Adult Mental Health System Research Articles

Meta-analysis reveals low language capacity in childhood is associated with mental health problems in adulthood.

Children and adolescents with language problems have poorer mental health compared with their non-language impaired peers. Less is known about mental health in adults with a history of language problems. This paper presents a systematic review and meta-analysis that addresses this gap in the literature. Specifically, it summarisesthe results from studies examining anxiety and depression in adults (aged 18 years and over) who were identified with language impairments or problems earlier in development. Five electronic databases (PsycINFO, ERIC, CINAHL, EMBASE and PubMed) were searched for studies comparing anxiety and/or depression in a sample of adults with and without a history of language problems. Nine studies were found that met the inclusion criteria. From each, an odds ratio (OR) was computed measuring the relationship between childhood language problems and anxiety or depression in adulthood. The OR was computed so values > 1 which indicated anxiety/depression were associated with a history of language problems. ORs were averaged using multilevel random effects meta-analysis. Averaging the study's findings across both anxiety and depression outcomes, we found that a history of childhood language problems was associated with poorer mental health in adulthood (OR = 1.79, p = 0.004). The association for anxiety was also significant (OR = 1.80, p = 0.012) and close to statistical significance for depression (OR = 1.60, p = 0.054). This review reveals that adults with a history of language problems are more likely to experience poorer mental health outcomes compared with controls. These findings demonstrate childhood language problems affect not only communication but also mental health and well-being in the long term. What is already known on the subject Prior research examining mental health in children and adolescents with language problems reveals a twofold increased risk of internalisingproblems, including anxiety and depression. However, little is known about mental health outcomes in adults with a history of language problems. What this paper adds to the existing knowledge The main finding was that childhood language problems are associated with increased risk of anxiety and depression in adulthood. What are the practical and clinical implications of this work? First, the study demonstrates childhood language problems increase the risk of poor mental health in adulthood. Second, in adult mental health settings there is a need to screen for language problems and, where applicable, adjust interventions to accommodate communicative needs for patients/clients. Solving these issues requires integration and recognition of the importance of speech-language therapy in the adult mental health system.

Working with adult families of origin: On the nature of rupture and repair

AbstractIn this paper, we report on findings from a three‐part enquiry into the essence of working with families of origin where all members are adult. Findings, in conversational form, describe the nature of adult family ruptures encountered, pathways to repair and unique factors associated with the therapeutic encounter with adult families relative to those with still dependent children. In exploring emergent themes, we hoped to come to some understandings of the models and unique skill sets that characterise and enhance family therapy with adult families. We found that, unlike families with younger children, adult children are often the more motivated sub‐system and indeed the drivers of a referral for therapy. The therapeutic focus centred around legacy work from prior unresolved family traumas or disrupted developmental processes. Features of the therapeutic process included supporting new and more proportional narratives about ingrained wounds, together with redefinition of caregiving relationships and a future gaze towards becoming an independent yet connected family structure. We consider the therapist's posture in validating the adult child's experience, contextualising parent histories and clearing emotional barriers that block healthy giving and receiving of care. Key decision points in the therapist's work included how to balance the past context of the rupture with its current legacy, and the place of exoneration versus forgiveness in the progression towards secure individuation. Findings may help refine therapeutic methods in the application of systemic therapies with adult family forms, particularly on the intersection with the adult mental health system.

Different perspectives in psychiatry: how family-oriented are professionals in Germany?

