Service Needs of Severely Disturbed Children
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...................
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Enc W. Tnrpin, PhD, Amy Forsyth-Stephens, MSW, and Benson P. Low, PhD
Introduction The treatment needs of severely and chronically mentally ill individuals, of any age, vary considerably depending upon personal characteristics (e.g., degree of disability, nature of symptomatology, willingness to accept treatment), and situational or environmental characteristics (e.g., availability of natural supports, residential situation, mobility of the individual). Ideally, the range of available services would be so broad, and care givers so flexible, that all clients would receive an appropriate, individualized menu of services. Unfortunately, human services, especially mental health, are largely program-driven, with clients matched to programs, rather than services matched to clients. Given that this infrastructure of care provision may be difficult to overtum, it is imperative that the development and design of state and local programs be based upon a concrete knowledge of client needs. Services for children* are especially subject to "blind" planning and implementation. There is a dearth of research in the area of children's mental health, most notable on the topic of severely mentally ill children.1 Analogous to the study of chronic mental illness among adults, the area of severe emotional disturbance (SED) among children is a relatively recently established field of research. Attention was drawn to the issue in 1982, when the unsettling book Unclaimed Children2 reported that two-thirds of all SED children do not receive the services they need. The book went on to document the failure of federal and state govemments to acknowledge and attempt to meet the mental health needs of children, resulting in a vast and deeply troubled population
with no advocacy, options, or hope. Five years later, the Office of Technology Assessment of the United States Congress3 underscored accusations put forth in Un-
claimed Children. In 1984, the National Institute of Mental Health initiated the Child and Adolescent Service System Program (CASSP) in an effort to address the national crisis in children's mental health.4 The goal of CASSP was, and continues to be, the promotion of system development through the funding of 40 state-level planning initiatives and two national research centers for the study of SED among children. Most of the research to date on service needs of SED children has been produced by state human service departments in response to legislative mandates or class action suits, or by CASSP-funded research institutes. Based upon work completed by many states, and by the CASSP research centers, an assumption has been promulgated that a complete range of services, on a continuum from most to least restrictive, must be developed to adequately meet the needs of severely emotionally disturbed children.5 Most recently, the "continuum of care" idea has been replaced by the concept of a "system of care" for SED children,6 From the University of Washington School of Medicine, Department of Psychiatry & Behavioral Sciences. Address reprint requests to Eric W. Trupin, PhD, Division of Community Psychiatry, Department of Psychiatry & Behavioral Sciences, School of Medicine, University of Washington, Mailstop RP-10, Seattle, WA 98195. This paper, submitted to the Journal July 9, 1990, was revised and accepted for publication January 23, 1991.
*In this article, "Children" refers to anyone under the age of 19 years.
American Journal of Public Health 975
Tmnpm et al.
which has a somewhat broader connotation. With the system perspective, more than a comprehensive spectrum of appropriate services is necessary. Just as critical are the underlying facilitating mechanisms, structures, and administrative processes to ensure that services are delivered and received in a coordinated, childfocused manner. There have been no empirical studies of the diverse service needs of severely emotionally disturbed male children versus female children. Similarly,there have been no reports of service need data by developmental groupings (i.e. young children, preteens, and adolescents). Only one report has documented the age and sex breakdowns of an SED child population. In North Carolina, Behar7 reports that the population of children qualifying as SED was 80 percent male, 20 percent female. Over three-fourths (78 percent) of the SED children were between the ages of 12 and 17; 14 percent were under the age of 12. This paper presents the findings of a statewide survey of the specific service needs of 1617 severely emotionally disturbed children. The large sample size of the survey permits analysis of service need data by age and sex categories. The possibility of identifying distinct ideal service continuums for male and female SED children of various age groups is discussed.
Method Design The survey of service needs of SED children took place in the context of a broader study of the children's mental health system in Washington State. This larger project, entitled the Children's Mental Health System Analysis, involved the administration of a Child Mental Health Survey to adult care takers of randomly selected, nonidentified children served by the Department of Social and Health Services (DSHS). The analysis of data occurred in two stages. The first stage involved the identification of children in the sample who were classifiable as SED (this procedure is described below under "Classification of Children as SED"). The second stage involved the examination of reported service need data for the subjects who were classified as SED according to our model. A significant design feature was the nonidentified status of children surveyed. Use of identified data would have required 976 American Journal of Public Health
informed consent for every child in the survey. Apart from the logistic demand such a requirement would have brought, institutional or agency refusals would have become a significant problem. While the use of nonidentified data facilitated more comprehensive surveying of children, it did limit control over the subject selection process, and precluded empirical analysis of subject attrition.
Subjects The subjects were 3,398 children and adolescents ages 0 to 18 who were selected randomly from the billing rosters of child-serving programs within the State's Department of Social and Health Services (DSHS). Nearly half of the subjects (N = 1,640) were clients of the DSHS Division of Children and Family Services (DCFS), which offers an array ofchildwelfare services including child protective services, foster care, group home care, in-home intervention, and emergency out-of-home placement. The remainder of the sample was made up of clients of the DSHS Division of Juvenile Rehabilitation (DJR; institutions, group homes, and parolees; N = 1,035); the DSHS Mental Health Division (DMH; inpatient, residential, day treatment, and outpatient; N = 524); and the DSHS Division of Developmental Disabilities (DDD; institutions and group homes; N = 199). Sample sizes were calculated by taking into consideration the population size, the a priori estimate of the rate at which SED would occur (50 percent in all DSHS groups), the range of the intended confidence interval (+5 percent), and the probability level for the confidence interval (95 percent). Sample sizes were inflated by a factor of 15 percent, to compensate for subject attrition. As an exception, the DSHS Division of Juvenile Rehabilitation made an administrative decision to survey all clients in their programs. All clients in programs with caseloads offewer than 150 were surveyed.
