Health Affairs, 22, no. 5 (2003): 39-50 doi: 10.1377/hlthaff.22.5.39 © 2003 by Project HOPE	New Online   Obama's Success & Next Steps   3 Health Policy Options for President Obama   A Hybrid Proposal   Bipartisan Compromise

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Child Mental Health

Trends And Issues In Child And Adolescent Mental Health

PROLOGUE: Addressing the needs of children and adolescents with mental illness is a major challenge for health care policymakers in the new century. The scope of the problem is staggering. An estimated 20 percent of American children have emotional disorders, while mental health service–related expenditures topped $11.75 billion in 1998 alone. And, lest the severity of the impact of mental illness on the young be underestimated, the National Advisory Mental Health Council’s workgroup on child and adolescent mental health has pointedly asserted that "no other illnesses damage so many children so seriously."

Sadly, despite the obvious magnitude and urgency of the demand, development of a comprehensive, coordinated approach to meeting the needs of such children remains elusive. The Subcommittee on Children and Family of the President’s New Freedom Commission on Mental Health has noted that while young people with emotional problems come in contact "with more than one specialized service system, including mental health, special education, child welfare, juvenile justice, substance abuse, and health...no agency or system is clearly responsible or accountable for them."

However, amid such dour realities, reason for optimism exists in notable progress that has been achieved over the past decade in the delivery and financing of mental health services for children. In the paper that follows, Sherry Glied and Allison Evans Cuellar report, among other things, on reductions in the out-of-pocket burden borne by families for children’s mental health care. Moreover, more children have access to effective treatment, as the "evidence base" for making care decisions has steadily improved. Despite such advancements, though, Glied and Cuellar are quick to note the need for the allocation of greater resources toward formulation and identification of evidence-based community treatment models geared toward seriously ill children that are readily applicable to "existing service systems."

Glied, a professor and department chair in the Mailman School of Public Health at Columbia University, served on the President’s Council of Economic Advisers under George H.W. Bush and Bill Clinton and is a member of the John D. and Catherine T. MacArthur Foundation’s network on mental health policy. Cuellar is an assistant professor at the Mailman School of Public Health.

Abstract

 
An estimated 11 percent of American children have a mental health impairment, yet they rely upon a piece of the health care system that does not work well. Government policies for children’s mental health operate in two ways: by affecting health insurance for children, and by funding services directly. Major changes within both categories have shaped the types, sources, and financing of services for children with mental health problems. These policies, along with scientific advances in child mental health, social changes, and health policy more generally, have contributed to an improvement in child mental health services over the past fifteen years.

Children with mental health problems rely upon a piece of the health care system that does not work well. Many of these children receive no care at all, and many of those who do receive services are never seen by the health care system but receive care through schools (the principal provider of services to children with emotional disorders), child welfare agencies, or the juvenile justice system.⁴ In contrast, children with serious mental health problems who do use services often report involvement with multiple agencies and sources. One study found that 92 percent of children with serious emotional disturbances received mental health services from two or more systems, and 19 percent, from four or more.⁵ This multiplicity of services is associated with poor coordination, duplication, and service redundancy. Thus, child mental health policy has the dual objectives of improving access to services and reorganizing those services that are delivered.

Government policies for children’s mental health operate in two ways. One set of policies affects health insurance for children, allowing them to pay for services received in the medical and specialty mental health sectors. Policies in this group include expansions of insurance coverage, such as the State Children’s Health Insurance Program (SCHIP), implementation of managed behavioral health care in the public and private sectors, and efforts to obtain parity of mental health benefits with those for general health care. A second set of policies directly funds mental health services for children. The most important policy in this group is federal financing of systems of care through the Comprehensive Community Mental Health Services for Children and Their Families Program, the largest federal program for children with serious emotional disturbances.⁶

Direct funds also finance school-based services and services in other systems such as juvenile justice and child welfare. Both categories of policies shape the types, sources, and financing of services received by children with mental health problems. But mental health policies are not the only—or often the most important—driver of child mental health services. Scientific advances in child mental health, social changes, and health policy more generally also have important effects. Together these changes have transformed the delivery of child mental health services over the past fifteen years. This paper examines these changes and discusses their relationship to government policies in child mental health.

