Behavioral Health Services For Children Research Articles

Psychiatric Residential Treatment Facilities for Child Behavioral Health Services in North Carolina Medicaid

Background Psychiatric residential treatment facilities (PRTFs) are non-hospital inpatient treatment settings for children with severe be­havioral health disorders. PRTFs are a restrictive and costly form of care that can potentially be avoided with community-based behavioral health services. Methods Statewide Medicaid enrollment and claims data for 2015–2022 were used to describe PRTF utilization in North Carolina. We examined annual episodes of care in PRTFs and compared trends before and during the COVID-19 public health emergency. Results From 2015 to 2022, 10,038 children insured by NC Medicaid entered a PRTF across 10,966 episodes of care. In the past five years (2018–2022), care in PRTFs resulted in Medicaid expenditures of over $550 million total, or over $100 million per year. In 2022, 42% of children who entered PRTFs were in foster care and 44% of children were placed in PRTFs outside of North Carolina. Limitations The analysis was limited to data collected for administrative purposes. Conclusions Current trends indicate an ongoing overrepresentation of children in foster care placed in PRTFs and increased out-of-state PRTF placements. Coordinated efforts in future research, policy, and practice are needed to determine the cause of these trends and iden­tify solutions.

Expanding Access to Home-Based Behavioral Health Services for Children in Foster Care.

Expanding Access to Home-Based Behavioral Health Services for Children in Foster Care.

A Qualitative Study of Military Connected parents’ Perceptions on Establishing and Maintaining Child Behavioral Health Services

Few studies have examined U.S. military parents’ perspectives in establishing, maintaining, and reestablishing child behavioral health services within the context of military life. This qualitative study focused on the experiences of military-connected parents raising children who were receiving non-psychiatric outpatient behavioral health services for a range of behavioral or emotional challenges. The purposes of the qualitative study were to understand parents’ perspectives on the unique challenges military families face while seeking treatment and to understand facilitators or barriers to treatment. Twenty-two parents across the branches of the U.S. military participated in semi-structured interviews. Data were analyzed using a grounded theory approach. Primary themes identified were difficulties reestablishing social and healthcare support networks when moving. When accessing behavioral health services, stigma, difficulty obtaining referrals, and family logistics were noted barriers. Facilitators included parental advocacy on behalf of their child and primary care providers providing quick referrals to specialized behavioral health services.

Evaluation of Telehealth in Child Behavioral Health Services Delivery During the COVID-19 Pandemic.

The authors quantified the impact of the use of telehealth services on patient-level clinical outcomes among children with complex behavioral and emotional needs in Idaho during the COVID-19 pandemic by comparing data collected in 2020 with data for the same months in 2019. Longitudinal statewide data of Child and Adolescent Needs and Strengths (CANS) assessments were extracted from Idaho's mental and behavioral health system. Prepandemic assessments were matched to midpandemic assessments. A linear mixed-effect model was used to explore four child-level outcomes: psychosocial strengths-building rate, rate of need resolution within a life-functioning domain, rate of need resolution within a behavior-emotional domain, and rate of need resolution within a high-risk behaviors domain. The number of new patients admitted to Idaho's state-funded mental and behavioral health program decreased almost twofold from April-December 2019 to April-December 2020 (N=4,458 vs. 2,794). For most children with complex needs, the use of telehealth was as effective in terms of strengths building and needs resolution as in-person services; for children whose caregivers had issues with access to transportation, availability of telehealth services improved outcomes for the children. The COVID-19 pandemic in 2020 was associated with a dramatic drop in the number of children served by Idaho's mental health program. Telehealth may effectively bridge mental health service delivery while patients and providers work toward the resolution of transportation issues or may serve as a more acceptable permanent format of service delivery for some populations.

Difficulty Obtaining Behavioral Health Services for Children: A National Survey of Multiphysician Practices.