Respondents The survey respondents were 3,398 adult DSHS professionals or staff members of agencies under contract with DSHS. Two-thirds of the respondents (65 percent) were case workers or facility staff employed either directly by DSHS, or by a contracted agency. The remaining onethird was made up of probation/parole officers and independent mental health professionals. Ninety-two percent of the respondents had at least a four-year college degree. The mean length of time that
a respondent had known the surveyed child was 12.2 months.
Suvey Instnrment Development and Reliability The data collection instrument, entitled the Child Mental Health Survey,* was developed after review of materials used by other states in similar but smaller-scale efforts.8 The survey instrument contained six sections with questions pertaining to: 1) sociodemographic background; 2) exposure to 13 mental health risk conditions; 3) current behavioral adjustment as measured by the Child Behavior Checklist (CBCL);9 4) past mental health treatment and placement history; 5) other handicapping conditions; and 6) mental health and social service needs. The section on service needs required the respondent to identify the subject's past receipt, current receipt, and current unmet need for any of 32 human services. The Child Mental Health Surveywas administered to pairs ofteachers of26 special education pupils and 30 regular education pupils, and to pairs of case workers of 10 children placed in mental health treatment programs in the community. Each of the respondents independently completed surveys on the selected child. Reliability coefficients were calculated on four sections of the survey: exposure to mental health risk factors, mental health treatment history, other handicaps, and current behavioral adjustment. The Kappas obtained for the sections on risk factors, treatment history, and other handicaps were in the acceptable and expected range, with most values above .60, and some exceeding .80.10 Reliability coefficients were not calculated on service need data. Interrater reliability was less of a concern for the service need data, as the caseworkerswho completed the survey forms were highly face valid, as they are the "natural" raters who drive the system of referrals for these SED children. Moreover, a meta-analysis on concordance of raters of children underscores that data from a single respondent typically provide a reasonable sample of what would be provided by other informants of the same tpe who see the child under generally similar conditions.10
Classification of Children as SED SED children from the sample were identified via MANOVA techniques. *The Child Mental Health Survey is available from the first author upon request.
August 1991, Vol. 81, No. 8
Children's Mental Health Service Needs
Each subject was treated as a group of one and then compared via Hotelling's T2 against a criterion SED group. The criterion SED group was defined as all children being served in the State's psychiatric residential treatment centers, and a specialized foster care program for previously psychiatrically hospitalized children. These programs provide the most comprehensive, intensive, and expensive mental health treatment offered by the state mental health system for children. It was the research team's consensus that children meeting the numerous requirements for admission to these programs are inarguably severely emotionally disturbed, and therefore comprise the most valid, conservative, and defensible criterion group for this study. Each subject was evaluated individually as to the likelihood of being drawn from the criterion group. Ifthe subjectwas discriminable, the subject was not classified as SED. The independent variables used in the discriminant analysis were: 1) MentalHealthRisk scored as the number of risk factors endorsed positively for the subject; 2) Chronicity, scored as positive if the subject was rated as experiencing severe aggressiveness and/orwithdrawal for a minimum duration of one year; 3) ServiceNeed, scored as the number ofmental heath services endorsed as "needed" or "currently received"; 4) IntemalizingBehavior Problem; which was the T-score from the CBCL Internalization Scale; and 5)Extemal*gBehavior Problem, which was the T-score from the CBCL Externalization Scale. These five measures are widely used and face valid with respect to the detection of the presence of an emotional or behavioral problem in children.11-14
Service Need Data Analysis Service need data were analyzed for those children classified as SED according to the above model. Data on the services indicated as "needed" by SED children were weighted by DSHS population estimates of SED children across age and sex categories. This was done in order to control for the varying age and sex distributions of the four subsamples (i.e. DCFS, DJR, DDD, DMH). The population estimates were based upon the prevalence distribution of SED in our subsamples. A log linear analysis technique was used to test for significant differences in service need among three age groups of SED children (6-11, 12-16, and 17-18 years), and between male and female SED children.
