Mental Health Service Use by Children With Serious Emotional and Behavioral Disturbance: Results From the LAMS Study

Abstract

An estimated 2.7 million children in the United States suffer from severe mental illness and mental illness causes significant impairment in 3% to 18% of children and adolescents (1–2). However, data from community-based studies document that children with impairing mental illnesses receive no services or only services in the educational system (3–4). When youth interact with multiple service sectors these sectors frequently do not work together to form a comprehensive treatment approach, and services are often inadequate to address symptoms and impairment (5–6). Little information exists about utilization and barriers specific to individual diagnoses, although data suggest that having a disruptive disorder is significantly associated with children's use of mental health services, but having a depressive disorder is not (7–8). Few studies have investigated service utilization of children diagnosed with more serious disorders such as bipolar disorder and psychosis. Examination of MEDSTAT’s MarketScan data for 1993 and 1996 found that youth receipt of mental health services fell from 4.2% to 3.0% (9). Frequency of specific diagnoses differed by service setting. Major depression/bipolar, other mental health diagnoses, and mild/moderate depression were most common in inpatient settings while hyperactivity, other mental health diagnoses, and adjustment reaction disorder were most common in outpatient settings. Similar analyses of MarketScan data from 1997 to 2000 found that the overall distribution of diagnoses changed little from 1997 to 2000 for hyperactivity, depressive disorders, adjustment disorders and other mental health disorders but significantly increased for bipolar disorders, schizophrenia, and anxiety disorders (10). Despite its low prevalence, bipolar disorder is associated with a disproportionate use of health services and significantly higher costs driven by more use of inpatient hospitalization (11). A study examining individuals with insurance claims in 1996 found nearly half (40%) of the adolescents diagnosed with bipolar disorder had at least one inpatient hospitalization within the year. Half of those (20%) had more than one inpatient hospitalization within the year. Almost 25% of those < 21 years exceeded 20 outpatient visits, and almost 50% of the hospitalized adolescents exceeded 30 inpatient days (12). Similarly, in the Course and Outcome of Bipolar Illness in Youth (COBY) study, approximately 80% of the youth diagnosed with bipolar disorder used services over a six month period. Sixty seven percent used outpatient services, 22%, inpatient/partial hospitalization services, and 12%, residential/therapeutic school-based services. Predictors of high levels of care included older age, female sex, greater symptom severity, and rapid cycling. Predictors of more restrictive treatment settings included suicidal and self-injurious behavior, comorbid conduct disorder, and parental substance use disorders (13). These studies suggest mental health service utilization patterns differ in important ways by diagnosis, and specific attention needs to be focused on the most severe disorders, both because of the paucity of information but also because these youth use the majority of services, particularly costly services such as hospitalization (11–12). The purpose of the current study is to describe service utilization by demographics and diagnoses for a cohort of children with emotional and behavioral disorders who were first time users of participating outpatient mental health clinics in four major Midwest cities. The current analyses contribute to the scant literature on children’s mental health service utilization by: (1) focusing on service use by a unique outpatient clinic population; (2) examining various types of services at all levels of care; and (3) exploring patterns of service utilization in the context of diagnosis. Specifically, we tested the hypothesis: Demographic characteristics (sex [male], age [older], race [White] and insurance coverage [private insurance]) and clinical characteristics (major mental illness, comorbid diagnoses, more impairment) will be related to utilization of more services and higher intensity services.