbursement.

Three key parts of the Federal health care financing system are Medicaid, Medicare, and

CHAMPUS. In 1985, Medicaid served 11 million

(296,297) dependent children under the age of 21,

but the amount of mental health benefits provided

to these children is believed to be minimal. Medicare provides no significant funding for children’s
136

mental health care, but Medicaid and other thirdparty payers that do fund such care are often influenced by Medicare’s payment policies. CHAMPUS

is the largest single health insurance program in

the country, providing coverage for health services to military dependents and retirees who are

unable to receive services through uniformed service medical treatment facilities. CHAMPUS spends

60 percent of its mental health expenditures on

treatment for children.

Medicaid .—Medicaid represents 55 percent of

all public health funds spent on children (645) and

has the potential to meet the needs of children who

are possibly at the greatest risk for developing

mental disorders, those who are in poverty and

those who are uninsured.

In general, Medicaid provides health insurance

to low-income families who meet certain categorical and financial criteria. These criteria, and

many of the services provided, are generally set

by the States, which provide a very significant

portion of the Medicaid funding. Medicaid serves

approximately 11 million children. Most important for purposes of this background paper is

that while beneficiaries may not be discriminated

against on the basis of diagnosis, States are free

to set limitations on Medicaid coverage for mental

health services (636). The percentage of Medicaid

funds devoted to mental health care is not known.

GAO is conducting a national survey of the mental health services available under Medicaid.

Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program provides

funds to screen, diagnose, and treat children under 21 who are members of families designated

as “categorically needy, ” and so is a potentially

important Federal initiative (434). The developmental assessment that is required as part of

EPSDT screening can reveal emotional difficulties and problems in behavior development. However, because of changes in eligibility, children

may not be followed long enough for a developmental assessment to be adequate; in addition,

few States deliver any substantial amount of mental health care through this program (358,595).

Efforts in the late 1970s to upgrade EPSDT into

a Child Health Assurance Program (CHAP), and

thus to specifically require mental health assessment and treatment for Medicaid-eligible children,

were not successful (595).An expansion of Medicaid eligibility passed in 1984 (Public Law 98-369)

is potentially important for preventing, detecting,

and treating mental health problems because it

makes additional women and children eligible for

medical services. Although this expansion of eligibility is sometimes referred to as a “modified

CHAP, ” it did not specifically require mental

health assessment and treatment for children.

In addition to the expansion of eligibility, another

potentially important change in the Medicaid program was incorporated in the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985

(Public Law 99-272), which was signed into law

on April 7, 1986. Under the provisions of COBRA,

States will be allowed to cover case management

services, which were defined as those services that

assist individuals eligible under Medicaid to gain

access to needed medical, social, educational, and

other services.

It appears that Medicaid may ensure that at

least some poor people obtain mental health care

who would not otherwise do so. An analysis by

Taube and Rupp (632a) found that poor and nearpoor Medicaid recipients were more likely than

nonrecipients to get mental health treatment. As

noted above, States have different Medicaid eligibility requirements, so Taube and Rupp were able

to compare persons who were of similar socioeconomic status. Taube and Rupp attribute the

greater use of mental health benefits by Medicaid recipients to the fact that Medicaid does not

allow cost-sharing (i.e., recipients are not required

to pay any of the costs of health services). Taube

and Rupp’s finding, as well as their interpretation,

is consistent with other studies which show that

the use of mental health care is responsive to the

cost of such care, although cost is not the only

factor which deter-mines whether people seek mental health care (206).

Medicare .—The Medicare program covers the

cost of hospitalization, medical care, and related

services for most persons over age 65, persons receiving social security disability insurance payments for 2 years, and persons with end-stage renal disease. Although only a small proportion of

Medicare program funds are directly devoted to
137

children (children who are disabled and dependents of deceased, retired, or disabled social security beneficiaries), Medicare influences health care

reimbursement nationwide. Not only have a number of States adopted Medicare rules for payment

of Medicaid and other insurance benefits, but nonFederal health insurance providers closely watch

Medicare.

The Social Security Amendments of 1983 (Public Law 98-21) mandated that Medicare adopt a

prospective payment system’ for hospitals (648,

649). Children’s hospitals and psychiatric hospitals, along with rehabilitation and long-term care

hospitals, have been temporarily exempted from

the new payment system; however, the system

does apply to psychiatric services provided in

nonspecialized units in general hospitals.

Medicare’s prospective payment system is based

on fixed per-case payment rates for patients in 467

diagnosis-related groups (DRGs), DRGs area patient classification system developed at Yale for

purposes of research on health care delivery.

There are nine DRGs for “mental diseases” and

six for substance abuse (see table 11).

DRG 431, “childhood mental disorders,” includes

diagnoses of childhood-onset mental disorders (see

ch. 3). Because many childhood diagnoses can

also be applied to adults (e. g., a problem such as

attention deficit disorder, which has its onset in

childhood), DRG 431 does not apply only to children. Furthermore, DRG 431 is not the only DRG

applied to children with mental disorders. Children with mental disorders that can also receive

an adult diagnosis (e. g., adolescents with drug or

alcohol abuse problems) are sometimes placed in

other categories. Nonetheless, DRG 431 is probably the most frequently used DRG for children,

and so deserves careful attention in the event a

prospective payment system is considered for the

children’s mental health care system.