August 1991, Vol. 81, No. 8
Results Survey Retum Rates The overall DSHS survey return rate 75 percent (i.e. 4,516 surveys were distributed, 3,398 were completed and returned). Return rates for the various participating divisions of DSHS ranged from a high of 95 percent for DJR to a low of 66 percent for DCFS. The high overall survey return rate was primarily a function of consistent DSHS involvement with the design and execution of the study. Most supervisors at local DSHS offices required 100 percent survey completion by their caseworkers, and actively monitored this assignment. Additionally, researchers distributed two reminder notices to DSHS supervisors during the time frame allotted for survey completion. All respondents were assured of, and received, feedback on the outcome of the survey. was
Service Needs of SED Chidren Of our sample of 3,398 children, 2,455 classified as SED according to our model (described above, a = .10). Of these 2,455 SED children identified from our original sample, data on 1,617 were used in this analysis of service needs. A total of 838 cases were eliminated due to the subject's age (less than 6 years) and/or an incomplete survey form. Children ages 0 through 5 were not included in this analysis due to the small size of that subsample (n = 96). Table 1 reports the estimated percent of the DSHS SED population needing various mental health and social services. Across all age and gender categories, over one-half of all SED children needed outpatient mental health treatment (defined as individual, group, or family therapy). Nearly one-half of SED children's families were in need of family support services for the parents and/or siblings. Interagency case management was needed by nearly one-third of SED children statewide. Other services which were commonly needed included schoolbased mental health services and psychological testing. Of all residentiafmpatient services, foster home placement and group home placement were the most commonly reported service needs. were
Age and Gender Service Need
Differentials Fourteen of the 32 possible mental health and social services listed on the Child Mental Health Survey showed sig-
nificant differences in reported need across the three age groups. These are displayed in Table 2. School children from age 6 through 11 (Group 1) were significantly higher than all other age groups in the need for respite care for their family members (11.0 percent, p < .000), and for therapeutic camp services (17.7 percent, p < .000). Children in Age Groups 1 and 2 (ages 6-11 and 12-16) displayed a higher need for school and home-based services than older SED children, specifically schoolbased mental health services (Group 1: 30.0 percent; Group 2: 27.4 percent), supervised after-school activities (Group 1: 20.3 percent; Group 2: 18.0 percent), and intensive in-home therapy (Group 1: 15.6 percent; Group 2: 18.8 percent). Children ages 12 through 16 (Group 2) were reported as more in need of foster home placements (18.9 percent, p < .001) and group home placements (12.6 percent, p < .000) than children in other age brackets. Data show that the need for both of these services peaks in the years 12 through 16, although the need pattem for the two services is quite different across the full developmental range. The need for foster home placement is high (12.3 percent) even within the 6 to 11 year old age group, and grows in the 12 to 16 year old group. At that point the need declines to 11.1 percent in the 17 to 18 year old age group. Group home placement, however, is low for the 6 to 11 year old age group, and then rises dramatically for the 12 to 16 year olds, staying relatively high (11.3 percent) for the 17 to 18 year old group. Older adolescents (Group 3, ages 1718) demonstrated a significantly higher need for outpatient alcohol or drug treatment (31.4 percent, p < .000), and inpatient alcohol or drug treatment (15.6 percent, p < .000) than the other age groups. They also demonstrated a much greater need than other age groups for training in independent living skills (58.6 percent, p < .000), vocational services (49.2 percent, p < .000), and supervised independent living arrangements (28.5 percent, p < .000). For each of these services, the expressed needwas nonexistent or extremely low for younger children (ages 6-11), increased for children ages 12 through 16, and peaked for children 17-18 years of age. Significant sex differences in endorsement of service need were identified among 11 ofthe 32 service types contained on the Child Mental Health Survey. These differences are also reported in Table 2. Females were significantly higher than males in their reported need for outAmerican Journal of Public Health 977
Trupin et al.
patient therapy (61.7 percent, p < .000), foster home placements (19.1 percent, p < .001), respite care (8.0 percent, p < .000), supervised independent living arrangements (7.6 percent, p < .001), and child protective services referral/intervention (9.6 percent, p < .000). Males were rated as having a significantly greater need for outpatient alcohol or drug treatment (16.2 percent, p < .000), inpatient alcohol or drug treatment (7.9 percent, p < .000), group home placement (10.6 percent, p < .000), training in independent living skills (19.0 percent, p < .000), and supervised afterschool activities (19.8 percent, p < .006).
Discussion Our survey of the professional caregivers of SED children generated a useful data base on the service needs of this population. While previous research and program planning efforts have identified only general categories of services appropriate for SED children, this broad-based study is the first to produce quantitative data on the extent of the SED population reported to be in need of a wide range of mental health, health, social, and support services. It is also the first study that further defines age and gender differences in types of needed services.
Overall Patterns of Service Need Across age and sex groupings, the most frequently reported needs, in descending order, were for: 1) outpatient therapy; 2) family support groups; 3) intersystem case management; 4) schoolbased mental health services; 5) psychological testing; 6) training in independent living skills; 7) intensive in-home therapy; and 8) supervised after-school activities. With the exception of outpatient therapy and psychological testing, all of these services would be considered "non-traditional" mental health services, or even outside the realm of mental health alto-
gether.6 We had anticipated that our survey of professionals would result in a high expressed need for residential or inpatient services, since respondents' level of familiarity with other more progressive treatment approaches was questionable. We reasoned that direct care providers might be hesitant to endorse non-traditional services as needed, especially if such services were not accessible to them. Clearly, this was not the outcome. The strong presence of CASSP in Washington State may be credited for a good
978 American Journal of Public Health
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Chilren's Mental Health Service Needs
deal of the progressive thinking of the state's professional care givers through conferences, newsletters, and an intensive effort to begin the creation of local intersystem case coordination committees. Not recognizing the significant impact of these educational efforts, we underestimated the knowledge base of our respondent pool. Unfortunately, Washington State's current service system reflects the national reality, in that treatment resources continue to be focused on a proportionally small number ofchildren who receive care on inpatient psychiatric units or other intensive residential treatment programs.3,15 Our data support the direction of CASSPfunded research and training centers and the National Mental Health Association in the endorsement of less restrictive home and school-based services, family support services, and comprehensive case management services as alternatives to costly out-of-home care.15.16
Age and Sec Differences Service planners generally tend to think of SED children as one class of service recipients. Our data suggest that there are significant differences in the service needs of male versus female children, and of differently aged children. These differ-
August 1991, Vol. 81, No. 8
ences have serious implications for the development and implementation of systems of care for the SED population. Our data demonstrate a substantial developmental gradient which must be considered when planning services for SED children. For school-aged children the educational setting clearly should play a large role in treatment planning. For example, school-based mental health services and supervised after school activities were distinct needs of 6-16 years olds. Therapeutic camp services and foster home placements were also highly endorsed for this subset of SED children. For the 17-18 year old group, there is a great need for services which prepare youth for the transition for adulthood, such as training in independent living skills, vocational services, and supervised independent living arrangements. The need for outpatient and inpatient alcohol! drug treatment also peaks for this age co-
hort. Sex differences in service need were less obvious than the developmental differences. Males demonstrated a greater need for transitional "adult" services, for alcohol and drug-related treatment, and for group home placement. Females, on the other hand, were in greater need of outpatient therapy, foster home place-
ments, respite care for their families, supervised living arrangements, and protective services. The services endorsed for males focused on home removal, treatment of addiction, and preparation for entry into the work force. Services endorsed for females focused on therapy, assistance to the girls' families, and protection from further harm. More research is needed to confirm whether these gender-linked service needs are valid indices of what SED children need in their treatment, or merely reflections of sex-based stereotypes of SED children's vulnerabilities and responsiveness to various treatments and interventions. American Journal of Public Health 979
Trupin et a.