ΒackgroundChildren of parents with a mental illness have up to 50% chance of developing a mental illness themselves. Numerous studies have shown that preventive family-oriented interventions can decrease the risk by 40% and that professionals are a decisive factor influencing family-oriented practice. There are also substantial differences between professions in terms of their family-oriented practices. This study examines the level of family-oriented practice for different professional groups in Germany.MethodsData were used from the baseline assessment of the two-group randomized controlled multicenter trial ci-chimps as a subproject of CHIMPS-NET, which took place from January 2020 to May 2021 in 18 clinical centers in Germany. Child and adolescent mental health systems as well as adult mental health systems took part and every professional involved in the treatment was invited to participate. Data was used from 475 mental health professionals including physicians, psychologists, psychotherapists for adults and for children and adolescents, occupational/ music/ physio/ art therapists/ (social) education workers and nursing/ education service. Family-oriented mental health practice was examined using the translated version of the Family-Focused Mental Health Practice Questionnaire (FFMHPQ) with means and standard deviations calculated for each of the 18 FFMHPQ-GV subscales. ANOVAs were computed to compare professions and significant differences were examined via post hoc analyses (Scheffé). Additionally, effect sizes were calculated (Omega squared).ResultsDifferences were seen between the professions in all aspects of family-oriented practice: Both regarding organizational policy and support aspects, issues concerning working with parent-clients, as well as professional skills and knowledge aspects. Psychotherapists for children and adolescents scored the highest family-oriented practices compared to all other professional groups on almost all subscales.ConclusionThis study examines the level of family-oriented practice for different professional groups in Germany. Apart from skills and knowledge about the impact of mental illness and parenting, psychotherapists for children and adolescents had the highest scores and engaged most in family-oriented practice. Psychotherapists for adults got the least workplace support for family-oriented practice but were competent providing resources and referral information to the concerned families and feel confidence working with them. Due to these results, a training need exists to improve skills and knowledge about the impact of mental illness and parenting. Additionally, there is still potential for institutional support in promoting family-oriented work.Trial registrationThe CHIMPS-NET-study was registered with the German Clinical Trials Register on 2019–12-19 (DRKS00020380) and with Clinical Trials on 2020–4-30 (NCT04369625), the ci-chimps-study was registered with the German Clinical Trials Register (DRKS00026217) on 2021–08-27 and with Clinical Trials on 2021–11-04 (NCT05106673).

Improving mental health care outcomes: the agile psychological medicine clinic

ABSTRACT Objective We hypothesised that providing evidence-based care to people presenting in crisis to three Emergency Departments and the 24/7 phone Psychiatric Triage Service in Victoria, Australia, would improve their clinical outcomes over time and experience of the adult mental health system. We tested this through a service prototype, the agile Psychological Medicine clinic. Method Descriptive statistics were used to understand the characteristics of people who presented in crisis. Patient journey maps were used to understand the impact of the system on the patient and assess whether they received the best clinical care over time. Insights from these analyses, and the evidence base, led to the development of the prototype. Using an open trial design, 194 patients received specialist treatment and effectiveness was measured through patient-reported outcome measures administered at initial and final appointments. Service utilisation was measured 12-months pre and post treatment. Results The agile Psychological Medicine clinic delivered value; outcomes significantly improved across psychological symptomology and behaviours. Reductions in emergency department presentations, phone triage calls and service costs resulted. Conclusions This innovative clinic demonstrated that access to front-end mental health treatment improves clinical outcomes, mitigates later complications and increases the prospects of keeping patients well over the longer term. KEY POINTS What is already known about this topic (1) Hospital emergency departments (EDs) can often be the initial point of care for people seeking immediate help for mental health crises. (2) Demand has increased, patient satisfaction has decreased and patients increasingly re-present in crisis. (3) Therapeutic alliance has been shown to be a robust predictor of treatment outcome. What this paper adds (1) Mental health care could be improved for those presenting in situational crises by bringing evidence-based treatment with a consistent clinician with whom they could form a therapeutic alliance (2) The agile Psychological Medicine clinic demonstrated that bringing specialist treatment to the front end of the system of care, improves clinical outcomes, mitigates later complications and increases the prospects of keeping patients well over the longer term. (3) Patients who engaged in treatment had a 37% reduction in ED presentations 12 months after therapeutic intervention resulting in significant cost savings. Abbreviations: aPM: agile Psychological Medicine; CATT: Crisis Assessment and Treatment Team; CBT: Cognitive behaviour therapy; CCT: Continuing Care Team; ECATT: Emergency Crisis Assessment and Treatment Team; ED: Emergency Department; PTS: Psychiatric Triage Service; SECASA: South Eastern Centre Against Sexual Assault

Trends in mental health system transformation: Integrating youth services within the Canadian context.

The current mental health services system in Canada is fragmented and transitions between the youth and adult mental health systems have been identified as needing significant improvement. Integrated Youth Services (IYS) are designed to be adaptable and developmentally appropriate as well as to promote seamless transitions, including during emerging adulthood. This article provides an overview of recent developments in Canadian mental health system transformation to promote the integration of services and the holistic promotion of youth well-being. We offer an overview of the current state of knowledge related to best practices in IYS in Canada and highlight areas for future development. We also introduce Frayme, a Canadian-based international knowledge translation platform designed to connect organizations working in the youth services system to accelerate the implementation of IYS.

