Children’s Mental Health

Children’s Mental Health-http://nccp.org/publications/pdf/text_929.pdf
What Every Policymaker Should Know
Shannon Stagman April 2010
Janice L. Cooper 2
CHildren’s Mental HealtH
What every Policymaker should Know
Shannon Stagman, Janice L. Cooper
Copyright © 2010 by the National Center for Children in Poverty
AuthorS
Janice L. Cooper, PhD, is interim director at NCCP and
assistant clinical professor, health Policy and Management
at Columbia university Mailman School of Public health.
Dr. Cooper directs unclaimed Children revisited, a series
of policy and impact analyses of mental health services
for children, adolescents, and their families. From 2005 to
2010, she led NCCP’s health and mental health team.
Shannon Stagman, MA, is a research analyst for early
childhood and health and mental health at NCCP. She works
primarily on Project thrive, the policy support initiative for the
State Early Childhood Comprehensive Systems (ECCS) funded
by the Maternal and Child health Bureau, and provides
research support for various mental health projects, including
Unclaimed Children Revisited: California Case Study.
ACkNowLEDgMENtS
the authors thank Christel Brellochs and Yumiko Aratani for
their guidance in the development of this brief. Special thanks
also to Morris Ardoin, Amy Palmisano, and telly Valdellon for
their production support.
this brief updates Children’s Mental Health: Facts for
Policymakers (Masi and Cooper 2006).
the national Center for Children in Poverty (nCCP) is the nation’s leading public
policy center dedicated to promoting the economic security, health, and well-being
of america’s low-income families and children. Using research to inform policy and
practice, nCCP seeks to advance family-oriented solutions and the strategic use of
public resources at the state and national levels to ensure positive outcomes for the next
generation. Founded in 1989 as a division of the Mailman school of Public Health at
Columbia University, nCCP is a nonpartisan, public interest research organization.National Center for Children in Poverty Children’s Mental Health 3
Children’s Mental Health
What Every Policymaker Should Know
Shannon Stagman | Janice L. Cooper April 2010
Mental health is a key component in a child’s healthy
development; children need to be healthy in order
to learn, grow, and lead productive lives. The mental
health service delivery system in its current state
does not sufficiently meet the needs of children
and youth, and most who are in need of mental
health services are not able to access them. With
the addition of effective treatments, services, and
supports, the mental health system can become
better equipped to help children and youth with
mental health problems, or those who are at risk,
to thrive and live successfully.
Children’s Mental Health Problems are Widespread
Mental health and substance abuse problems occur
commonly among today’s youth
1
and begin at a
young age.
2
♦ One in five children birth to 18 has a diagnosable
mental disorder.
3
♦ One in 10 youth has serious mental health problems that are severe enough to impair how they
function at home, in school, or in the community.
4
♦ The onset of major mental illness may occur as
early as 7 to 11 years old.
5
♦ Roughly half of all lifetime mental health disorders
start by the mid‐teens.
6 7
♦ Individual and enviromental risk factors that
increase the likelihood of mental health problems
include receiving public assistance, having unemployed or teenage parents, or being in the foster care
system. These and other factors can be identified
and addressed in the early years.
8
♦ Among youths aged 12 to 17, 4.4 percent had serious emotional disorders in 2008.
9
♦ In 2008, 9.3 percent of youths were illicit drug users,
and rates of alcohol use were 3.4 percent among
persons aged 12 or 13; 13.1 percent of persons aged
14 or 15; and 26.2 percent of 16- or 17-year-olds.
10
♦ The rate of substance dependence or abuse among
youths aged 12 to 17 was 7.6 percent, slightly higher
than that of adults aged 26 or older (7.0 percent).
11
Children and youth at increased risk for mental
health problems include those in low-income households, those in the child welfare and juvenile justice
systems, and those in military families.
♦ Twenty-one percent of low-income children and
youth aged 6 to 17 have mental health problems.
12
♦ Fifty-seven percent of these children and youth
with mental health problems come from households living at or below the federal poverty level.