Limitations of this study lie in its narrow focus on professional respondents, the non-random nature of the final sample, and the survey's exclusion of preventive services. First, our survey respondents were exclusively the professional care givers of SED children. This clearly provides only one perspective on what a given child's treatment needs may be. Family members, school personnel, and other persons in the child's support circle are equally valid respondents. Nevertheless, given that the focus of the survey was on SED children who were "system veterans" with well-known and extensive patient histories, input from the primary professional care givers was a good starting point. This in no way precludes the need to vigorously solicit the participation of parents and teachers in the development of individual children's treatment plans and larger scale planning endeavors. Second, for the analyses of service need data, the ultimate data base of SED children was a nonrandom approximate 50 percent of our original random sample of children. Cases were eliminated for three possible reasons: 1) the survey form was not returned; 2) the survey form was returned, but was missing critical information; or 3) the child was under 6 years of age. Ideally, our final sample would have been of a completely random nature. However, because the subjects were unidentified to the investigators, and since no special services were offered to children as a result of survey responses, the final sample appeared not to be biased systematically. Case worker-related factors, such as excessive paperwork demands, rather than child-related factors, appeared to contnbute to the rate of subject loss.
.. .
gram Announcement: Child and Adolescent Service System Program. Washington, DC: NIMH, December 1983. 5. Friedman RM: Major issues in mental health seIvices for children. Admin Ment Health. 1986;14:6-13. 6. Stroul BA, Friedman RM: A System of Care for Severely Emotionally Disturbed Children and Youth. Washington, DC: CASSP Technical Assistance Center, Georgetown University, 1986. 7. Behar L: Changing patterns of state responsibility: A case study of North Carolina. J Clin Child PsychoL 1985;14:188-195. 8. Stroul BA: Child and Adolescent Service System Program State Needs Assessment Materials. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center, 1985. 9. Achenbach TM, Edelbrock C: Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: Department of Psychiatry, University of Vermont, 1978. 10. Achenbach TM, McConaughy SH, Howell CT: Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psych BulL 1987;101:213-232. 11. Achenbach TM: Developmental Psychopathology. New York: Wiley, 1982. 12. Boyle MH, Offord DR, Hoffman HG, etak Ontario child health study. Arch Gen Psychiatry. 1988;45:1120-1126. 13. Mooney KC, Thompson R, Nelson JM: Risk factors and the Child Behavior Checklist in a child mental health center setting. J Abnorm Child PsychoL 1987;15:67-73. 14. Garrison WT, Earls F: The Child Behavior Checklist as a screening instrument for young children. JAm Acad Child Psychiatry. 1985;24:76-80. 15. Zeigler-Dendy CA: Invisible Children Project: Final Report and Recommendations of the Invisible Children Project. Washington, DC: National Mental Health Association, 1989. 16. Research and Training Center for Children's Mental Health: Update: Improving services for emotionally disturbed children. Tampa, FL: The Center, Winter 1988-89.
Third, because children who were already classifiable as SED were the subjects of this study, primary preventive services were completely excluded from the range of services offered as possible service needs on our data collection instrument. Readers must keep in mind that the services highlighted as "most needed" by our survey represent the narrow but critical range of mental health and other services for those children who are already identified as SED. Services such as community education, parent training, teen parenting classes, substance abuse prevention, advocacy, early childhood intervention, etc., are very important elements of a comprehensive strategy to combat severe childhood mental illness. El
Study Limitations
Acknowledgments This research was supported in part by the Washington State Department of Social and Health Services, Mental Health Division, contract number6500-62476, and National Institute on Disability and Rehabilitation Research grant number H133C80002.