Like most DRGs, DRG 431 does not differentiate patient episodes by problem severity, treatment modality and setting, or the patient’s history, The Medicare payment rate for DRG 43 I

is based on an adjusted average (the geometric

mean2 of lengths of stay (LOS) in the hospital

among patients with this diagnosis. In the case

of DRG 431, this equals 15.4 days. As indicated

in table 11, however, DRG 431 is the mental disorder DRG category with the most variation in

LOS (632), with few patients being treated close

to the 15.4-day mean LOS. Approximately 25 percent of patients in DRG 431 have an LOS less than

10 days, while 25 percent have an LOS greater

than 75 days. Since DRG-based payment by

Medicare does not take LOS into account, a hospital treating an individual with a childhood-onset

mental disorder for 75 days receives the same

Medicare payment as a hospital treating the individual for 1 day or for 15.4 days.

Variation in LOS for DRG 431 aside, there are

a number of potentially serious problems connected with application of a DRG-based payment

system to children’s mental health care (581). One

basic problem is that there is no theoretical or empirical evidence to indicate that the use of treatment resources is related to a mentally disturbed

child’s diagnosis. Systems of classifying mental

disorders (such as the American Psychiatric Association’s Diagnostic and Statistical Manual or the

World Health Organization’s International Classification of Diseases) indicate only the related set

of conditions that have been found for a particular syndrome. These systems were not designed

to be used for reimbursement purposes (19) and

do not necessarily indicate the severity of a mental disturbance. Especially for children, mental

health treatment decisions may be based on the

family’s ability to manage the child as well as on

the multiplicity of problems faced by the child.

In the absence of a direct relationship between

diagnosis and length/intensity/cost of mental

health treatment, DRG-based payment will not

be likely to match a child’s need for services. In

the short term, a mismatch between DRG-based

payment and the cost of needed services may result in some (probably the most troubled) children’s being denied services. It may also result in

‘Prospective payment, payment to health care providers based

on rates established in advance, is an alternative to retrospective

cost-based reimbursement, under which payment to providers is

based on the amount and type of services they provide (648,707).

‘Like the arithmetic mean, or average, the geometic mean is a

central value in a distribution of scores that serves as a summary

measure of the scores. By relying on logarithms, the geometric mean

has the advantage of being less influenced by the uneven distribution of scores.
138

Table 11 .–Lengths of Stay Associated With Mental Disorder Diagnosis-Related Groups (DRGs)

Ranked by Interquartile Range

Length of stay in days

Interquartile

b

range (75th

Geometric 25th 75th percentile minus

DRG meana

percentile percentile 25th percentile

Childhood mental disorders (431). . . . . . . . . . . . . . . . . . . . . . 15.4 9.8 75.5 65.0

Organic disturbances and mental retardation (429). . . . . . . 8.8 9.2 34.4 25.0

Psychoses (430) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.8 8.7 32.7 24.0

Alcohol dependence (436) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1 4.8 26.9 22.0

Disorders of personality and impulse control (428). . . . . . . 8.3 4.8 25.5 20.0

Depressive neuroses (426) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4 6.1 25,3 19.0

Drug dependence (434). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.1 6.9 25.5 18.0

Neuroses except depressive (427) . . . . . . . . . . . . . . . . . . . . . 6.9 4.8 22.4 17.0

Other mental disorder diagnoses (432) . . . . . . . . . . . . . . . . . 7.2 7.7 23.0 15.0

Drug use except dependence (435) . . . . . . . . . . . . . . . . . . . . 8.0 4,2 19.4 15.0

Acute adjustment reaction/disturbances of psychosocial

dysfunction (425) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.8 3.3 18.3 15.0

Alcohol use except dependence (437) . . . . . . . . . . . . . . . . . . 3.5 3.1 14.8 11,0

Alcohol- and substance-induced organic mental

syndrome (438) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.9 3.9 15.5 11.0

Substance use and substance-induced organic mental

disorder left against medical advice (433) . . . . . . . . . . . . 2.5 1.9 9.6 7.0

a

Like 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 hospitals are provided an incentive to treat “simple”

cases. The long-term impact on the range and

quality of available services is unknown (649).

i A second critical problem with the application

of a DRG-based payment system to children’s

mental health care is that the data used to calculate average LOS, on which DRG payment is

based, were derived from past experience in a

sample of adult acute care hospitals. Data reflecting the types of treatments given to children in

specialized psychiatric units or in psychiatric hospitals were not included.

Even if LOS data were available from hospital

facilities that treat mentally disturbed children,

however, there would be a serious problem in

using such data. Most health benefit programs

have limitations on the type and amount of both

inpatient and outpatient treatment provided. In

addition, most benefit programs provide more

generous coverage for inpatient care than for outpatient, residential treatment center (RTC), or day

treatment (600).

The fundamental problem with application of

a DRG-based payment system to children’s mental health services is that basing payment on a

broad category of diagnosis such as “childhood

mental disorders” ignores the body of literature

on the variety of treatment needs of mentally disturbed children. This problem exists for other

DRGs and other vulnerable populations as well

(649). A DRG-based prospective payment system

may control costs and maintain quality of care

for patients who require specific medical or surgical procedures (i.e., non-mental-health care),

but it seems inappropriate and potentially harmful to apply such a DRG-based payment system

to children’s mental health care.

