[Federal Register Volume 62, Number 193 (Monday, October 6, 1997)]
[Notices]
[Pages 52139-52145]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-26372]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration


Estimation Methodology for Children With a Serious Emotional 
Disturbance (SED)

AGENCY: Center for Mental Health Services, Substance Abuse and Mental 
Health Services Administration, HHS.

ACTION: Solicitation of comments.

-----------------------------------------------------------------------

SUMMARY: This notice describes the proposed methodology for identifying 
and estimating the number of children with a serious emotional 
disturbance (SED) within each State. This notice is being served as 
part of the requirement of Public Law 102-321, the ADAMHA 
Reorganization Act of 1992.

Comment Period: The Administrator is requesting written comments which 
must be received on or before December 5, 1997.

Addresses: Comments should be sent to Judith Katz-Leavy, M.Ed., Senior 
Policy Analyst, Office of Policy, Planning, and Administration, Center 
for Mental Health Services, Parklawn Building Room 15-87, 5600 Fishers 
Lane, Rockville, MD 20857. (301) 443-1563 fax.

For Further Information Contact: A detailed paper outlining the 
estimation methodology described here is available from: Judith Katz-
Leavy M.Ed., Senior Policy Analyst, Office of Policy, Planning, and 
Administration, Center for Mental Health Services, Parklawn Building 
Room 15-87, 5600 Fishers Lane, Rockville, MD 20857. (301)443-1563 fax.

Background

    Public Law 102-321, the ADAMHA Reorganization Act of 1992, amended 
the Public Health Service Act and created the Substance Abuse and 
Mental Health Services Administration (SAMHSA). The Center for Mental 
Health Services (CMHS) was established within SAMHSA to coordinate 
Federal efforts in the prevention, treatment, and promotion of mental 
health. Title II of Public Law 102-321 establishes a Block Grant for 
Community Mental Health Services (Block Grant) administered by CMHS, 
which permits the allocation of funds to States for the provision of 
community mental health services to children with a serious emotional 
disturbance and adults with a serious mental illness. Public Law 102-
321 stipulates that States estimate the incidence (number of new cases) 
and prevalence (total number of cases in a year) in their applications 
for Block Grant funds, see 42 U.S.C. 300 (2). The statute also requires 
the Secretary to establish definitions for adults with a serious mental 
illness and children with a serious emotional disturbance. In addition, 
the Secretary is required to develop standardized methods for the 
states to use in providing the estimates required as part of their 
block grant applications. See 42 U.S.C. 300 (2). As part of the process 
of implementing this new block grant, definitions of the terms 
``children with a serious emotional disturbance'' and ``adults with a 
serious mental illness'' were announced on May 20, 1993, in Federal 
Register Volume 58, No 96, p. 29422. Subsequently, a group of technical 
experts was convened by CMHS to develop an estimation methodology to 
``operationalize the key concepts'' in the definition of children with 
a serious emotional disturbance. A similar group has prepared an 
estimation methodology for adults with a serious mental illness.

Serious Emotional Disturbance (SED)

    The CMHS definition is that ``children with serious emotional 
disturbance'' are persons:

--From birth up to age 18;
--Who currently or at any time during the past year;
--Have had a diagnosable mental, behavioral, or emotional disorder of 
sufficient duration to meet diagnostic criteria specified within DSM-
III-R
--That resulted in functional impairment which substantially interferes 
with or limits the child's role or functioning in family, school, or 
community activities (p.29425).