Trends Since The Mid-1980s

Top Trends Since The Mid-1980s Financing Policy Managed care Policy For Systems Of... Editor's Notes NOTES

 
Evidence base The evidence base for treatments of children with mental health problems has historically been narrower than that for adults. Recently, however, that evidence base has expanded. For example, new clinical trials of children on psychotropic drugs that had already been tested in adults have yielded information about the efficacy of several antidepressants in children.⁷ Substantial resources have been devoted to developing and testing new psychotherapeutic and psychosocial interventions. Finally, further improvement of the evidence base and the development of new dosing regimens for well-established therapies, such as stimulants for attention-deficit/hyperactivity disorder (ADHD), have made it easier and more socially acceptable to treat children with these drugs.⁸

Treatment frequency The expanded evidence base and armamentarium of drugs have led to tremendous growth in the number of children who receive treatment for mental health problems. Because physicians alone dispense medications, this growth has been concentrated in the medical sector (Exhibit 1). Between 1985 and 1994 the number of visits to physicians that included the prescription of a psychotropic medication increased by nearly 2.5 million.⁹ From 1994 through 1999 the number increased by nearly an additional million, to 4.5 million visits. From 1985 through 1999 the percentage of children’s physician visits that included a mental health diagnosis nearly tripled.¹⁰ Virtually all of this increase consisted of visits at which psychotropic medications were prescribed.

Note, however, that even at the higher rates seen in 1998, the portion of children who received treatment for a mental health diagnosis did not approach the prevalence of serious disorders. Earlier epidemiologic studies found that children with mental health problems who received treatment were more likely to receive it in school than in the medical system. Even the recent higher rates of medical service use are below the rates of school-based use in those earlier studies.¹² Furthermore, the match between disorder and receipt of services is far from perfect: Some children who are receiving services do not meet diagnostic criteria, and many others who do meet criteria are not receiving services.¹³

Link to primary care Much of the increase in treatment over this period occurred through more frequent diagnosis and treatment of mental illness during primary care visits. More than four times as many visits to general practitioners involved a psychiatric diagnosis in 1999 than in 1985 (3,217,000 versus 757,000). This pattern is consistent with the many efforts made during this period to increase the role of primary care physicians, including pediatricians, in diagnosing and treating mental health problems. These efforts meshed well with the growing evidence base for psychopharmacological treatment of children. The explosion in prescribing followed the potent combination of increased awareness of a problem and the availability of a tool that could easily be used to address that problem within the parameters of usual office practice.

However, several studies have shown that primary care providers often misdiagnose mental health problems in children, missing illnesses in some children and overdiagnosing others.¹⁴ When they provide drug treatment, primary care providers often underdose and undermonitor treatment, so that the outcomes are well below those attained in clinical trials.¹⁵ Finally, primary care providers rarely provide psychosocial treatment as an adjunct to pharmacological treatment. The average patient visit to a general practitioner including prescription of a psychotropic drug was only twenty-three minutes long—50 percent longer than the average visit by a patient without a mental health problem.¹⁶

Mental health care spending Despite these expansions in outpatient and pharmacological treatment, aggregate nominal spending on child mental health services remained virtually unchanged over this period, mainly because these expansions coincided with a sharp decline in costly inpatient service use. During the mid-1980s increases in the cost of juvenile inpatient services—particularly in private psychiatric facilities—were the main source of mental health care cost increases. In 1986 inpatient expenses accounted for about two-thirds of total mental health spending, and 26.4 children per 100,000 population were under care for a mental condition in a hospital inpatient facility that year.¹⁷ In 1988 an estimated $1.9 billion (1998 dollars) was spent on inpatient treatment of children with mental health problems.¹⁸ These high rates of inpatient use were troubling both because of their high cost and because there is little or no evidence to suggest that inpatient care is beneficial to children with mental health problems. Indeed, some studies suggest that some types of inpatient care may exacerbate children’s problems.¹⁹