Civilian Health and Medical Program of the

Uniformed Services. —CHAMPUS is a health insurance program administered by the U.S. Department of Defense (DOD). CHAMPUS provides

health benefits to 6.5 million military dependents

and retirees who are unable to receive services

through uniformed service medical treatment facilities, and is known as one of the most generous third-party payers for mental health care.
139

Primarily because few uniformed service medical treatment facilities offer mental health services, CHAMPUS devotes a higher percentage of

its benefit payments (16 to 19 percent [643a,655];

also see table 8) to mental health services than do

most private insurance plans. Another reason that

CHAMPUS devotes a high percentage of its benefit payments to mental health services is that military families often live in areas not adequately

served by outpatient mental health professionals;

for families in areas not served by outpatient facilities, the only mental health treatment option

may be psychiatric hospitalization, or, for children, care in an RTC. Inpatient and RTC treatment are typically more expensive than outpatient

treatment; and CHAMPUS spends up to 75 percent of its mental health benefits on inpatient and

RTC treatment (548), despite the presence of an

unusually rigorous peer review system which must

certify all care (inpatient, outpatient, residential)

as medically or psychologically necessary (548,

549).

In their efforts to control the costs of mental

health care under CHAMPUS, both Congress and

CHAMPUS have implemented provisions for

maximum benefits for mental health care in psychiatric hospitals and, more recently, in RTCs.

The effect of one such provision—a 60-day “cap”

on inpatient psychiatric hospitalization—illustrates

how changes in reimbursement policy can change

the type of services available. This example is not

definitive, however, because the change in

CHAMPUS reimbursement policy was not introduced experimentally (i.e., with use of a control

group experiencing no changes in coverage).

Thus, alternative explanations for subsequent variations in treatment services, such as changes in

treatment philosophy, cannot be ruled out.

Under the 60-day cap, exceptional justification

of medical necessity has to be provided for psychiatric hospitalization longer than 60 days for

both adults and children or CHAMPUS will not

pay for the care. Extension of the 60-day limit is

granted only if a patient is a danger to himself/

herself or others; or if the patient has a medical

complication and only an inpatient hospital facility can provide appropriate treatment. The cap

does not affect RTCs.

A 1985 DOD analysis of the first year’s experience with the 60-day cap concluded that the 60-

day limit on inpatient psychiatric hospitalization

had resulted in a $34.2 million “cost avoidance, ”

representing 22 percent of the total CHAMPUS

spent for inpatient and RTC mental health care

in calendar year 1983 (655). Perhaps as expected,

there was a 66-percent increase in RTC admissions

in 1983, although the costs of RTC stays were not

included in DOD’s analysis (655). The cost of inpatient care cannot be separated from the costs

of RTC care in CHAMPUS’s data system. DOD’s

analysis was adjusted, however, for an estimated

80,000 outpatient visits attributed to the 60-day

cap.

On the basis of its 1985 analysis and subsequent

monitoring, CHAMPUS more recently estimated

that there would be a 100-percent increase in admissions to RTCs between 1983 and 1986 (from

425 in 1983 to about 850 in 1986 [643a]). In addition, CHAMPUS reported that since the imposition of the 60-day cap, there had been an increase

in the number of RTCs attached to psychiatric

hospitals that had applied and been approved under CHAMPUS (from 13 in December 1982 to 30

in December 1985 [643a]). In order to provide additional long-term control over cost escalation,

CHAMPUS has since developed a new policy to

limit its payments for RTC care.

As do all health care cost-containment efforts,

CHAMPUS’s attempts to limit costs raise concerns

about maintaining good quality care. CHAMPUS

monitors quality through its unusually rigorous

peer review system and its approval processes

(548, 549). In addition, GAO is studying methods for assessing the quality of care provided

under CHAMPUS.

The Education for All Handicapped Children

Act (Public Law 94-142)

The Education for All Handicapped Children

Act (Public Law 94-142) mandates that all physically and mentally handicapped children be provided a free, appropriate education and the “related services” necessary to obtain an education

(see ch. 7). The Federal Government provides a

small amount of grant money to States to help

them implement this law.
140

There is continuing debate about whether mental health care is properly included under “related

services.” Even those who consider mental health

interventions necessary for education disagree

about where the responsibility for payment lies—

with the school system, the welfare system, the

health care system, or the mental health care system. There is additional concern about the costs

and personnel required when residential treatment

is indicated, and about whether the school systems should be required to pay for the entire costs

of residential placements or only for the education-related costs (109). Evidence suggests that the

services available to mentally disturbed children

through Public Law 94-142 vary considerably by

State (657). When this background paper was being written, a study was being conducted to determine what related services, including mental

health services, were being provided under Public Law 94-142 (666).