    The definition goes on to indicate that, ``these disorders include 
any mental disorder (including those of biological etiology) listed in 
DSM-III-R or their ICD-9-CM equivalent (and subsequent revisions) with 
the exception of DSM-III-R `V' codes, substance use, and developmental 
disorders, which are excluded, unless they co-occur with another 
diagnosable serious emotional disturbance'' (p. 29425).
    Further, the definition indicates that, ``Functional impairment is 
defined as difficulties that substantially interfere with or limit a 
child or adolescent from achieving or maintaining one or more 
developmentally-appropriate social, behavioral, cognitive, 
communicative, or adaptive skills. Functional impairments of episodic, 
recurrent, and continuous duration are included unless they are 
temporary and expected responses to stressful events in their 
environment. Children who would have met functional impairment criteria 
during the referenced year without the benefit of treatment or other 
support services are included in this definition'' (p. 29425).
    The first decision that was made was to focus on community 
epidemiological studies done in the United States that used either the 
DSM-III-R, or its predecessor, the DSM-III, and that provided 
information on the prevalence of mental disorders using a structured 
interview procedure. The group decided that given the relatively small 
number of community epidemiological studies that had been conducted in 
the United States, it would be a mistake to exclude those few studies 
that had used the DSM-III, given its considerable similarity to the 
DSM-III-R.
    The most frequently used structured interview procedure was the 
Diagnostic Interview Schedule for Children (DISC), originally developed 
by A. Costello and his colleagues (A. Costello, Edelbrock, Dulcan, 
Kalas, & Klaric, l984), which includes both child and parent versions. 
Other interview procedures include the Diagnostic Interview for 
Children and Adolescents (DICA, Herjanic & Reich, l982), the Child and 
Adolescent Psychiatric Assessment (CAPA, Angold & E. Costello, l995), 
and the Composite International Diagnostic Interview (CIDI, Kessler et 
al, 1994).
    The group elected to consider that a child met the criteria of a 
diagnosable disorder either if a diagnosis was obtained from his/her 
own report on the structured interview, or from the parent's report on 
the structured interview, or from the combination of the youth's report 
and the parent's report, even if neither one met the criteria 
separately. While there are other approaches to combining data from two 
or more sources that were considered and have been used (Cohen, Velez, 
& Kohn, l987; Reich & Earls, 1987), the group chose to use this 
``either/or'' approach because it was believed that

[[Page 52140]]

discrepant responses can be a source of valuable information.
    The greater challenge for the group was operationalizing the 
concept of ``functional impairment which substantially interferes with 
or limits the child's role or functioning in family, school, or 
community activities'' (Federal Register, l993, p. 29425). Part of the 
difficulty was in identifying appropriate measures, and understanding 
the inter-relationship between the different measures, but the greatest 
difficulty was in determining the appropriate threshold or cut-off 
point on a scale for concluding that there was functional impairment 
that was ``substantially'' interfering with functioning.
    After much discussion, it was decided that in the absence of any 
``gold standard'' that could be used as a basis for establishing such a 
cut-off point, and in the absence of any social validation process that 
has established a consensus on what the threshold should be, data would 
be presented for cut-off points at two levels of functional impairment. 
This has the benefit of providing additional information to planners 
and policy-makers to use, and to stimulate further discussion and 
research to try to better establish an appropriate threshold. The 
higher prevalence rate to be reported, which uses the more inclusive or 
less conservative cut-off point, still meets the definition of 
``seriously emotionally disturbed.'' The less inclusive and more 
conservative estimate can be used for more targeted efforts to plan on 
behalf of a more limited number of children whose level of functional 
impairment is especially severe.
    A variety of measures of impairment were used in the community 
studies, and their psychometric properties were reviewed for the group 
by Hodges (l994). The most frequently used measure is a global measure, 
the Children's Global Assessment Scale (Bird, Canino, Rubio-Stipec, & 
Ribera, 1987; Shaffer, Gould, Brasic, Ambrosini, Fisher, Bird, & 
Ahwalia, 1983), on which a youngster receives a rating ranging from 0 
to 100 with lower scores indicating greater impairment. Scores are 
given in ten point intervals, and for each score there is a narrative 
description of the meaning of the score.
    The group considered several potential cut-off points on the CGAS, 
and decided to use a score of 60 or lower as the cut-off point for the 
less conservative definition of serious emotional disturbance. The 
narrative description for 60 is:
    ``Variable functioning with sporadic difficulties or symptoms in 
several but not all social areas. Disturbance would be apparent to 
those who encounter the child in a dysfunctional setting or time but 
not to those who see the child in settings where functioning is 
appropriate.''
    This decision was made partly on the basis of the work by Bird and 
his colleagues that indicates that, ``Empirical work has demonstrated 
that the optimal cut-off score on the CGAS that demonstrates definite 
impairment is a score lower than 6l'' (Bird, Shaffer, Fisher, Gould, 
Staghezza, Chen, & Hoven, l993, p. 103).
    The score of 50 will be used as the more stringent cut-off point to 
denote the more severe impairment. The narrative description for 50 is: 
``Moderate degree of interference in functioning in most social areas 
or severe impairment of functioning in one area, such as might result 
from, for example, suicidal preoccupations and ruminations, school 
refusal and other forms of anxiety, obsessive rituals, major conversion 
symptoms, frequent anxiety attacks, frequent episodes of aggressive or 
other anti-social behavior with some preservation of meaningful social 
relationships''.