In the United States, primary care practices rely on scarce resources to deliver evidence-based care for children with behavioral health disorders such as depression, anxiety, other mental illness, or substance use disorders. We estimated the proportion of practices that have difficulty accessing these resources and whether practices owned by a health system or participating in Medicaid accountable care organizations (ACOs) report less difficulty. This national cross-sectional study examined how difficult it is for practices to obtain pediatric (1) medication advice, (2) evidence-based psychotherapy, and (3) family-based therapy. We used the National Survey of Healthcare Organizations and Systems 2017-2018 (46.9% response rate), which sampled multiphysician primary and multispecialty care practices including 1,410 practices that care for children. We characterized practices' experience as "difficult" relative to "not at all difficult" using a 4-point ordinal scale. We used mixed-effects generalized linear models to estimate differences comparing system-owned vs independent practices and Medicaid ACO participants vs nonparticipants, adjusting for practice attributes. More than 85% of practices found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. Adjusting for practice attributes, the percent experiencing difficulty was similar between system-owned and independent practices but was less for Medicaid ACO participants for medication advice (81% vs 89%; P = .021) and evidence-based psychotherapy (81% vs 90%; P = .006); differences were not significant for family-based treatment (85% vs 91%; P = .107). Most multiphysician practices struggle to obtain advice and services for child behavioral health needs, which are increasing nationally. Future studies should investigate the source of observed associations.

Simpler Than Possible: Insurance Mandates for Autism Spectrum Disorders.

The diagnosis and management of autism spectrum disorder (ASD) and co-occurring medical and behavioral health conditions strain both health and educational resources in the United States. State mandates for insurance coverage for ASD-related health care were intended to improve access to indicated services, with inclusion of board-certified behavior analysts (BCBAs) as a newly licensed group of professionals to provide one approach to evidence-based intervention. McBain et al1 examined the association of the state by state passage of legislation on one indicator of access to services: number of providers who serve this population. Mandated insurance coverage, especially more-generous coverage, was associated with a greater growth in the workforce of BCBAs, a small increase in the number of child psychiatrists, and no change in the number of pediatricians.The authors acknowledged the associational nature of their study and their inability to explore use or distribution of services. However, when interpreting the impact of insurance mandates that focus primarily on reimbursement for applied behavioral analysis (ABA) as an intervention, there are additional implications that must be considered when examining actual health care provided for individuals with ASD. The insurance mandate did little to improve serious deficits in access to diagnostic services or to address the training needs of existing and available pediatric care providers.2 Augmenting workforce capacity includes current efforts to enhance pediatricians’ ability to contribute to timely ASD diagnosis, thereby promoting earlier entrance to intervention.3,4 Most interventions provided for children and youth with ASD have not been impacted by the wave of insurance legislation over the past decade but are provided through the legal mandate of the Individuals with Disabilities Education Act through the educational system. Consistent with patterns in specialty behavioral health care, special education and community services are not equitably distributed across a representative population (eg, based on race, ethnicity, age, income, language, and geographic region).5Increases in provider numbers resultant from insurance mandate legislation may imply false equivalence with evidence-based practice. Although behavior analytic services are efficacious for some,6 there is an increasing evidence base for interventions (eg, naturalistic developmental behavioral interventions7) that are not covered by insurance mandates. There is insufficient evidence to assume a single approach is effective for all individuals with ASD. Factors such as child characteristics and family choice become increasingly important drivers of treatment selection as predictors of success and outcome measurement are studied in greater depth. However, insurance legislation that is directly tied to funding ABA and advocated in parallel to licensure for BCBAs8 sends a message that ABA is the only effective intervention. This may come at the cost of awareness of and reimbursement for other possibly efficacious interventions, as well as development of comprehensive care plans including both the educational and medical systems.An additional erroneous assumption is that an increase in number of BCBAs and child psychiatrists leads to increased access to care. Indeed, families who are generally under-represented in service systems on the basis of race, ethnicity, and income level are especially likely to report unmet service needs.5 Such disparities are exacerbated by Medicaid restrictions for insurance mandates, which may disproportionately affect populations that are already underserved. Second, service quality remains independent from access. Community-based early intervention services, for instance, are delivered with highly variable fidelity, which may affect child outcomes. In addition, despite the general conviction in the field that more intensive intervention yields more positive results, conventions around the minimum recommended number of hours of ABA are not rooted in evidence.9 Recommendations to steer families toward readily available services should not supplant individualized, evidence-based determinations for intervention selection based on child and family variables and preferences.McBain et al1 add support to the evidence that the overall supply of child behavioral health services in the United States is inadequate to address the existing needs of not only children but people with ASD across the life span. We echo the recommendation that policies do need to address the existing behavioral and medical health needs but also suggest the following: (1) in addition to increasing the numbers of psychiatrists and BCBAs, the existing interprofessional workforce needs education and supports to improve quality of care; (2) care coordination must be recognized and funded as a method to improve efficiencies and access across health and educational systems; (3) providers and service systems must prioritize equitable access to services for all families; and (4) innovative research in this area will include the development and evaluation of cost-efficient and effective interventions for all people with ASD. Per Albert Einstein, “Everything should be made as simple as possible, but not simpler.” Full consideration of these numerous system complexities is necessary to adequately address the needs of individuals with ASD and their families.

