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Emerging adults discontinue behavioral health treatment at rates ranging from 30% to 50%. This study explored dropout using semi-structured interviews ( N = 20). Participants were engaged in a group therapy program, Healthy Transitions. Findings revealed the lack of therapeutic relationship and logistical issues such as cost, transportation, and conflicting work schedules contributed to dropout. Participants indicated that alleviating logistical barriers and feeling a connection to their peers and group leader prevented dropout. This program was free, transportation was provided, and sessions were in the evening. Participants expressed peer educators made them feel less judged and/or stigmatized than a one-on-one therapy appointment. These findings reinforce logistical issues and lack of a therapeutic relationship contribute to dropout and highlight the benefits of flexible scheduling and reinforce the importance of a therapeutic relationship in preventing dropout.

Trauma exposure and comorbid substance use are highly prevalent among female drug court participants. Despite the pervasiveness of the issue, few studies have investigated the impact of posttraumatic stress symptoms (PTSS) and nonmedical prescription drug use among this specific population. The present study examined the impact of posttraumatic stress, social support, and nonmedical prescription drug use on graduation outcomes among female participants in a specialized drug court program (N = 210). Participants either received motivational enhancement therapy/cognitive behavioral therapy (MET-CBT; N = 210) or both MET-CBT and Seeking Safety through intensive outpatient treatment (n = 109). The findings indicated that graduation was negatively correlated with posttraumatic stress, r = -.19, p = .007, d = 0.40; past 90-day nonmedical prescription painkiller, opiate, and analgesic use, r = -.19, p = .001, d = 0.44; tangible social support, r = -.24, p = < .001, d = 0.51; and past-month substance use problems, r = -.25, p < .001, d = .50. In addition, past-month substance use problems, OR = 0.84, 95% CI [0.72, 0.97]; PTSS, OR = 0.90, 95 % CI [0.82, 0.99]; and tangible social support, OR = 0.94, 95% CI [0.89, 0.98], were significant negative predictors of graduation. These results speak to the importance of facilitating the development of specialized evidence-based drug court interventions that target and improve comorbid substance use and trauma outcomes among female drug court participants to reduce recidivism and set a precedent for future research to replicate and expand upon these findings.

Purpose The Center for Epidemiologic Studies Depression (CES-D) scale is a widely used instrument for studying depression in the general population. It has been translated into several languages. Cross-cultural relevance of the construct of depression and cultural equivalence of the CES-D items used to measure it are crucial for international research on depression. Given the increasing number of refugees from Eritrea entering the USA and Europe, there is a need among health care researchers and providers for an instrument to assess depressive symptoms in the native language of this vulnerable population. The paper aims to discuss these issues. Design/methodology/approach The study employed forward–backward translation and assessed the CES-D scale for cross-cultural research and depression screening among Tigrigna-speaking Eritrean refugees. Forward–backward translation, cognitive interview and semantic analysis were conducted to ensure equivalence of comprehension of the items and instructions between Tigrigna- and English-speaking samples. Multi-group confirmatory factor analysis was used to assess the measurement invariance of the translated version. Findings Translation efforts were successful as reflected by the results of semantic analysis and pilot testing. Evidence supporting the measurement invariance of data collected using the Tigrigna version of the CES-D was obtained from a sample of 253 Eritrean refugees in the USA. Practical implications The findings of this study provide support for reliability and validity of data collected using the Tigrigna version of the CES-D scale. This important tool for assessing depression symptoms among Eritrean refugees is now available for health care providers and researchers working with this vulnerable population. Originality/value This work is an original work of the authors and it has not been published previously.

Community collaboration has become increasingly common in behavioral health services. Conflict is likely to occur in any community coalition bringing together organizations with differing mandates, missions, and histories. However, research on how coalitions identify and handle conflict, and on the impact of conflict on sustainability is scarce. An exploratory study examined conflict in two federally funded children's "systems of care" using site visits and concept mapping to describe differences in how sites conceptualize and respond to conflict. Results suggest that unacknowledged and unaddressed conflict can negatively affect the development and sustainability of sites, and that focusing on cooperation may, paradoxically, make it more difficult to acknowledge conflict and to implement conflict transformation processes. Implications for behavioral health administrators are discussed, including potential interventions that could address these issues.

Objectives To (1) examine the quality of life of individuals with Ménierè’s disease in relation to symptom severity, social supports, and coping styles and (2) develop a prediction model to identify factors most strongly associated with quality of life. Methods Data were collected using a web-based survey that included previously developed and validated measures (i.e. SF-12, Dizziness Handicap Inventory, Hearing Handicap Inventory for Elderly Screening Version, Iowa Tinnitus Handicap Questionnaire, Interpersonal Support Evaluation List, Brief COPES, Lehman’s Quality of Life). Ninety-five individuals with Ménierè’s disease who were members of one of five online Ménierè’s disease support groups responded to the survey. Results The findings indicated that symptom severity was negatively associated with patients’ quality of life, social supports were positively associated with quality of life, and the use of negative coping styles (e.g. substance use, blaming) was negatively associated with quality of life. Four predictors (i.e. SF-12 mental health, dizziness severity, self-esteem support, and negative coping styles) accounted for 62% of the variance in quality of life. Discussion The findings suggest that the factors associated with the quality of life of patients with Ménierè’s disease are similar to those reported in the literature among patients with other chronic illnesses. The results also suggested that emphasis on psychosocial factors may be an important aspect of a comprehensive treatment intervention for individuals with Ménierè’s disease.