References 1. Saxe L, Cross TP, Silverman N: Children's mental health: The gap between what we know and what we do. Am PsychoL 1988;
43:800-87. 2. Knitzer J: Unclaimed Children: The Failure ofPublic Responsibility to Children and Adolescents in Need of Mental Health Services. Washington, DC: Children's Defense Fund, 1982. 3. Saxe L, CrossTP, Silverman N: Children's Mental Health: Problems and Services. Durham, NC: Duke University Press, 1987. (Original work published by the Office of Technology Assessment, US Congress. Washington, DC: Govt Printing Of-
fice, 1986.) 4. National Institute of Mental Health: Pro-
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980 American Joumal of Public Health
August 1
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Enc W. Tnrpin, PhD, Amy Forsyth-Stephens, MSW, and Benson P. Low, PhD
Introduction The treatment needs of severely and chronically mentally ill individuals, of any age, vary considerably depending upon personal characteristics (e.g., degree of disability, nature of symptomatology, willingness to accept treatment), and situational or environmental characteristics (e.g., availability of natural supports, residential situation, mobility of the individual). Ideally, the range of available services would be so broad, and care givers so flexible, that all clients would receive an appropriate, individualized menu of services. Unfortunately, human services, especially mental health, are largely program-driven, with clients matched to programs, rather than services matched to clients. Given that this infrastructure of care provision may be difficult to overtum, it is imperative that the development and design of state and local programs be based upon a concrete knowledge of client needs. Services for children* are especially subject to "blind" planning and implementation. There is a dearth of research in the area of children's mental health, most notable on the topic of severely mentally ill children.1 Analogous to the study of chronic mental illness among adults, the area of severe emotional disturbance (SED) among children is a relatively recently established field of research. Attention was drawn to the issue in 1982, when the unsettling book Unclaimed Children2 reported that two-thirds of all SED children do not receive the services they need. The book went on to document the failure of federal and state govemments to acknowledge and attempt to meet the mental health needs of children, resulting in a vast and deeply troubled population
with no advocacy, options, or hope. Five years later, the Office of Technology Assessment of the United States Congress3 underscored accusations put forth in Un-
claimed Children. In 1984, the National Institute of Mental Health initiated the Child and Adolescent Service System Program (CASSP) in an effort to address the national crisis in children's mental health.4 The goal of CASSP was, and continues to be, the promotion of system development through the funding of 40 state-level planning initiatives and two national research centers for the study of SED among children. Most of the research to date on service needs of SED children has been produced by state human service departments in response to legislative mandates or class action suits, or by CASSP-funded research institutes. Based upon work completed by many states, and by the CASSP research centers, an assumption has been promulgated that a complete range of services, on a continuum from most to least restrictive, must be developed to adequately meet the needs of severely emotionally disturbed children.5 Most recently, the "continuum of care" idea has been replaced by the concept of a "system of care" for SED children,6 From the University of Washington School of Medicine, Department of Psychiatry & Behavioral Sciences. Address reprint requests to Eric W. Trupin, PhD, Division of Community Psychiatry, Department of Psychiatry & Behavioral Sciences, School of Medicine, University of Washington, Mailstop RP-10, Seattle, WA 98195. This paper, submitted to the Journal July 9, 1990, was revised and accepted for publication January 23, 1991.
*In this article, "Children" refers to anyone under the age of 19 years.
American Journal of Public Health 975
Tmnpm et al.
which has a somewhat broader connotation. With the system perspective, more than a comprehensive spectrum of appropriate services is necessary. Just as critical are the underlying facilitating mechanisms, structures, and administrative processes to ensure that services are delivered and received in a coordinated, childfocused manner. There have been no empirical studies of the diverse service needs of severely emotionally disturbed male children versus female children. Similarly,there have been no reports of service need data by developmental groupings (i.e. young children, preteens, and adolescents). Only one report has documented the age and sex breakdowns of an SED child population. In North Carolina, Behar7 reports that the population of children qualifying as SED was 80 percent male, 20 percent female. Over three-fourths (78 percent) of the SED children were between the ages of 12 and 17; 14 percent were under the age of 12. This paper presents the findings of a statewide survey of the specific service needs of 1617 severely emotionally disturbed children. The large sample size of the survey permits analysis of service need data by age and sex categories. The possibility of identifying distinct ideal service continuums for male and female SED children of various age groups is discussed.
Method Design The survey of service needs of SED children took place in the context of a broader study of the children's mental health system in Washington State. This larger project, entitled the Children's Mental Health System Analysis, involved the administration of a Child Mental Health Survey to adult care takers of randomly selected, nonidentified children served by the Department of Social and Health Services (DSHS). The analysis of data occurred in two stages. The first stage involved the identification of children in the sample who were classifiable as SED (this procedure is described below under "Classification of Children as SED"). The second stage involved the examination of reported service need data for the subjects who were classified as SED according to our model. A significant design feature was the nonidentified status of children surveyed. Use of identified data would have required 976 American Journal of Public Health
informed consent for every child in the survey. Apart from the logistic demand such a requirement would have brought, institutional or agency refusals would have become a significant problem. While the use of nonidentified data facilitated more comprehensive surveying of children, it did limit control over the subject selection process, and precluded empirical analysis of subject attrition.
Subjects The subjects were 3,398 children and adolescents ages 0 to 18 who were selected randomly from the billing rosters of child-serving programs within the State's Department of Social and Health Services (DSHS). Nearly half of the subjects (N = 1,640) were clients of the DSHS Division of Children and Family Services (DCFS), which offers an array ofchildwelfare services including child protective services, foster care, group home care, in-home intervention, and emergency out-of-home placement. The remainder of the sample was made up of clients of the DSHS Division of Juvenile Rehabilitation (DJR; institutions, group homes, and parolees; N = 1,035); the DSHS Mental Health Division (DMH; inpatient, residential, day treatment, and outpatient; N = 524); and the DSHS Division of Developmental Disabilities (DDD; institutions and group homes; N = 199). Sample sizes were calculated by taking into consideration the population size, the a priori estimate of the rate at which SED would occur (50 percent in all DSHS groups), the range of the intended confidence interval (+5 percent), and the probability level for the confidence interval (95 percent). Sample sizes were inflated by a factor of 15 percent, to compensate for subject attrition. As an exception, the DSHS Division of Juvenile Rehabilitation made an administrative decision to survey all clients in their programs. All clients in programs with caseloads offewer than 150 were surveyed.
