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Why Teenagers Come for Treatment: A Ten-Year Prospective Epidemiological Study in Woodlawn
Why Teenagers Come for Treatment A Te n-Year Prosp ecti ve Epidemiological St udy
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Wood law n
Sheppard G. Kellam, M .D., J eannette D. Branch, M.A ., C. H endricks B rown, Ph.D., and Gary R ussell, B .A .
Abstra ct , The fac to rs that in flu e nce people to com e for psychi atr ic treatment a rc not well kn own . Th is report comes from a lo ng-t e r m prospective stu d y of the 1966-1967 first-
grad e population of childre n and fam ilies in Woodlawn. a po or. black , u rban co m m u n ity on C hicago'S So u th Sid e, These ch ild re n, now ad olesce n ts. were rece nt ly reassessed in a l D-ycar fo llow-u p and were off ered access to a free , broad psychiatric tr ea tm en t program . Pri or and cu r re n t psych olo gical and socia l problems d id not d iscr im inate those who ca me for th e program from those who did not . However, th e black college stud e n ts who con du cted the reassessment sessions were signif ica n t in determini ng whi ch te e nagers ca me for tr eatme nt. J ou rnal of the Amaican A cad emy ofC lu ld Psychiall y , 20 :477-95 , 1981 .
E p idem iology is t he stud y of t he q ua nt ity and distribu tion of illness, d isorder, o r d ysfu nct ion in po pulations and of t he enviro nmental factors t ha t play im po r tant r ole s in the ir origins a nd conti n uation . A co ncern wit h to ta l d efinabl e populations , alo ng D r. Kellam is Projessor oj Psychiatry and D irector of th e S ocial Psychiat ry St udy Center, Department of Psychiatr », University of Chicago (58 1 I S outh K emoo od A venue, Ch icago, JL 6 063 7) , iohere reprint" //lay be requested. M1'.I. Branch is Field W ork Associate Professor in Psychia try and SCIlior R escarcli Analyst, C. H endricks B m wn is Chief Statistician , a nd M r. Russell uiasjormerl» a statistician, all at th e Soc ia l Psyrh iatrv Sl nrfy (;",,11'>', t i; authors wish to acknowledge th e cru cial con tribu tions of th e fa mi lies, chi ldren, and com mu nity board 1II1'lIIbas of Woodlawn, w ho ova the last seventeen yea1'.l have p rouid ed su/JIJO rt and g nida n ce / in' thi s research and ola v ice enterprise . Th e teachers, principa ls, and district superintenden ts of the Chicago public schools an d the Chicago Archd iocesan schools were also essential con tributors, Dr, Curtis M elnick, [ormerls Associa te S up erin tendent , and Mr. Geo rge Flo res oI th e Chicago B oard oI Education were eS!JI,cially important. Ou r [i as! am i current colleagues at the Soci al VI )'I'hiatl y Study Center ha ve provided essen tia l hd!J. W e 1'''!Jecia lly unsh to thank Margaret Ensminger, Ph .D ., and Georg» Bohrnstedt, Ph .D . Till ' folloioi ng g ran ts iULVe suppor ted these studies : State of I ll i nois Department oj' M l'llta l I l eallh giants 17 -2 2 '1, 17-332 , and DI'vlH 820-0 2 ; 1'. 1I.S. grant M H-1 5760 ; the M al/ria Falk Medical Fund ; Nation a l I nstitute on D ru g Abuse grants J>A -()0 78 7 a nd 1/ 8 1 -DA 0 1730 ; and most reccn tls i/lOlp fro m OlJia of Human D eoelopm ent Services g ra nt 90 C W 6 43 . 000 2-7 I fl HtH I/2 003-0477 SO1.58 I() I!l8 1 Am eri can Acad em y o f C h ild l'sychiatry.