State-Community System of Care Development: an Exploratory Longitudinal Review.

The system of care (SOC) philosophy evolved into a framework to support access to effective behavioral health services for children. This study explored the use of the System of Care Implementation Survey (SOCIS) to monitor SOC development during one Midwestern state's federal planning and expansion grants. Utilizing a translational framework, results showed that despite fluctuations in SOC factor implementation over time, state and local SOCs had mid-level development. Further, inferential analysis of select factors indicated that outreach and access to services and the skilled provider network were significantly worse over time. Significant improvement in the treatment quality was documented but not sustained. Changes for Family Choice and Voice and Collaboration were not statistically significant. Variability in survey participation limited the evaluation. Refinement of evaluation methods is needed to monitor progress and to manage SOC development.

The effect of child mental health service use on child safety and permanency in substance misusing families

Research has shown that parental substance misuse leads to a great number of adverse child protection outcomes for children including delays in reunification and reentry into out-of-home care. Although studies suggest that provision of behavioral health services for children can serve as a protective factor in this regard, empirical evidence for the beneficial effect of these services for families experiencing substance misuse is lacking. This study examined whether receipt of children’s behavioral health services mitigated the effects of parental substance misuse with regard to child safety and permanency outcomes. The study sample included all children who either entered or exited out-of-home care in Florida anytime between July 2007 and June 2010 and were enrolled in the Child Welfare-Prepaid Mental Health plan. Data were obtained from the Florida Safe Families Network (FSFN) and Medicaid claims data sets. Cox regression was used to examine time to reunification and time to reentry into care. Findings revealed that parental substance misuse was significantly negatively associated with family reunification. The presence of parental substance misuse significantly reduced the likelihood of family reunification, whether or not children received mental health services. However, children who received mental health services and were reunified with their parents were almost three times less likely to reenter out-of-home care – even in families experiencing parental substance misuse. Receipt of behavioral health services was differentially associated with time to reunification and reentry into out-of-home care. As child welfare systems strive to become more family focused, e.g. addressing parent and child needs, these findings suggest that mental health service delivery to children in foster care remains important.

Collaborative Care to Improve Access and Quality in School-Based Behavioral Health.

Collaborative care (CC) is a well-established approach for the delivery of accessible behavioral health services in integrated health care settings. Substantial evidence supports its effectiveness in improving the quality and outcomes of adult services, and growing research indicates utility with child and adolescent populations. To date, studies examining CC models for youth have focused exclusively on primary-care settings. Nevertheless, as the most common integrated service delivery setting for youth, the education sector is an equally important context for improving access to behavioral health services for children and adolescents. We provide a narrative review of the literature on CC, describes the relevance of CC to schools, and details its alignment with contemporary movements in education and school-based behavioral health. Potential adaptations of the CC model for use in schools are detailed to improve: (1) behavioral health service accessibility, (2) the capacity of schools to provide behavioral health services, and (3) school service effectiveness through use of evidence-based practices. Although little research has explored the applicability of CC in the education sector, the model holds potential promise to improve the quality and efficiency of school-based behavioral health services.

