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2001 Annual Report to Congress on the Evaluation
of the Comprehensive Community Mental Health
Services for Children and Their Families Program
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EXECUTIVE SUMMARY
Over the past three decades, increasing attention has been given to the needs of children and adolescents with serious emotional disturbance. Beginning with the findings from the Joint Commission on the Mental Health of Children (National Institute of Mental Health, 1969) and substantiated by numerous subsequent studies, task forces, and reports, children with serious emotional disturbance typically were found to be underserved or served inappropriately by a fragmented mental health services system. In response to these findings, Federal leadership, along with a growing family movement, began to emerge and create a new paradigm for serving the estimated 4.5 to 6.3 million children in the United States who have a serious emotional disturbance (Friedman, Katz-Leavy, Manderscheid, & Sondheimer, 1999). This paradigm shift has resulted in a system-of-care approach, designed to help build comprehensive service systems that allow children with emotional disturbance to receive a comprehensive array of integrated, community-based services.
The system-of-care approach is based on a philosophy built on three hallmark tenets: (a) mental health service systems are driven by the needs and preferences of the child and family; (b) services are community based with their management built on multi-agency collaborations; and (c) the services offered, the agencies participating, and the programs generated to meet the mental health needs of the children are responsive to the cultural context and other characteristics of the populations being served.
To develop a system of care consistent with the theoretical approach described above, a community must focus its service program activities at two distinct levels: (a) infrastructure to house, organize, and manage the integrated program elements; and (b) service delivery to provide services, treatments, and supports that are offered directly to children and families.
The Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA) has had the primary responsibility for translating this framework into a program of services and supports that now exists in 67 grant communities around the country. Beginning with a funding mechanism to support the creation of a service system infrastructure called the Child and Adolescent Service System Program (CASSP) in 1986 and culminating with the passage of the Children's and Communities Mental Health Services Improvement Act in 1992, CMHS has championed the development of community-based, family-focused, and culturally competent systems of care. Funding for these systems of care is provided through CMHS's Comprehensive Community Mental Health Services for Children and Their Families Program.
This program, in its eighth year, provides grants to States, communities, territories, American Indian tribes, and Alaskan Native communities to improve and expand their systems of care to meet the needs of children and adolescents with serious emotional disturbance and their families. These include children and youth with a serious emotional disturbance from birth to age 21 who currently have, or at any time during the past year had, a mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994), that resulted in functional impairment that substantially interferes with or limits one or more major life activities. Administered by CMHS's Child, Adolescent and Family Branch, funding for the initiative has grown from an initial $5 million in its first year to the FY 2001 level of $91.7 million.
In addition to developing systems of care, the CMHS program is mandated by Congress to demonstrate the effectiveness of these systems. The foremost method to demonstrate program effectiveness is through evaluation. Beyond serving as a fiscal watchdog, evaluation-both of specific grant community programs and of the combined effect of many systems of care-can inform CMHS about what works best for whom, and under what conditions. As such, it helps guide new directions for current grant communities and sets a benchmark for future generations of community-based systems of care. Government Performance and Results Act (GPRA) measures set for this program include increases in average number of children receiving services, collaboration among child-serving agencies, stability of children's living arrangements and family satisfaction, decreases in the use of inpatient or residential services, and improvement in child clinical and functional outcomes as indicators of program effectiveness. Information about program performance on these measures is presented in detail throughout the 2001 Annual Report to Congress.
This report presents evaluation findings as of FY 2001. Findings from the evaluation of the first cohort of grant communities, funded in 1993 and 1994, have been presented in previous Reports to Congress (CMHS, 1996, 1997, 1998, 1999, 2000). This report includes findings from the cohorts funded in 1997, 1998, and 1999 with the exception of findings from the first longitudinal comparison study, which was conducted in grant communities funded in 1993-94. Chapter II presents findings from the system-of-care assessments. Chapter III provides an in-depth analysis of the Phase I comparison study conducted from 1997 to 2000, including overview, methods, and results. Chapter IV provides the most recent findings from the descriptive and outcomes studies and preliminary findings from the second comparison study that began in 1999. Chapter V presents a progress report on the Phase II comparison study, which is being conducted in communities funded in 1997. Preliminary results from the special studies currently being conducted are found in Chapter VI. Chapter VII presents the activities of partners affiliated with the Comprehensive Community Mental Health Services for Children and Their Families Program. References are found in Chapter VIII.