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with the social and physical environments in which these populations live, is a key characteristic of the field. Because of this orientation to total populations of healthy and ill, functional and dysfunctional, epidemiology is strategic for the determination of differences between sick and healthy individuals. Epidemiological research is also in a good position to study helpseeking behavior by the ill, the dysfunctional, and even the normal members of the total population. The questions "Who becomes a patient?" and "Under what circumstances?" are amenable to study in epidemiological research precisely because the denominator includes healthy as well as ill, functioning as well as non functioning individ uals. In this paper we will review the literature and describe data on the importance of symptoms or psychological distress and other factors in the help-seeking of a total population of adolescents who, when they were in first grade, lived in Woodlawn, a black ghetto community on Chicago's South Side. Our population consists of the total first-grade cohort of 1966-67, whom we periodically assessed in first grade, again in third grade, and recently at age 16
or 17, when they were also offered an opportunity to seek help in a broad treatment program addressing the psychosocial needs of adolescents. The program was offered free and included transportation to and from the home, thus providing an opportunity to study helpseeking among this important population of teenagers without confounding the problem of lack of funds or difficulties in transportation. We will examine factors as far back in the life course of the teenagers as first grade. Early family characteristics, school success and failure, and psychological well-being will be examined, as well as current social structural, social adaptational, and psychological conditions which hypothetically might influence their coming for help in the treatment program. The measure of outcome used here is whether or not the teenager came in for the initial interview session of the treatment program. Since its beginning in 1963, the Woodlawn project has combined the study of mental health and illness with the provision of services. Throughout the project we have received the support of a community board composed of leaders from the community's larger citizen organizations. The board has played an advise and consent role in the design of service and research and has spec-
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ified that research be coupled with service (Kellam and Branch, 1971; Kellam et al., 1972). All the teenagers whom we are studying spent their first-grade year in the same community. Age-specific and community-specific studies such as this one are necessary complements to broader studies of social and psychological function, such as those on national probability samples. Because community studies focus on defined populations, they may reveal higher or lower rates of illness or of seeking help than such rates in other communities or in less homogeneous samples (Kellam et al., 1975). Community studies are also necessary because national scale planning cannot be based on nationwide statistics, which do not reflect the different needs of different areas (Rutter et al., 1970). Mental health and illness have been shown to vary considerably from one community to another, and therefore warrant attention from studies within specific kinds of communities. The relationships among social, psychological, and biological variables and seeking help may indeed vary from one kind of community to another. Woodlawn is a community on the South Side of Chicago. Between 1955 and 1966 it became black and substantially overcrowded with low median income and high unemployment (DeVise, 1967). It ranked among the four most impoverished Chicago neighborhoods by 1966, though some sections of Woodlawn have higher median income and more home ownership than others. Between 1963 and 1969 we studied all first-graders in Woodlawn three times each year and reassessed those who remained in the community in their third-grade years. We gathered extensive information on the families of two cohorts-half of the 1964-65 first-graders (randomly selected) and all of the 1966-67 firstgraders-by interviewing their mothers or mother surrogates during their first-grade years. These data include household composition, income and welfare status, geographic and social mo-
bility, social interaction within and outside the household, the psychological well-being and value orientation of the mother, and the mother's ratings of how well her child was doing. The target population for long-term study was the first-graders of 1966-67, particularly the 1,242 families whose children were present in Woodlawn first-grade classrooms during the entire school year. By the time of the 10-year follow-up more than two thirds of that population no longer lived in Woodlawn. However,
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we located and reinterviewed 939 (75%) of the mothers or mother surrogatcs of the 1,242 families in the follow-up (Agrawal et al., 1978). The mothers' refusal rate was 5.9%. The additional 18.5% could not be reinterviewed because the families had moved from Chicago, or, in a few cases, because the child from the study population had died. Of the 939 teenage children of the reinterviewed mothers, 705 (75%) participated in the reassessments, 14.5% refused to participate, and 10.4% could not be found, had moved out of Chicago, were in an institution, or had run away. The study population for this paper consists of 685 of the 705 teenagers whom we reassessed. Twenty teenagers were needed for pilot work in the early phases of the treatment program and were excluded from analysis. To study differences between those reassessed and those not reassessed we compared three groups from the original population, including: (1) children who participated in the follow-up as teenagers, all of whose mothers or mother surrogates had participated; (2) children who did not participate but whose mothers had; and (3) children who did not participate and whose mothers also