Decline of inpatient care By 1996 inpatient care (of all types) accounted for only 33 percent of total mental health spending.²⁰ The number of children under care in general hospital inpatient facilities had fallen by 33 percent.²¹ National spending on inpatient care of children had declined to $1.2 billion. Care in residential treatment centers, which tend to be less costly than inpatient facilities, climbed steadily through the 1980s but flattened and declined slightly beginning in 1990.²²

These aggregate figures mask enormous changes in the way that inpatient and residential treatment facilities were used. In the mid-1980s children admitted to hospitals had very long stays—averaging eighteen days in general hospital in-patient units.²³ In the late 1990s lengths-of-stay had fallen dramatically—to eight days in general hospital inpatient units.²⁴ Rather than serving as treatment modalities, inpatient units are increasingly providing crisis care and discharging seriously ill children for community follow-up.

Community-based care These new patterns of care—increased use of medication treatment through the medical system and more limited use of specialized in-patient facilities—have put greater demand on community-based modes of therapy and on services in the specialty medical sector. Many communities now report lack of availability of child psychiatrists and of inpatient hospital beds for crisis care of children.²⁵ Shortages of child psychiatrists may be offset by the availability of other child mental health specialty providers (such as psychologists and social workers), who can fill some of these service gaps.²⁶

Along with the increase in primary care treatment during the 1990s, the use of child psychiatric services also increased. The number of visits by children to child psychiatrists more than doubled between 1985 and 1999.²⁷ This increase is consistent with the reduced reliance on inpatient care for children with serious emotional disturbances and with the increased number of children who enter mental health services through general practitioners and are then referred further along within the medical sector.

Supply of child psychiatrists Increased use of specialty mental health professionals was not accompanied by a substantial increase in supply. After rising slowly through the 1980s, the ratio of child psychiatrists to children has remained flat since 1990. Even this average masks more serious problems in some areas: The 6,000 child psychiatrists in the United States are very unevenly distributed, and many in office-based practice do not treat Medicaid patients.²⁸ In addition, the earnings of child psychiatrists have increased only slightly. Yet despite the apparent need for more providers in many areas, residency slots in child psychiatry regularly go unfilled.²⁹

Alternatives to inpatient care Institutional alternatives to long-term hospitalization are also lacking in many communities. Reductions in inpatient service use have been accompanied by increases in the use of case management services, partial hospitalization, and other community-based services. However, the increase in the provision of these services—particularly evidence-based services—has not kept pace with reductions in inpatient service use. Without viable community-based alternatives, families rely on crisis hospitalization in general hospital beds. The number of short (less than three days) stays in general hospital inpatient beds by child psychiatric patients increased by 41 percent from 1986 to 2000.³⁰

Financing Policy

Top Trends Since The Mid-1980s Financing Policy Managed care Policy For Systems Of... Editor's Notes NOTES

 
The patterns of child mental health service use described above were strongly affected by changes in the structure of health insurance in this period. Expansions of Medicaid in the late 1980s and the introduction of SCHIP in the late 1990s altered the insurance distribution among children who used mental health services. The share of all children, and of children using services, who were uninsured fell. While children without insurance are about as likely as those with coverage to have received some mental health services, uninsured children are likely to use services less intensively.³¹ Public insurance covered children who would otherwise have been uninsured. In addition, to some extent, public insurance coverage displaced private insurance. By 1998, 20 percent of children with a diagnosed mental health problem were publicly insured.³²

Medicaid and SCHIP Public insurance has always covered a disproportionate share of children with mental health problems. Children with serious emotional disturbances (SED) who qualify for Supplemental Security Income (SSI)—a group that nearly tripled over the 1990s following litigation and subsequent regulations—are also eligible for Medicaid.³³ Those eligible for Medicaid because they participated in Aid to Families with Dependent Children (AFDC) or foster care also tended to have much higher rates of mental health problems than privately insured children had. The new groups of children who have entered public insurance tend to have fewer serious mental health problems than their predecessors had. Nonetheless, this switch in coverage is important to them, because mental health benefits in Medicaid and SCHIP tend to be more comprehensive than those in the private sector (although SCHIP benefits are often not as generous as Medicaid benefits).

This broadening of the population also has implications for the treatment of children with more serious disorders. State Medicaid directors must now consider both seriously and less seriously ill children in making policy decisions, and this may dilute the program’s focus on the most seriously ill.