Figure ES-1
This Executive Summary presents findings from four types of evaluation data, described as follows:
- Outcomes data based on project site evaluations of a selected group of about 950 children assessed at intake and 6 months, who will continue to be evaluated for up to 36 months. Outcomes measures applied in the evaluation included-but were not limited to-an assessment of the child's clinical and social functioning, strengths, educational performance, stability of living arrangements, delinquent activities and engagement with law enforcement, and substance use, as well as assessment of family functioning, family resources, and strains experienced by caregivers of children with serious emotional disturbance. These were coupled with an assessment of services received and child and family ratings of satisfaction with services provided. Instruments typically used in the field of children's mental health, including the Child Behavior Checklist (CBCL; Achenbach, 1991), the Child and Adolescent Functional Assessment Scale (CAFAS; Hodges, 1990), and the Behavioral and Emotional Rating Scale (BERS; Epstein & Sharma, 1998), were used to collect these data.
- Service system assessment data collected during multiple years through systemwide and family assessments of service delivery in system-of-care communities.
- Child and family outcomes data as well as service system assessment and management information system (MIS) data obtained in communities with system-of-care grants and communities without these grants.
- Descriptive data (e.g., demographic information, diagnostic status, functional characteristics, and referral sources) obtained at the time children entered services.
The evaluation is comprehensive and involves the grant communities, the children and families served by the CMHS programs, service providers, and partner agencies (Holden, Friedman, & Santiago, 2001). It also involves non-funded comparison communities. The number of grantees, participants, components, and methodologies incorporated into the evaluation make it the most extensive study ever undertaken of a children's mental health services initiative. The core components of the evaluation, as mandated by the legislation, are briefly described below.
The format for reporting findings in this Executive Summary is to present a brief finding followed by its corresponding graph. Findings of change over time are reported as the change occurring among children from the time of entry into services to subsequent data collection times.
A list of the grant communities funded in 1993, 1994, 1997, 1998, 1999, and 2000 under this congressionally mandated program is on pages xliv-xlvi.
CHILD OUTCOMES
Preliminary findings showed improvements for children during their first 6 months in services.
Children's Behavioral and Emotional Strengths Improved
After 6 months in system-of-care services, almost 50 percent of the caregivers reported significant improvements in their children's strengths, 28.5 percent reported stable levels of strengths, and 22.6 percent reported a deterioration in overall strengths, as measured by the Behavioral and Emotional Rating Scale. Of those who improved, 18.5 percent reported above average strengths, 44.1 percent reported average strengths, and 37.4 percent reported below average strengths at 6 months (see Figure ES-2).
Behavioral and Emotional Problems Were Reduced
After 6 months in system-of-care services, 36 percent of the children showed significant improvement in their total problem behaviors, as measured by the Child Behavior Checklist. Half of these children had scores that fell below those indicating a need for clinical care at 6 months. Over half of the children remained stable in their reported problems (see Figure ES-3).
As displayed in Figure ES-4, children without a diagnosis of attention-deficit/hyperactivity disorder (ADHD) experienced greater reduction in problems than those diagnosed with ADHD.
Increases in Behavioral and Emotional Strengths Were Accompanied by Reductions in Behavioral and Emotional Problems
After 6 months in system-of-care services, children whose behavioral and emotional strengths improved had the greatest reduction in their behavioral and emotional problems (see Figure ES-5).
Functional Impairment Was Reduced
Six months after entry into systems of care, average CAFAS scores declined from 103.26 (intake) to 84.78 (6 months), indicating improvement in children's overall functioning in society and interaction with others. Youth aged 11-15 years experienced significantly greater improvement in overall CAFAS scores than children aged 5-10 years or those aged 16-18 years (see Figure ES-6).
School Attendance Improved
Regular attendance at school is critical to a child's future professional and economic success. School attendance increased among children during their first 6 months in systems of care. Among 348 children, 67.9 percent attended school regularly (75 percent or more of the time) during the 6 months before entering systems of care. After 6 months in systems of care, 72.3 percent of children attended school regularly.