Background and Purpose: The longitudinal invariance of the Center for Epidemiologic Studies-Depression (CES-D) scale among middle-aged and older adults is unknown. This study examined the factorial invariance of the CES-D scale in a large cohort of community-based adults longitudinally. Methods: 1,204 participants completed the 20-item CES-D scale at 4 time points 1 year apart. Structural equation modeling was used to identify best fitting model using longitudinal data at baseline and at 1-, 2-, and 3-year follow-up. Results: The 4-factor model showed partial invariance over 3 years. Two of the 6 noninvariant items were consistently noninvariant at the 3 follow-up points. Conclusion: Special consideration should be given to these 2 items when using the CES-D scale in healthy adults (45-75 years old).Keywords: depression; invariance; structural equation modeling; measurement; CES-DDeveloped by the National Institute of Mental Health Center for Epidemiologic Studies, the Center for Epidemiological Studies-Depression (CES-D) scale is one of the most commonly used measures of depressive symptoms especially in community-based studies involving adult populations (Edwards, 2010; Murphy, 2011). The CES-D scale is a depressive symptom measurement scale that requires participants to report the frequency of feeling or occurrence of each of the 20 scale items in the past week. The items have been chosen to reflect various components of depression including feelings of guilt and worthlessness, depressed mood, helplessness and hopelessness, psychomotor retardation, sleep disturbance, and loss of appetite (Radloff, 1977). Each item is rated on a 4-point scale of 0 5 rarely or none of the time (less than 1 day); 1 5 some or a little of the time (1-2 days); 2 5 occasionally or a moderate amount of the time (3-4 days); and 3 5 most or all of the time (5-7 days). For 16 items in the instrument, a higher score represent more impairment, whereas for the remaining 4 items (Items 4, 8, 12, and 16), the scores are reversed, that is, a higher score represents less impairment. Reponses to the 20 items in the CES-D scale are summed to identify the level of depressive symptoms experienced by individuals in the past 1 week. A score of 16 or more indicates depressive risk (Radloff, 1977). The 20 CES-D scale items are listed with their abbreviations and factor structure in Table 1.PSYCHOMETRIC PROPERTIES OF CENTER FOR EPIDEMIOLOGICAL STUDIES-DEPRESSION SCALEThe factor structure of the scale has been debated for many years. The first factor analysis was done by Radloff in 1977. The author conducted principal component analyses (with ones in the main diagonal) with varimax rotation of the 20-item scale for three groups of samples taken from the general population and reported four factors. These factors were interpreted as depressed affect (blues depressed, lonely, cry, sad), positive affect (good, hopeful, happy, enjoy), somatic/vegetative (bothered, appetite, effort, sleep, get going), and interpersonal (unfriendly, dislike). Figure 1 shows the CES-D scale correlated four-factor model by Radloff (1977).The four-factor structure by Radloff (1977) has been replicated in other studies (Devins et al., 1988; Golding & Aneshensel, 1989; Knight, Williams, McGee, & Olaman, 1997; Roberts, 1980; Roberts, Vernon, & Rhoades, 1989). However, in some studies, the number of items used and the grouping of the items in to the factors varied. Other studies (Brown, Jose, Ng, & Guo, 2002; Chapleski, Lamphere, Kaczynski, Lichtenberg, & Dwyer, 1997; Guarnaccia, Angel, & Worobey, 1989; Miller, Markides, & Black, 1997) that tested the factor structure of the CES-D scale concluded that the depressed affect and somatic/vegetative items load on a single factor rather than two separate factors as proposed by Radloff (1977). Additional CES-D scale factor models reported in the literature include two factors (Edman et al., 1999) and seven factors (Callahan & Wolinsky, 1994), with only one item loading on two of the seven factors. …

This study examined the relationship between continuing bonds (CBs) among 50 bereaved youth (ages 11–17) and their bereaved adult caregivers, and predictors of CBs among youth. Results indicated there was not a significant relationship between caregiver CB and youth CB. However, significant relationships were found between youth bereavement symptomatology, their relationship to the deceased, and youth CB. Specifically, youth with higher levels of symptomatology and those who lost an immediate family member were more likely to maintain CBs. Results suggest the need for practitioners to incorporate grief symptomatology and CBs in assessment and intervention with bereaved youth.

The purpose of this study was to examine the prevalence of self-perceived oral health needs among Medicaid-enrolled adults with and without mental health problems and to identify factors predictive of enrollees’ perceived oral health needs. The study involved a secondary analysis of 1,721 respondents to the Florida Health Services Survey. Contrary to the previous research, the findings from this study indicated that respondents with mental health problems (52.9%) did not differ significantly in their dental needs compared to those who did not have mental health problems (49.3%). The results from a logistic regression suggested that after controlling for demographic characteristics, substance abuse problems and functional needs increased the likelihood of self-reported oral health needs, whereas the receipt of Supplemental Security Income (SSI) was associated with decreased dental needs. The prevalence of unmet dental needs among these respondents (i.e., 23%) supported the conclusion that a significant gap exists in the accessibility of oral health services among this population.