Coordination of Services

The State Comprehensive Mental Health

Services Plan Act of 1986 (Public Law 99-660)

In response to the perceived inadequacy and

fragmentation of services for individuals who are

perhaps most in need of coordinated mental health

and other system services—the chronically mentally ill, Congress has passed legislation to encourage a continuum of services and coordination among agencies. The most recent legislation

in this vein is Public Law 99-660, the State Comprehensive Mental Health Services Plan Act of

1986, passed in November 1986. This law authorizes a total of $20 million in grants to States for

fiscal years 1987 and 1988 for the development

of State comprehensive mental health services

plans and provides direction on the content of

such plans. Perhaps most significant, State plans

are required to provide for the establishment and

implementation of organized community-based

systems of care for chronically mentally ill individuals; and to require the provision of case management to each chronically mentally ill individual. The law also expands the focus of the already

existing Federal Community Support Program (in

NIMH) to include the homeless chronically mentally ill.

It is too early to tell, of course, how States will

respond to the new grant program or to what extent the program will affect children. An earlier

program to encourage the integration of mental

health and other services for children, CASSP,

was, as is described below, enthusiastically responded to by States. Neither the new program

nor CASSP, however, address the needs of children with mental health problems that are not yet

severe or chronic. The analysis in this background

paper, 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 response to the lack of coordination among the settings and systems providing services to children

with mental health problems. Modeled after the

Community Support Program for the chronically

mentally ill, CASSP was created by Congress in

1984 after repeated findings that because of a lack

of coordination among systems of care, the individual programs designed to assist mentally disturbed children were frequently not used. The

goal of CASSP is to ensure the availability of a

comprehensive, coordinated system of care specifically for severely mentally disturbed children

and adolescents.

Several themes developed earlier in this background paper point to the need for coordinating

mental health and other children’s services. Disturbed children often have more than one mental health problem (e.g., an attention deficit and

reading disorder that become apparent in school

combined with aggressive behavior in the neighborhood). Many troubled children also have educational, physical, legal, economic, or family

problems in addition to their mental disturbance.

Given the interactions among disturbed children’s

problems, effective intervention often requires the

provision of a variety of multiple mental health

and other services. CASSP was based on the belief that coordination among mental health treatment and other service systems is necessary to ensure that severely disturbed children receive all

the services they need, organized into a comprehensive treatment plan, and timed to achieve optimal beneficial effects.
141

CASSP is designed to improve States’ capacities to offer aid to severely mentally disturbed children. CASSP assists States in developing systems

of care through planning grants, as well as technical assistance and training. States that receive

CASSP grants are required, initially, to develop

a child mental health authority and to organize

a “coalition” of State agencies whose work affects

children. Once a comprehensive State-level system is developed, the goal is to replicate the coordination effort at local levels.

It is too early to assess the effectiveness of the

CASSP grant program, but the program incorporates a number of elements of an ideal system

that have long been discussed. By focusing on the

organization of services, it advances the goals of

placing children in appropriate settings and having providers make treatment decisions based on

clinical needs rather than on maintaining fiscal solvency. CASSP is designed to help States develop

mechanisms which may differ across localities and

available resources, and it appears to be an important mechanism to facilitate development of

such locally controlled systems of care. As described in chapter 9 of this background paper,

State authorities and NIMH are jointly developing an evaluation of CASSP’s effects.

Research and Training

For research related to children’s mental health

and for training clinical and research professionals

in this area, the Federal Government is virtually

the only source of funds. With few exceptions,

such as the MacArthur Foundation, neither philanthropic foundations nor individual donors support research or training in the mental health field

(309). SMHAs spend very little on research and

training. Some critics charge that the funds available to support mental health research are inadequate to take advantage of “exciting” research opportunities or even to foster rational development

of the field (309). Research on childhood mental

disorders is frequently used as a prime example

of the opportunities that are missed.

Funds for research pertaining to children’s mental health are available primarily through NIMH.

NIMH research grants are available for a range

of disciplines, including behavioral science research, clinical research, the neuroscience, pharmacological and somatic treatments, and psychosocial treatments. As shown in table 8, NIMH

estimates that roughly $27.2 million was made

available in fiscal year 1985 for intramural and

extramural research relating to children’s mental

health (665). This amount represents 17 percent

of NIMH’s research budget (see table 8).

The main direct source of funds for training

mental health professionals to treat children is the

clinical training program of NIMH. Since 1983,

congressional appropriations committees have requested that NIMH allocate a portion of its clinical training funds specifically to mental health

professionals who treat underserved populations,

including children. Because NIMH has limited

funds overall and commitments to continue existing training grants, however, the impact on children’s mental health services has only begun to

be seen.

In fiscal year 1985, NIMH allocated approximately 15 percent of its clinical training funds,

or $4.8 million, to training programs dealing at

least in part with children’s mental health issues

(see table 8).

A major reason for targeting NIMH clinical

training funds to professionals who treat children

is that there appear to be insufficient numbers of

well-trained professionals to meet children’s needs.

According to 1976 data (109), only 10 percent of

psychiatrists are specifically trained to treat children, and less than 1 percent of psychologists primarily serve children. According to NIMH data,

there are approximately 3,000 child psychiatrists,

5,000 clinical child psychologists, 7,000 child and

family-oriented social workers, and 1,000 child/

family-oriented mental health nurses (358). Estimates of the numbers of professionals needed have

consistently been much higher.