Respondents The survey respondents were 3,398 adult DSHS professionals or staff members of agencies under contract with DSHS. Two-thirds of the respondents (65 percent) were case workers or facility staff employed either directly by DSHS, or by a contracted agency. The remaining onethird was made up of probation/parole officers and independent mental health professionals. Ninety-two percent of the respondents had at least a four-year college degree. The mean length of time that
a respondent had known the surveyed child was 12.2 months.
Suvey Instnrment Development and Reliability The data collection instrument, entitled the Child Mental Health Survey,* was developed after review of materials used by other states in similar but smaller-scale efforts.8 The survey instrument contained six sections with questions pertaining to: 1) sociodemographic background; 2) exposure to 13 mental health risk conditions; 3) current behavioral adjustment as measured by the Child Behavior Checklist (CBCL);9 4) past mental health treatment and placement history; 5) other handicapping conditions; and 6) mental health and social service needs. The section on service needs required the respondent to identify the subject's past receipt, current receipt, and current unmet need for any of 32 human services. The Child Mental Health Surveywas administered to pairs ofteachers of26 special education pupils and 30 regular education pupils, and to pairs of case workers of 10 children placed in mental health treatment programs in the community. Each of the respondents independently completed surveys on the selected child. Reliability coefficients were calculated on four sections of the survey: exposure to mental health risk factors, mental health treatment history, other handicaps, and current behavioral adjustment. The Kappas obtained for the sections on risk factors, treatment history, and other handicaps were in the acceptable and expected range, with most values above .60, and some exceeding .80.10 Reliability coefficients were not calculated on service need data. Interrater reliability was less of a concern for the service need data, as the caseworkerswho completed the survey forms were highly face valid, as they are the "natural" raters who drive the system of referrals for these SED children. Moreover, a meta-analysis on concordance of raters of children underscores that data from a single respondent typically provide a reasonable sample of what would be provided by other informants of the same tpe who see the child under generally similar conditions.10
Classification of Children as SED SED children from the sample were identified via MANOVA techniques. *The Child Mental Health Survey is available from the first author upon request.
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Children's Mental Health Service Needs
Each subject was treated as a group of one and then compared via Hotelling's T2 against a criterion SED group. The criterion SED group was defined as all children being served in the State's psychiatric residential treatment centers, and a specialized foster care program for previously psychiatrically hospitalized children. These programs provide the most comprehensive, intensive, and expensive mental health treatment offered by the state mental health system for children. It was the research team's consensus that children meeting the numerous requirements for admission to these programs are inarguably severely emotionally disturbed, and therefore comprise the most valid, conservative, and defensible criterion group for this study. Each subject was evaluated individually as to the likelihood of being drawn from the criterion group. Ifthe subjectwas discriminable, the subject was not classified as SED. The independent variables used in the discriminant analysis were: 1) MentalHealthRisk scored as the number of risk factors endorsed positively for the subject; 2) Chronicity, scored as positive if the subject was rated as experiencing severe aggressiveness and/orwithdrawal for a minimum duration of one year; 3) ServiceNeed, scored as the number ofmental heath services endorsed as "needed" or "currently received"; 4) IntemalizingBehavior Problem; which was the T-score from the CBCL Internalization Scale; and 5)Extemal*gBehavior Problem, which was the T-score from the CBCL Externalization Scale. These five measures are widely used and face valid with respect to the detection of the presence of an emotional or behavioral problem in children.11-14
Service Need Data Analysis Service need data were analyzed for those children classified as SED according to the above model. Data on the services indicated as "needed" by SED children were weighted by DSHS population estimates of SED children across age and sex categories. This was done in order to control for the varying age and sex distributions of the four subsamples (i.e. DCFS, DJR, DDD, DMH). The population estimates were based upon the prevalence distribution of SED in our subsamples. A log linear analysis technique was used to test for significant differences in service need among three age groups of SED children (6-11, 12-16, and 17-18 years), and between male and female SED children.