In randomized controlled trials (RCTs), the most compelling need is to determine whether the treatment condition was more effective than control. However, it is generally recognized that not all participants in the treatment group of most clinical trials benefit equally. While subgroup analyses are often used to compare treatment effectiveness across pre-determined subgroups categorized by patient characteristics, methods to empirically identify naturally occurring clusters of persons who benefit most from the treatment group have rarely been implemented. This article provides a modeling framework to accomplish this important task. Utilizing information about individuals from the treatment group who had poor outcomes, the present study proposes an a priori clustering strategy that classifies the individuals with initially good outcomes in the treatment group into: (a) group GE (good outcome, effective), the latent subgroup of individuals for whom the treatment is likely to be effective and (b) group GI (good outcome, ineffective), the latent subgroup of individuals for whom the treatment is not likely to be effective. The method is illustrated through a re-analysis of a publically available data set from the National Institute on Drug Abuse. The RCT examines the effectiveness of motivational enhancement therapy from 461 outpatients with substance abuse problems. The proposed method identified latent subgroups GE and GI, and the comparison between the two groups revealed several significantly different and informative characteristics even though both subgroups had good outcomes during the immediate post-therapy period. As a diagnostic means utilizing out-of-sample forecasting performance, the present study compared the relapse rates during the long-term follow-up period for the two subgroups. As expected, group GI, composed of individuals for whom the treatment was hypothesized to be ineffective, had a significantly higher relapse rate than group GE (63% vs. 27%; χ 2 = 9.99, p-value = .002).

When undergraduates engage in hands-on research experiences, particularly intense mentored experiences, they are more likely to pursue graduate studies in the sciences and take a more assertive role in their learning and career activities. Such early career experiences have been identified as essential in the development of the next generation of researchers. The authors describe the decade long development, structure, and evaluation outcomes of a summer research experience for undergraduates designed to provide an intense, yet supportive, research experience that helps inspire the next generation of scientists. Future considerations for the program are also provided.

How are characteristics of communities associated with the implementation of the principles of systems of care (SOC)? This study uses multilevel modeling with a stratified random sample (N = 225) of US counties to explore community-level predictors of the implementation factors of the System of Care Implementation Survey. A model composed of community-level social indicators fits well with 5 of 14 factors identified as relevant for effective SOCs. As hypothesized, community disadvantage was negatively and residential stability positively associated with the implementation of SOC principles. Designation as a mental health professional shortage area was positively related to some implementation scores, as was the percentage of minority residents, while rurality was not significantly associated with any of the factors. Given the limitations of the study, the results should be interpreted with caution, but suggest that further research is merited to clarify these relationships that could inform efforts directed at promoting SOCs.

A major impediment to obtaining national information on systems of care implementation has been the lack of a psychometrically sound large-scale survey instrument. The present study provided information on the factorial and concurrent validity of the Systems of Care Implementation Survey scales. Multilevel confirmatory factor analysis and multilevel regression analysis were used to test these indicators of internal and external validity. Two hundred twenty-five counties were randomly selected and stratified by population size and poverty level. Nine hundred ten informants responded to the survey questionnaire, M = 4.04 informants per county (SD = 3.17). Results indicated that all models had at least adequate fit to the data, with nine of the 14 factor models having excellent fit. Overall, 11 of the 14 factors had some indication that receiving federal funding to create systems of care was associated with higher scores on the factors. Implications for future research were discussed.

The results of a survey to measure the implementation of the systems of care (SOC) approach in a nationally representative sample of counties are presented. The results from 910 informants within 225 counties reveal a moderate level of implementation of SOC factors, with the level of poverty and population size influencing implementation. Furthermore, mental health informants generally tended to rate the implementation of systems of care greater than administrators associated with the school system, other family serving agency personnel or family members. Family members and school personnel tended to rate the implementation lowest, while staff from the other child serving agencies tended to rate the implementation closer to mental health administrators. A quarter of the counties (26%) surveyed rated themselves as having adequate levels of implementation on 11 or more of the 14 factors, while 75% rated themselves as having adequate levels of implementation on six or more of the 14 factors measured. Implications for federal policies regarding systems of care implementation are discussed.

Ethical standards and issues associated with the access and use of state Medicaid administrative data for research purposes from the data owners’ perspective (i.e., state Medicaid authorities) were examined. Key informants at Medicaid authorities were surveyed regarding their states’ policies and procedures related to the access and use of Medicaid data for research purposes. Results indicate that although a majority of states permit the use of Medicaid data by independent investigators for research purposes (74%), there is substantial variability across states in both the frequency with which access is granted as well as with the policies and procedures governing the access to these data. Literature on existing “best practices” by data owners regarding the use of administrative data in research is combined with survey findings to add the discussion in this highly important area and proposed guiding principles for administrative data owners and custodians are offered.

The federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program requires mental health screening of Medicaid-eligible children as part of primary care medical assessments. However, decisions related to selection of a screening tool remain with the states. States need access to brief, cost effective, easily administered screening tools to comply with these regulations. This paper examines the psychometric properties of the Pediatric Symptom Checklist (PSC) reported on 6,590 children ages 6-22 enrolled in Florida’s Medicaid program across seven areas of the state, whose caregivers participated in a mail survey at least once between 1998 and 2007. Results suggest the PSC has both good internal consistency and stability over time across children with varying health and mental health conditions. The PSC demonstrated excellent discriminant validity regarding its ability to differentiate among children with varying levels of disabilities. Evidence of the PSCs construct validity was found based on its significant associations with other measures in predicted directions. At the recommended cut-off score of 28, the PSC exhibited good sensitivity, specificity, positive predictive value, and negative predictive value. Collectively, these findings support the use of the PSC as an appropriate measure for screening the psychosocial needs of children enrolled in Medicaid.