Talking to children about parental mental illness: The experiences of well parents.

Children of parents with mental illness are not routinely included in psychoeducational and supportive family interventions provided by adult mental health systems. The family, therefore, is an important and, sometimes, the only source of information and support for them. To understand the experiences of well parents in talking to their children about parental mental illness. This article presents the findings of a qualitative study of the experiences of well parents in talking to their children about parental mental illness. Ten well parents whose spouses were diagnosed with a severe mental illness participated in the study. Socio-demographic information, family details and history of the spouse's mental illness along with their experiences of talking to children about parental mental illness, the perceived risks and benefits, challenges they faced and the role of others in the process were recorded. Qualitative data were analysed using interpretative phenomenological analysis. The themes of 'distancing children from parental mental illness', 'avoiding conversations about the illness', 'giving and receiving emotional support', 'providing explanations of the illness' and 'regulating other sources of information' show the complex ways in which well parents influence their children's understanding of parental mental illness. The findings are examined in the background of what is known about this topic from the perspective of children or of the parent with illness. Possible ways to support well parents in families affected by parental mental illness are discussed. This study is a step forward in the understanding of how families talk to children about parental mental illness and provides the perspective of the well parent.

Transitioning Adolescents with Emotional and Behavioral Disorders from Most-to-Least Possible Restrictive Environments: Views of Transition Service Providers

ABSTRACTThis study examined the transition from most-to-least possible restrictive environments for youth with emotional and behavioral disorders. Components of positive transition experiences were identified from the literature as planning for transition at intake in such a way as to promote continuity of care, family involvement, academic and employment success, and assistance in navigating the adult mental health system and services. In this phenomenological study, transition service providers were interviewed to explore the transition practices currently utilized, and results were compared to recommended practices in the literature. Transition professionals were able to identify consistency, gradual change, individualization, communication between providers, opportunities for community experiences, and youth involvement in the transition as necessary to successful transition.

Paving the Way to Change for Youth at the Gap between Child and Adolescent and Adult Mental Health Services.

By 2020 mental illness will be one of the 5 most common illnesses causing morbidity, mortality and disability among youth. At least 20% of Canadian youth have a psychiatric disorder the impact of which can dramatically alter their life trajectory. Focus on the factors contributing to this problem is crucial. Lack of coordination between child and adolescent mental health systems (CAMHS) and adult mental health systems (AMHS) and consequent disruption of care during this vulnerable time of transition is one such factor. Reasons for and the impact of this divide are multilayered, many of which are embedded in outdated, poorly informed approaches to care for this population in transition. This paper considers the etiology behind these reasons as potential foci for change. The paper also briefly outlines recent initiatives ongoing in Canada and internationally that reflect appreciation of these factors in the attempt to minimize the gap in service provision for youth in transition. The need to continue with research and program development endeavours for youth with mental illness whereby access to services and readiness for transition is no longer determined by age is strongly supported.

Child responsible personnel in adult mental health services.

BackgroundChildren who have parents with mental health problems are a vulnerable group. Intervening early to support parents with a mental illness can contribute to improve outcomes for children. Rigging the adult mental health system in such a manner that child responsible personnel are designated in wards is a strategy to systematically address the needs of families. It has since 2010 been mandatory for Norwegian hospitals to appoint such personnel in all hospital wards. The current study aimed to investigate the appointment of child responsible personnel in the adult mental health services in a regional hospital with local clinics. Additionally, to describe the characteristics of child responsible staff in terms of gender and educational background, their competence, clinical practice and knowledge about parental mental illness. A final aim was to study whether or not the clinics had established collaboration with other services concerning follow-up for the children of parents with mental illness.MethodParticipants in this study are the staff at psychiatric clinics in a large university hospital in Norway. Practitioners were asked to answer a questionnaire prior to the initial process of implementing the new legislation in 2010 (N = 219). After a three-year period of implementing routines to adopt the new law in the clinic, the same survey was sent out to the staff in 2013 (N = 185) to monitor if changes were taking place. To study if the changes were sustained within the clinics, we conducted a two-year follow up in 2015 (N = 108).ResultsThe results indicated that the systematic work to change clinical practice in the participating hospital had made a difference. Routines to follow up children’s patients after the new legislation had to some extent been implemented. The child responsible personnel had more knowledge and awareness about the consequences of parental mental illness for children.ConclusionThe results of this study suggested that the systems change of establishing child responsible personnel within adult mental health services may be a tool contributing to safeguarding children of mentally ill parents. However, the role of being a child responsible should be further developed and defined.