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Results Survey Retum Rates The overall DSHS survey return rate 75 percent (i.e. 4,516 surveys were distributed, 3,398 were completed and returned). Return rates for the various participating divisions of DSHS ranged from a high of 95 percent for DJR to a low of 66 percent for DCFS. The high overall survey return rate was primarily a function of consistent DSHS involvement with the design and execution of the study. Most supervisors at local DSHS offices required 100 percent survey completion by their caseworkers, and actively monitored this assignment. Additionally, researchers distributed two reminder notices to DSHS supervisors during the time frame allotted for survey completion. All respondents were assured of, and received, feedback on the outcome of the survey. was
Service Needs of SED Chidren Of our sample of 3,398 children, 2,455 classified as SED according to our model (described above, a = .10). Of these 2,455 SED children identified from our original sample, data on 1,617 were used in this analysis of service needs. A total of 838 cases were eliminated due to the subject's age (less than 6 years) and/or an incomplete survey form. Children ages 0 through 5 were not included in this analysis due to the small size of that subsample (n = 96). Table 1 reports the estimated percent of the DSHS SED population needing various mental health and social services. Across all age and gender categories, over one-half of all SED children needed outpatient mental health treatment (defined as individual, group, or family therapy). Nearly one-half of SED children's families were in need of family support services for the parents and/or siblings. Interagency case management was needed by nearly one-third of SED children statewide. Other services which were commonly needed included schoolbased mental health services and psychological testing. Of all residentiafmpatient services, foster home placement and group home placement were the most commonly reported service needs. were
Age and Gender Service Need
Differentials Fourteen of the 32 possible mental health and social services listed on the Child Mental Health Survey showed sig-
nificant differences in reported need across the three age groups. These are displayed in Table 2. School children from age 6 through 11 (Group 1) were significantly higher than all other age groups in the need for respite care for their family members (11.0 percent, p < .000), and for therapeutic camp services (17.7 percent, p < .000). Children in Age Groups 1 and 2 (ages 6-11 and 12-16) displayed a higher need for school and home-based services than older SED children, specifically schoolbased mental health services (Group 1: 30.0 percent; Group 2: 27.4 percent), supervised after-school activities (Group 1: 20.3 percent; Group 2: 18.0 percent), and intensive in-home therapy (Group 1: 15.6 percent; Group 2: 18.8 percent). Children ages 12 through 16 (Group 2) were reported as more in need of foster home placements (18.9 percent, p < .001) and group home placements (12.6 percent, p < .000) than children in other age brackets. Data show that the need for both of these services peaks in the years 12 through 16, although the need pattem for the two services is quite different across the full developmental range. The need for foster home placement is high (12.3 percent) even within the 6 to 11 year old age group, and grows in the 12 to 16 year old group. At that point the need declines to 11.1 percent in the 17 to 18 year old age group. Group home placement, however, is low for the 6 to 11 year old age group, and then rises dramatically for the 12 to 16 year olds, staying relatively high (11.3 percent) for the 17 to 18 year old group. Older adolescents (Group 3, ages 1718) demonstrated a significantly higher need for outpatient alcohol or drug treatment (31.4 percent, p < .000), and inpatient alcohol or drug treatment (15.6 percent, p < .000) than the other age groups. They also demonstrated a much greater need than other age groups for training in independent living skills (58.6 percent, p < .000), vocational services (49.2 percent, p < .000), and supervised independent living arrangements (28.5 percent, p < .000). For each of these services, the expressed needwas nonexistent or extremely low for younger children (ages 6-11), increased for children ages 12 through 16, and peaked for children 17-18 years of age. Significant sex differences in endorsement of service need were identified among 11 ofthe 32 service types contained on the Child Mental Health Survey. These differences are also reported in Table 2. Females were significantly higher than males in their reported need for outAmerican Journal of Public Health 977
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patient therapy (61.7 percent, p < .000), foster home placements (19.1 percent, p < .001), respite care (8.0 percent, p < .000), supervised independent living arrangements (7.6 percent, p < .001), and child protective services referral/intervention (9.6 percent, p < .000). Males were rated as having a significantly greater need for outpatient alcohol or drug treatment (16.2 percent, p < .000), inpatient alcohol or drug treatment (7.9 percent, p < .000), group home placement (10.6 percent, p < .000), training in independent living skills (19.0 percent, p < .000), and supervised afterschool activities (19.8 percent, p < .006).
Discussion Our survey of the professional caregivers of SED children generated a useful data base on the service needs of this population. While previous research and program planning efforts have identified only general categories of services appropriate for SED children, this broad-based study is the first to produce quantitative data on the extent of the SED population reported to be in need of a wide range of mental health, health, social, and support services. It is also the first study that further defines age and gender differences in types of needed services.
Overall Patterns of Service Need Across age and sex groupings, the most frequently reported needs, in descending order, were for: 1) outpatient therapy; 2) family support groups; 3) intersystem case management; 4) schoolbased mental health services; 5) psychological testing; 6) training in independent living skills; 7) intensive in-home therapy; and 8) supervised after-school activities. With the exception of outpatient therapy and psychological testing, all of these services would be considered "non-traditional" mental health services, or even outside the realm of mental health alto-
gether.6 We had anticipated that our survey of professionals would result in a high expressed need for residential or inpatient services, since respondents' level of familiarity with other more progressive treatment approaches was questionable. We reasoned that direct care providers might be hesitant to endorse non-traditional services as needed, especially if such services were not accessible to them. Clearly, this was not the outcome. The strong presence of CASSP in Washington State may be credited for a good
978 American Journal of Public Health
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deal of the progressive thinking of the state's professional care givers through conferences, newsletters, and an intensive effort to begin the creation of local intersystem case coordination committees. Not recognizing the significant impact of these educational efforts, we underestimated the knowledge base of our respondent pool. Unfortunately, Washington State's current service system reflects the national reality, in that treatment resources continue to be focused on a proportionally small number ofchildren who receive care on inpatient psychiatric units or other intensive residential treatment programs.3,15 Our data support the direction of CASSPfunded research and training centers and the National Mental Health Association in the endorsement of less restrictive home and school-based services, family support services, and comprehensive case management services as alternatives to costly out-of-home care.15.16