The treatment of Medicaid enrollees diagnosed with depression or schizophrenia was examined to determine whether adherence to treatment guideline was associated with health care financing strategy, clinical outcomes, and cost-effectiveness. Individuals in a fee-for-service condition were significantly more likely to receive treatment consistent with guidelines than those in managed care. Mental health costs were higher for individuals diagnosed with schizophrenia, individuals in an acute phase of illness at intake into the study, and those receiving treatment consistent with practice guidelines. Being in an acute phase of illness and having treatment that comported with recommended practice guidelines were associated with higher total social costs. Policy implications of the findings and recommendations for future research are discussed.

Resilience researchers from diverse disciplines and cultural settings face formidable challenges in conceptualizing and developing standardized metrics of resilience that are representative of adolescent and young adult experiences across cultures. We discuss these issues using the case example of a pilot study involving researchers in 14 sites in 11 countries. The goal of the International Resilience Project was to develop a culturally and contextually relevant measure of youth resilience, the Child and Youth Resilience Measure (CYRM). Cultural sensitivity and an iterative research design introduced to the study a number of problems that future studies of resilience will need to address: ambiguity in the definition of positive outcomes; a lack of predictability of models across cultures; and measurement design challenges.

Managed care financing strategies that involve financial risk to insurers can reduce budgeted health expenditures. However, resource substitution may occur and negate apparent savings in budgeted expenditures. These substitutions may be important for individuals with disabling illnesses. The distribution of societal costs for adults with mental illnesses enrolled in plans that differ in their financial risk is examined to evaluate the degree to which risk-based financing strategies result in net savings or in the differential distribution of costs across public or private payers.Six hundred twenty-eight adults with severe mental illnesses enrolled in three Medicaid plans that differ in financial risk arrangements were followed for 1 year to determine the distribution of resource use across Medicaid and other payers. Self-reported service use was obtained through interviews. Cost data were derived from self-reported expenditure, administrative, or agency data. Statistical procedures were used to control for preexisting group differences.Managed care was associated with a tendency toward reduced overall costs to Medicaid. However, private expenditures for managed care enrollees offset decreased Medicaid expenditures, resulting in no net difference in societal costs associated with managed care.Understanding the distribution of societal costs is essential in evaluating health care financing strategies. For adults with mental illnesses, efforts to manage Medicaid expenditures may result in substituting individual and family resources for Medicaid services. Government must focus on the distribution of societal costs since risk-based financing strategies may redistribute costs across the fragmented human services sector and result in unintended system inefficiencies.

African American youth face a number of challenges to prosocial development that the majority of American youth never encounter. Despite this, the research clearly documents that African American youth often are resilient in the face of these challenges. This article explores various factors associated with resilience in African American children and their implications for practitioners. An ecologic framework described by Bronfenbrenner is used as an organizing framework for understanding interventions at the micro-, mezzo-, and exo-system levels. In this article, the importance of identity formation, maintenance of social networks, and exposure to safe and supportive environments is expressed in conjunction with recommendations for practitioners. Practitioners are encouraged to stress the promotion of ethnic and racial identity and self-efficacy with the youth and their family and the involvement of the youth and family in meaningful activities through local community centers, schools, churches, and other organizations serving youth. A case study of an African American girl, from age 16 into adulthood and motherhood, is presented to illustrate the interplay between protective and risk factors.

This article examines the degree to which various demographic characteristics, personality traits, and environmental factors are associated with overall emotional well-being of 125 adolescent girls whose mothers were involved in welfare reform. Daughters participated in a 4-year, mixed method study and annually completed a structured interview protocol and a sub-group also completed a qualitative interview. The quantitative findings from the study suggest that daughters having an internal locus of control, experiencing fewer negative life events, and reporting stronger parental and teacher social support had enhanced emotional well-being over the 4-year study compared to daughters without these factors. The findings were further elaborated with examples from qualitative interviews conducted with the daughters. The findings were used to propose prevention activities using a tertiary mental health preventive intervention framework.

Trust in healthcare providers is associated with clinical outcomes among adult patients. Children with disabilities have complex health needs that place stress on caregivers. Consequently, they are increasingly likely to rely on their children's health care providers to ensure children's health care needs are met. However, no studies have explored factors affecting caregivers’ trust in their children's providers. We assessed caregivers’ trust in their children's providers and identified predictive factors of trust. The results indicate that children's disability condition, functional status, age, the providers’ specialty, and the type of health care plan are significant predicators of caregiver's trust. Specifically, caregivers of children with emotional/behavioral disabilities and children with poor physical or emotional/behavioral functioning reported less trust in their children's providers compared to caregivers of children without physical disabilities or no disability and those having higher levels of physical or emotional/behavioral functioning. In addition, caregivers of younger children had more trust compared to caregivers of older children. Caregivers of children enrolled in a managed care plan for physical health care reported less trust compared to caregivers of children in other organizational arrangements. Finally, caregivers reported more trust in physical health providers compared to mental health providers.

SUMMARY Interviews with 215 recent welfare leavers are summarized. Women's access to health care, their health status, and rates of unmet need were examined. The impact of prior mental health contacts on these issues was also examined. About 31% were uninsured. Women in poorer health were more likely to have insurance than women in better health. This was not true for mental health; women were equally likely to lack insurance regardless of mental health status. Working women with prior mental health contacts were less likely to have employer-based coverage than those without contacts. Women informed about Transitional Medicaid Assistance were 2.5 times more likely to have coverage. The need for insurance was highlighted given 10% to 27% of the women had unmet health/mental health needs. The findings reveal the need to ensure that women leaving TANF do not lose access to basic health care and document the challenges health-related problems pose for many attempting to achieve self-sufficiency.