had not. We found no differences among the groups of children's or mothers' early psychological well-being, early family income, family type, or welfare status. Young mothers refused to participate somewhat more often than older mothers. The third group was somewhat more mobile before and during first grade, and was more likely to have been in parochial school in first grade. It was harder to trace parochial school students because these schools lacked the centralized, computerized records that the Chicago public school system maintains. We found significant differences in only 3 of 21 first-grade performance measures. We conclude thus far that the population we were able to reassess in the 10-year follow-up differs from the cases not reassessed only in terms of early mobility, age of mother, and parochial school enrollment. (For an overview of the Woodlawn project and the areas that have been investigated, see Kellam et al., 1981 b.) 'THE
FOLLow-U P
ASSESSMENT AND THE
INVITATION TO TREATMENT
In 1966-67 and in 1975-76 we interviewed the mothers or mother surrogates in their homes. In the earlier period the students were assessed in the schools that they attended, but in 1976 teenage as-
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sessments took place at our program offices in Woodlawn. Free transportation was provided. The teenagers were assessed in groups, usually of 5 to 8. Two instruments were administered by black college students in one 2-hour session in a standardized process that emphasized hearing the concerns of the teenagers, engendering trust, and assuring confidentiality. The assessment instruments, "How I Feel" and "What's Happening," were presented simultaneously on slides and on an audiotape that had been prepared by a black actor, a procedure which corrected for reading difficulty and helped to standardize the pace (Petersen and Kellam, 1977). Since the assessments took place at the program offices, where both the assessment and service staff were housed, each small group of teenagers was invited after the assessment session to tour the facilities. The treatment program was described to them. After the tour the teenagers returned to the assessment room and were asked to check a box on the "What's Happening" instrument if they wanted further contact. After each assessment session, the names of the teenagers requesting further contact were given to the treatment staff, who then contacted the teenager by telephone or, if necessary, by a home visit. The staff person invited the teenager to attend an initial session in which his or her needs and interests would be explored and aspects of the program would be determined as appropriate for initial participation. This method of making contact permitted the staff to engage with the teenager and his or her parents. THE TREATMENT PROGRAM
The treatment program, which had been described to the teenagers at the end of the assessment session, included two interrelated levels of care and access to a third. The first level was peer intervention. The staff consisted of peer leaders who were one year older than the study teenagers and peer counselors who were black college students. The peer leaders worked with the study teenagers mainly in the teenagers' neighborhoods, linking teenagers to significant others, including schools and neighborhood agencies. They also functioned as leaders in the rap sessions which were held every week for about two hours. The peer counselors coordinated the work of the peer leaders with the supervision and support of professional staff, and also did some individual counseling.
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The second level of intervention provided professional services as a backup to peer intervention. These services included skill training and psychotherapy. Skill training primarily involved the enhancement of the teenagers' skills in reading, mathematics, and communication. Psychotherapy included individual and group therapy. The team providing these second-level services was composed of a psychiatrist as consultant, a social worker, two teachers at the master's degree level, and a trained community worker. The social worker, in addition to meeting clinical responsibilities, supervised the peer counselors and leaders and maintained the linkage between the staffs of first and second levels. The second level of intervention generally was aimed at the needs of those whose troubles were more severe. In some cases it was useful to support a teenager's participation at both levels. In addition to the two levels of intervention described, daily 24-hour crisis response was offered in the form of home visits and access to the University of Chicago Hospitals and to a state mental health center polydrug unit for inpatient care. Our aim was to develop a therapeutic program which would enable teenagers to resolve feelings of distress and problems with drugs, school, and peers; and develop self-esteem in an atmosphere which would likely make them feel reasonably free to attend. OTHER STUDIES ON SEEKING TREATMENT
In studies of issues that persuade children and adolescents to come for psychiatric help, investigators have most often concluded that factors other than symptoms or problem behaviors of the child played major roles. Opinions on the exact role of symptoms or problem behaviors range from those who think it is not a factor to those who think it is one of many factors that bring a child to a clinic. Lurie's (1974) epidemiological survey of 3- to 18-year-olds in Westchester County, New York-a socially, economically, and ethnically diverse area-found that the mother's attitude was more significant than the severity of the child's disturbance in determining whether help was sought. Composition of household and sex of child were also important; male children were more often brought for treatment, particularly from homes headed by females.