Managed care

Top Trends Since The Mid-1980s Financing Policy Managed care Policy For Systems Of... Editor's Notes NOTES

 
Private insurers and Medicaid programs in most states have shifted much of their mental health coverage into managed behavioral health care. By 1999 forty-two states operated some form of managed behavioral health care program—triple the number in 1996.³⁴ Some of these arrangements include children with SED in all plans; others "carve out" the care of such children to special plans. In these arrangements, Medicaid contracts with private insurers to provide service to Medicaid beneficiaries, generally paying on a capitated basis.

Managed behavioral health care for children and adolescents has generated very large savings, mainly through sharp reductions in the use of inpatient services accomplished through utilization review. In themselves, these reductions are not expected to have had substantial effects on child mental health outcomes, because the value of inpatient services for children is widely disputed. However, no studies have been conducted to document the overall effects on children’s mental health and well-being.³⁵ The lack of evidence of negative outcomes combined with the sizable cost savings suggest that managed behavioral health care has probably been a success in children’s mental health care. Nonetheless, the switch to managed care raises the potential for risk selection, underservice, and cost shifting for children, just as it does for adults. One preliminary study found that children with SED were 20 percent more likely than other patients of the same age to be disenrolled from managed care plans.³⁶ A study of Medicaid managed care in Pennsylvania found a higher rate of disenrollment for children with psychiatric admissions than for those with other admissions.³⁷

Many analysts have expressed concern that by underserving or disenrolling children with mental health problems, the introduction of managed care could shift the burden of mental health care to public systems outside the traditional medical and mental health sectors, such as juvenile justice, special education, or child welfare. To date, there is no convincing evidence that this has occurred.³⁸

Although the negative potential effects of managed behavioral health care do not seem to have materialized, neither have many of the hoped-for benefits. Studies document some increases in alternative community-based care in some managed care settings, but the effects are not large or widespread.³⁹ Problems of service coordination persist and in some cases are exacerbated by Medicaid managed care.

Parity The final element in child mental health financing policy has been the effort to achieve parity of mental health benefits with general health benefits. The past five years have seen a variety of legislative efforts to achieve this. In 1996 Congress passed the Mental Health Parity Act. Implemented in 1998, the act is limited in that it only requires parity in benefits if mental health coverage is offered. It applies to lifetime and annual dollar limits only and does not require parity in copayments, deductibles, or limits on days or visits. Some states have gone further and have passed legislation requiring that there be parity between mental health and medical benefits, although some of these laws are limited to particular types of mental health conditions only.⁴⁰ Nonetheless, a recent survey of private insurance benefits documents the persistence of visit limits for child inpatient and outpatient care.⁴¹

Out-of-pocket burden In spite of the limitations of parity legislation, changes in patterns of care and in insurance have led to improvements in the financial burden of child mental health care. The out-of-pocket share of payments for the average child with a mental health problem fell from 47 percent to 33.5 percent between 1987 and 1998, a 45 percent reduction in real out-of-pocket payments.⁴² Children with serious problems also benefited from this reduction: The out-of-pocket share at the high end of the expense distribution fell over this period.

The decline in out-of-pocket burden came about for four reasons. First, the shift of children from uninsurance and private insurance to Medicaid and SCHIP, programs that incorporate no or very low copayments, reduced the potential out-of-pocket exposure. Second, for children remaining in private insurance, managed care substituted nonfinancial rationing mechanisms, such as utilization review, for cost sharing. Third, increases in treatment occurred through increased medication use in general practice, and mental health care provided by general practitioners is not usually treated as a mental health benefit in private insurance contracts. Visit limits and copayment differences did not apply to this care. Finally, prescription drug coverage, which generally covers drugs that treat mental health problems in the same way that it covers other drugs, grew substantially between 1988 and 1998, reducing many families’ out-of-pocket burden. While parity has not been achieved, and some families still face substantial out-of-pocket burdens for mental health care, the extent of the problem has diminished.