13
A greater proportion of children and youth in the
child welfare and juvenile justice systems have
mental health problems than those in the general
population.
♦ Fifty percent of children and youth in the child
welfare system have mental health problems.
14
♦ Youth in residential treatment centers, 69 percent
of whom come from the juvenile justice and child
welfare systems, have extremely high rates of
mental and behavioral health disorders compared
to the general population.
15
♦ Sixty-seven to seventy percent of youth in the
juvenile justice system have a diagnosable mental
health disorder.
164
Children and youth in military families tend to have
higher rates of mental health problems than those
in the general population, and those mental health
problems are especially pronounced during a parent’s deployment.
♦ Thirty-two percent of children of military families
scored as “high risk” for child psychosocial
morbidity, 2.5 times the national average.
17
♦ There is a higher prevalence of emotional and behavioral difficulties in youth aged 11 to 17 in military families compared to the general population.
18
♦ During a parent’s deployment, children exhibit
behavior changes including changes in school
performance, lashing out in anger, disrespecting
authority figures, and symptoms of depression.
19
♦ Children age 3 to 5 with a deployed parent exhibit
more behavioral symptoms than their peers without a deployed parent.
20
♦ The rate of child maltreatment in families of enlisted Army soldiers is 42 percent higher during combat deployment than during non-deployment.
21
Most Children and Youth with Mental Health Problems struggle to succeed
Children and youth with mental health problems
have lower educational achievement, greater involvement with the criminal justice system, and
fewer stable and longer-term placements in the
child welfare system than their peers. When treated,
children and youth with mental health problems fare
better at home, in schools, and in their communities.
Children and youth in preschool and elementary
school with mental health problems are more
likely to experience problems
at school, be absent, or be
suspended or expelled than are
children with other disabilities.
♦ Preschool children face
expulsion rates three times
higher than children in
kindergarten through 12th
grade, due in part to lack
of attention to socialemotional needs.
22
♦ African-American preschoolers are three to
five times more likely to be expelled than their
white, Latino, or Asian-American peers.
23
♦ In the course of the school year, children with
mental health problems may miss as many as
18 to 22 days.
24
♦ Their rates of suspension and expulsion are
three times higher than those of their peers.
25
♦ Among all students, African-Americans are
more likely to be suspended or expelled than
their white peers (40 vs. 15 percent).
26
Youth in high school with mental health problems
are more likely to fail or drop out of school.
♦ Up to 14 percent of youth with mental health
problems receive mostly Ds and Fs (compared to
seven percent for all children with disabilities).
27
♦ Up to 44 percent of them drop out of high
school.
28
♦ Over 10 percent of high school dropouts were
attributable to mental health disorders.
29
Youth in the child welfare and
juvenile justice systems with
mental health issues do less
well than others. In the child
welfare system, children with
mental health issues experience
additional problems compared
to those without a mental
health disorder.
♦ They are less likely to be placed in permanent
homes.
30
♦ They are more likely to experience a placement
change than children without a mental health
disorder.
31
♦ They are more likely to be placed out of home in
order to access services.
32
♦ They are more likely to rely on restrictive or costly
services such as juvenile detention, residential
treatment, and emergency rooms.
33
When treated, children
and youth with mental
health problems fare
better at home, in schools,
and in their communities.National Center for Children in Poverty Children’s Mental Health 5
Many Children and Youth are Unable to access needed services
In 2007, 3.1 million youth (12.7 percent) received
treatment or counseling in a specialty mental health
setting for emotional or behavior problems. An
additional 11.8 percent of youth received mental
health services in an education setting, along with
2.9 percent who received services in a general
medical setting.
34
Though this indicates that some
are able to access services, it is clear that most
children and youth with mental health problems do
not receive needed services.
♦ Seventy-five to 80 percent of children and youth
in need of mental health services do not receive
them.
35
♦ Thirty-seven to 52 percent of adolescents and young
adults who were hospitalized for a suicide attempt
received mental health services in the month prior.
36
♦ Only 29 percent of youth expressing suicide
ideation in the prior year received mental health
services.