Age and Sec Differences Service planners generally tend to think of SED children as one class of service recipients. Our data suggest that there are significant differences in the service needs of male versus female children, and of differently aged children. These differ-
August 1991, Vol. 81, No. 8
ences have serious implications for the development and implementation of systems of care for the SED population. Our data demonstrate a substantial developmental gradient which must be considered when planning services for SED children. For school-aged children the educational setting clearly should play a large role in treatment planning. For example, school-based mental health services and supervised after school activities were distinct needs of 6-16 years olds. Therapeutic camp services and foster home placements were also highly endorsed for this subset of SED children. For the 17-18 year old group, there is a great need for services which prepare youth for the transition for adulthood, such as training in independent living skills, vocational services, and supervised independent living arrangements. The need for outpatient and inpatient alcohol! drug treatment also peaks for this age co-
hort. Sex differences in service need were less obvious than the developmental differences. Males demonstrated a greater need for transitional "adult" services, for alcohol and drug-related treatment, and for group home placement. Females, on the other hand, were in greater need of outpatient therapy, foster home place-
ments, respite care for their families, supervised living arrangements, and protective services. The services endorsed for males focused on home removal, treatment of addiction, and preparation for entry into the work force. Services endorsed for females focused on therapy, assistance to the girls' families, and protection from further harm. More research is needed to confirm whether these gender-linked service needs are valid indices of what SED children need in their treatment, or merely reflections of sex-based stereotypes of SED children's vulnerabilities and responsiveness to various treatments and interventions. American Journal of Public Health 979
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Limitations of this study lie in its narrow focus on professional respondents, the non-random nature of the final sample, and the survey's exclusion of preventive services. First, our survey respondents were exclusively the professional care givers of SED children. This clearly provides only one perspective on what a given child's treatment needs may be. Family members, school personnel, and other persons in the child's support circle are equally valid respondents. Nevertheless, given that the focus of the survey was on SED children who were "system veterans" with well-known and extensive patient histories, input from the primary professional care givers was a good starting point. This in no way precludes the need to vigorously solicit the participation of parents and teachers in the development of individual children's treatment plans and larger scale planning endeavors. Second, for the analyses of service need data, the ultimate data base of SED children was a nonrandom approximate 50 percent of our original random sample of children. Cases were eliminated for three possible reasons: 1) the survey form was not returned; 2) the survey form was returned, but was missing critical information; or 3) the child was under 6 years of age. Ideally, our final sample would have been of a completely random nature. However, because the subjects were unidentified to the investigators, and since no special services were offered to children as a result of survey responses, the final sample appeared not to be biased systematically. Case worker-related factors, such as excessive paperwork demands, rather than child-related factors, appeared to contnbute to the rate of subject loss.
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gram Announcement: Child and Adolescent Service System Program. Washington, DC: NIMH, December 1983. 5. Friedman RM: Major issues in mental health seIvices for children. Admin Ment Health. 1986;14:6-13. 6. Stroul BA, Friedman RM: A System of Care for Severely Emotionally Disturbed Children and Youth. Washington, DC: CASSP Technical Assistance Center, Georgetown University, 1986. 7. Behar L: Changing patterns of state responsibility: A case study of North Carolina. J Clin Child PsychoL 1985;14:188-195. 8. Stroul BA: Child and Adolescent Service System Program State Needs Assessment Materials. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center, 1985. 9. Achenbach TM, Edelbrock C: Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: Department of Psychiatry, University of Vermont, 1978. 10. Achenbach TM, McConaughy SH, Howell CT: Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psych BulL 1987;101:213-232. 11. Achenbach TM: Developmental Psychopathology. New York: Wiley, 1982. 12. Boyle MH, Offord DR, Hoffman HG, etak Ontario child health study. Arch Gen Psychiatry. 1988;45:1120-1126. 13. Mooney KC, Thompson R, Nelson JM: Risk factors and the Child Behavior Checklist in a child mental health center setting. J Abnorm Child PsychoL 1987;15:67-73. 14. Garrison WT, Earls F: The Child Behavior Checklist as a screening instrument for young children. JAm Acad Child Psychiatry. 1985;24:76-80. 15. Zeigler-Dendy CA: Invisible Children Project: Final Report and Recommendations of the Invisible Children Project. Washington, DC: National Mental Health Association, 1989. 16. Research and Training Center for Children's Mental Health: Update: Improving services for emotionally disturbed children. Tampa, FL: The Center, Winter 1988-89.
Third, because children who were already classifiable as SED were the subjects of this study, primary preventive services were completely excluded from the range of services offered as possible service needs on our data collection instrument. Readers must keep in mind that the services highlighted as "most needed" by our survey represent the narrow but critical range of mental health and other services for those children who are already identified as SED. Services such as community education, parent training, teen parenting classes, substance abuse prevention, advocacy, early childhood intervention, etc., are very important elements of a comprehensive strategy to combat severe childhood mental illness. El
Study Limitations
Acknowledgments This research was supported in part by the Washington State Department of Social and Health Services, Mental Health Division, contract number6500-62476, and National Institute on Disability and Rehabilitation Research grant number H133C80002.
References 1. Saxe L, Cross TP, Silverman N: Children's mental health: The gap between what we know and what we do. Am PsychoL 1988;
43:800-87. 2. Knitzer J: Unclaimed Children: The Failure ofPublic Responsibility to Children and Adolescents in Need of Mental Health Services. Washington, DC: Children's Defense Fund, 1982. 3. Saxe L, CrossTP, Silverman N: Children's Mental Health: Problems and Services. Durham, NC: Duke University Press, 1987. (Original work published by the Office of Technology Assessment, US Congress. Washington, DC: Govt Printing Of-
fice, 1986.) 4. National Institute of Mental Health: Pro-
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