Understanding Demographic and Clinical Trends among Children and Families Served by Systems of Care

Robert L. Stephens, Mary Spooner, Russell A. Carleton

Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) through the Child, Adolescent and

Family Branch, Center for Mental Health Services

Systems of Care

• Children’s Mental Health Initiative (CMHI) longest continuously funded children’s mental health program in U.S. history

• CMHI funds provision of services to children/youth that are

- Effective - Accessible

- Coordinated - Culturally competent

-Individualized - Least restrictive

- Community-Based - Collaborative

- Family driven/youth guided - Coordinated

Background

• Walrath et al. (2009) examined trends in the characteristics of children served by CMHI in sites initially funded in 1994 through 2004

• Specifically, emotional and behavioral problems and demographic characteristics of children entering services

• Found that children entering services later in a site’s funding cycle had less severe problems

• Sites funded in later cohorts served children with more severe problems than earlier cohorts

Walrath, C., Godoy Garraza, L., Stephens, R., Azur, M., Miech, R., & Leaf, P. (2009). Trends in characteristics of children

served by the Children’s Mental Health Initiative: 1994-2007. Administration and Policy in Mental Health and Mental Health

Services Research, 36(6), 361-373.

Research Questions

• What patterns in symptoms have emerged over the past 12 years for those presenting for services in systems of care?

• Do levels of symptoms at intake change over time within grantees and across funding cohorts?

• Do symptom levels vary by demographic characteristics?

National Evaluation of CMHI

• SAMHSA-funded initiative

• 106 sites initially funded from 2002 to 2010

• More than 125,000 children and youth have received services

• Data collected between October 2003 and December 2014 on outcomes of children and youth receiving system of care services

Methods

• Caregivers interviewed within 30 days of child’s first service event (and every 6 months)

• Youth aged 11 years and older also interviewed at intake (and every 6 months)

• Current analyses focus on intake data only

• Measures include

– Child Behavior Checklist (CBCL)

• Internalizing T-scores

• Externalizing T-scores

– Columbia Impairment Scale (CIS)

Demographics of Study Participants, Grantees Initially Funded 2002–2010

Gender (n = 15,793) Percentage

Male 62.5%

Female 37.5%

Poverty Status (n = 13,314) Percentage

Below Poverty 58.8%

At/Near Poverty 15.2%

Well Above Poverty 26.0%

Age (n = 15,785)

Mean Age 11.20 (SD = 5.0)

(n = 15,669)

Most Common Diagnoses of Children Served by Grantees Initially Funded 2002–2010

Diagnosis (n = 13,560) Percentage*

Mood Disorders 37.5%

Attention-Deficit/Hyperactivity Disorder 35.8%

Oppositional Defiant Disorder 22.8%

Adjustment Disorders 13.6%

Anxiety Disorders 9.3%

PTSD/Acute Stress Disorder 8.9%

Disruptive Behavior Disorder 8.3%

Substance Use Disorders 7.6%

Diagnoses based on DSM–IV criteria.

*Because children may have more than one diagnosis, percentages for diagnoses may sum to more than 100%.

Clinical Outcomes by Funding Cohort

CBCL Internalizing Problems

CBCL Externalizing Problems

CIS Total Score

Funding Cohort N Mean s.d. N Mean s.d. n Mean s.d. 2002

(24 sites)

3,574 64.94 10.00

3,574 69.16 10.16

3,600 22.69 10.77 2004

(4 sites)

829 66.66 9.74

829 70.67 9.57

828 23.97 9.75 2005

(25 sites)

3,862 64.67 10.32

3,862 69.04 10.62

3,707 21.99 10.59 2006

(5 sites)

808 62.43 11.29

808 66.52 10.58

815 20.48 9.38 2008

(18 sites)

1,953 65.19 10.34

1,953 69.12 11.21

1,908 22.54 10.51 2009

(20 sites)

2,393 64.49 10.86

2,393 67.41 11.29

2,365 22.27 11.26 2010

(9 sites)

583 63.31 11.54

583 67.05 12.21

529 20.18 10.91

Analysis Strategy

• Mixed Linear Modeling

– Modeling symptoms levels at intake

• Symptoms are centered around the grand mean

– Fixed effect predictors include race/ethnicity, gender, age (linear and quadratic), and referral source

– Year of enrollment nested within the grant cohort

• All children/youth enrolled in Year 2 (or earlier) of the grant are in 1st enrollment cohort, all enrolled Year 3 are in 2nd, etc.

Internalizing Symptoms

Parameter Estimate Sig.

Referral Source

- Justice -2.675 < .001

- School -0.856 .010

- Mental Health 0.850 .005

- Physical Health 0.947 .088

- Child Welfare -1.173 .001

- Caregiver/Self -0.273 .417

- Other 0 —

Male -0.640 .001

Age 0.027 .262

Age^2 -0.047 < .001

Parameter Estimate Sig.

Race/Ethnicity

- Native American -4.343 < .001

- African-American -2.062 < .001

- White/Caucasian 1.657 < .001

- Other 0.330 .349

- Hispanic/Latina(o) 0 —

Year enrolled (’02 cohort) -0.465 .009

Year enrolled (’04 cohort) -0.002 .995

Year enrolled (’05 cohort) -0.242 .111

Year enrolled (’06 cohort) -1.273 .001

Year enrolled (’08 cohort) -0.180 .449

Year enrolled (’09 cohort) -0.549 .007

Year enrolled (’10 cohort) 0.904 .218

Externalizing Symptoms

Parameter Estimate Sig.

Referral Source

- Justice 1.149 .004

- School -1.879 < .001

- Mental Health 0.694 .024

- Physical Health -0.285 .616

- Child Welfare -0.560 .134

- Caregiver/Self -1.245

Clinical Impairment

Parameter Estimate Sig.

Referral Source

- Justice -0.049 .902

- School -1.039 .002

- Mental Health 1.149 < .001

- Physical Health 0.064 .914

- Child Welfare -0.637 .095

- Caregiver/Self -0.494 .157

- Other —

Male 0.154 .413

Age 0.097 < .001

Age^2 -0.083 < .001

Parameter Estimate Sig.

Race/Ethnicity

- Native American -2.476 < .001

- African-American 1.933 < .001

- White/Caucasian 4.291 < .001

- Other 2.382 < .001

- Hispanic/Latina(o) —

Year enrolled (’02 cohort) -1.253 < .001

Year enrolled (’04 cohort) 0.318 .379

Year enrolled (’05 cohort) -0.053 .736

Year enrolled (’06 cohort) -0.850 .025

Year enrolled (’08 cohort) -0.246 .312

Year enrolled (’09 cohort) -0.033 .874

Year enrolled (’10 cohort) 0.959 .236

CBCL Internalizing Problems by Funding Cohort and Enrollment Year

CBCL Externalizing Problems by Funding Cohort and Enrollment Year

CIS Total Scores by Funding Cohort and Enrollment Year

Findings

• There is evidence that over time, symptoms for children and youth at entry to services have declined, although the magnitude of this effect was small.

• Over time, the relative severity of cases fell as a grantee moved further into its grant funding cycle.

• Demographic factors such as age, gender, referral source, and race/ethnicity were significant predictors of symptoms levels.

Implications for Practice

• Some systems of care are still most likely to serve children and youth with higher symptoms levels at the beginning of their grant funding cycle.

• System of care implementation requires time, and systems serving children with more severe symptoms before reaching successful implementation may not be optimally prepared.

• Because referral sources are a significant predictor of symptoms, the severity of symptoms for an agency’s caseload is likely to reflect the populations of its most frequent referral sources.

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