Funds for training mental health researchers (as

opposed to clinicians) are available through NIMH

under authority of the National Research Services Awards Act (Public Law 93-348). Although

the Institute of Medicine (309) has called for increased funding of research training in children’s

mental health, calling this a “relatively unstudied

area, ” only $1.1 million for training researchers

was available through NIMH in fiscal year 1984

(664).
— .——————

142

Information about the mental health training

funds available from agencies other than NIMH

is less clear. The Education for All Handicapped

Children Act (Public Law 94-142) includes Federal funding for training special education personnel, but this training is directed at all handicapping

conditions covered under the law. Although it is

certain that funds could be well used for professional development in child welfare, juvenile justice, and education agencies to promote the integration of mental health services with these

related services, there are currently no major Federal programs to support this kind of integrative

training.

Prevention and Other Services

A number of Federal programs provide funds

that may be used to support delivery of mental

health treatment or that have a clearly positive

or preventive role in children’s mental health.

These include the programs that primarily provide health services, as well as those providing

social services, nutrition assistance, and direct or

indirect financial payments.

The Maternal and Child Health block grant is

a Federal program that provides funds to the

States for services to mothers and children, particularly in low-income families. Since adequate

health care is vital for promoting normal and

healthy development in children, these block grant

funds can play a significant role in the prevention of mental illness in children. Medical care

providers who treat children who have no link

with mental health care providers through the

schools or other agencies are often the first to identify emotional or psychological problems that

may require treatment (see ch. 7).

A Federal program related to the Maternal and

Child Health block grant, the Primary Care block

grant, gives Federal funds directly to community

health centers for general health care services to

medically underserved populations. These general

health care services provide a measure of prevention and screening for mental health problems

affecting children and their families, and provide

a point of contact with health care providers. Similarly, the Preventive Health and Health Services

block grant provides Federal funds to States for

a variety of preventive health programs, including home health services, rape prevention and

treatment services, and demonstration projects

specifically designed to deter consumption of alcohol among children and adolescents. Many of

these programs serve an important prevention

function for mental disorders.

Three other major Federal support programs

have important effects on children’s mental health.

The Title XX Social Services block grant provides

funds to States for a wide variety of social services to children and families, including day care,

protective services for children, family planning,

adoption, and foster care. These services have

played a major role in the promotion of child welfare. The Adoption Assistance and Child Welfare

Act (Public Law 96-272) funds child welfare services, foster care, adoption assistance for hard-toplace children (including those who are emotionally or intellectually handicapped), and has, in

general, been helpful in financing support services to aid children and families in crisis. Project

Head Start provides educational, social, health,

and nutrition services to low-income preschool

children. The long-term effectiveness of Head

Start programs in preventing problems is now well

recognized (728; also see ch. 9).

Among the other Federal programs that relate

to children’s mental health, directly or indirectly,

are funding programs designed to enable individuals to meet basic health, nutrition, and cost-ofliving needs. Such programs include the Child

Abuse Prevention and Treatment Act programs;

Victims of Crime Act programs; Developmental

Disabilities Assistance and Bill of Rights Act programs; Family Planning programs; the Foster

Grandparents Program; the Adolescent Family

Life Program; the Food Stamp Program; the Supplemental Food Program for Women, Infants, and

Children; School Lunch programs; Aid to Families with Dependent Children; Supplemental

Security Income; Child Support Enforcement programs; and income tax deductions for adopting

special-needs children. As part of the overall Federal effort relevant to children’s mental health,

these programs provide a considerable amount of

assistance. It is not clear, however, that the assistance provided by these programs is coordinated

so that individual children are protected. Previ-
143

ous analyses (e. g., 358,595), anecdotal evidence, of CASSP and experience under the State Comand observations of the experts consulted during prehensive Mental Health Services Plan Act will

the preparation of this background paper suggest suggest additional ways in which such coordinathat a coordinated system for providing children’s tion can be implemented.

services would be helpful. Perhaps the evaluation

CONCLUSION

It is quite well estab

children are in need of

both to treat diagnosable

ished that a great many

mental health services—

e disorders and to reduce

environmental risk factors (see ch. 2). It is also

agreed that children’s mental health services need

to be based on extensive and sound research;

guided by appropriately trained personnel; and

supported by sufficient funds and incentives to

encourage coordination among providers, including those in non-mental-health systems.

Federal, State, local, and private contributions

to provision of mental health services are substantial. The gap between the need for children’s services and the availability of such services, however,

implies that even these considerable efforts fall

short of bridging the gap (e.g., 358,359). The mental health services available for children appear

to be inadequate. In addition, research on children’s mental health and illness appears to be inadequately funded.

