Mental health services use among school-aged children with disabilities: the role of sociodemographics, functional limitations, family burdens, and care coordination.

Children with disabilities or chronic illnesses have been shown to be at increased risk for psychological morbidity (Bennett 1994; Bussing et al. 1995; Drotar 1997; Lavigne and Faier-Routman 1992; Noll et al. 1999; Pless, Roghmann, and Haggerty 1972; Roizen et al. 1996; Witt, Riley, and Coiro 2003), and to have an elevated need for mental health care services. Little is known, however, about access to and use of mental health services among children with disabilities. Few children are identified as having mental health problems in the primary care setting (Brandenburg, Friedman, and Silver 1990; Costello 1986; Costello, Angold, Burns, Stangl et al. 1996; Costello et al. 1988; Lavigne et al. 1993); even among disabled children with poor psychosocial adjustment, most are not identified in primary care, and only a small percentage of those identified receive mental health services (Cadman et al. 1987). The presence of a psychiatric disorder is a determinant of increased use of mental health services among children (Cunningham and Freiman 1996; Koot and Verhulst 1992; Laitinen-Krispijn et al. 1999; Pfeffer, Plutchik, and Mizruchi 1986; Pottick et al. 1995; Roghmann et al. 1982). The sociodemographic factors most often associated with mental health care use are the child's age (Cohen and Hesselbart 1993), gender (Chabra et al. 1999; Laitinen-Krispijn et al. 1999; Zahner and Daskalakis 1997), race/ethnicity (Chabra et al. 1999; Hoberman 1992), residence (Cohen and Hesselbart 1993), and socioeconomic status (Cohen and Hesselbart 1993; Cunningham and Freiman 1996; Lurie 1974). In addition, family factors such as maternal distress (Garralda, Bowman, and Mandalia 1999) and family conflict and burden (Angold et al. 1998; Briggs-Gowan et al. 2000; Lavigne et al. 1998; Zahner and Daskalakis 1997) have been correlated with children's use of mental health care. Some studies also have indicated that disability status and health problems are important determinants (Cadman et al. 1987; Gortmaker et al. 1990; John et al. 1995; Zahner and Daskalakis 1997). One factor that may play a role in identification, referral, and access to mental health care for children with disabilities is “care coordination.” Coordination of medical care plays a pivotal role in obtaining specialty care for children with special health care needs (Smith, Layne, and Garell 1994; Ziring et al. 1999). Health care providers, predominantly physicians, most often coordinate medical services for children with disabilities (Briskin and Liptak 1995; Liptak 1995; Liptak and Revell 1989). Lack of coordination between the medical and mental health sectors is thought to restrict access to needed mental health services for all children (Stroul et al. 1998), as well as children with disabilities and chronic conditions (Sabbeth and Stein 1990). Family involvement in care coordination also may increase use of mental health services. Family members are often the most knowledgeable about children's health care needs, and can be essential in identifying mental health problems and assisting in the process of obtaining mental health services (Glascoe 2000; Glascoe and Dworkin 1995). In fact, Wildman and colleagues found that parental disclosure of a child's psychosocial problems was a better predictor of physician identification of a mental health problem than the presence of the child's symptoms (Wildman, Kizilbash, and Smucker 1999). Clinical studies also suggest that parent–provider interactions (Garrison et al. 1992) and levels of agreement about treatment increase the likelihood of receipt of services, and often determine the type of setting in which care is delivered to children with mental health problems (Gardner et al. 2000). Nearly all recent studies of the use of mental health services among children with disabilities have been conducted on convenience samples of families already actively involved with health or mental health care systems in limited geographic areas. This study draws on a nationally representative population-based sample to investigate the factors that are associated with use of mental health care and variations in use by care settings (inpatient, outpatient, and school-based settings) for school-aged children with disabilities. We expect poor psychosocial adjustment, functioning, sociodemographic, and family characteristics to be correlated with overall use and use in each care setting. We hypothesize that the involvement of health professionals in the care coordination process will be associated with increased use of mental health services.