Worker, workplace or families: What influences family focused practices in adult mental health?

Introduction Family focused practice is thought to lead to positive outcomes for all family members. However, there are multiple barriers and enablers in adult mental health services to practitioners undertaking these actions. Aim The aim of this study was to examine the relative importance of worker, workforce and family factors to predict family focused practices (FFPs) in adult mental health services. Method Three hundred and seven adult mental health workers completed a 45 items family focused practice measure of 16 family focused practices. Thesis It was found that worker skill and knowledge about family work and an ability to assess the degree of parental insight into the child's connections to other family members and the community were important predictors of FFP, along with the closely related-worker confidence. While aspects of the worker, workplace and family each contribute to FFPs, this study highlighted the importance of worker skill, knowledge and confidence as central issues for adult mental health workers. Implications for practice Study implications include the need for training in specific FFPs, the provision of time to engage with clients on parenting issues and the need 5 to ensure that there are adequate services for workers to refer family members to.

Adapting services to engage young adults in ICCD clubhouses.

This article describes efforts to develop and offer supports for young adults within two clubhouse programs affiliated with the International Center for Clubhouse Development (ICCD). In response to a need to address service gaps and create supports to engage young adults transitioning to the adult mental health system, the authors describe the background, development, and adaptations of services and supports for young adults within their respective clubhouse programs. The authors highlight details and challenges associated with program adaptation and success stories of transition aged youth actively engaged in their clubhouses. Published literature, personal observation, and member feedback. These clubhouse programs share successful strategies used to engage young adults including outreach efforts led by young adults, developing supports and linkages with local educational institutions, addressing housing issues specific to young adults, and using current technologies that young adults find appealing. These strategies may prove useful to other service models that serve this population. Clubhouses affiliated with the ICCD show promise in expanding their approach and services to engage and support young adults.

Letter.

Back to table of contents Previous article Next article LetterFull AccessLetterMaggie Jarry M.S.Lindy Fox M.A., L.A.D.C.Carol Coussons de Reyes M.S.Maggie Jarry M.S.Search for more papers by this authorLindy Fox M.A., L.A.D.C.Search for more papers by this authorCarol Coussons de Reyes M.S.Search for more papers by this authorPublished Online:1 May 2010https://doi.org/10.1176/ps.2010.61.5.532AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Lifting the Veil: ReplyIn Reply: More than five million children in the United States have a parent with a serious mental illness, such as schizophrenia, bipolar disorder, and major depression, and some of these parents have co-occurring addictions. It is estimated that 68% of women and 57% of men with a serious mental illness are parents ( 1 ) and that 73% of women and 68% of men with posttraumatic stress disorder are parents ( 2 ). Yet it remains common to find mental health professionals who are unaware of or unwilling to see the relevance of this topic to their work and to the success of the people they serve. With this in mind, we strongly urge readers to consider the concrete recommendations in the letter from Dr. Heru and her colleagues. However, the scope of this dialogue and their recommendations should go further. Our key message is this: Just as we now recognize that employment is a viable option for people with mental illness, we need to recognize that parenting is also a viable life choice for these individuals, including those with illnesses regarded as severe and persistent. Supported parenting should be integrated into all adult mental health systems. Training for mental health professionals should include an understanding of the benefits of working with families. Professionals should be aware of and make available the supportive resources needed to address consumer parents' deepest concerns for their children and thereby contribute to parent and family wellness. Strengthening parenting skills enhances familial attachment and motivates parents toward recovery while also addressing the developmental needs of their children. Data should be collected on the parenting status of people who use adult mental health systems in order to understand where supportive parenting resources can be incorporated. Resources to enhance psychoeducation for young family members exist and are being rapidly developed in the United States and abroad (the fall 2009 special issue of Psychiatric Rehabilitation Journal provides an overview). These resources can be used today while we develop a national infrastructure for supported parenting. The Substance Abuse and Mental Health Services Administration should publish materials for supportive education of children who have a parent with mental illness, as it has for children with addicted parents. Furthermore, parents should not fear losing custody of their children when they disclose their personal health information to any authority, nor should adults who access mental health services be discouraged from having children if that is one of their life goals. For these reasons, mental health systems should partner with child and family services systems to support families.Understanding the unique experiences of daughters and sons who have a parent with mental illness should be a goal of future research. Daughters and sons need access to information that identifies and normalizes their common experiences. Research should go beyond estimating the statistical likelihood of future mental illness among these children to encompass other aspects of this group's experience and demographic characteristics. Daughters and sons often report difficulty with identity formation and preoccupation with the belief that they will experience the same mental illness as their parents. Therefore, we urge that the recommendations in this letter be balanced with an understanding that the need to screen children for illnesses is small compared with the need to unveil fortifying messages of resilience and hope within the family.Ms. Jarry, author of the December Personal Accounts column, is joined in her response by Ms. Fox, who is affiliated with the Dartmouth Psychiatric Research Center, Concord, New Hampshire, and Ms. Coussons de Reyes, a certified peer specialist with the Office of Consumer Affairs, Division of Behavioral Health, Lincoln, Nebraska.