Data Sources

    There are no national epidemiological studies of mental disorders 
for children and/or adolescents that have been conducted in the United 
States. This deficit makes it difficult to derive prevalence rates that 
are generalizable to the entire United States. In the absence of 
national studies, the group chose to examine the results from eight 
smaller, and more localized studies including, Kashani, et.al (1987), 
Costello, et. al (1988) (1994), Bird, et. al (1988), Kessler, et. al 
(1994), Jensen, et. al (1995), MECA (Lahey, et. al, 1996, Shaffer, et. 
al, 1996), and Costello, et. al (1995). (see Table 1 for a summary of 
these studies).
    The group of technical experts determined that it is not possible 
to develop estimates of incidence using currently available data. 
However, it is important to note that incidence is always a subset of 
prevalence. In the future, incidence and prevalence data will be 
collected.

                                         Table One.--Summary of Studies                                         
----------------------------------------------------------------------------------------------------------------
                                                                 SystemSample size and                          
                Study                   Measure and DSM system            age             Measure of impairment 
----------------------------------------------------------------------------------------------------------------
Kashani et al 1987...................  DICA/DSMIII............  N=150, 14-16 yr. olds..  Rating of 3 or 4 by    
                                                                                          Clinicians on 4 Point 
                                                                                          Scale of Need for Tx  
                                                                                          and Impairment.       
Costello et al 1988..................  DISC 1.3 DSMIII........  Screened=789,            CGAS 60 or less.       
                                                                 Interviewed=278, 7-11                          
                                                                 yr. olds.                                      
1994 (follow-up).....................  DISC 2.3 DSMIIIR.......  Screened=789,            CGAS 60 or less.       
                                                                 Interviewed=263, 12-18                         
                                                                 yr. olds.                                      
Bird et al 1988......................  DISC 1.3*/DSMIII.......  n=777 first stage n=386  CGAS 60 or less.       
                                                                 second stage 4-16 yr.                          
                                                                 olds                                           
Kessler et al 1994...................  CIDI/DSMIII-R (adult     n=600 (about) 15-17 yr.  Aggregation of 5       
                                        diagnoses).              olds (Part of study of   Measure.              
                                                                 15-54 yr. olds).                               
Jensen et al 1995....................  DISC2.1/DSMIIIR........  n=295 6-17 yr. old.....  <bullet>In tx or in    
                                                                                          need of tx.           
                                                                                         <bullet>Internal       
                                                                                          Impairment (1 or      
                                                                                          more).                
                                                                                         <bullet>Internal       
                                                                                          Impairment (2 Domains 
                                                                                          or more).             
MECA (Lahey et al, 1996 Shaffer et     DISC2.1/DSMIII-R.......  n=1265 9-17 yr. olds...  <bullet>CGAS 60 or     
 al, 1996).                                                                               Less.                 
                                                                                         <bullet>CGAS 50 or     
                                                                                          less.                 
                                                                                         <bullet>Internal       
                                                                                          Impairment,           
                                                                                           (3 or more),         
                                                                                           (5 or more).         

[[Page 52141]]

                                                                                                                
Costello et al 1995..................  CAPA/DSMIII-R..........  2 stages n=4500 9, 11,   <bullet>Internal       
                                                                 and 13 yr. olds.         Impairment,           
                                                                                           (1 or more),         
                                                                                           (2 or more),         
                                                                                           (3 or more).         
                                                                                         <bullet>CGAS (60 or    
                                                                                          less) CAFAS (20 or    
                                                                                          higher).              
----------------------------------------------------------------------------------------------------------------