Policy For Systems Of Care

Top Trends Since The Mid-1980s Financing Policy Managed care Policy For Systems Of... Editor's Notes NOTES

 
Children’s mental health needs differ from adults’ needs in part because of the circumstances of children’s lives. Children with mental disorders are typically involved in many service systems, attend school, and live with their families. Indeed, most children who receive mental health services are seen outside the medical and mental health systems. For this reason, since 1984 the centerpiece of child mental health policy has been the development of systems of care that would integrate care across these diverse settings. Federal financing for this effort began with the Child and Adolescent Service System Program (CASSP) in 1984 and continued with Comprehensive Community Mental Health Services for Children and Families ($78 million in 1999).⁴³

Mental health policies for community-based services also respond to the fact that the medical sector does not—and probably cannot—provide all of the services that children need. Prevalence of treatment in medical settings is still well below the estimated prevalence of disorder. In many communities formal mental health services simply do not exist. Community-based providers finance and provide services to children who are not adequately treated in the medical care sector and do not have access to formal specialty mental health care. Furthermore, the service needs of severely ill children go well beyond the specialty medical sector. Financing for systems of care is often the only policy-directed funding that provides these additional elements of care to many severely ill children.

Recent evidence has called into question the logic of emphasizing interagency coordination through systems of care. Several large studies conducted in the 1990s suggest that coordination and the development of systems of care alone are not associated with major improvements in mental health outcomes for most children.⁴⁴ In some settings, coordination of care may even lead to diffusion of responsibility and inferior results.⁴⁵ These studies suggest that what is being coordinated is more important than the coordination itself.

Along with these disappointing findings has come an encouraging raft of evidence that specific community-based programs are effective in improving outcomes for children. These programs, which have mainly been designed as alternatives to inpatient treatment, include multisystemic therapy for conduct disorder, therapeutic foster care, and certain case management and wraparound service models.⁴⁶ Controlled studies show that these programs can generate impressive results in real-world settings.⁴⁷ However, the success of these programs, which are typically formal, precisely defined in treatment manuals, and theoretically based, generally depends on fidelity to the details of the model. Divergence from the script or modification of the design often reduces the efficacy of the intervention. In many ways, the implementation of evidence-based interventions in communities resembles the introduction of psychopharmacological prescribing in primary care. Community providers, like primary care doctors, often reduce the dosage of their intervention below clinically desirable levels.

The challenge for policy focused on systems of care is to develop mechanisms to diffuse and usefully implement these evidence-based interventions in community-based settings and to align research funding accordingly.⁴⁸ The models used to develop informal systems of agency coordination models may not be effective in disseminating these more formal practices.⁴⁹

The delivery and financing of child mental health services have greatly improved in the past decade: The out-of-pocket burden of financing mental health care has fallen; more children have health insurance that covers mental health services; the evidence base for service provision has expanded; and more children are receiving effective therapies today than ever before. Despite these successes, problems remain. Most children still do not have access to effective therapies, and for many children with very serious problems, mental health service systems still have no solutions available.

During the 1980s severely ill children received a great deal of costly, but largely ineffective, inpatient care. Today’s delivery system rations inpatient and costly specialty services more strictly. But the evidence-based community alternatives to these services do not yet exist in most places, and the limited availability of specialty services leaves some children with few options. Research is needed to identify evidence-based community treatment modalities that can effectively treat seriously ill children and that can readily and practically be implemented in existing service systems. This should be a priority for federal research funding. Mental health policy must work to develop incentives and models that will diffuse these evidence-based treatment modalities once they exist.

Editor's Notes

Top Trends Since The Mid-1980s Financing Policy Managed care Policy For Systems Of... Editor's Notes NOTES

 
The authors thank the John D. and Catherine T. MacArthur Foundation for research funding. Kathrine Jack and Sarah Little provided helpful research assistance. Cristiane Duarte, Richard Frank, Michael Friedman, Kimberly Hoagwood, Ping Wu, and participants at a conference held by Health Affairs provided useful suggestions but are not responsible for any remaining errors and do not necessarily endorse the opinions voiced herein.