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Similar conclusions were reported at a child guidance center in eastern Massachusetts. Ewalt et al. (1972) studied which of the children brought by their parents for evaluation actually began treatment. The center served children from birth to age 18 in a population of diverse socioeconomic backgrounds. The mother's attitude, rather than the child's symptoms, was a major predictor. If the mother was worried about her child's problem or if she characterized the child as stubborn, she was likely to seek treatment for the child. Mothers with at least a high school education were more likely to continue with treatment. Shepherd et al. (1966) did a cross-sectional epidemiological survey of the mental health of school children in Buckinghamshire County, England. This study first involved a large representative sample of children between the ages of 5 and 16, followed by a comparison of 50 of these children who were matched by symptom status to a group of 50 children attending child guidance clinics. The mental health and reaction of the parents, especially of the mothers, distinguished clearly between the clinic and nonclinic children. Mothers of clinic children were more likely to be anxious, depressed, and easily upset by stress, less able to cope with their children, and more prone to discuss their problems and to seek advice. Rutter (1972) discussed the Shepherd et al. study and pointed out that the design did not allow the inference that symptoms could be discounted from influencing clinic attendance. We can infer that other factors were also im portant and that other children in the community with comparable levels of symptomatology did not come to the clinic. At the Hill Center in New Haven, Connecticut, Novack et al. (1975) examined the use of children's mental health services by persons under 20 over a 3-year period. This health center is located in an inner-city neighborhood and serves a low-income population of blacks, Spanish-speaking whites, and other whites. The group receiving mental health services was compared to all children under 20 who were registered for general medical care during the same period, and to all children under 20 years of age living within the census tract served by the center. Males were predominant as patients regardless of ethnic origin. Children from female-headed households were significantly more likely to come for treatment than children from two-parent families. Approximately two thirds of the children receiving mental health services
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were from families on public assistance. On the other hand, symptoms did not distinguish those who received mental health services from those who did not. In another study, Conners (1970) compared clinic and nonclinic children and found certain symptom items discriminated the two grou ps. He factor-analyzed parent symptom ratings of 316 psychiatric clinic patients and 365 nonclinic black and white children between the ages of 5 and 16. Conners found that similar symptom patterns appear in clinic and nonclinic children, but that symptoms were more severe in the clinic children. We compared Conners's data to our Woodlawn data. Mothers' ratings of their first-grade children's symptoms in our population were based on the discriminating items used by Conners. The Woodlawn symptom levels proved to be generally similar to those of Conners's nonclinic group and less severe than those of his clinic children (Kellam et al., 1975). The importance of factors other than patient's symptoms in help-seeking may not be limited to mental health services. Tessler and Mechanic (1978) studied factors affecting children's use of physicians' services in a prepaid group practice. In this study of 175 mothers and their 336 children under 12 years old, the psychological distress of the mother (rather than the child's symptoms) was a predictor of the amount of use of physicians by the child. Although these studies differ in methodology (and in purpose in some cases), most of them indicate that the mother's mental wellbeing and values and attitudes about seeking help were related to her bringing her child for help. Whether the mother was the only adult, the sex and age of the child, and factors in addition to or instead of the presence or severity of symptoms discriminate between those who came and those who did not. Several of these studies, when assessing the importance of ethnicity, found similar results within all groups. DEFINING AND MEASURING MENTAL HEALTH
In the Woodlawn studies (Kellam et al., 1975) we conceptualize mental health in two dimensions: psychological well-being and social adaptational status (SAS). Psychological well-being is the primary component of the traditional psychiatric view of mental health-how the individual feels about himself or herself-assessed by means of self-reports or of psychiatric indicators. Social adaptational status is how a significant other-a natural rater-in a par-