Estimation Procedures

    Based on the CMHS definition of serious emotional disturbance, and 
the existing data bases which provide prevalence rates that can be 
applied to this definition, it is estimated that the prevalence rate of 
serious emotional disturbance in children 9-17 years of age is in the 
range of 9-13 percent. Presently, the data are inadequate to estimate 
prevalence rates for children under the age of nine. It is also 
concluded that if a more stringent definition of impairment is desired 
than was used for the estimated range of 9-13 percent, then the range 
is from 5-9 percent. The difference between the two estimates is that 
the measured level of functional impairment is greater in the second 
estimate and has been characterized in Figure 1 as ``extreme functional 
impairment.'' Children at both levels of impairment are considered to 
have a ``serious emotional disturbance'' however; the group of children 
falling into the range of 5-9 pecent constitutes a subset of the 9-13 
percent.
    It should be noted that the estimated prevalence range for 9-17 
year olds is higher than the range recommended by Kessler et al. (1995) 
for serious mental illness in adults (5.7 percent). The higher estimate 
for 9-17 years olds is consistent with the fact that using the National 
Comorbidity Study (NCS) data base, which served as the main data base 
for the estimation of prevalence in adults, Kessler found that the 12 
month prevalence for 15-17 year olds was 8.7 percent. The twelve month 
prevalance for 18-54 year olds was 6.5 percent. To further understand 
this difference, however, it is important to recognize that within the 
18-54 year range there are differences associated with age. For 
example, in Kessler's first article, it was reported that ``disorders 
are consistently most prevalent in the youngest cohort (age range 15-24 
years) and generally decline monotonically with age'' (Kessler et al., 
1994, p. 13). This was also the case with serious mental illness, as 
reported by Kessler et al. (1995). This finding of highest prevalence 
rates in youngest adults with rates decreasing with increasing age was 
not only obtained in the NCS but also in the Epidemiological Catchment 
Area study, completed in the early 1980s (Regier et al., 1988). Also, 
the longitudinal research by Cohen et al. (1993), and the findings by 
Reinherz et al. (1993) on 17-19 year olds point to especially high 
prevalence rates for older adolescents.
    Within the 9-17 year age range, the data are adequate to permit 
determination of gender and socio-economic differences but are not 
adequate to permit determination of race differences. The comparative 
analyses by Costello & Messer (l995) are particularly useful for 
looking at gender and socio-economic differences. Both for global and 
specific measures of impairment, they find the prevalence rates of 
serious emotional disturbance in the samples already mentioned to be 
about twice as high in low socio-economic groups as in high socio-
economic groups. This finding is consistent for every one of the seven 
data bases included in the analysis by Costello & Messer (l995). Jensen 
et al. (l995) fail to find different prevalence rates by socio-economic 
status in their study. However, as they point out the socio-economic 
range in their sample was limited by the fact that all of the 
youngsters were military dependents.
    The following steps were taken to adjust for the difference in 
state socio-economic circumstances. The 1995 estimates of children and 
adolescents with serious emotional disturbance by state are provided in 
Table 3.

Step 1

    States were sorted by poverty rates (1995), in ascending order. 
Using this sort order, States were initially classified into three 
groups of equal proportions, i.e., the first 17 states were put into 
Group A; the next 17 States into Group B; the remaining 17 States, into 
Group C. However, in reviewing the results, we noted that observations 
17 and 18 differed by .01 percent. Observation number 18 was included 
in group A. For this reason, Group A has 18 cases, Group B has 16 
cases, and Group C has 17 cases. Group A is the group that has a 
relatively low percentage of children in poverty. Group B is the mid 
point, and Group C is the group with the highest percentage of children 
in poverty.

Step 2

    At a level of functioning of 50 (LOF=50), the number of children 
and adolescents with SED is calculated to be between 5-7 percent of the 
number of youth 9-17 years for Group A. For Group B, the estimate is 
between 6-8 percent of the number of youth 9-17 years. The estimated 
SED population for Group C is calculated to be between 7-9 percent of 
the number of youth 9-17 years.

Step 3

    At a level of functioning of 60 (LOF=60), the number of children 
and adolescents with SED is calculated to be between 9-11 percent of 
the number of youth 9-17 years for Group A. For Group B, the estimate 
is between 10-12 percent of the number of youth 9-17 years. The 
estimated SED population for Group C is calculated to be between 11-13 
percent of the number of youth 9-17 years.

[[Page 52142]]



    Table 2.--1995 Estimates of Children and Adolescents With Serious Emotional Disturbance; State Estimates    
                                                   Algorithms                                                   
----------------------------------------------------------------------------------------------------------------
                                                                             Estimated population               
                                                             ---------------------------------------------------
                                                                       LOF*=50                   LOF*=60        
                           States                            ---------------------------------------------------
                                                              Lower limit  Upper limit  Lower limit  Upper limit
                                                               (percent)    (percent)    (percent)    (percent) 
----------------------------------------------------------------------------------------------------------------
Group A, Lowest percent in poverty..........................            5            7            9           11
Group B, Medium percent in poverty..........................            6            8           10           12
Group C, Highest percent in poverty.........................            7            9           11          13 
----------------------------------------------------------------------------------------------------------------
*LOF=Level of functioning from the Children's Global Assessment Scale.                                          