37
Delivery of and access to mental health services and
supports vary depending on the state in which a
child or youth with mental health needs lives.
♦ There is a 30 percent difference between the states
with the highest and lowest unmet need for mental
health services (51 to 81 percent).
38
Children and youth from diverse racial and ethnic
groups and from families who face language barriers
are often less likely to receive services for their mental health problems than white children and youth.
♦ Thirty-one percent of white children and youth
receive mental health services.
39
♦ Thirteen percent of children from diverse racial and
ethnic backgrounds receive mental health services.
40
♦ Non-Hispanic/Latino white children and youth
have the highest rates of mental health services
usage, while Asian American/Pacific Islander
children have the lowest rates.
41
♦ Hispanic/Latino and African-American children
in urban areas receive less mental health care than
their white peers.
42
♦ Among children in the child welfare system,
African-Americans have less access to counseling
than white children.
43
Some children and youth with the most intense
needs and some who are insured do not receive
mental health services.
♦ In juvenile detention facilities, 85 percent of youth
with psychiatric disorders report at least one perceived barrier to service usage, including the belief
that problems would go away without help, uncertainty about where to go, or cost of services.
44
♦ Eighty-five percent of children and youth in need
of mental health services in the child welfare system do not receive them.
45
♦ Privately-insured families with children in need of
mental health care face significantly greater financial barriers than families with children without
mental health needs.
46
♦ Families with children who have mental health
problems bear a disproportionate amount of coinsurance, putting an added strain on caregivers.
47
♦ Seventy-nine percent of children with private
health insurance and 73 percent with public health
insurance have unmet mental health needs.
48
♦ In the child welfare system, both privately insured
and uninsured children are less likely to receive
needed mental health counseling than those with
public insurance.
49
A gap also exists between need and treatment for
youth with substance use disorders that sometimes
occur with mental health problems.
♦ Only 9.3 percent of the 1.2 million youths 12
through 17 years of age in need of treatment for an
illicit drug use problem in 2008 received specialty
facility-based treatment.
50
♦ Of the 1.2 million youths who needed treatment
for an alcohol use problem, only 6.2 percent
received treatment at a specialty facility.
51
It is clear that most children and
youth with mental health problems
do not receive needed services.6
the Public Mental Health service delivery system remains largely ineffective
for Children and Youth
Even among those children and youth who are able
to access mental health services, quality of care is
often deficient. There is an insufficient number of
providers, and many of them do not use effective,
evidence-based, or empirically supported practices.
The service delivery system lacks key elements of
supportive infrastructure which results in poor
provider capacity and competency. Components
of a strong infrastructure include provider training
and retention, adequate reimbursement, strong
information technology systems, and robust family
involvement in policy.
♦ Information technology, such as electronic health
records and management and accountability
systems, is a key component in infrastructure that
supports efficiency and quality improvements.
52
♦ Despite this, there is not currently widespread use
of these tools.
53
♦ Family advocacy, support and education organizations (FASEOs) are frequently asked to make
up for the absence or inadequacy of local mental
health services, while facing fiscal fragility and uncertain sources of revenue. This results in a family
advocacy network that is largely unstable.
54
Financing for children’s mental health remains
inadequate. While there are no current estimates of
overall national spending, it is projected that federal
agencies contributed nearly $6 billion to preventive
services in 2007.
55
Despite this financial support, and
due in large part to a deficit of flexible fiscal support
for the system and for service users, quality of care
suffers and many children and youth do not receive
the services they need.
♦ Finance policies drive the capacity and quality of
the services provided for children and youth with
mental health conditions.
56
♦ Restrictive funding streams impede the ability of
system leaders to provide services based on the
individual needs of the child and family within the
context of their community.
57
♦ Flexible funding strategies improve service innovation and increase the system’s ability to provide
needed services.
58
♦ Service capacity overflow leads to high use of
costly forms of care, such as emergency rooms.