School Performance Improved
Children's school achievement also improved during the first 6 months in systems of care. Fewer children received failing grades after 6 months in systems of care and more children received passing grades. The percentage of children with a passing grade (a grade average of C or better) increased from 58.9 percent at intake to 65.8 percent after 6 months in systems of care among 535 children. Failing grades fell from 17 percent to 14 percent. Children receiving a grade of "D" fell from 15 percent to 9 percent during their first 6 months in systems of care.
Law Enforcement Contacts Were Reduced
Fewer youth reported being accused by the police of breaking the law, arrested, convicted of crimes, or sent to a jail or detention center during the first 6 months in systems of care than in the 6 months before entering systems of care. The greatest decrease was in the percentage of youth spending time in jail or detention centers (30.6 percent at intake, 23.1 percent at 6 months). This change represents a 25 percent reduction in the number of youth who spent time in these facilities.
There was also a decrease from intake to 6 months in other self-reported delinquent behaviors such as being rowdy in a public place and carrying a weapon (see Figure ES-7). These types of behaviors typically lead to encounters with authorities; consequently, reductions in these behaviors may reduce subsequent contacts with law enforcement.
Fewer Youth Reported Use of Cigarettes, Alcohol, and Marijuana
An examination of self-reported substance use across time for youth with both intake and 6 month substance use information shows that a lower percentage of youth reported recent (during the past 6 months) cigarette, alcohol, and marijuana use after 6 months in services than reported use at intake (see Figure ES-8).
Decreases in the percentage of youth reporting any cigarette, alcohol, or marijuana use from entry into system-of-care services to 6 months after entering these services differed by service experience among youth who reported 6-month substance use at both data points. The 108 youth who received recreational services experienced a 28 percent decrease in substance use. The 91 youth who received services in a restrictive setting experienced a 12 percent decrease in substance use, and the 311 youth who received outpatient services experienced a 10 percent decrease in substance use. Youth who received medication treatment and monitoring experienced only a 6 percent decrease in substance use.
Residential Stability Improved
Establishing stability in the living situations of children who may have had multiple, short-term placements, ranging from the homes of relatives to foster homes and residential treatment facilities, is an important goal of the program. Single residential living arrangements among children who remained in services for 6 months made a 14 percent gain over similar placements at intake (see Figure ES-9).
When comparing changes in living placements from intake to 6 months, the majority of the children (65 percent) lived in the same type of placement at intake and 6 months. Of these children, 79 percent stayed in family settings.
FINDINGS FROM THE COMPARISON OF SYSTEM-OF-CARE FUNDED COMMUNITIES AND NON-FUNDED COMMUNITIES IN PHASE I
When children in one funded system-of-care community (Stark County, Ohio) were compared to children in a matched, non-funded, non-system-of-care community (Mahoning County, Ohio), children with the most serious problems in the funded system-of-care community, the group targeted by the CMHS program, experienced greater rates of change in behavioral and emotional problems.
Children in System-of-Care Communities Experienced Greater Reductions in Externalizing Problems During First 18 Months than Children in Non-System-of-Care Communities
According to reports by caregivers, children in Stark County, the system-of-care community, entered services with slightly fewer externalizing behavioral and emotional problems than children in Mahoning County, the non-system-of-care community. Children in Stark County improved at a greater rate initially; however, children in both communities reached equivalent levels of improvement after 24 months after intake into services (see Figure ES-10).
Recidivism Rates Were Lower for Stark County System-of-Care Children
Offense data were available for any child in the study who had been charged with an offense between 1997 and 2000 based on Juvenile Court data from both counties. Thus, these data cover a period of time both before and after a child entered the study. All 4 years of the juvenile offense data were used in the current analyses, regardless of when a child was enrolled into the study. The periods for which offense data were available before and after study entry varied across children, depending upon when they were enrolled (e.g., more offense data are available after study entry for children enrolled earlier). For the period following study entry, recidivism in Mahoning County was greater than in Stark County. Specifically, children with two or more charges before study entry were more likely to have two or more charges after study entry in Mahoning County than in Stark County. Figure ES-11 presents a summary of the number of juvenile justice charges after study entry for those children with two or more charges prior to entering the study. While only 6 percent of children from Mahoning County did not recidivate after study entry, 30 percent of children from Stark County did not recidivate after committing two or more offenses prior to study entry. Thus, the Stark County system of care appears to have a greater impact on reducing recidivism among the most chronic juvenile offenders compared to the Mahoning County traditional service delivery system.