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ticular social field rates the individual's performance on the tasks that the natural rater sets for him or her. Examples of natural raters in social fields are the parent in the child's home, the student's teacher in the classroom, particular individuals in the teenager's peer group, and the foreman on the job. On a broader societal level, illicit drug use and delinquency are SAS matters, judged by the courts and the police. We have defined SAS and psychological well-being as separate concepts and have measured them independent of each other so that we may study their long-term interrelationships as well as the outcome of each. In 1966-67 the first-graders' teachers and mothers assessed the first-graders' social adaptational status using structured standardized interviews and scales. IQ and readiness test scores were used as additional measures, since they are tasks that children are expected to perform. Both the clinicians and the mothers of the first-graders reported on the children's psychological well-being. In the l Ovyear follow-up self-reports were feasible. Mothers and teenagers reported on the teenagers' psychological well-being and on the teenagers' social adaptational status in a variety of social fields. First-Grade Social Adaptational Status
We chose the child's classroom for the primary measurement of first-grade social adaptational status and used the teacher as natural rater because of the importance of that social field and that natural rater at that point in the child's life cycle. The Teacher Observation of Classroom Adaptation is comprised of six global rating scales to measure SAS: social contact (sitting alone, having few friends); authority acceptance (fighting, breaking rules); maturation (clinging, not working independently); cognitive achievement (not learning up to ability as the teacher perceives it); concentration (short attention span); and an overall, global scale of how well the child is performing as a student. Each teacher rated all of her students in this standardized interview on 4-point scales ranging from adaptive to severely maladaptive behavior (Kellam et al., 1975). Teachers made these ratings early in the first-grade school year, at midyear, and at its end. In the first-grade family interview the mothers or mother surrogates of the first-graders rated them on the same scales. The Metropolitan Readiness Test Scores and KuhlmannAnderson IQ scores serve as quasi-SAS measures. The Metropolitan Readiness Test measures a child's readiness for school learning
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(Anastasi, 1968). The readiness test was administered ea rly in first grad e a nd the Kuhlm ann-Anderson IQ Test toward the middle of first grade by the teachers o r staff of the public scho o ls that the first-graders attended. Both tests have been show n to correlate sig nifica n tly with other SAS mea sures; reliability a nd valid ity studies o f the first-grad e m easures can be found in Kellam et. £11. (1975) . First-Grade Psychological Well-Being
Two measures of the psychological well -being o f the first-grad ers are used in this paper. Direct Clin ical Observation is a r ating of the ch ild re n made early in fir st gr ad e and at its e nd by pairs of clinicians on scales of flatn ess, d epression, anxiety, hyp erkinesis, bizarre behavior, and a global scale of whether (or how severely) the child was symptomatic. The second measure is th e Mother Symptom Inventory (MSI) co m ple te d by the mothers o r mother surroga tes in the family interview during the first-g rade year. The MSI is a 38-item inventory adapted from previous inv esti gations of the e p ide m io lo gy of symptoms among child re n (Conners , 1970; Kellam e t al. , 1975). T eenage Psychological W ell-Being and Social Adaptational Stat us
As had been the ca se with the first-grade famil y interview s, trained a nd ex pe r ienced bla ck females interviewed th e mo th ers or mother surro gates of the teenagers in th eir homes. The fa m ily interviews included , among o t he r thin gs, ratings by the mo ther of the teenager's ps ychological well-be ing on several sca les, ratings of the teenager's social adaptati onal stat us on a scale esse n tially sim ila r to th e scal e us ed in the firs t-grad e famil y interview , r atings of the mother's perception o f her own psychologi cal we ll-be in g, and fam ily a tmosp he re variabl es. Self-reports on teenagers' psychological well -being were made in the" How I Feel" instrument, a measure designed to ass ess psychiatric symptoms, self- esteem, body satisfaction, and se lf-pe rce p tio n of social adaptational status a nd satisfaction with it. The other selfr eport instrument, the " Wha t's Happening," included questions about drug use, antisocial behavior, social involvement, and problems in school. VALIDITY OF TH E MEASURES OF MENTAL H EALTH