NOTES

Top Trends Since The Mid-1980s Financing Policy Managed care Policy For Systems Of... Editor's Notes NOTES

 

1. U.S. Department of Health and Human Services, Mental Health:A Report of the Surgeon General (Rockville, Md.: DHHS, 1999).
2. S.Glied and D. Pine, "Consequences and Correlates of Adolescent Depression," Archive of Pediatric Adolescent Medicine 156, no. 10 (2002): 1009–1014; L.Arseneault et al., "Mental Disorders and Violence in a Total Birth Cohort: Results of the Dunedin Study," Archives of General Psychiatry 75, no. 10 (2002): 979–986; P.Ellickson, H. Saner, and K.A. McGuigan, "Profiles of Violent Youth: Substance Abuse and Other Concurrent Problems," American Journal of Public Health 87, no. 6 (1997): 985–991[Abstract/Free Full Text]; and D.S.Elliott, D. Huizinga, and S. Menard, Multiple Problem Youth: Delinquency, Substance Abuse, and Mental Problems (New York: Springer-Verlag, 1989), 67.
3. A.E.Garland et al., "Prevalence of Psychiatric Disorders in Youths across Five Sectors of Care," Journal of the American Academy of Child and Adolescent Psychiatry 40, no. 4 (2001): 409–148[CrossRef][ISI][Medline]; and S.Glied et al., "Children’s Access to Mental Health Care: Does Insurance Matter?" Health Affairs (Jan/Feb 1997): 167–174.
4. DHHS, Mental Health; E.M.Z.Farmer et al., "Pathways into and through Mental Health Services for Children and Adolescents," Psychiatric Services 54, no. 1 (2003): 60–66; [Abstract/Free Full Text]B.J.Burns et al., "Children’s Mental Heath Service Use across Service Sectors," Health Affairs (Fall 1995): 147–159; E.Farmer et al., "Use Persistence and Intensity: Patterns of Care for Children’s Mental Health across One Year," Community Mental Health Journal 25, no. 1 (1999): 31–46; and S.Glied et al., "Child Outpatient Mental Health Service Use: Why Doesn’t Insurance Matter?" Journal of Mental Health Policy and Economics 1, no. 4 (1998): 173–187.[CrossRef][Medline]
5. C.W.Hoven et al., "Mental Health Service Use by Disturbed Youth: Five Service Systems vs. the Community" (Paper presented at the 126th Annual Meeting of the American Public Health Association, Washington, D.C., 15–19 November 1998).
6. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Annual Report to Congress on the Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program, 1999 (Rockville, Md.: SAMHSA, 1999).
7. DHHS, Mental Health, 141.
8. Ibid., 146.
9. H.A.Pincus et al., "Prescribing Trends in Psychotropic Medications: Primary Care, Psychiatry, and Other Medical Specialties," Journal of the American Medical Association 279, no. 7 (1998): 526–531[Abstract/Free Full Text]; and J.M.Zito et al., "Rising Prevalence of Antidepressants among U.S. Youths," Pediatrics 109, no. 5 (2002): 721–727.[Abstract/Free Full Text]
10. Authors’ tabulations of data from the National Ambulatory Medical Care Survey (NAMCS).
11. Authors’ tabulations of data from the National Medical Expenditure Survey (NMES) and the Medical Expenditure Panel Survey (MEPS).
12. E.M.Howell, J.A. Buck, and J.L. Teich, "Mental Health Benefits under SCHIP," Health Affairs (Nov/Dec 2000): 291–297; and K.Hoagwood and H. Erwin, "Effectiveness of School-Based Mental Health Services for Children," Journal of Child and Family Studies 19, no. 6 (1997): 435–451.[CrossRef]
13. For example, in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, 14 percent of youth who did not meet diagnostic criteria had received some mental health services, compared with 36 percent of youths who met diagnostic criteria. P.J. Leaf et al., "Mental Health Service Use in the Community and Schools: Results from the Four-Community MECA Study," Journal of the American Academy of Child and Adolescent Psychiatry 35, no. 7 (1996): 889–897.[CrossRef][ISI][Medline]