This five-site study compared Medicaid managed behavioral health programs and fee-for-service programs on use and quality of services, satisfaction, and symptoms and functioning of adults with serious mental illness.Adults with serious mental illness in managed care programs (N=958) and fee-for-service programs (N=1,011) in five states were interviewed after the implementation of managed care and six months later. After a multiple regression to standardize the groups for case mix differences, a meta-analysis using a random-effects model was conducted, and bioequivalence methods were used to determine whether differences were significant for clinical or policy purposes.A significantly smaller proportion of the managed care group received inpatient care (5.7 percent compared with 11.5 percent). The managed care group received significantly more hours of primary care (4.9 compared with 4.5 hours) and was significantly less healthy. However, none of these differences exceed the bioequivalence criterion of 5 percent. Managed care and fee for service were "not different but not equivalent" on 20 of 34 dependent variables. Cochrane's Q statistic, which measured intersite consistency, was significant for 20 variables.Managed care and fee-for-service Medicaid programs did not differ on most measures; however, a lack of sufficient power was evident for many measures. Full endorsement of managed care for vulnerable populations will require further research that assumes low penetration rates and intersite variability.

Mental health courts successfully divert defendants into treatment. However, few studies have examined whether this increased access to services positively affects client outcomes. This study compared changes in symptoms in a sample of defendants in Broward County mental health court with such changes in a comparison sample of defendants in a regular court.Participants included 116 defendants from mental health court and 101 defendants from a magistrate court who were assessed one, four, and eight months after an initial court appearance by using the Brief Psychiatric Rating Scale (BPRS). Both administrative and self-report data were used to identify defendants who received treatment after their initial court appearance. Participants were included in our analysis if they had at least one follow-up interview.A total of 97 defendants from mental health court and 77 from the regular court were included in our analysis. Analyses of covariance performed on changes in BPRS scores revealed no significant main effects by type of court, receipt of treatment, or the interaction between type of court and receipt of treatment.Although mental health courts have been found to increase defendants' access to mental health services, they have little control over the type and quality of services that defendants receive. The fact that reductions in symptoms were not observed among defendants who received treatment in either court setting more likely reflects the chronic nature of their disorders and concerns about the adequacy of our public mental health system, rather than a failure of the mental health court.

Child resilience is viewed as the capacity to use internal and external resources to successfully master stage-specific developmental issues. Smith and Carlson (1997) concluded that resilience can be described in three ways: 1) equated with coping, defined as efforts to restore or maintain equilibrium in the presence of significant stress; 2) conceptualized as the ability to recover in the face of trauma; and 3) defined as protective factors or mechanisms that mediate the relationship between risk and competency.

We present our findings on the current well-being of 125 adolescent girls living in families receiving Temporary Assistance for Needy Families Program (TANF) in terms of their health, mental health, and substance abuse status, academic performance, and teenage behaviors. This mixed-method study included separate structured face-to-face interviews with each adolescent and her mother. In addition, 20 daughters were randomly selected and completed more in-depth qualitative interviews. The findings suggest that generally the daughters were in good physical health although they reported mental health problems at about twice the rate that would be expected in a general pediatric sample. Further, about 3–5% of the daughters had a potential serious substance abuse problem. With respect to school, about 28% were not currently attending school although the majority of daughters who were attending school maintained a B average or better. Nearly two-thirds of the daughters reported being sexually active and almost 17% of the adolescents had children of their own, much higher than the 2.9% national rate of girls in this age cohort. While many of these daughters’ life circumstances may not be optimal, findings from both the quantitative and qualitative interviews with both mothers and daughters indicate that these daughters possess many strengths, abilities, and desires.

The comorbidity of health and mental health problems among Medicaid-enrolled children and youth in Florida with a designated health or mental health disability was examined and compared to that of Medicaid-enrolled children with no disability. Slightly higher rates of health problems (42%) were found among children with mental health disabilities compared to the rate of mental health problems (35%) found among children with health disabilities.Within both groups, similar rates (~ 26%) of current comorbid health and mental health problems were found. Regarding health services, less than 1% to 11% of the children experiencing significant health problems were receiving no services, depending on disability group. Rates of unmet mental health needs were higher, ranging from 4% among children with no identified disability to 22% among children with an identified health disability.These data support the need for a comprehensive health policy emphasizing the assessment of all Medicaid-enrolled children with disabilities for comorbid health or mental health problems.