Service Experiences Embodied System-of-Care Principles at High Levels in Stark County
Services data were collected from the community mental health centers (CMHC) through which children were enrolled into the study in Stark and Mahoning Counties. Each CMHC has a computerized management information system (MIS) used for internal management purposes and to bill insurance companies, Medicaid organizations, families, and other parties responsible for payment. The charges for services were collected for the study to compare the costs for serving children in the system of care to the costs in the matched comparison community.
Stark County Provided More Services and a Broader Mix of Individual, Family, and Group Counseling than the Non-System-of-Care Community
Children and families in the Stark County system of care received more than twice as many services in the first 18 months after study entry as children and families in the Mahoning County CMHC. Children in Stark County and Mahoning County differed in patterns of use of various types of counseling. The Mahoning County CMHC relied more heavily on individual counseling, while the Stark County CMHC provided a broader mix of individual, family, and group counseling. Ninety-five percent of children received individual counseling from the Mahoning County CMHC compared to 75 percent from the Stark County CMHC. However, the Stark County CMHC provided family or group counseling to 82 percent of children compared to 11 percent of children at the Mahoning County CMHC (see Figure ES-12).
Children in Systems of Care with Severe Impairment Received Significantly More Hours of Services Across Time
When children were divided into severe and less severe groups based on CAFAS total scores, the average hours of services continually decreased for children in both groups for both the Stark County CMHC and the Mahoning County CMHC over the first 18 months after study entry (see Figure ES-13). However, while there was no difference in the average hours of services received by the two severity groups in Mahoning County, children in the severe group in Stark County received significantly more hours of services on average than those in the less severe group. This difference suggests that services delivered in the Stark County system of care probably were more individualized to the needs of children and families than those delivered in Mahoning County, the non-system-of-care community.
Children Receiving Services in a System of Care Had Fewer Juvenile Justice Placements
From the service data collected from community child-serving providers, the Stark County system of care appeared to be slightly more effective in reducing juvenile detention services children received in the community as displayed in Figure ES-14. In the first 18 months after study entry, 7 percent fewer children were placed in juvenile detention centers in Stark County as compared to children in Mahoning County; however, the percentage of children placed through the local child welfare provider was slightly higher in Stark County. While an equal percentage of children in both communities was placed in special education programs, slightly more children were placed in inpatient hospitals and residential treatment centers in Mahoning County for mental health treatment at some time during the first 18 months of services.
PHASE II COMPARISON STUDY: PRELIMINARY FINDINGS
The Phase II comparison study includes two system-of-care communities and two matched, non-funded, non-system-of-care communities in Alabama and Nebraska. Findings from this second comparison study are preliminary at this early stage of the study.
Children in System-of-Care Communities Received Needed Services
Children in system-of-care communities were significantly more likely to receive case management, medication treatment and monitoring, and day treatment or group home services than those in the non-system-of-care communities (see Figure ES-15).
In the system-of-care communities, children who received medication treatment and monitoring, day treatment or group home, or residential services had higher Externalizing and Internalizing CBCL scores, indicating greater emotional and behavioral problems, and higher CAFAS scores, indicating greater impairment in social functioning, than children who did not receive these services. Families who received respite had children with higher externalizing behavior problems than those who did not receive this service.
SERVICES RECEIVED IN COMMUNITIES FUNDED IN 1997 AND 1998
Children and Families Received a Broad Array of Services
Children and families received a broad array of services during their first 6 months in system-of-care services. The number of services received by any individual child or family ranged from 1 to 16 (average of 5.8 services). Figure ES-16 shows the percentage of children receiving different types of services.
The majority of children (97.4 percent) received at least one traditional service, including services such as individual, family or group therapy; case management; assessment; medication treatment and monitoring; or crisis stabilization. Most children (71.7 percent) also received at least one innovative service, including services such as recreational activities, family preservation, caregiver support, and respite. Fewer than one-third received services in a restrictive setting (e.g., residential treatment or inpatient hospital setting).