14. S.Horwitz et al., "Identification and Management of Psychosocial and Developmental Problems in Community-Based, Primary Care Pediatric Practices," Pediatrics 89, no. 3 (1998): 480–485.
15. P.S.Jensen et al., "Psychoactive Medication Prescribing Practices for U.S. Children: Gaps between Research and Clinical Practice," Journal of the American Academy of Child and Adolescent Psychiatry 38, no. 5 (1999): 557–565.[CrossRef][ISI][Medline]
16. Authors’ tabulations of data from NAMCS, 1999.
17. R.Sturm et al., "National Estimates of Mental Health Utilization and Expenditures for Children in 1998," Working Paper no. 205 (Los Angeles: Research Center on Managed Care for Psychiatric Disorders, 2000); and authors’ tabulations of data from the 1986 Client/Patient Sample Survey as reported in M.J.Rosenstein, L.J. Milazzo-Sayre, and R.W. Manderscheid, "Characteristics of Persons Using Specialty In-patient, Outpatient, and Partial Care Programs in 1986," in National Institute of Mental Health, Mental Health, United States, 1990, Pub. no. (ADM)90-1708, ed. R.W. Manderscheid and M.A. Sonnenschein (Washington: U.S. GPO, 1990), 139–172.
18. Authors’ tabulations of data from the Hospital Cost and Utilization Project (HCUP) database.
19. DHHS, Mental Health, 171–172.
20. Sturm et al., "National Estimates."
21. Authors’ tabulations of data from the 1986 and 1997 Client/Patient Sample Survey as reported in Rosenstein et al., "Characteristics of Persons"; and L.J.Milazzo-Sayre et al., "Persons Treated in Specialty Mental Health Care Programs, United States, 1997," in NIMH, Mental Health, United States, 2000, www.mentalhealth.org/publications/allpubs/SMA01-3537/chapter15.asp (21 May 2003).
22. R.W.Manderscheid et al., "Highlights of Organized Mental Health Services in 1998 and Major National and State Trends," in NIMH, Mental Health, United States, 2000, www.mentalhealth.org/publications/allpubs/SMA01-3537/chapter14.asp (21 May 2003).
23. Authors’ tabulations of data from the National Hospital Discharge Survey.
24. Manderscheid et al., "Highlights of Organized Mental Health Services in 1998."
25. S.Geballe, "The State of Children’s Mental Health in Connecticut: A Brief Overview" (Farmington: Connecticut Health Foundation, 2002); American Academy of Child and Adolescent Psychiatry, "AACAP Work Force Data Sheet: Critical Shortage of Child and Adolescent Psychiatrists," www.aacap.org/training/workforce.htm (31 December 2002); C.R.Thomas, "National Distribution of Child and Adolescent Psychiatrists," Journal of the American Academy of Child and Adolescent Psychiatry 38, no. 1 (1999): 9–15; [CrossRef][ISI][Medline]Maryland Health Care Commission, "An Analysis and Evaluation of Certificate of Need Regulation in Maryland: Working Paper, Child and Adolescent Inpatient Psychiatric and RTC Services," 18 October 2001, www.mhcc.state.md.us/resources/conapps/study_report/childaiprtc.pdf (10 June 2003); B.Walsh, "Child Psychiatrists: Few and Far Between," Maine Press Herald, 18 August 2002; Mental Health Connection of Tarrant County, "Six Major Reasons Why Health Care Is Scarce in Tarrant County," 2002, www.mhctc.org/reasons.htm (21 May 2003); B.Walsh, "Once Back in Maine, Assistance Is Hard to Find," Maine Press Herald, 10 November 2002; and K.Jackson, "Three Days, Three Lives Lost," 2003, www.tbo.com/health/suicide/day2.htm (11 July 2003).
26. There do not appear to be systemwide shortages in the supply of these professionals. For information about psychologist and social worker supply, see Bureau of Labor Statistics, "Occupational Outlook Handbook, 2002–2003: Psychologists," www.bls.gov/oco/ocos056.htm (10 June 2003); and BLS, "Occupational Outlook Handbook, 2002–2003: Social Workers," www.bls.gov/oco/ocos060.htm (10 June 2003).
27. Authors’ calculations of data from the NACS.