Since 1995 when President Clinton issued Executive Order 12975 instructing the Office for the Protection from Research Risks (OPRR) to review its policies protecting the fights of individuals participating in research, there has been an increased focus on past lapses of research ethics (for example, Tuskegee syphilis study, cold war radiation experiments) and heightened scrutiny on ongoing studies. In May 2000 the OPRR suspended nearly all government-funded human subject research at Duke University Medical Center, claiming administrators failed to correct problems with a research safety oversight (ABC News, 2000). After the death of Ellen Roche, a volunteer in an asthma study at Johns Hopkins University, the OPRR suspended human subject research at that university (ABC News, 2001). There have been an increasing number of institutions sanctioned for failure to adequately protect research participants. Nevertheless, although the risks to participants in social work research rarely include death, these incidents should serve as a constant reminder of the need to examine the adequacy of the profession's research processes and the effect that research has on participants. This study documented the research experiences of women who participated in a study on welfare reform. Specifically, the study examined four issues: (1) the prevalence of adverse emotional reactions among study participants, (2) the extent to which participants understood the consent disclosure, (3) whether the placement of information in the consent form affected participants' understanding of the study, and (4) any relationship between the women's levels of understanding of the consent disclosure and the likelihood of experiencing adverse emotional reactions. It is important for investigators to be aware of the frequency with which study participants experience adverse emotional reactions and to document what stimuli evoke them so that future participants can be better informed of these potential psychological risks. In addition, it is important for researchers to understand if and how the placement of information in consent disclosures affects participants' level of understanding about a study so that the profession can continue to improve its procedures used to convey information about the study to potential participants. One of the foundational principles outlined by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978) in the Belmont Report is "beneficence." The Commission used the term to highlight researchers' obligations to protect participants from risk. Risks include physical risks, such as drug side effects that might occur during clinical trials; legal risks, such as possible arrest and prosecution that could result from disclosure of criminal activity if confidentiality is breached; social risks, such as stigma that might occur from participating in a study on mental illness; and psychological risks, such as stress or anxiety that could result from being asked sensitive questions. Risk consists of two components: (1) the probability or prevalence of risk and (2) the magnitude or severity of the risk. The probability relates to the likelihood that a risk will happen, whereas the magnitude refers to the seriousness of the risk should it occur. In biomedical research, consent forms frequently contain specific information on both the probability and severity of risk. An examination of several medical consent forms reviewed by the University of South Florida's Institutional Review Board (IRB) illustrates this point. One disclosure from a study on breast cancer states, "Likely side effects are those that occur in more than 5 percent of patients who undergo the procedure. The likely risks associated with this procedure are slight discomfort and/or pain, bruising at the site ..." Another consent form from a drug trial on osteogenesis imperfecta in children states, "Irritation of the food tube (called the esophagus) leading from the mouth to the stomach occurs in 1-2 percent of adult patients taking a similar dose. …

In this article, we describe the outcomes associated with a 3-year research demonstration project. It is the second of a two-part article concerned with this research conducted in the Bronx, New York, to examine the efficacy of three models of intensive in-home services—Home-Based Crisis Intervention (HBCI), Enhanced Home-Based Crisis Intervention (HBCI+),and Crisis Case Management—as alternatives to hospitalization for children experiencing a psychiatric crisis. In Part I (Evans, Boothroyd, & Armstrong, 1997), we described the features of the three program models, the research design, data collection measures, and the presenting characteristics of the children and families. In Part 2, we describe the success of maintaining children at home (82%) and the increases in family adaptability, children's self-concept, and parental self-efficacy both at discharge and at 6 months postdischarge. Enrollees in two of the models (HBCI and HBCI+) experienced a significant increase in family cohesion,although this was not maintained at 6 months postdischarge. While enrollees in the enhanced program showed significant increase in social support at discharge, all enrollees experienced this at 6 months postdischarge.

The creation of specialty mental health courts has emerged as a strategy to address the impact of persons with mental illness in the criminal justice system by consolidating the management of certain types of cases into a single court. This article describes an evaluation of the nation's first such court, the Broward County Mental Health Court. The purpose is to alert those who may conduct future evaluations of these types of courts to some of the contextual, logistic, and management features of our evaluation and the challenges we have encountered doing field research in this unique legal setting.

As performance indicators and outcomes measures become essential parts of doing business, providers of mental health services are developing and using a number of access measures. One that is being used with increasing frequency is service penetration. However, the lack of standard methods for calculating and reporting service penetration has made the comparison of penetration rates across studies difficult. This article discusses the conceptualization and operationalization of service penetration. In addition, it presents an exploratory study of service penetration using data from the same persons using very different data sources; these data were collected during an evaluation of a Medicaid managed care system in Florida. The article offers recommendations for the use and reporting of service penetration rates.

Since 1993, the Substance Abuse and Mental Health Services Administration has invested more than $1 billion establishing systems of care (SOC) in over 173 local communities to provide services to children with mental, emotional, and behavioral problems and their families. The SOC model requires that effective partnerships be developed between parents and professionals and also among different service sectors and agencies. To date, there has been no systematic examination of these interagency partnerships associated with the presence of conflict and its management. This paper reports the findings from a survey of the members of the governing boards of currently funded and graduated SOC sites related to interorganizational conflict. The results indicated that conflict was common in SOC regardless of the stage of the system’s development. The most common types of conflict included incompatible goals, interpersonal relationships, and overlapping authority. When conflict occurred, a number of management efforts were used including analyzing the conflict and developing a strategy to deal with it and dealing with the conflict behind the scenes. Suggestions are provided for identifying and managing conflict.

This manuscript focuses on the environmental safety and exposure to violence of a group of particularly vulnerable children ages 5 to 18 years. These children, 96% of whom are African American or Hispanic, resided in the Bronx, New York and presented at a psychiatric emergency room in crisis. The Bronx is New York City's poorest borough and 20% of the murders in New York State are committed there. Of the approximately 300 children eventually enrolled in the master study, 41% were exposed to at least one unsafe environment (home, neighborhood, school or school neighborhood); 21% were exposed to one unsafe environment; 14% to two; 5% to three, and 1% to four unsafe environments. A subsample of 36 children was studied intensively for their direct exposure to violence. Only 50% rated themselves as feeling safe on the streets, while about 80% felt safe at home. The percentage of children who reported witnessing acts of violence was 31% for shootings, 23% for stabbings, 26% for robberies, and 87% for beatings. Two case studies of these children are presented and the implications of these findings are discussed.