59
A major strategy among policymakers for attaining
optimal service quality is the implementation of
evidence-based practices (EBPs), which are those
practices for which there is valid scientific evidence
of effectiveness. States encounter many barriers
in adopting EBPs in large systems, including lack
of fidelity to models, mismatch between provider
preparation and expectations of practice, and large
variation in the ability to transport from one setting
to another.
60
♦ Perspectives on evidence-based practices are
mixed, with some providers expressing doubts and
concerns about the effectiveness of EBPs.
61
♦ Service users and family members are not
well-informed about EBPs, and many consider
receiving care with fidelity to EBP models a
tertiary concern when they experience great
difficulty in obtaining any quality care at all.
62
♦ State infrastructure support to implement effective
practices is variable, limited in scope, pays insufficient attention to cultural needs, and lacks consistent fiscal support.
63
Legislative Changes on the Horizon
Recent federal legislation holds promise for increasing
access to and the quality of children’s mental health
services. Children’s Health Insurance Program Reauthorization 2009 requires that mental health and substance
abuse benefits are equal to other medical benefits in
health insurance. Similar provisions are included in the
Patient Protection and Affordability Care 2010. Consistent with the Wellstone-Domenici Act (2008), it requires
mental health and substance abuse benefits in the individual and group market to be on par with medical benefits. It makes providers of mental health and substance
abuse services a high priority in the law for increasing
the work-force competency and availability of community
based services. The law also provides for prevention and
early intervention and includes mental health as part of
the quality initiatives to manage chronic conditions, along
with a range of initiatives to address disparities. National Center for Children in Poverty Children’s Mental Health 7
effective Policy strategies to enhance Mental Health for Children, Youth, and Families
♦ Increase access to effective, empirically-supported
practices like mental health consultation with
a specific focus on young children. Preschool
children with access to mental health consultation
exhibit less disruptive behavior and have lower
expulsion rates.
64
♦ Develop systems to identify at-risk children. Identifying those children and youth most at risk for poor
mental health outcomes is instrumental in designing
effective strategies for prevention and intervention.
65
♦ Coordinate services and hold child- and youthserving systems accountable. Robust service coordination in the child welfare system reduces gaps
in access to services between African-American
and white children and youth.
66
Outcome-based
systems are better able to track youth outcomes,
improve provider capacity, and tailor services.
67
♦ Finance and provide mental health services and
supports that meet the developmental needs of
children. Treatment and supports using a developmental framework are more likely to respond to
the changing needs of children and youth.
68
♦ Increase adoption of electronic health records,
and implement information systems for quality assurance, accountability, and data sharing
across providers, agencies and counties. A system
for sharing records facilitates joint planning and
improves efficiency and quality of care.
69
♦ Fund and apply consistent use of effective
treatments and supports. A range of effective
treatments exist to help children and youth with
mental health problems to function well in home,
school, and community settings.
70
♦ Engage families and youth in their own treatment planning and decisions. Family support and
family-based treatment are critical to children and
youth resilience. Reaching out to community stakeholders to increase their awareness and knowledge
regarding EBPs will enhance youth and family
engagement, which fosters treatment effectiveness.
71
♦ Provide culturally and linguistically competent
services. Attention to providers’ cultural and
language competence leads to improved mental
health outcomes and greater adoption of effective
practices.
72
♦ Finance and implement concrete strategies to
identify and prevent mental health problems and
intervene early. Empirically-supported prevention
and early intervention strategies support children
and youth resilience and ability to succeed.
73
♦ Ensure that the implementation of health reform
recognizes the need to support a comprehensive
array of benefits from prevention to treatment.
Health insurance expansion is associated with
increases in access to mental health services.
74
endnotes
1. Children ages 12 to 17 are classified as youth in this
fact sheet.
2. New Freedom Commission on Mental Health. 2003.
Achieving the Promise: Transforming Mental Health Care
in America. Final Report (DHHS Pub. No. SMA-03-
3832) Rockville, MD: U.S. Department of Health and
Human Services, Substance Abuse and Mental Health
Services Administration. Accessed Dec. 8, 2009 from
www.mentalhealthcommission.gov/reports/reports.htm.