Although local control of service delivery is believed to be optimal for the necessary case management of children with problems and potential

problems, and although the private sector could

arrange to provide more and better mental health

services, it may be that a larger role for the Federal Government is desirable. Such a role could

include a statement of principle for mental health

analogous to that articulated for education in Public Law 94-142, which mandates that all children

be guaranteed a free, appropriate education. It

could also include increased Federal efforts to

eradicate environmental risk factors or reduce

Photo credit: OTA

their impact on children, to continue to promote

coordination of services, and to fund research and

training in the children’s mental health field.
Appendixes
Appendix A

Workshop Participants and

Other Acknowledgments

Workshop on Children’s Mental Health

Leonore Behar, Chair

Chief of Child Mental Health Services, North Carolina Department of Human Resources

Division

Mark Blotcky

Timberlawn Hospital

Dallas, TX

Dennis D. Drotar

of Men al Health, Mental Retardation, and Substance Abuse Services

Raleigh, NC

Judith Meyers

Policy Analyst2

Office of the Governor

Rainbow Babies and Children’s Hospital

Cleveland, OH

Susan Goldstein

Department of Child and Family Psychiatry

Group Health Association

Washington, DC

Erv Janssen

Director, Children’s Division

Menninger Foundation

Topeka, KS

Hubert E. Jones

Dean, School of Social Work

Boston University

Boston, MA

Patricia King

Professor

Georgetown Law Center

Washington, DC

Jane Knitzer

Director, Division of Research, Demonstrations,

and Policyl

Bank Street College of Education

New York, NY

Gerald P. Koocher

Department of Psychiatry

Children’s Hospital Medical Center

Boston, MA

Boston, MA

Joseph J. Palombi

Family Counseling

Fairfax, VA

Patricia C. Pothier

Professor

Center

University of California, School of Nursing

San Francisco, CA

Jack Shonkoff

Department of Pediatrics

University of Massachusetts

Worcester, MA

Jerry Wiener

Chairman

Department of Psychiatry

George Washington University Medical School

Washington, DC

Edward Zigler

Department of Psychology

Yale University

New Haven, CT

NIMH Liaison

Michael Fishman

Assistant Director for Children and Youth

National Institute of Mental Health

Rockville, MD

I Formerly with the Bunting Institute, Radcliffe College, Cambridge, MA,

‘Formerly Associate Director, Bush Program in Child Development and social PoIIcy, Universit y of Michigan, Ann Arbor, MI

147
148

Workshop on Children’s Mental Health Treatment Effectiveness

Anthony Broskowski

Executive Director

Northside Community Mental Health Center

Tampa, FL

Donald Cohen

Director, Child Study Center

Yale University

New Haven, CT

John P. Docherty

Chief, Psychosocial Treatments Research Branchl

National Institute of Mental Health

Rockville, MD

Michael E. Fishman

Associate Director for Children and Youth

National Institute of Mental Health

Rockville, MD

Alan E. Kazdin

Professor of Psychiatry and Psychology

Western Psychiatric Institute and Clinic

Pittsburgh, PA

Ira Lourie

Director, Child and Adolescent Service System

Program

National Institute of Mental Health

Rockville, MD

Natalie Reatig

Pharmacologic and Somatic Treatments Research

Branch

National Institute of Mental Health

Rockville, MD

INo longer with NIMH.

Acknowledgments

OTA would like to thank the following people for their assistance in the development of this background

paper.

Richard Brunstetter

National Institute of Mental Health

Rockville, MD

Lana Buck

National Association of Private Psychiatric

Hospitals

Washington, DC

Barbara Burns

National Institute of Mental Health

Rockville, MD

Anne Copeland

Boston University

Boston, MA

Mary Crosby

American Academy of Child and Adolescent

Psychiatry

Washington, DC

Phyllis Old Dog Cross

Indian Health Service

Rapid City, SD

Michelle Fine

University of Pennsylvania

Philadelphia, PA

Judith Gardner

Boston, MA

Ellen Greenberg Garrison

American Psychological Association

Washington, DC

Howard Goldman

National Institute of Mental Health

Rockville, MD

Dennis C. Harper

University of Iowa

Iowa City, IA

Victor Indrisano

Office of U.S. Rep. Edward R. Roybal

Washington, DC

Joseph Jacobs

Bureau of Health Care Delivery and Assistance

U.S. Public Health Service

Felton Earls Rockville, MD

Washington University School of Medicine Judith Jacobs

St. Louis, MO National Institute

Glen Elliott Rockville, MD

Stanford University

Stanford, CA

of Mental Health
149

Phyllis A. Katz

Institute for Research on Social Problems

Boulder, CO

Judith Katz-Leavy

National Institute of Mental Health

Rockville, MD

Samuel C. Klagsbrun

Four Winds Hospital

Katohah, NY

Lt. Col. Melvin Kolb

Office of the Civilian Health and Medical Program

of the Uniformed Services

Aurora, CO

Richard Krugman

National Center for Child Abuse

Denver, CO

Sidney S. Lee

Milbank Memorial Fund

New York, NY

Beryce W. MacLennan

U.S. General Accounting Office

Washington, DC

Noel Mazade

Noel Mazade & Associates, Inc.

Garrett Park, MD

Irving Philips

University of California

San Francisco, CA

Cornelia Porter

Office of Senator Daniel K. Inouye

Washington, DC

Paul Posner

U.S. General Accounting Office

Washington, DC

Lenore Radloff

National Institute of Mental Health

Rockville, MD

Mason Russell

Policy Analysis

Brookline, MA

Jack Sarmanian

Adult/Adolescent Counseling, Inc.