We will report briefly o n so me resu lts of th e IO-year follow-up to show th e relationships o f important measures in first grade to
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teenage outcomes. We do this to show the considerable strength and the specificity of prediction of these early variables to teenage psychological distress and problem behaviors, outcomes that one might think would be associated with coming for help. The teenage psychological and social behavioral measures can be viewed, then, as having developmental importance in the sense of having evolved over at least this segment of the child's life. The 'reacher Observation of Classroom Adaptation is our primary measure of first-grade social adaptational status. In prior analyses of these ratings, shyness (having few friends, sitting alone), aggressiveness (breaking rules, fighting with other children), and learning problems proved to be strong predictors of teenage substance use and psychiatric symptoms (Kellam et al., 1980; Kellam et al., 1981a). "Learning problems" refers to the three social tasks assessed by teachers in addition to social contact (shyness) and authority acceptance (aggressiveness), They are maturation (acting with sufficient independence to accomplish first-grade tasks), cognitive achievement (learning up to ability as the teacher perceives it), and concentration (paying attention for a sufficient span of time to allow for teaching and learning). For similar concepts of learning problems, see Kohn and Rosman (1972) and Lambert and Nicoll (1977). First-grade males with learning problems were roughly twice as likely to be among the more severely symptomatic teenagers 10 years later as other first-graders, whether or not the other firstgraders were seen as shy or aggressive (Kellam et al., 1978, 1980, 1981a). Few teenage males who were symptomatic, however, were also heavy users of drugs, alcohol, or cigarettes. Shyness and aggressiveness in first grade, not learning problems, were important predictors of teenage substance use for males. Shy first-grade males were far less frequent substance users 10 years later than aggressive first-grade males. First-grade males with adapting or learning problems were in the middle in regard to teenager substance use. For both males and females, first-grade IQ and Metropolitan Readiness Test scores also predicted teenage substance use. The better-scoring students used more drugs than the worse-scoring students (Kellam et al., 1978, 1980, 1981a). Measurements of psychological well-being made during first grade were related to teenage symptoms among females but not males. The Mother Symptom Inventory (MS1), completed by the mother while the child was in first grade, had a positive correlation with females' symptoms 10 years later (Kellam et al., 1981 a).
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The Dir ect Clinical Observation had no significan t rel ationships ; th ere were only a few fir st- grad ers who were r at ed as symptomatic by thi s method (Ke lla m e t al., 197 8). Children whose mothers we re the only adult in the household did not ad apt as well as o the r child r e n to ex pecte d performance fr om fir st to third grad es (Ke llam e t al ., 1977). T he presence of ce r ta in other adults in the home, for example, the ch ild' s father or grandmother, was associated with a higher frequ ency of adaptation durin g th ese early school years. The effects o f family typ e (i.e ., the co m bina tio n of adults in the home) seem to operate indirectly and diminish over time, havin g had their direct effect o n males as well as o n females early in th e schoo l years. Early learnin g problems in schoo l are associated with a high incidence of sym pt oms 10 years lat er for males and to a lesser extent for femal es. For females, the mother's own early and e vo lving psychological well-being and expectations of her daughter's ed uca tion were r elated to the daughter's sym p tom status (Kellam e t al., 1978, 1981a). PREDI CTORS 01" SEl~KIN G HELP