3. Ibid.
4. Ibid.
5. Kessler, R. C.; Beglund, P.; Demler, O.; Jin, R.;
Walters, E. E. 2005. Lifetime Prevalence and the Ageof-onset Distributions of DSM-IV Disorders in the
National Comorbidity Survey Replication. Archives of
General Psychiatry 62(6): 593-602.
6.Kessler, R. C.; Amminger, G. P.; Aguilar-Gaxiola,
S.; Alonso, J.; Lee, S.; Ustun, T. B. 2007. Age of Onset
of Mental Disorders: A Review of Recent Literature.
Current Opinion Psychiatry 20(4): 359-364.
7. Kessler, R.C. et al. 2007. Lifetime Prevalence and
Age-of-onset Distributions of Mental Disorders in the
World Health Organization’s World Mental Health
Survey Initiative. World Psychiatry 6: 168-176.
8. Knitzer, J.; Lefkowitz, J. 2006. Helping the Most
Vulnerable Infants, Toddlers, and their Families
(Pathways to Early School Success Issue Brief No. 1).
New York, NY: National Center for Children in Poverty,
Columbia University Mailman School of Public Health.
9. U.S. Substance Abuse and Mental Health
Administration, Office of Applied Statistics. 2009.
Results from the 2008 National Survey on Drug
Use and Health: National Findings. Accessed
Jan. 22, 2010 from http://www.oas.samhsa.gov/
NSDUH/2k8NSDUH/2k8results.cfm#8.2.
10. See endnote 9.
11. Ibid.
12. Howell, E. 2004. Access to Children’s Mental Health
Services under Medicaid and SCHIP. Washington, DC:
Urban Institute.
13. Ibid.
14. Burns, B.; Phillips, S.; Wagner, H.; Barth, R.;
Kolko, D.; Campbell, Y.; Yandsverk, J. 2004. Mental
Health Need and Access to Mental Health Services
by Youths Involved with Child Welfare: A National
Survey. Journal of the American Academy of Child and
Adolescent Psychiatry 43(8): 960-970.
15. Dale, N.; Baker, A. J. L.; Anastasio, E.; Purcell, J.
2007. Characteristics of Children in Residential Treatment in New York State. Child Welfare 86(1): 5-27.
16. Skowyra, K. R; Cocozza, J. J. 2006. Blueprint for
Change: A Comprehensive Model for the Identification
and Treatment of Youth with Mental Health Needs in
Contact with the Juvenile Justice System. Delmar, NY:
The National Center for Mental Health and Juvenile
Justice and Policy Research Associates, Inc. Accessed
Dec. 8, 2009 from www.ncmhjj.com/Blueprint/pdfs/
Blueprint.pdf.
17. Flake, E. M.; Davis, B. E.; Johnson, P. L.;
Middleton, L. S. 2009. The Psychosocial Effects of
Deployment on Children. Journal of Developmental &
Behavioral Pediatrics 30(4): 271-278.
18. Chandra, A.; Lara-Cinisomo, S.; Jaycox, L.;
Tanielian, T.; Burns, R. 2010. Children on the
Homefront: The Experience of Children from Military
Families. Pediatrics 125:13-22.
19. Huebner, Angela J.; Mancini, Jay A. 2005.
Adjustments Among Adolescents in Military Families
When a Parent is Deployed. Military Family Research
Institute, Purdue University.
20. Chartrand, M. M.; Frank, D. A.; White, L.
F.; Shope, T. R. 2008. Effect of Parents’ Wartime
Deployment on the Behavior of Young Children in
Military Families. Archives of Pediatric Adolescent
Medicine 162(11): 1009-1014.
21. Gibbs, Deborah A.; Martin, Sandra L.; Kupper,
Lawrence L.; Johnson, Ruby E. 2007. Child
Maltreatment in Enlisted Soldiers’ Families During
Combat-Related Deployments. Journal of the
American Medical Association 298: 528-535. 8
22. Gilliam, W. S. 2005. Prekindergarteners Left Behind:
Expulsion Rates in State Prekindergarten Programs. FCD
Policy Brief Series 3. New York, NY: Foundation for Child
Development. Accessed Dec. 15, 2009 from http://www.
plan4preschool.org/documents/pk-expulsion.pdf.