        Table 3.--1995 Estimates of Children and Adolescents With Serious Emotional Disturbance by State        
----------------------------------------------------------------------------------------------------------------
                                                                       LOF*=50                   LOF*=60        
             State                  Number of     Percent in ---------------------------------------------------
                                   youth 9-17      poverty    Lower limit  Upper limit  Lower limit  Upper limit
----------------------------------------------------------------------------------------------------------------
    Total......................      33,706,204  ...........    2,118,269    2,792,391    3,466,516    4,140,636
 1  New Hampshire..............         147,695         4.07        7,385       10,339       13,293       16,246
                                --------------------------------------------------------------------------------
 2  Alaska.....................          90,955         8.96        4,548        6,367        8,186       10,005
 3  New Jersey.................         932,671         9.60       46,634       65,287       83,940       10,259
 4  Utah.......................         349,086         9.76       17,454       24,436       31,418        3,839
 5  Minnesota..................         643,892        11.30       32,195       45,072       57,950       70,828
 6  Colorado...................         491,930        11.34       24,597       34,435       44,274       54,112
 7  Nebraska...................         231,037        11.62       11,552       16,173       20,793       25,414
 8  Missouri...................         709,439        11.74       35,472       49,661       63,850       78,038
 9  Kansas.....................         354,722        12.55       17,736       24,831       31,925       39,019
10  Wisconsin..................         706,004        12.56       35,300       49,420       63,540       77,660
11  Hawaii.....................         143,901        13.97        7,195       10,073       12,951       15,829
12  North Dakota...............          91,443        14.13        4,572        6,401        8,230       10,059
13  Virginia...................         790,359        14.38       39,518       55,325       71,132       86,939
14  Nevada.....................         186,695        14.41        9,335       13,069       16,803       20,536
15  Indiana....................         758,633        15.24       37,932       53,104       68,277       83,450
16  Rhode Island...............         115,176        15.36        5,759        8,062       10,366       12,669
17  Delaware...................          85,396        15.56        4,270        5,978        7,686        9,394
18  Maine......................         160,434        15.57        8,022       11,230       14,439       17,648
19  Vermont....................          76,500        15.79        4,590        6,120        7,650        9,180
20  Maryland...................         608,209        15.80       36,493       48,657       60,821       72,985
21  Wyoming....................          75,106        16.21        4,506        6,008        7,511        9,013
22  Georgia....................         942,161        16.30       56,530       75,373       94,216      113,059
23  Massachusetts..............         680,101        17.12       40,806       54,408       68,010       81,612
24  Iowa.......................         385,583        17.39       23,135       30,847       38,558       46,270
25  Washington.................         714,567        17.81       42,874       57,165       71,457       85,748
26  Connecticut................         378,473        18.03       22,708       30,278       37,847       45,417
27  Pennsylvania...............       1,462,731        18.07       87,764      117,018      146,273      175,528
28  Oregon.....................         411,543        18.22       24,693       32,923       41,154       49,385
29  Michigan...................       1,275,452        18.36       76,527      102,036      127,545      153,054
30  Ohio.......................       1,451,220        19.33       87,073      116,098      145,122      174,146
31  Idaho......................         183,829        20.57       11,030       14,706       18,383       22,059
32  South Dakota...............         108,855        20.74        6,531        8,708       10,886       13,063
33  North Carolina.............         879,091        21.06       52,745       70,327       87,909      105,491
34  Kentucky...................         504,373        21.25       30,262       40,350       50,437       60,525
35  Illinois...................       1,517,182        22.14      106,203      136,546      166,890      197,234
36  Tennessee..................         658,573        22.23       46,100       59,272       72,443       85,614
37  Montana....................         126,834        22.39        8,878       11,415       13,952       16,488
38  Arkansas...................         337,718        22.44       23,640       30,395       37,149       43,903
39  Texas......................       2,623,654        24.53      183,656      236,129      288,602      341,075
40  California.................       3,968,950        24.97      277,827      357,206      436,585      515,964
41  Oklahoma...................         457,496        24.98       32,025       41,175       50,325       59,474
42  Arizona....................         542,019        25.31       37,941       48,782       59,622       70,462
43  Florida....................       1,623,697        25.50      113,659      146,133      178,607      211,081
44  New York...................       2,141,435        25.51      149,900      192,729      235,558      278,387
45  West Virginia..............         231,390        26.93       16,197       20,825       25,453       30,081
46  Alabama....................         547,671        27.50       38,337       49,290       60,244       71,197
47  Louisiana..................         639,158        29.69       44,741       57,524       70,307       83,091
48  South Carolina.............         470,875        32.11       32,961       42,379       51,796       61,214
49  Washington, DC.............          48,365        35.33        3,386        4,353        5,320        6,287
50  New Mexico.................         251,231        36.59       17,586       22,611       27,635       32,660
51  Mississippi................         392,694        37.03       27,489       35,342       43,196       51,050
----------------------------------------------------------------------------------------------------------