Maiden, MA

Larry Silver

National Institute of Mental Health

Rockville, MD

Morton Silverman

National Institute

Rockville, MD

Carl R. Smith

Iowa Department

Des Moines, IA

Albert J. Solnit

Yale University

New Haven, CT

Fredric Solomon

of Mental Health

of Public Instruction

Institute of Medicine

Washington, DC

Brian Stabler

American Psychological Association

Washington, DC

Bonnie Strickland

University of Massachusetts

Amherst, MA

Susan Thompson-Hoffman

U.S. Department of Education

Washington, DC

Carl Tishler

Columbus, OH

Gail Toff

Intergovernmental Health Policy Project

Washington, DC

Judith L. Wagner

Office of Technology Assessment

Washington, DC

Ted Wagner

U.S. General Accounting Office

Washington, DC

Kathleen Wells

Bellefaire

Cleveland, OH

Diana Zuckerman

Subcommittee on Intergovernmental Relations and

Human Resources

House Government Operations Committee

Washington, DC
Appendix B

List of Acronyms and Glossary of Terms

List of Acronyms

ADAMHA –Alcohol, Drug Abuse, and Mental Health

Administration (DHHS)

ADM –Alcohol, Drug Abuse, and Mental Health

(block grant)

CASSP —Child and Adolescent Service System

Program (NIMH)

CDF —Children’s Defense Fund

CHAMPUS —Civilian Health and Medical Program

CMHC

COBRA

DHEW

DHHS

DISC

DOD

DRG

DSM-III

EPSDT

FSCP

GAO

LOS

of the Uniformed Services

—community mental health center

—Consolidated Omnibus Budget Reconciliation 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, Diagnosis, and Treatment program (Medicaid)

—Family Support Center Program

–General Accounting Office (U.S.

Congress)

—length of stay

NASMHPD—Na;ional Association of State Mental

Health Program Directors

NIMH –National Institute of Mental Health

(ADAMHA)

OTA –Office of Technology Assessment (U.S.

Congress)

PDD —pervasive developmental disorder

RTC —residential treatment center for emotionally disturbed children

SDD —specific developmental disorder

SMHA —State Mental Health Agency

Glossary of Terms

Adjustment disorder: A type of mental disorder

defined by DSM-III as “a maladaptive reaction to

an identifiable psychosocial stressor that occurs

within three months of the onset of the stressor. ”

Adjustment disorders are manifest in impaired functioning or in excessive reactions to the stressor,

symptoms which typically remit after the stressor

ceases or, if the stressor continues, when a new level

of adaptive functioning is achieved.

Aftercare: Mental health services provided after the

individual’s initial encounter with the mental health

care system (e. g., RTC treatment after psychiatric

hospitalization).

Anorexia nervosa: A mental disorder characterized by

intense fear of becoming obese, disturbance of body

image, significant weight loss (accounted for by no

known physical disorder), refusal to maintain a

minimal normal body weight, and the absence of

menstruation in females.

Anxiety disorders: A category of mental health disorders characterized by a child’s intense feelings of

apprehension, tension, or uneasiness. These feelings

may result from the anticipation of danger, either

internal or external. Anxiety is manifested by physiological changes such as sweating, tremor, and

rapid pulse. Such disorders include phobic disorders, obsessive compulsive disorders, and posttraumatic stress disorders, as well as “generalized

anxiety disorders. ”

Behavior disorders: A set of childhood-onset mental

disorders characterized by behavior that disturbs

or harms the patient or others and which causes

distress or disability. Such disorders include attention deficit disorder and conduct disorder.

Behavioral therapy: Psychotherapy based on the

assumption that a child learns persistent pathological behavior from his or her experience with the

social environment. Therapists using behavioral

techniques systematically analyze the child’s problem and environment and seek to change specific

problem behavior by altering the child’s environment.

Bulimia: A mental disorder characterized by binge

eating accompanied by an awareness that the eating

pattern is abnormal, fear of not being able to stop

eating voluntarily, and depressed mood and selfdeprecating thoughts following the eating binges.

Binges are usually terminated temporarily by abdominal pain, sleep, social interruption, or induced

vomiting.

Cognitive therapy: Psychotherapy based on a view

that mental health problems should be treated

through altering the way children think about their

behavior and their environments. Therapists attempt to change the thinking that takes place during

a child’s troublesome behavior and/or try to influence how children think about themselves and

others.

150
151

Community mental health centers (CMHCs): Programs initially established by the Federal Government through the Community Mental Health Centers Act of 1963, to provide comprehensive mental

health services to all residents of a specified geographic area regardless of their ability to pay. With

the passage of the Alcohol, Drug Abuse, and Mental

Health block grant, federally funded CMHCs ceased

to exist as legal entities, but Federal funds continue

to be provided indirectly via State Mental Health

Agencies.

Continuum of care: A coordinated system to provide

comprehensive children’s mental health care at all

levels needed.

Day treatment/partial hospitalization: Mental health

treatment programs that provide extended care to

children who do not need 24-hour treatment but do

require more intensive treatment than 1 or 2 hours

a week of therapy. One form of day treatment,

partial hospitalization, arranges care for children

who need the treatment offered in a psychiatric hospital during the day but are able to return home in

the evening,

Developmental disorders: A set of mental disorders

characterized by deviations from the normal path

of child development. Such disorders may be pervasive, thereby affecting multiple areas of development (e. g., autism), or specific, affecting only one

aspect of development (e. g., arithmetic disorder).

