Research on Community-Based Mental Health Services for Children and Adolescents: Volume 14

As we have discussed, recognition of the specialized needs of children and adolescents has taken place late in many domains. The same could be said with regard to the mental health services research enterprise. Kimberly Hoagwood, a prominent child mental health services researcher and for many years the program officer overseeing the National Institute of Mental Health's services research portfolio in the area of child mental health services research, recently observed that research in this area has lagged behind that for adults by roughly 10 years (Hoagwood, 2005). Indeed, as late as 1999, Burns was calling for the development of a services research agenda for youth with serious emotional disturbances (Burns, 1999).

Depression is a prevalent, debilitating condition that will replace cancer as the second leading cause of morbidity within the next decade and, according to the Global Burden of Disease Study, ranks number one in disability-adjusted life years for females 5 years and older worldwide (Blehar & Oren, 1997; Murray & Lopez, 1996). Depression in the workplace has been linked to increased absenteeism and productivity loss, is equal to the costs of diabetes and hypertension, and these costs are almost equal to the direct costs of depression treatment (Kessler et al., 1999; Marlowe, 2002; Druss, Rosenheck, & Sledge, 2000; Elinson, Houck, Marcus, & Pincus, 2004). A national study of individuals 15–54 years documented a lifetime prevalence of 17.1% and found that depression was more common in females, young adults, and those with less education (Blazer, Kessler, McGonagle, & Swartz, 1994; Kessler, McGonagle, Swartz, Blazer, & Nelson, 1993; Substance Abuse and Mental Health Services Administration, 2000; Kessler et al., 1994a, 1994b; Bebbington et al., 2003).

Public schools possess a unique constellation of opportunities and challenges for mental health service provision. Schools, as settings within a larger ecological context, can be a community institution that supports a child as s/he develops assets for resilient development while providing opportunities for a range of life choices. School is the setting where children can learn and practice peer relations and social norms, and it can be a refuge where children who have many environmental risks can find structure and effective methods of success (Doll, 1999). When Willie Horton, the infamous bank robber, was asked why he robbed banks, he responded, “Because that's where the money is.” At a most basic level, schools are where the children are. Every day more than 52 million students attend over 1,14,000 schools in the United States, and including the 6 million adult staff, this amounts to almost one-fifth of the population passing through the Nation's schools on any given weekday (New Freedom Commission on Mental Health, 2003).

All individuals are challenged by the movement from being an adolescent living at home and attending school to being an adult typically heading a household and working to support him or herself. This period of time is called the transition to adulthood and is even more challenging for youth from vulnerable populations such as youth with disabilities, in foster care, in juvenile justice system, and the like (Osgood, Foster, Flanagan, & Ruth, 2005). The ages that transition encompasses have not gained consensus in research literature or policy. It begins at ages 14–16 in policies such as the Individuals with Disabilities Education Act (IDEA; PL101-476, 1997 and 2004 amendments) or Federal programs such as the Social Security Administration's SSI Youth Transition Demonstration Projects, which identifies ages 22 and 25, respectively, as ending transition. Recent studies on young adulthood in the general population (Settersten, Frustenberg, & Rumbaut, 2005), found that by age 30, the rapid changes of young adulthood had typically stabilized. Thus, using the broadest ages indicated by policy and research, transition to stable adulthood encompasses ages 14–30.

The belief that children have mental health needs different than those of adults is a relatively recent phenomenon. Systematic field studies of mental illness began in the early 19th century (Anthony, Eaton, & Henderson, 1995), although awareness of these illnesses and the recognition of the need for treatment were well established by the 1600s (Grob, 1994). Field studies and census data from mental hospitals in the 1800s reveal few cases of mental illness identified among children under the age of 16. In the late 19th and early 20th centuries, the recognition that children have specific mental health needs arose as the result of the confluence of several factors. The Progressive Movement promoted child labor and mandatory public education laws that created legal separations between the role of children and adults (Abbott, 1908; Sutton, 1983). Hall (1905) helped popularize the idea that childhood and adolescence constituted distinct periods of development. Perhaps most pressing, however, was a perceived rise in juvenile delinquency and sexual promiscuity. To address these problems, separate courts were established for juvenile offenders to keep children out of institutions and to provide treatment and rehabilitation (Alper, 1941). Based on the work of Healy and Bronner (1916), researchers and policy makers began to think of juvenile crime as arising from “mental conflicts” in children. Institutions such as the Chicago Juvenile Psychopathic Institute and the Boston Psychopathic Hospital were established to care for these children (Horn, 1989).