[[Page 52143]]

    Analyses show very similar prevalence rates for girls and boys in 
the seven sites. The absence of gender differences is also apparent in 
the findings of Jensen et al. (1995). Kessler (1995), however, reports 
a higher prevalence rate in females than males using the adult 
diagnostic categories, and an older adolescent sample (15-17 year 
olds). There is no indication that overall prevalence rate of serious 
emotional disturbance differs by gender within the 9-17 year age range 
although there clearly are gender differences in prevalence of 
particular diagnoses, such as conduct disorder and depression, and 
there are suggestions that the rates may diverge in later years of 
adolescence.
    Overall, there is support for the use of socio-economic status as a 
correction factor in developing a methodology for the estimation of the 
prevalence of serious emotional disturbance. There is no empercial 
basis at this point for using other correction factors.

Conclusions

    Of the 33 million children and adolescents between the ages of 9-17 
in the United States, 9-13 percent or 3.5-4 million of these youngsters 
have a serious emotional disturbance at a score of 60 or lower on the 
Children's Global Assessment Scale. A more stringent definition of 
impairment, representing a score of 50 or lower on the Children's 
Global Assessment Scale shows a range of 5-9 percent or 2.1-2.8 million 
youngsters with a serious emotional disturbance (see Figure 1). 
Currently there are not sufficient studies to determine the prevalence 
rate in very young children ages birth--8. Therefore the estimated 
number of children with serious emotional disturbance presented here is 
a low estmate since it only included data for 9-17 year olds.

Limitations

    There are several limitations for these estimates. First, it must 
be recognized that these estimated ranges are based on the findings 
from many modest-sized studies which varied not only in population but 
often in instruments that were used (particularly for measurement of 
impairment), methods that were used to collect the data, and even the 
diagnostic system that was used.
    Second, there are only two studies that include youngsters under 
the age of nine, and these studies are not adequate to provide a base 
for any estimate of the prevalence of serious emotional disturbance for 
children under the age of nine. The estimate presented here is intended 
for children between nine and 17 years of age.
    Third, the data are also inadequate to determine prevalence 
estimates for children of different racial and ethnic backgrounds. 
Several of the studies included youngsters of color in their sample and 
two studies were done exclusively on Hispanic youngsters in Puerto Rico 
(Bird et al., 1988, & one of the MECA sites). However, the sample sizes 
are too small and not sufficiently representative of African-American, 
Hispanic, Asian American, or native American populations to permit 
estimates to be made.
    Fourth, with the absence of any large national studies, it is not 
possible to determine whether rates differ in urban versus rural areas, 
or different regions of the country.

Scope of Application

    Inclusion in or exclusion from the definition is not intended to 
confer or deny eligibility for any service or benefit at the Federal, 
State, or local levels. Only a portion of children with a serious 
emotional disturbance seek treatment in any given year. Due to the 
episodic nature of serious emotional disturbance, some children and 
adolescents may not require mental health service at any particular 
time. Additionally, the definition is not intended to restrict the 
flexibility or responsibility of the State or local government to 
tailor publicly funded service systems to meet local needs and 
priorities. However, all individuals whose services are funded through 
Federal Community Mental Health Services Block Grant funds must fall 
within the criteria set forth in these definitions. Any ancillary use 
of these definitions for purposes other than those identified in the 
legislation is outside the purview and control of CMHS.
    It is anticipated that additional work will be done in future years 
to refine and update the estimation methodology. CMHS will keep States 
apprised as this work develops.