Accessing Behavioral Health Services: Introduction to a Special Issue of Research, Policy, and Practice

There is an urgency to improve accessibility of behavioral health services for children and families given both an increasing need and decreasing support. This special issue aims to advance our understanding of what works to make behavioral health services for children accessible through a collection of articles that examine the issue from research, policy, and practice perspectives. The five research articles included in this special issue examine the organizational and contextual features necessary to improve the accessibility of children’s behavioral health services, thus building upon the growing literature that can inform practice and policy. In addition, the special issue also includes three articles describing the practices and outcomes of innovative state and local community partnerships, with the goal of using practice to inform research and policy. The interconnectedness of research, policy, and practice—coupled with the need for ongoing communication in the arena of children’s behavioral health services—is further examined in the commentary that concludes this special issue. Taken together, the collection advances our understanding of how children’s behavioral health services can be more accessible to all, and provides a model for future integration across research, policy, and practice efforts.

The School Psychologist’s Role in Leading Multidisciplinary School-Based Threat Assessment Teams

School psychologists have long been regarded for their expertise in the assessment, evaluation, and delivery of mental and behavioral health services for children in schools. Given the growing attention to school safety, crisis prevention, and crisis intervention, school psychologists are also increasingly called upon to assist with systems-level prevention efforts and individual assessments of risk for targeted violence through participation in school-based threat assessments. In this article, I define the role of the school psychologist within the multidisciplinary threat assessment team in conducting comprehensive assessments and developing individualized interventions to mitigate threats of violence in schools. From my experience conducting threat assessments as a school psychologist, implications for schools, school-based practitioners, and university trainers are also explored.

Comprehensive Behavioral Health and School Psychology: An Implementation Agenda

The preceding articles provide important examples and guidance for the provision of high-quality behavioral health services for children and adolescents in schools. In this article, we discuss (a) ...

Behavioral Health Integration in Large Multi-group Pediatric Practice

There is increasing interest in methods to improve access to behavioral health services for children and adolescents. Children's Community Pediatric Behavioral Health Service (CCPBHS) is an integrated behavioral health service whose method of (a) creating a leadership team with empowered administrative and clinical stakeholders who can act on a commitment to change and (b) having a clear mission statement with integrated administrative and clinical care processes can serve as a model for implementing integration efforts within the medical home. Community Pediatrics Behavioral Health Service (CPBHS) is a sustainable initiative that improved the utilization of physical health and behavioral health systems for youth and improved the utilization of evidence-based interventions for youth served in primary care.

New frontiers in building mental, emotional and behavioral health in children and youth: Introduction to the special section.

The passage of the Patient Protection and Affordable Care Act (ACA; 2010) has had tremendous influence on behavioral health in the United States (Alker & Chester, 2015). Shortly after its passage, the editors of this special section became interested in examining the provisions of the ACA related to care for mental, emotional, and behavioral disorders in children and youth and synthesizing their implications in the context of other contemporary trends in children's behavioral health promotion. We first developed a white paper with the goal of increasing our own understanding of these issues and their possible influence on the status quo of designing, implementing, financing, and evaluating behavioral health services for children and their families. From our discussions came the idea of developing a special section in the American Journal of Orthopsychiatry featuring input from researchers who have been exploring these issues and who have tangible and relevant examples of "new frontiers" in building mental, emotional, and behavioral health for children and youth. The result is the current special section, the purpose of which is to highlight the importance of prevention in behavioral health and to explore examples of efforts that have used a broad public health approach to prevention and early intervention in mental, emotional, and substance use disorders in children and youth. Before introducing the seven articles in this special section, we describe in detail our foundational thinking about building mental, emotional, and behavioral health for children and youth, as expressed in our initial white paper on this topic. (PsycINFO Database Record