Network analysis involves the examination of the structure and patterning of relationships among a set of persons or agencies by taking into account the relations or ties that exist, as well as those that do not, among various groups (Knoke & Kuklinski, 1982). For the evaluation project, the structure of relationships within the county behavioral health service network, were examined over the course of three years. The method applied interorganizational theory and a network analytic approach, based on the works of Heflinger and Northrup (Heflinger, 1996; Heflinger & Northrup, 1998, 2000a), Morrissey and colleagues (Morrissey et al., 1994, 1998; Morrissey, 1992; Morrissey, Tausig, & Lindsey, 1985), Van de Ven (1976), and Bolland and Wilson (1991a, 1991b, 1994).

A first, basic question regarding the complexity of systems of care addresses the degrees to which individuals who are served by one program or service sector are also served by another program or service sector during the same time period. Program managers need to know whether and to what degree the young people on their caseload are also on the caseload of another specified program. The need for service coordination between community mental health and juvenile justice programs in the same geographical region, for instance, is indicated by the number of young people on both programs. This information also provides higher level system managers with an indication of the degree to which the community mental health program is serving this group of young people who have an elevated need for mental health services. Where there are integrated information systems or where individual information systems share unique person identifiers, caseload integration can be directly measured. In the absence of the ability to share unique person identifiers, information about caseload overlap may be derived using the statistical technology of Probabilistic Population Estimation (PPE).

Two major reform movements have shaped child and adolescent mental health services over the past quarter-century: the Systems of Care movement, and more recently, the movement toward evidence-based practice. Results from several studies indicate that youth served in traditional residential or inpatient care may experience difficulty re-entering their natural environments, or were released into physically and emotionally unsafe homes (Bruns & Burchard, 2000; President's Commission on Mental Health, 1978; Stortz, 2000; Stroul & Friedman, 1986; U.S. Department of Health and Human Services, 1999). The cost of hospitalizing youth also became a policy concern (Henggeler et al., 1999b; Kielser, 1993; U.S. Department of Health and Human Services, 1999). For example, it is estimated that from the late 1980s through 1990 inpatient treatment consumed nearly half of all expenditures for child and adolescent mental health care although the services were found not to be very effective (Burns, 1991; Burns & Friedman, 1990). More recent analyses indicate that at least 1/3 of all mental health expenditures for youth are associated with inpatient hospitalization (Ringel & Sturm, 2001).

A system of care is a function-specific, rather than agency-specific approach defined as a “comprehensive spectrum of mental health and other necessary services which are organized into a coordinated network to meet the multiple and changing needs of children and adolescents with severe emotional disturbances and their families” (Stroul & Friedman, 1986). A system of care provides a mental health delivery system for children with SED with a wide array of accessible, community-based services that focus on children's individual needs, include the family in treatment planning, and provide culturally competent services. System of care services are provided by multiple child serving agencies and are collaborative and coordinated (Stroul & Friedman, 1986).

Systems of care and evidence-based practice possess distinct histories. Though each developed out of attempts to improve services to youth with emotional and behavioral disorders, they did so from perspectives so different as to appear diametrically opposed. Service systems exist at multiple levels, including the practice, program, and system levels (Rosenblatt, 1988, 2005; Rosenblatt & Woodbridge, 2003). Research on health and mental health service systems similarly varies, often by level of the service system, with the research methods, independent and dependent variables, populations of interest, and ultimately the consumers of the research product interacting differentially in the creation and understanding of what constitutes a knowledge base for service delivery. Systems of care and, with limited exceptions, evidence-based practices exist at different levels of the service delivery structure, require and derive from different research approaches, and speak to overlapping but historically different audiences.