23. Ibid.
24. Blackorby, J.; Cameto, R. 2004. Changes in School
Engagement and Academic Performance of Students with
Disabilities. In Wave 1 Wave 2 Overview (SEELS). Menlo
Park, CA: SRI International.
25. Ibid.
26. Ibid.
27. Blackorby, J.; Cohorst, M.; Garza, N.; Guzman, A.
2003. The Academic Performance of Secondary School
Students with Disabilities. In The Achievements of Youth
with Disabilities During Secondary School. Menlo Park,
CA: SRI International.
28. Wagner, M. 2005. Youth with Disabilities Leaving
Secondary School. In Changes Over Time in the Early Post
School Outcomes of Youth with Disabilities: A Report of
Findings from the National Longitudinal Transition Study
(NTLS) and the National Longitudinal Transition Study-2
(NTLS2). Menlo Park, CA: SRI International.
29. Breslau, J.; Lane, M.; Sampson, N.; Kessler, R. C.
2008. Mental Disorders and Subsequent Educational
Attainment in a US National Sample. Journal or
Psychiatric Research 42: 708-716.
30. Smithgall, C.; Gladden, R. M.; Yang, D. H.; George, R.
2005. Behavioral Problems and Educational Disruptions among Children in Out-of-home Care in Chicago
(Chapin Hall Working Paper). Chicago, IL: Chapin Hall
Center for Children at the University of Chicago.
31. Ibid.
Zinn, Andrew; Decoursey, Jan; Goerge, Robert; Courtney,
Mark. 2006. A Study of Placement Stability in Illinois
(Chapin Hall Working Paper). Chicago, IL: Chapin Hall
Center for Children at the University of Chicago.
Park, Jung Min; Ryan, Joseph P. 2009. Placement and
Permanency Outcomes for Children in Out-of-Home
Care by Prior Inpatient Mental Health Treatment.
Research on Social Work Practice 19(1): 42-51.
32. Hurlburt, M. S.; Leslie, L. K.; Landsverk, J.; Barth,
R.; Burns,B.; Gibbons, R. D.; Slymen, D. J.; Zhang, J.
2004. Contextual Predictors of Mental Health Service
use Among Children Open to Child Welfare. Archives of
General Psychiatry 61(12):1217-1224.
33. U.S. House of Representatives, Committee on
Government Reform, Minority Staff Special Investigations
Division. 2004. Incarceration of Youth Who are Waiting
for Community Mental Health Services in the United
States (Report prepared for Rep. Henry A. Waxman and
Sen. Susan Collins). Washington, DC: U.S. House of
Representatives, Committee on Government Reform.
Pottick, K.; Warner, L. A.; Yoder, K. A. 2005. Youths
Living Away from Families in the US Mental Health
System: Opportunities for Targeted Intervention. Journal
of Behavioral Health Services & Research 32(2): 264-281.
Almgren, G. Marcenko, M. O. 2001. Emergency Room
Use among Foster Care Sample: The Influence of
Placement History, Chronic Illness, Psychiatric Diagnosis,
and Care Factors. Brief Treatment and Crisis Intervention
1(1): 55-64.
34. See endnote 9.
35. Kataoka, S.; Zhang, L.; Wells, K. 2002. Unmet Need
for Mental Health Care among U.S. Children: Variation
by Ethnicity and Insurance Status. American Journal of
Psychiatry 159(9): 1548-1555.
36. Freedenthal, Stacey. 2007. Racial Disparities in Mental
Health Service Use by Adolescents Who Thought About
or Attempted Suicide. Suicide and Life-Threatening
Behavior 37(1): 22-34.
37. Ibid.
38. U.S. Substance Abuse and Mental Health
Administration, Office of Applied Statistics. 2004.