Issues in Medicaid Policy and System Transformation: Recommendations From the President's Commission

Issues in Medicaid Policy and System Transformation: Recommendations From the President's Commission

Within-State Availability of Transition-to-Adulthood Services for Youths With Serious Mental Health Conditions

This study describes the existence and nature of services within state child and adult mental health systems that support the transition from adolescence to adulthood. State child and adult mental health administrators from all but one state were interviewed by telephone with a semistructured questionnaire regarding transition services in their state mental health system, such as supported housing, vocational support, preparation for independent living, and dual diagnosis treatment. Eight states were deemed sufficiently decentralized to render state-level administrator reports invalid. Specific service data from the remaining 41 states and the District of Columbia were analyzed with descriptive statistics. One-quarter of child state mental health systems and one-half of adult state mental health systems offered no transition services, and few provided any kind of transition service at more than one site. Most types of transition services were available at all in less than 20 percent of the states. Across the United States transition support services are lacking. The adult system in particular will require major transformation to provide the service capacity that is needed to meet the current standards of transition service accessibility for young Americans with serious mental health conditions.

Within-State Availability of Transition-to-Adulthood Services for Youths With Serious Mental Health Conditions

This study describes the existence and nature of services within state child and adult mental health systems that support the transition from adolescence to adulthood.State child and adult mental health administrators from all but one state were interviewed by telephone with a semistructured questionnaire regarding transition services in their state mental health system, such as supported housing, vocational support, preparation for independent living, and dual diagnosis treatment. Eight states were deemed sufficiently decentralized to render state-level administrator reports invalid. Specific service data from the remaining 41 states and the District of Columbia were analyzed with descriptive statistics.One-quarter of child state mental health systems and one-half of adult state mental health systems offered no transition services, and few provided any kind of transition service at more than one site. Most types of transition services were available at all in less than 20 percent of the states.Across the United States transition support services are lacking. The adult system in particular will require major transformation to provide the service capacity that is needed to meet the current standards of transition service accessibility for young Americans with serious mental health conditions.

Youth Transitioning to Adulthood: Effects of Different Population Policies in Child and Adult Mental Health Service Systems

The transition from adolescence into adulthood is a period of rapid psychosocial development that underlies the acquisition of the skills and capacities to function as adults. For young people with serious mental health (MH) conditions, the movement into adulthood is precarious. Most adolescents with psychiatric disorders continue to have those disorders in young adulthood. Psychiatric disorders during the transition to adulthood, roughly ages 16-30, seriously impede the development of adult role functioning. These ages span those served by state child and adult MH systems. For adolescents in child MH and young adults in adult MH systems, continuity of care and the provision of age-appropriate supports are needed to assist them in their quest for adult functioning. One challenge to the continuity of care across child and adult MH systems may stem from differing population policies. Population policies are those that define a system's eligible or target population. The important questions for transition-aged youth include: Do population policies used in the adult MH system differ from those used in the child MH system? If so, does this restrict access to services for adolescents aging out of the child MH system? This brief describes a study which examined these questions by comparing the population policies of child and adult state MH systems.