This paper summarizes the mail survey findings of 1,634 respondents examining the impact of welfare reform, namely the Work and Gain Economic Self Sufficiency (WAGES) program, in two urban areas of Florida. The health and mental health status, quality of life, and service needs of adults and children who had left WAGES were compared with those of current recipients. Findings indicate that 60% of the respondents had left WAGES during a 14-month period. Compared to former WAGES recipients, current recipients reported significantly poorer health and mental health status. Additionally, the children of current recipients had significantly greater health needs compared to those of former WAGES recipients. Although no group difference existed regarding the children's mental health status, the percentage of children scoring above the criterion suggesting a need for further psychosocial evaluation was twice the rate that would be expected in a general pediatric sample. Transportation was the only service need in which a significant group difference was found, with current recipients reporting significantly greater need compared to former recipients. Compared to former WAGES recipients, current recipients reported significantly lower levels of satisfaction with their leisure opportunities, employment or educational status, financial condition, legal and safety, family's health, and with their overall quality of their lives.

Little is known about the characteristics of children and youth presenting at emergency settings in psychiatric crisis, and virtually nothing is known about their outcomes. The purpose of this study is to describe the clinical profiles of 238 children presenting at two psychiatric emergency settings and enrolled in a randomized controlled trial of three intensive in-home interventions. A second purpose is to examine child mental health outcomes, based on clinical profile and to suggest the utility of using a clinical-profiles approach.

Experiences of adults with mental illness who participated in a 12-month managed care study are summarized. During exit interviews, participants were asked about consent procedures, study purpose, if questions were intrusive or anxiety producing, and concerns about information disclosure. Respondents rated their experience and likelihood of future participation. Almost 38% did not remember the consent procedures. Among those who did, 22.4% reported they lacked adequate detail about the scope of the study. Nearly 3% felt pressured into participating. Although most participants (96%) reported positive experiences, 8.8% became anxious, 16.8% were afraid responses would be disclosed, and 16.7% indicated questions were invasive. Age, race/ethnicity, and gender were not associated with adverse reactions. Symptomatology and perceived inadequacies in consent procedures were significantly, albeit weakly, associated with adverse reactions. Although most participants experienced no distress, rates of adverse responses among persons with mental illness exceeded those of community-based samples. Strategies for minimizing negative reactions are discussed.

Respite care is widely believed to be an important support service for families raising a child with a disability. We report the findings of a respite care utilization study conducted within the context of a larger research and demonstration project examining three models of intensive, in-home services for children experiencing psychiatric crises. Respite care, both in-home and out-of-home, was a support service available to families in two of the three study conditions. Overall, 34% of 146 eligible families used in-home and or out-of-home respite care. Utilization was lower than the estimates developed prior to implementation, prompting an inquiry at the end of the first project year designed to maximize use and to gather more information on caregiver and service provider attitudes toward respite care. The inquiry included caregiver and provider focus groups, surveys, and enhanced data collection and analysis. Caregiver interviews indicated that many families did not fully understand what it meant to receive respite care or even that it was available to them. A comparative analysis of respite care users and non-users revealed that respite care users were more likely to have younger children, children who had a greater number of assessed functional impairments, and fewer social supports. Respite care users also reported greater difficulty managing their children's difficult behaviors.

Studies including humor in testing were reviewed using performance and self-report criteria. With effects of humor judged using performance (test score) criteria, no supporting main effects were found. However, researchers found interactions with anxiety, gender, stress instructions, and humor appreciation. Humor affected students' perceptions of testing; with self-report criteria, there were supportive main effects and an interaction with humor type and field independence. Findings are discussed in terms of the construct of humor, humor type, format, and criteria measures. Additional topics for discussion include interactions, receiving a humor treatment, problematical subgroups, and implications for research and practice. Would testing be more humane with humor included? Test developers might consider including humor in tests, especially under certain conditions.

This article describes a 3-year research demonstration project originally funded by the National Institute of Mental Health and now funded in part by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. This project, which was conducted in the Bronx, New York, examined the efficacy of 3 models of intensive in-home services as alternatives to hospitalization for children experiencing serious psychiatric crises. All programs were 4- to 6-week interventions. The first, Home-Based Crisis Intervention (HBCI), was modeled on the Homebuilders model of family preservation; the second, Enhanced HBCI (HBCI+), added respite care, flexible service money, parent advocate and support services, and additional staff training in cultural competence and violence management. Crisis Case Management, the third model, used case managers to assess child and family needs and link them to services, as well as respite care and flexible money. The specific features of the 3 program models, the research design, and data collection measures are described. The intake data on the children and families are presented, and implications for providing services and for future research are discussed.