Characteristics of Children Receiving Medication Services
Characteristics of children who received medication treatment and monitoring are displayed in Figure ES-17. Children receiving this service differed significantly from those who did not with regard to gender, age, diagnosis, and referral source.
CAREGIVER RATINGS OF SERVICES
Caregivers Rated Service Activities at a High Satisfaction Level
- Caregivers were satisfied with services. Over 75 percent of the caregivers indicated that they were satisfied or very satisfied with services received (see Figure ES-18).
- Caregivers were satisfied with their child's progress. Almost 65 percent of the caregivers were satisfied or very satisfied with their child's progress after 6 months in services (see Figure ES-18).
- Caregivers reported satisfaction with involvement in planning services. Over 80 percent of the caregivers reported being satisfied or very satisfied with their level of involvement with planning services (see Figure ES-18).
- Caregivers reported satisfaction with their providers' respect for their family's beliefs and understanding of their family's traditions. Over 80 percent of caregivers reported satisfaction with their providers' respect for their family's beliefs and understanding of their family's traditions (see Figure ES-18).
YOUTH RATINGS OF SERVICES
Youth Rated Service Activities at a High Satisfaction Level
- Overall youth reported greater satisfaction with their progress but less satisfaction with services than caregivers reported.
- Youth were satisfied with services. Over 70 percent of youth indicated that they were satisfied or very satisfied with services received (see Figure ES-19).
- Youth were satisfied with their progress. Overall, 74 percent of youth were satisfied or very satisfied with their progress after 6 months in services (see Figure ES-19).
- Youth reported satisfaction with involvement in planning services. Over 65 percent of youth reported being satisfied or very satisfied with their level of involvement with planning services (see Figure ES-19).
- Youth reported satisfaction with their providers' respect for their family's beliefs and understanding of their family's traditions. Over 73 percent of youth reported satisfaction with their providers' respect for their family's beliefs and understanding of their family's traditions (see Figure ES-19).
CHARACTERISTICS OF SERVICES RECEIVED THAT CAREGIVERS FOUND MOST HELPFUL
In order to examine issues unique to each family and each system of care, 6 months after entry into systems of care, caregivers were asked, "What has been the most helpful thing about the services you and your child have received over the past 6 months?" Many of the responses to this question emphasized improvement in children's attitudes, behaviors, and school performance. Other responses highlighted improved communication between caregivers and children, while others noted their families' increased understanding about their children's severe emotional disturbance. Some caregivers praised specific programs. Many of the overarching principles of systems of care (outlined in Chapters I and II) were mentioned as factors that were most helpful about the services received during the first 6 months in services.
A Sample of Caregiver Responses to the Question
"What has been the most helpful thing about the services you and your child have received over the past 6 months?"
- Family preservation
- Medication monitoring
- Service provider comes to the house
- Working with school and getting their input
- Wraparound technique addresses all issues
- Changed daughter's attitude-happier, more confident
- My son's attitude has changed and grades have improved
- Having someone to talk to about my son
- Not feeling like I'm doing this all by myself
- They help us to communicate better
- Helped the family function
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HOW SYSTEMS OF CARE IN CMHS GRANT COMMUNITIES DEVELOP, IMPLEMENT GUIDING PRINCIPLES, AND ACHIEVE SUCCESS OVER TIME
The evaluation of service system implementation was based on eight principles. The eight system-of-care principles are family focused, individualized, culturally competent, interagency, collaborative/coordinated, accessible, community based, and least restrictive.
Grant communities funded in 1997 and 1998 that were assessed three times between their second and fourth grant year made significant progress in implementing systems of care for services to children with serious emotional disturbance. Some observations from these multiple assessments follow:
- In grant communities, system-of-care principles are being manifested across the board.
- The majority of grant communities consistently performed well (above the mid-range in system-of-care assessments) across most system-of-care principles and across the three assessment points.
- No grant communities performed poorly, in a consistent manner, in their implementation of infrastructure and services according to the eight guiding system-of-care principles.
- At the three assessments points, grant communities scored highest on the principles of family focused, accessible, and individualized care, indicating that effective efforts had been made to
- involve families in the care of all children, to recognize that families are important contributors and equal partners in any effort to serve children, and to maximize family involvement in system and service processes;
- minimize barriers to services in terms of physical location, convenience of scheduling, and financial constraints; and
- ensure that provision of care is expressly child centered, addresses child-specific needs, and recognizes and incorporates child-specific strengths.