State child mental health efforts to support youth in transition to adulthood

The ability of state child mental health (MH) systems to facilitate the transition to adulthood of adolescents in their systems was studied by interviewing members of the Children, Youth and Families Division of the National Association of State Mental Health Program Directors (NASMHPD). Results demonstrated that transition services within the state child MH systems are sparse, nationally. Continuity of services as youth age into adulthood is hampered because of generally separate child and adult MH systems, each with separate policies defining who accesses those services, lack of clarity about procedures to access adult MH services, and lack of shared client planning between adult and child MH systems. These findings suggest that adolescents in state child MH systems have difficulty accessing services that will help them with the difficult task of learning to function as an adult. Public MH systems should examine their capacity to provide transition supports and make needed improvements.

Caring for Young Adults With Mental Illness

Back to table of contents Previous article Next article LettersFull AccessCaring for Young Adults With Mental IllnessBruce J. Henry, J.D., and Robert J. Giugliano, Ph.D.Bruce J. HenrySearch for more papers by this author, J.D., and Robert J. GiuglianoSearch for more papers by this author, Ph.D.Published Online:1 Jul 2004https://doi.org/10.1176/appi.ps.55.7.835-aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: We appreciate Dr. Sederer's recognition of the long-standing lack of appropriate and adequate housing and clinically and developmentally specific services for young adults with mental illness and co-occurring substance use disorders.In describing the approach taken by the New York Department of Mental Health and Hygiene (DMHH), Dr. Sederer said, "we identify need, engage in effective planning, and support advocacy for needed services, and on the basis of these efforts we direct funding for populations in need." Who are the "we" in DMHH who are engaged in this approach for young adults? Unless and until there is a "we" for young adults in both DMHH and the New York State Office of Mental Health, this population will continue to be neglected.The absence of a "we" has resulted in young adults' being worse off now than they were a few years ago when an agency decided to respond to a request for proposals for supportive housing for mentally ill young adults aging out of foster care. The program was poorly designed and underfunded. Not able to manage the young adults and not able to obtain any additional support from DMHH, the agency closed the program and returned the grant to the city. Young adults have less housing and services now than they've ever had.There are necessary risks involved in change, and the problems of compartmentalization and splintering are certainly preferable to the complete absence of appropriate and adequate housing and services. The absence of an organized and ongoing approach to dealing with young adults has contributed to the major clinical problems this population presents and the fragmentation of the system. The current adult mental health system does not offer appropriate and adequate housing or services for adolescents when they reach age 18.At Covenant House about 1,000 homeless mentally ill young adults have participated in our mental health day program since 1996, and we have nowhere to send them. These systemic problems are long-standing, but the time has come to actually do something about them. We look forward to working with Dr. Sederer and with the New York State Office of Mental Health to develop strategies for the solution of these problems.Mr. Henry is executive director of Covenant House in New York City, where Dr. Giugliano is director of mental health. FiguresReferencesCited byDetailsCited ByNone Volume 55Issue 7 July 2004Pages 835-a-835 Metrics PDF download History Published online 1 July 2004 Published in print 1 July 2004

Where Have All the Children Gone? Movement from Child to Adult Mental Health Systems

The mental health histories of the 448 children 15 and 16 years of age who were admitted to state-operated children's psychiatric inpatient services in New York during 1982 were reviewed for the 11 year period through April 1993, Thirty-three percent were served as adults (after age 18) in the state-operated adult civil mental health system; 42% of these individuals were still receiving services at the end of the period. 113 of the 146 individuals served as adults were served only in the civil system. Thirteen percent of the cohort received some of their mental health services as adults in the state-operated adult forensic mental health system due to criminal law involvement. This includes nine percent who received mental health services while they were inmates in state prisons. Twenty four of the 57 forensic clients received services as adults only in the forensic system. Diagnostic, demographic, and service history characteristics of the groups were compared to foster an early understanding of policy and programmatic issues related to movement from the child mental health system to the adult system. Baseline (1982) information was used to identify predictors of later service utilization.