Impact of Location and Availability of Behavioral Health Services for Children

Literature suggests advantages for co-locating behavioral health care in primary care. We compared the impact of location of services on attendance at behavioral health appointments when access to care was assured for externalizing behavior problems with referral as usual. Two primary care pediatric practices had an evidence-based parenting program co-located in the practice for parents of children aged 2-12years and two practices had the program available using an enhanced-referral procedure for locations external to the practices. The program was available at the regional children's hospital (referral as usual). During an 8-month period, the rate of attendance at first appointments was significantly higher in the co-located than the enhanced referral condition (.38 and .12% of patient visits, respectively; χ(2)=13.32; p<.0003; OR=3.10; 95% CI: 1.63, 5.89). These outcomes, while low, were better than the near 0 rate of attendance to referral as usual. Availability of behavioral health services in both conditions increased rates of attended appointments. However, the low rates of attendance indicate increasing availability of services, alone, is not sufficient to decrease the unmet need of children with behavioral problems. Factors other than availability must be addressed in order to improve outcomes for children.

New Jersey Children's Behavioral Healthcare System: Cross service delivery planning for transitional population of youth (ages 16 and 18+ years)

The continued need for improvement within a ‘system of care’ is essential as the need for mental health services by those ‘youth’ within the child welfare system continually grows. This article outlines the statewide reform of New Jersey's Children's Behavioral Healthcare System, which began in 2000, as well as including the recommendations of the University of South Florida as part of their ‘Final Report: Independent Assessment of New Jersey's Child Behavioral Health Services’ on continued changes within the system of care. Successful outcomes have resulted from this welfare reform initiative, which include most notably the significant caseload decrease of the Division of Youth and Family Services (DYFS) and the creation of a new cabinet entity, the Department of Children and Families (DCF). This article specifically outlines systemic recommendations to best serve the target population of ‘transitional’ youth between the ages of 16 to 18+ years utilizing interagency cooperation based upon ‘theory of change’ and Total Clinical Outcomes Management (TCOM) strategies.

Rural behavioral health services for children and adolescents: An ecological and community psychology analysis

AbstractWhile psychology has tended to focus on urban issues in research and practice, rural areas have undergone a series of changes in recent years that have increased the need for behavioral health services. A variety of social and economic factors has contributed both to the increasing needs and to the inability of the existing services to meet them. In this article, the authors survey the literature on rural behavioral health issues, focusing on children and adolescents, to highlight the status of knowledge and approaches to intervention. A conceptual rubric based on the social ecological perspective is used. First, what is known about rural behavioral health and health care for youth is described at the ontogenetic, micro‐, meso‐, and macrosystem levels. Strategies that have been proposed to address problems in rural behavioral health care are also presented at the different levels. General principles for future intervention and research are proposed that recognize the unique context of rural communities, use local knowledge and ideas, incorporate the efforts of informal systems of care using a strength‐based approach, and identify and work toward solving the macrosystem issues that underlie rural health problems. © 2006 Wiley Periodicals, Inc.

A Program Evaluation Strategy in a Community-Based Behavioral Health and Education Services Agency for Children and Families

Evaluation research and outcomes measurement in the arena of behavioral health services for children must be adapted for the community agency setting. Through evaluation research, it is possible to address service goals as well as more traditional academic research goals. This article examines a variety of activities that have been implemented to evaluate children’s behavioral and educational services in a Northern California non-profit community agency. It is noted that there are multiple formats for collecting information from and providing comments to children’s parents, their clinicians, and program administration staff, all of which can be used to effectively address service-focused evaluation research goals. Challenges to doing scientifically rigorous research in a community setting require additional considerations regarding organizational culture and structure. Based on the experiences of the authors and the experiences of others, the article describes general principles that can guide evaluation research and outcomes measurement with children and their families in the community health agency setting.

Community-level changes in behavioral health care following capitated contracting

As capitated managed care contracts are becoming more prevalent in the delivery of behavioral health services, it is important to review community experiences with these contracts. A survey of all community agencies in one area that provided or interacted with behavioral health services for children and adolescents was administered during the implementation of a clinically-managed demonstration and again four years later after the transition to a capitated managed care contract. The following changes were reported under the capitated contract: 1. a) problems in service delivery experienced by the target population increased; 2. b) quality of behavioral health and related services available decreased; 3. (c) service system performance decreased, 4. (d) the extent to which goals of an effective behavioral health service system were being attained was also rated as significantly decreased; and 5. (e) coordination of services for the target population and collaboration among providers declined.