28. AACAP, "AACAP Work Force Data Sheet"; and Thomas, "National Distribution of Child and Adolescent Psychiatrists."
29. AACAP, "AACAP Work Force Data Sheet."
30. Authors’ tabulations of data from the National Hospital Discharge Survey.
31. Glied et al., "Children’s Access to Mental Health Care"; C.L.White et al., "Factors Associated with Admission to Public and Private Hospitals from a Psychiatric Emergency Screening Site," Psychiatric Services 46, no. 5 (1995): 467–472[Abstract/Free Full Text]; and D.Yohanna et al., "Characteristics of Short-Stay Admissions to a Psychiatric In-patient Service," Journal of Behavioral Health Services and Research 25, no. 3 (1998): 337–345.[CrossRef]
32. Agency for Healthcare Research and Quality, "MEPS HC-028: 1998 Full Year Consolidated Data File," December 2001, www.meps.ahrq.gov/Puf/PufDetail.asp?ID=69 (30 July 2003).
33. U.S. General Accounting Office, Supplemental Security Income: SSA Needs a Uniform Standard for Assessing Childhood Disability, Pub. no. GAO/HEHS-98-123 (Washington: GAO, 1998).
34. SAMHSA, State Profiles, 1999, on Public Sector Managed Behavioral Health Care, Pub. no. SMA00-3432 (Rockville, Md.: SAMHSA, 2000).
35. A.B.Hutchinson and E.M. Foster, "The Effect of Medicaid Managed Care on Mental Health Care for Children: A Review of the Literature," Mental Health Services Research 5, no. 1 (2003): 39–54.[CrossRef][Medline]
36. SAMHSA, "Child, Adolescent, and Family Program Summary," May 1999, www.mentalhealth.org/cmhs/childrenscampaign/cafbprog.htm (30 May 2001).
37. S.H.Scholle et al., "Changes in Medicaid Managed Care Enrollment among Children," Health Affairs (Mar/Apr 1997): 164–170.
38. Hutchinson and Foster, "The Effect of Medicaid Managed Care."
39. A.M.Libby et al., "Substitution in a Medicaid Mental Health Carve-Out: Services and Costs," Journal of Health Care Finance 28, no. 4 (2002): 11–23[Medline]; and Burns et al., "Managed Behavioral Health Care."
40. National Institutes of Health, Insurance Parity for Mental Health: Cost, Access, and Quality, Final Report to Congress by the National Advisory Mental Health Council, Pub. no. 00-4787, June 2000, www.nimh.nih.gov/parity/paritytoc.cfm (30 May 2001).
41. P.B.Peele et al., "Exclusions and Limitations in Children’s Behavioral Health Care Coverage," Psychiatric Services 53, no. 5 (2002): 591–594.[Abstract/Free Full Text]
42. Authors’ tabulations of data from MEPS.
43. SAMHSA, Center for Mental Health Services, Annual Report to Congress.
44. L.Bickman et al., "Long-Term Effects of a System of Care on Children and Adolescents," Journal of Behavioral Health Services and Research 26, no. 2 (1999): 185–202; and L.Bickman, "A Continuum of Care: More Is Not Always Better," American Psychologist 51, no. 7 (1996): 921–933.
45. C.Glisson and A. Hemmelgarn, "The Effects of Organizational Climate and Interorganizational Coordination on the Quality and Outcomes of Children’s Service Systems," Child Abuse and Neglect 22, no. 5 (1998): 401–421.[CrossRef][ISI][Medline]
46. DHHS, Mental Health, 172; and B.J.Burns, "Reasons for Hope for Children and Families: A Perspective and Overview," in Community Treatment for Youth, ed. B.J. Burns and K. Hoagwood (New York: Oxford University Press, 2002), 3–15.
47. J.Burchard, E. Bruns, and S. Burchard, "The Wraparound Approach," in Community Treatment for Youth, ed. Burns and Hoagwood, 69–90; and S.Schoenwald and M. Rowland, "Multisystemic Therapy," in Community Treatment for Youth, ed. Burns and Hoagwood, 91–116.
48. S.M.Horwitz et al., "Barriers to Health Care Research for Children and Youth with Psychosocial Problems," Journal of the American Medical Association 288, no. 12 (2002): 1508–1512.[Abstract/Free Full Text]
49. Burns, "Reasons for Hope."

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