References

Achenbach, T.M., & Edelbrock, C. (1983). Manual for the Child 
Behavior Checklist and Revised Child Behavior Profile. Burlington, 
VT: Queen City Printers.
Angold, A., & Costello, E.J. (1995). A test-retest reliability study 
of child-reported psychiatric symptoms and diagnoses using the Child 
and Adolescent Psychiatric Assessment (CAPA-C). Psychological 
Medicine, 25, 755-762.
Bird, H.R., Canino, G., Rubio-Stipec, M., Gould, M.S., Riobera, J., 
Sesman, M., Woodbury, M., Huertas-Goldman, S., Pagan, A., Sanchez-
Lacay, A., & Moscoso, M. (1988). Estimates of the prevalence of 
childhood maladjustment in a community survey in Puerto Rico. 
Archives of General Psychiatry, 45, 1120-1126.
Bird, H.R., Canino, G., Rubio-Stipec, M., & Ribera, J. C. (1987). 
Further measures of the psychometric properties of the children's 
global assessment scale. Archives of General Psychiatry, 44, 821-
824.
Bird, H.R., Shaffer, D., Fisher, P., Gould, M.S., Staghezza, B., 
Chen, J. Y., & Hoven, C. (1993). The Columbia Impairment Scale 
(CIS): Pilot findings on a measure of global impairment for children 
and adolescents. International Journal of Methods in Psychiatric 
Research, 3, 167-176.
Brandenburg, N.A., Friedman, R.M., & Silver, S. (1990). The 
epidemiology of childhood psychiatric disorders: Recent prevalence 
findings and methodologic issues. Journal of the American Academy of 
Child and Adolescent Psychiatry, 29, 76-83.
Canino, G. (1994). Personal communication.
Cohen, P., Cohen, J., Kasen, S., Velez, C.N., Hartmark, C., Johnson, 
J., Rojas, M., Brook, J., & Streuning, E.L. (1993). An 
epidemiological study of disorders in late childhood and 
adolescence: 1. Age and gender-specific prevalence. Journal of Child 
Psychology and Psychiatry, 34, 851-867.
Cohen, P., Velez, C.N., Kohn, M., Schwab-Stone, M., & Johnson, J. 
(1987). Child psychiatric diagnosis by computer algorithm: 
Theoretical issues and empirical tests. Journal of the American 
Academy of Child & Adolescent Psychiatry, 26, 631-638.
Costello, E.J. (1989). Developments in chidl psychiatric 
epidemiology. Journal of the American Academy of Child and 
Adolescent Psychiatry, 28, 836-841.
Costello, A.J., Edelbrock, C.S., Dulcan, M.K., Kalas, R., & Klaric, 
S.H. (1984). Report on the NIMH Diagnostic Interview Schedule for 
Children (DISC). Pittsburgh, Pa.: Department of Psychiatry, 
University of Pittsburgh.
Costello, E.J., Angold, A., Burns, B.J., Erkanli, A., Stangl, D., & 
Tweed, D. (1995). The Great Smoky Mountains Study of Youth: II. 
Functional impairment and severe emotional disturbances. Unpublished 
manuscript, Department of Psychiatry, Duke University.
Costello, E.J., Edelbrock, C., Costello, A.J., Dulcan, M.K., Burns, 
B.J., & Brent, D. (1988). Psychopathology in pediatric primary care: 
The new hidden morbidity. Pediatrics, 82, 415-424.
Costello, E.J., & Messer, S.C. (1995). Rates and correlates of 
serious emotional disturbance: Secondary analysis of epidemiologic 
data sets. Paper prepared for Center for Mental Health Services, 
Rockville, Md.

[[Page 52144]]