- At the three assessment points, grant communities scored lowest on the principles of cultural competence and interagency collaboration, indicating less success with
- ensuring that the service system was sensitive and responsive to the inherent value of differences related to race, religion, language, national origin, gender, socioeconomic background, and community-specific characteristics; or
- establishing and facilitating multi-agency involvement.
CHARACTERISTICS AND SERVICE EXPERIENCE OF CHILDREN AND FAMILIES SERVED IN GRANT COMMUNITIES FUNDED IN 1997, 1998, AND 1999
Children with Serious Emotional Disturbances Were Disproportionately Poor, Male, and in Living Situations Other Than Two-Parent Homes
- More than two-thirds of children served were boys. About 68 percent of the children were boys and 32 percent were girls (see Table ES-1).
- More than half of children were in early adolescence. The children's average age across grant communities was 12.2 years. Among the children, 28 percent were aged 10 years or younger, 51 percent were aged 11-15 years, and 21 percent were aged 16 years or older (see Table ES-1).
- A diverse racial-ethnic population was served. Sixty percent of the children were White, 23 percent were African-American, 12 percent were American Indian, 10 percent were Hispanic, 1.1 percent were Asian American, Native Hawaiian or Pacific Islander, and 6 percent were of other racial or ethnic background (see Table ES-1).
- The majority of families were poor. Forty-nine percent of the children lived in households with an annual income of less than $15,000 (see Table ES-1). According to the 2001 U.S. Department of Health and Human Services (DHHS) poverty guidelines, a family of four with two children is living in poverty if their income is below $17,650 (DHHS, 2001).
- Mother-maintained households had the highest poverty rates. Sixty-seven percent of those living with their mother only were living below the poverty threshold as compared to 43 percent of those living with both parents and 40 percent of those living with their father only. This high percentage of single-mother and two-parent low-income households in systems of care far exceeds the national rate. Nationally, 35 percent of all female-maintained, single-parent households and 7 percent of two-parent households had poverty-level incomes in 2001 (U.S. Census Bureau, 2001).
Most Children Received Services Prior to Entering System-of-Care Programs
- The majority of children received outpatient services (65 percent) and school-based services (54 percent) in the year prior to entry into system-of-care programs.
- Children 5 years or older were more likely to have received outpatient services (68 percent for children 5-10 years old, 66 percent for those 11-15 years old, and 64 percent for youth 16 years or older), compared to those younger than 5 years (35 percent). Age differences were also observed for school-based services.
Children Entered Systems of Care Through Various Sources
- Twenty-nine percent of the 3,795 children were referred by mental health agencies, 19 percent by juvenile justice agencies, 18 percent by schools, 13 percent by child welfare/child protective services, 11 percent by caregivers or youth themselves, and 11 percent by others such as family friends, physical health clinics, and substance abuse clinics.
Children Differed by Source of Referral
- Referral source differed significantly by gender. Boys were more likely to be referred from juvenile justice agencies (20 percent vs. 17 percent of girls), whereas girls had a higher probability of being referred by child welfare/child protective services (16 percent vs. 11 percent of boys).
- Children who had taken medication in the past 6 months were almost twice as likely to be referred by mental health agencies as those who had not taken medication, whereas the likelihood of self-referrals (parent or self-referrals) was significantly higher for those who did not take medication (15 percent vs. 7 percent of those who took medication).
Children Entered System-of-Care Programs with Various Problems
Caregivers of 85 percent of children mentioned at least one problem that led to their children's referral to services. The most frequently reported problems were non-compliance (40 percent) and physical aggression (39 percent). Among those children with caregiver-identified presenting problems, 80 percent had two or more problems, and their caregivers reported an average of four problems.
Boys and Girls Differed in Their Presenting Problems
Girls were more likely to be identified with problems of an internalizing nature such as eating disorders, sadness, self-injury, suicide attempt and ideation, and poor self-esteem. Girls also had a higher probability of having run away from home than boys. Boys tended to have more problems of an externalizing nature such as physical aggression, property damage, hyperactive-impulsive behavior, attentional difficulties, and police contact (see Figure ES-20).