Diagnostic Interview Schedule for Children (DISC):

A child-oriented version of the Diagnostic Interview

Schedule, a questionnaire developed for use by the

National Institute of Mental Health for its epidemiologic catchment area survey of mental disability in

adults.

Eating disorders: Psychophysiological disorders characterized by disturbances in eating. Such disorders

include anorexia nervosa and bulimia.

Emotional disorders: Mental disorders characterized

by the presence of an emotional problem and considerable impairment of a child’s ability to function.

Such disorders include anxiety and childhood depression.

Encopresis: A psychophysiological disorder characterized by defecation at inappropriate times.

Enuresis: A psychophysiological disorder characterized by involuntary bedwetting or other lack of

control over urination.

Family therapy: A type of psychotherapy based on the

idea that a child’s problems are manifestations of

disturbed interactions within a family rather than

problems that lie within the child alone. Treatment

heavily involves other family members as well as

the child (e.g., in sessions attended by the entire

family) because it is believed that a child cannot

change if the family as a whole does not change.

Group therapy: A type of psychotherapy in which the

focus is on helping individuals develop healthier

ways of relating to other people, although therapy

groups serve other purposes.

Inpatient treatment: Provision of mental health services to persons staying in a hospital overnight.

Integration of services: The establishment of interrelationships among mental health and other service

systems (e. g., the educational, health care, welfare,

and juvenile justice systems) so that programs to

prevent mental health problems can be offered,

children in need of mental health services can be

identified, and mental health treatment can be provided at the site where problems are identified.

Length of stay (LOS): The number of days between

the date of admission to a health care facility and

the discharge date.

Mental disorder: In this background paper, any of the

diagnoses classified as mental disorders by the

American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders

(DSM-III). Generally, DSM-III defines a mental disorder as a clinically significant behavioral or psychological syndrome or pattern that occurs in an

individual and that is typically associated with either a painful symptom (distress) or impairment in

one or more areas of functioning (disability).

Mental health problem: In this background paper, either a mental disorder or more general subclinical

problem affecting mental health but not meeting the

criteria for a diagnosable mental disorder.

Mental health services: Any of the wide range of

services designed to meet mental health needs but

primarily including therapies and prevention

techniques.

Neuroleptics: Any drug (e.g., certain tranquilizers)

used to reduce psychotic behavior.

Neurosis: Currently, there is no consensus in the

mental health field as to the definition of neurosis,

and the category neuroses was not included in

DSM-III although it had been included in previous

Diagnostic and Statistical Manuals. The term

neurosis is usually used to refer to emotional

disorders caused by unconscious conflict and characterized chiefly by anxiety.

Outpatient treatment: Provision of mental health

services on an ambulatory basis to persons who do

not require 24-hour or partial hospitalization.

Settings for outpatient treatment include community mental health centers and private mental health

practices.

Primary prevention: Efforts to avert mental health
152

problems altogether. For children, these efforts

include interventions directed at parents and educators.

Private psychiatric hospital: A hospital operated privately by individuals, partnerships, corporations,

or nonprofit organizations, primarily for the care

of persons with serious mental disorders.

Psychodynamic therapy: Psychotherapy based on the

theory that changes in cognition and emotions will

be followed by changes in behavior.

Psychopharmacological therapy: Therapy involving

the use of psychoactive medications such as stimulants, antidepressants, or neuroleptics.

Psychophysiological disorders: Mental health disorders that involve a disturbance in some aspect of

bodily functioning usually involving a combination

of mental and physical factors. Such disorders

include stereotyped movement disorders; eating

disorders such as anorexia and bulimia; and enuresis

and encopresis.

Residential treatment center (RTC): A residential facility, not licensed as a psychiatric hospital, whose

primary purpose is the provision of individually

planned programs of mental health treatment

services in conjunction with residential care for

children and youths primarily under the age of 18.

The term used by NIMH is “residential treatment

centers for emotionally disturbed children, ” but

children with other mental disorders are also treated

in these facilities.

Secondary prevention: Efforts to detect mental health

problems in their early stages of development and

to apply techniques to reduce the severity and

duration of incipient problems.

State and county mental hospital: A psychiatric hospital that is under the auspices of a State or county

government, or operated jointly by both a State and

county government.

State Mental Health Agencies (SMHAs): Agencies

under the auspices of State governments, staffed

through the State, and offering mental health

services to State residents in need of mental health

care. State mental health agencies may supervise

State mental hospitals, CMHCs, RTCs, and/or day

treatment facilities.

Stereotyped movement disorders: Psychophysiological

disorders characterized by involuntary movements

of bodily parts (i. e., tics).

Substance use/abuse disorders: A set of mental

disorders characterized by maladaptive behavioral

changes resulting from regular use of substances

that affect the central nervous system. Substance

use and abuse disorders are not classified as childhood-onset mental disorders by DSM-III, but

children can be afflicted by them.

Tertiary prevention: Attempts to arrest further deterioration in individuals ‘who already suffer from

severe mental health problems (disorders).

Treatment can be considered tertiary prevention.

The term is not used in this background paper.
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