Researchers from the State University of New York at Albany and the New York State Office of Mental Health have been engaged in testing an experimental approach to evaluating systems thinking interventions. This research calls for a similar systems thinking intervention to be repeated in four counties with four control counties also selected and observed via pre- and post-intervention measures. The overall context of the project focuses on integration of mental health and vocational rehabilitation services. The experiment is designed to evaluate measurable outcomes, including shifts in goal structures and change strategies of the management team, shifts in relative alignment of the management team as a whole, perceived success of the intervention, and changes in systems and procedures necessary to improve client services. This article presents a framework for evaluating systems thinking interventions as well as preliminary findings from the pilot test. © 1997 by John Wiley & Sons, Ltd. Syst. Dyn. Rev. 13, 149‐169, 1997

The Simple Screening Instrument for Substance Abuse (SSI-SA) is gaining widespread use as a self-report measure of substance abuse; yet, little information exists regarding the instrument’s psychometric properties. This study examined the SSI’s psychometric properties within a population of 6,664 adult Medicaid enrollees in Florida, who responded to a survey conducted as part of a statewide evaluation of Medicaid services. The SSI-SA had excellent internal consistency (.85). Evidence of the SSI’s validity was strong; SSI-SA scores distinguished among individuals with and without substance abuse needs and were significantly correlated with a measure of functioning in daily living. Using the recommended SSI-SA cutoff score of 4 or higher to indicate the presence of a substance abuse problem, the SSI-SA had respectable sensitivity (.82) and specificity (.90).

Depression is the fourth leading cause of global burden of disease [1]. Depression is present in all regions of the world, significantly affecting the younger and older age groups (World Health Organization [WHO], 2000; Institute for Health Metrics and Evaluation [IHME], 2013) [2]. It is estimated that upwards of 8% of adolescents meet criteria for depression [3]. Depression during adolescence is a disabling condition that is associated with serious long-term morbidities and an increased risk of suicide [3-6]. It has been reported that among adolescents with major depression, as many as 7% commit suicide in their early adult years [7]. Yet despite these alarming statistics, adolescent depression often goes undiagnosed despite the availability of screening tools that have been demonstrated to be effective (National Institute for Health Care Management [NIHCM], 2010).

The children’s system of care framework has been extensively implemented in the U.S. Since its inception in 1993, the Comprehensive Community Mental Health Services for Children and Their Families Program has invested in excess of $1 billion supporting the development of systems of care in 164 grantee sites across the country. Despite these efforts to implement children’s systems of care nationally, little is known about the extent to which the principles and values actually have been put into practice outside of the funded grantee sites. This paper describes the development of the Systems of Care Implementation Survey, a measure designed specifically for the first ever study assessing the level of implementation of factors contributing to effective children’s systems of care in a nationally representative sample of counties throughout the U.S.

The results of a survey to measure the implementation of the systems of care (SOC) approach in a nationally representative sample of counties are presented. The results from 910 informants within 225 counties reveal a moderate level of implementation of SOC factors, with the level of poverty and population size influencing implementation. Furthermore, mental health informants generally tended to rate the implementation of systems of care greater than administrators associated with the school system, other family serving agency personnel or family members. Family members and school personnel tended to rate the implementation lowest, while staff from the other child serving agencies tended to rate the implementation closer to mental health administrators. A quarter of the counties (26%) surveyed rated themselves as having adequate levels of implementation on 11 or more of the 14 factors, while 75% rated themselves as having adequate levels of implementation on six or more of the 14 factors measured. Implications for federal policies regarding systems of care implementation are discussed.

The Colorado Symptom Index (CSI: Shern et al. 1994, Milbank Quart 72:123-148) is widely used in research as a self-report measure of psychiatric symptomatology, yet little information exists regarding the scale's psychometric properties. Additionally, the CSI has no cut-off score denoting the need for further psychiatric assessment. This study examined the CSI's psychometric properties and established a cut-off score. Analyses were based on 3,874 adult Florida Medicaid respondents. The CSI had excellent internal consistency (.92) and test-retest reliability (.71). Evidence of the CSI's validity was strong; CSI scores distinguished among individuals with and without mental health services needs and were significantly correlated with functioning. Results using a contrasting groups approach indicate that 30 is a reasonable "clinical" cut-off score. At this score, the CSI had respectable sensitivity (.76) and specificity (.68) and a ROC curve analysis suggests that the CSI is "fair to good" discriminator of individuals with psychiatric disabilities.

Depression is a leading cause of disability [World Health Organization (WHO), 2001] with economic costs exceeding 63 billion dollars per year in the US [U.S. Department of Health and Human Services (DHHS), 1999]. The challenges of treating depression among the poor are compounded by broader social needs. This study examined the prevalence of depression and psychosocial needs among enrollees in an indigent health care plan. Results indicated clinical levels of depression were present in 28.6% of respondents (n=1,405). Depressed respondents were significantly more likely (p0.001) to have co-occurring alcohol (OR=1.78; CI(95) =1.32-2.40), drug (OR=2.67; CI(95) =1.80-3.98), and health (OR=5.44; CI(95) = 4.12-7.19) problems compared to non-depressed respondents. Significantly more social needs were also associated with depression. Depressed respondents averaged 7.8 needs compared to 3.6 among non-depressed respondents. Needs included a significantly increased likelihood (p0.001) of lacking sufficient food (OR=2.56; CI(95) =1.97-3.34), shelter (OR=3.67; CI(95) =2.23-6.05), or money (OR=3.18; CI(95) = 2.39-4.23) and having more legal (OR=2.95; CI(95) =2.22-3.92) and family (OR=3.00; CI(95) =2.32-3.86) problems. The high rates of co-occurring social needs among individuals with clinical depression underscores the need for comprehensive, coordinated care in order to improve their quality of life and also reduce high utilization of crisis management services.