CHILD RISK FACTORS
Caregivers reported at least one child risk factor for 70 percent of children.
Girls Experienced More Risk Factors
Girls had a higher probability than boys of having a caregiver report three or more risk factors than boys (31 percent vs. 21 percent of boys). Girls had a higher probability of having run away, having been sexually abused, and having attempted suicide, while caregivers of boys were more likely to report that their children had been sexually abusive to others (see Figure ES-21).
FAMILY RISK FACTORS
The Majority of the Families Had Experienced at Least One Family Risk Factor
Almost all children (94 percent) were exposed to at least one family risk factor. Fifty-five percent of the caregivers reported three or more family risk factors experienced by children's biological families. Of all family risk factors, history of substance use was the most frequently cited risk factor (66 percent), followed by mental illness (51 percent), domestic violence/spousal abuse (49 percent), felony conviction (47 percent), and previous psychiatric hospitalization (30 percent).
There were significant age differences in the likelihood of having experienced mental illness, felony conviction, and domestic violence, with children aged 5-10 years experiencing these risks with greater frequency than children in other age groups (see Figure ES-22). For example, caregivers of 54 percent children aged 5-10 reported a history of domestic violence in the biological family, which was significantly higher than for the other three age groups.
DIAGNOSTIC CHARACTERISTICS
The highest percentage of the children with valid diagnostic information were reported to have attention-deficit/hyperactivity disorder (ADHD; 34 percent), followed by oppositional defiant disorders (27 percent), mood disorders (including depression and bipolar disorders; 25 percent), adjustment disorder (17 percent), and conduct disorders (11 percent; see Figure ES-23 for a full list of diagnostic categories and the percentage of cases in each category).
Diagnosis Differed by Referral Source
Children referred from juvenile justice agencies were most likely to have a substance-related disorder (20 percent) as compared to those referred from other agencies (3 percent for schools, 4 percent for mental health agencies, 6 percent for self, and 10 percent for social service referrals). Children referred from schools and mental health agencies were twice as likely to be diagnosed with ADHD (45 percent and 41 percent, respectively) than those referred from juvenile justice agencies (21 percent).
EDUCATIONAL STATUS
- The majority of school-aged children (95 percent of the 1,425 children) attended school in the 6 months prior to intake.
- At intake, 67.5 percent (of 1,098 children with attendance data) attended school on a regular basis (more than 75 percent of days), while 19.5 percent attended more often than not (50 to 75 percent of days) and 12.9 percent attended infrequently (less than 50 percent of the time).
The Majority of Children Had an Individualized Education Plan (IEP)
- Fifty-two percent of the children who attended school had an Individualized Education Plan (IEP) at intake into system-of-care services.
- Sixty-six percent of the IEPs reflected behavioral/emotional disturbances. Forty-four percent of the children had an IEP for challenges due to learning disabilities, and 18 percent had an IEP for physical disabilities and various other reasons such as vision and hearing impairment (see Figure ES-24).
School Performance Was Highest Among Those Attending School Regularly
As expected, school performance was highest among those who attended school regularly (see Figure ES-25). Children attending school more than 50 percent of the time were twice as likely to have a grade average of C or better than those who attended less than 50 percent of the time.
JUVENILE JUSTICE STATUS
Contacts with the Juvenile Justice System
- Among the youth aged 11 years or older reporting on their own delinquent behavior, 62.7 percent reported engaging in at least one delinquent behavior in the 6 months before entering services, and 65.9 percent reported at least some involvement with the law.
- Of youth aged 11 years or older, 54.5 percent had been accused of breaking the law by the police in their lifetimes, 43.5 percent had been arrested, 36.8 percent were found guilty in court, 42.5 percent had been on probation, and 34.9 percent had been in a detention center for breaking the law.
- Youth who reported any involvement with the law were significantly older than those who did not report involvement, and boys were more likely to report all forms of involvement than girls (see Table ES-2).
SUBSTANCE USE STATUS
Over half of the youth 11 or older who provided self-reports of substance use had tried alcohol or cigarettes at least once, and nearly half had tried marijuana at least one time in their lifetime (see Figure ES-26). Approximately 27 percent of 1,004 youth reported using at least one illicit drug (other than marijuana) in their lifetime.
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