Costello, E.J., & Tweed, D.L. (1994). A review of recent empirical 
studies linking the prevalence of functional impairment with that of 
emotional and behavioral illness or disorder in children and 
adolescents. Paper prepared for the Center for Mental Health 
Services, Rockville, Md.
Friedman, R.M., Kutash, K., & Duchnowski, A.J. (1996). The 
population of concern: Defining the issues. In B. A. Stroul (Ed.), 
Children's Mental Health: Creating Systems of Care in a Changing 
Society. Paul H. Brookes, Baltimore, p. 69-95.
Hernjanic, B., & Reich, W. (1982). Development of a structured 
psychiatric interview for children: Agreement between child and 
parent on individual symptoms. Journal of Abnormal Child Psychology, 
10, 307-324.
Hodges, K. (1990). Manual for the Child and Adolescent Functional 
Assessment Scale. Unpublished manuscript, Ann Arbor, Michigan.
Hodges, K. (1994). Measures for assessing impairment in children and 
adolescents. Paper prepared for the Center for Mental Health 
Services, Rockville, MD.
Jensen, P.S., Watanabe, H.K., Richters, J.E., Cortes, R., Roper, M., 
& Liu, S. (1995). Psychopathology among children and adolescents 
living on a military base. Journal of the American Academy of Child 
and Adolescent Psychiatry, 34, 1514-1524.
Kashani, J.H., Beck, N.C., Hoeper, E.W., Fallahi, C., Corcoran, 
C.M., McAllister, J.A., Rosenberg, T.K., & Reid, J.C. (1987). 
Psychiatric disorders in a community sample of adolescents. American 
Journal of Psychiatry, 43, 255-262.
Kessler, R.C. (1995). Personal communication.
Kessler, R.C., Berglund, P.A., Leaf, P.J., Kouzis, A.C., Bruce, 
M.L., Friedman, R.M., Grosser, R.C., Kennedy, C., Kuehnel, T.G., 
Laska, E.M., Manderscheid, R.W., Narrow, B., Rosenbeck, R.A., 
Santoni, T.W., & Schneier, M. (1995). Estimation of the 12-month 
prevalence of serious mental illness (SMI). Unpublished manuscript. 
Center for Mental Health Services, Rockville, MD.
Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., 
Eshleman, S., Wittchen, H.U., & Kendler, K.S. (1994). Lifetime and 
12-month prevalence of DSM--III--R psychiatric disorders in the 
United States: Results from the National Comorbidity Study. Archives 
of General Psychiatry, 51, 8-19.
Lahey, B.B., Flagg, E.W., Bird, H.R., Schwab-Stone, M., Canino, G., 
Dulcan, M.K., Leaf, P.J., Davies, M., Brogan, D., Bourdon, K., 
Horwitz, S.M., Rubio-Stipec, M., Freeman, D.H., Lichtman, J., 
Shaffer, D., Goodman, S.H., Narrow, W.E., Weissman, M.M., Kandel, 
D.B., Jensen, P.S., Richters, J.E., & Regier, D.A. (1996). The NIMH 
methods for the epidemiology of child and adolescent mental 
disorders (MECA) study: Background and methodology. Journal of the 
American Academy of Child and Adolescent Psychiatry. 35, 855-864.
Leaf, P.J., Alegria, M., Cohen, P., Goodman, S.H., Horwitz, S.M., 
Hoven, C.W., Narrow, W.E., Vaden-Kiernan, M., Regier, D.A. (1996). 
Mental health service use in the community and schools: Results from 
the four-community MECA study. Journal of Child and Adolescent 
Psychiatry 35, 889-897.
National Advisory Mental Health Council. (1993). Health care reform 
for Americans with severe mental illnesses. American Journal of 
Psychiatry, 150, 1447-1465.
Regier, D. A., Boyd, J. H., Burke, J. D., Jr., Rae, D. S., Myers, J. 
K., Kramer, M., Robins, L. N., George, L. K., Karno, M., & Locke, B. 
(1988). One-month prevalence of mental disorders in the United 
States. Archives of General Psychiatry, 45, 977-986.
Reich, W., & Earls, F. (1987). Rules for making psychiatric 
diagnoses in children on the basis of multiple sources of 
information. Journal of Abnormal Child Psychology, 14, 601-616.
Reinherz, H. Z., Gianconia, R. M., Lefkowitz, E. S., Pakiz, B., & 
Frost, A. K. (1993). Prevalence of psychiatric disorders in a 
community population of older adolescents. Journal of the American 
Academy of Child & Adolescent Psychiatry, 32, 369-377.
Robins, L. N. (1985). Epidemiology: Reflections on testing the 
validity of psychiatric interviews. Archives of General Psychiatry, 
42, 918-924.
Shaffer, D. Personal communication. July & August, 1994.
Shaffer, D., Fisher, P., Dulcan, M., Davies, M., Piacentini, J., 
Schwab-Stone, M., Lahey, B. B., Bourdon, K., Jensen, P., Bird, H., 
Canino, G., & Regier, D. (1996). The NIMH Diagnostic Interview 
Schedule for Children (DISC 2): Description, acceptability, 
prevalences, and performance in the MECA study. Journal of the 
American Academy of Child and Adolescent Psychiatry, 35, 865-877.
Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., 
Bird, H., & Aluwahlia, S. (1983). A children's global assessment 
scale (CGAS). Archives of General Psychiatry, 40, 1228-1231. 
Substance Abuse and Mental Health Services Administration (1993). 
Final notice establishing definitions for (1) Children with a 
serious emotional disturbance, and (2) adults with a serious mental 
illness. Federal Register, 58(96), 29422-29425.

BILLING CODE 4160-20-U

[[Page 52145]]

[GRAPHIC] [TIFF OMITTED] TN06OC97.002



BILLING CODE 4160-20-C

    Dated: September 22, 1997.
Richard Kopanda,
Executive Officer SAMHSA.
[FR Doc. 97-26372 Filed 10-3-97; 8:45 am]
BILLING CODE 4160-20-U