Youth Substance Use and Family Income (National
Survey on Drug Use and Health). The NSDUH Report.
Accessed Dec. 8,2009 from www.oas.samhsa.gov/2k4/
youthIncome/youthIncome.htm.
Sturm, R.; Ringel, J. S.; Andreyeva, T. 2003. Geographic
Disparities in Children’s Mental Health Care. Pediatrics
112(4): 308.
39. Ringel, J. S.; Sturm, R. 2001. National Estimates of
Mental Health Utilization and Expenditures for Children
in 1998. Journal of Behavioral Health Services & Research
28(3): 319-333.
40. Ibid.
41. Garland, A.F.; Lau, A.S.; Yeh, M.; McCabe, K.M.;
Hough, R.L.; Landsverk, J.A. 2005. Racial and Ethnic
Differences in Utilization of Mental Health Services
Among High-Risk Youths. American Journal of Psychiatry
162: 1336–1343.
42. Howell, E.; McFeeters, J. 2008. Children’s Mental
Health Care: Differences by Race/Ethnicity in Urban/
Rural Areas. Journal of Health Care for the Poor and
Underserved 19: 237–247.
43. Wells, R.; Hillemeier, M. M.; Bai, Y.; Belue, R. 2009.
Health Service Access across Racial/Ethnic Groups of
Children in the Child Welfare System. Child Abuse &
Neglect 33: 282–292.
44. Abram, K. M.; Paskar, L. D.; Washburn, J. J.; Teplin,
L A. 2008. Perceived Barriers to Mental Health Services
Among Youths in Detention. Journal of the American
Academy of Child & Adolescent Psychiatry 47(3): 301-308.
45. See endnote 17.
46. Busch, Susan H.; Barry, Colleen L. 2009. Does Private
Insurance Adequately Protect Families of Children with
Mental Health Disorders? Pediatrics 124(4): S399-S406.
47. Busch, S.; Barry, C. 2007. Mental Health Disorders
in Childhood: Assessing the Burden on Families. Health
Affairs 26(4): 1088-1095.
48. See endnote 37.
49. See endnote 46.
50. See endnote 9.
51. Ibid.
52. Coffey, R. M.; Buck, J. A.; Kassed, C.; Dilonardo, J.;
Forhan, C.; Marder, W. D.; et al. 2008. Transforming Mental Health and Substance Abuse Data Systems in the United
States. Psychiatric Services 59(11): 1257-1263.
Chaudry B.; Wang J.; Wu S.; Maglione M.; Mojica W.;
Roth E.; Morton S.C.; Shekelle P.G. 2006. Systematic
Review: Impact of Health Information Technology on
Quality, Efficiency, and Costs of Medical Care Annual
Internal Medicine 144: E12-E22.
53. Jha A.K.; Ferris T.G.; Donelan K.; DesRoches C.;
Shields A.; Rosenbaum S.; Blumenthal D. 2006. How
Common are Electronic Health Records in the United
States? A Summary of the Evidence. Health Affairs
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54. Hoagwood, K.; Green, E.; Kelleher, K.; Schoewald,
S.; Rolls-Reutz, J.; Landsverk, J.; et al. 2008. Family
Advocacy, Support and Education in Children’s Mental
Health: Results of a National Survey. Administration and
Policy in Mental Health & Mental Health Services Research
35(1-2): 73-83.
55. O’Connell, Mary Ellen; Boat, Thomas; Warner,
Kenneth E.; Editors. 2009. Preventing Mental, Emotional,
and Behavioral Disorders Among Young People: Progress
and Possibilities. Board on Children, Youth and Families
(BOCYF); Institute of Medicine (IOM); Behavioral and
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56. Cooper, J.L. 2008. Towards Better Behavioral Health
for Children, Youth and their Families: Financing that
Supports Knowledge. New York, NY: National Center
for Children in Poverty, Columbia University Mailman
School of Public Health.
57. Ibid.
58. Biebel, K.; Katz-Levy, K.; Nicholson, J.; Williams,
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