Our measure of outcome in this report is whe t he r or not a teenager ca me for the initial sess ion of the tr eatment program. A bo ut 20 % of the 332 males a nd 25 % of the 35 0 females did co me for treatment ; the difference is not significa nt. In or de r to identify the factors leading to treatm ent , we first examin ed the three major d om ain s: psychological we ll-be in g, social ada pta tio nal status, and fa m ily a tm osp he r e. All th ree were measured in first grade and at age 16 to 17. Along with the cha r acte ristics of th e assessment sessions themselves , these d omains form a fairl y broad array of influences hypotheticall y likel y to predispose the teenager toward co m ing for help . A mother's ratings for her child 's symptoms in first grade did not predict coming for trea tment. The teenagers' self-r atings of psychological well-being, whi ch included psy ch opathology (49 items) , sel f-estee m (7 item s), a nd body satisfaction (10 items), had no relationship to co m in g for treatment. These tests were Pearson ian chi-sq ua re s calculated on two-way tables o f ps ychological well-being ver sus pati ent status. One se t of scales for these three co ns tr uc ts was ge ne ra te d by Rasch model scaling, a technique used exte ns ively in ed ucatio nal testing (Lo rd and No vick, 1968). Sin ce the Rasch sca le is a monotone transformation o f a total morbidity sco re it is useful when a
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single underlying factor exists. This score showed no relationship to coming for treatment. Six factors were also examined within the psychopathology items: anxious, angry, depressive, bizzare peculiar, bizarre paranoid, and obsessive/compulsive feelings. The scales were examined categorically in a test for independence and continuously in a multivariate logistic mode (Lord and Novick, 1968) for a relationship with coming in for an intake interview. No relationship was found for either sex. Neither self-perception of teenage social adaptational status in any of several social fields nor satisfaction with it was related to coming for treatment. Similarly, the mother's evaluation of the teenager's psychological well-being in the areas of anxiety, depression, bizarreness, and self-esteem did not show a relation to coming for help. We have described the strong lingering effects of first-grade SAS on teenage symptoms and substance use. The following domains were examined in detail and none had any relationship with coming for help: early and late first-grade teacher ratings of SAS, the first-grade Metropolitan Readiness Test and IQ scores, self-reports by teenagers of lifetime substance use, antisocial behavior, and the quantity and intensity of teenage social involvement. An appraisal by the mother of the child's social adaptational status was taken at both time periods. She was asked to rate the child on the same scales as used by the teacher. In all of these tests only one rating was predictive of coming for intake. Males and females who were rated as more aggressive by their mothers in the follow-up interviews were more likely to come for treatment. This is a possibly interesting result with doubtful validity, given the multitude of insignificant results in this domain. The family variables were studied in terms of change and stability between first grade and follow-up. By cross-classifying responses to identically worded questions in the two mother interviews, we ascertained whether a quality or level of family atmosphere had been maintained, had changed for the better, or had changed for the worse by the time the child was a teenager. The categories for family type included being reared by a mother who was the only adult at home, mother and father, and mother living with an adult other than the child's father. Other family related change measures included income, geographic or social mobility, the mother's psychological well-being, and her expectations regarding how far her child would go in school. No significant relationships were found for either males or fe-
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males between any of the family atmosphere variables and treatment intake. To measure the influence of family characteristics on coming for treatment, we performed Pearson chi-square tests separately for each family variable. Since the mother's permission was necessary before a child in this study could be contacted, we cannot evaluate the interest in treatment of teenagers whose mothers did not give their permission. However, for those teenagers who were contacted, the mother's interest in treatment for herself did not influence the child's coming for help. Similarly, mothers who showed deep concern for their children's psychological distress or social maladaptation had little effect on their child's coming for treatment, aggressiveness being the single exception. The clear inability of family, social adaptational, and psychological measures to predict patient status led to the consideration of factors associated with the assessment session itself. We established that the rate of intake differed from session to session. By comparing the data with a model that assumed equal possibilities of intake for all individuals, we found that sessions often had much higher or much lower proportions of teenagers coming for treatment than expected (p < 0.001). In seeking an explanation for the discrepancies, we considered a number of characteristics of the assessment session. These factors were designed to tap two potential sources of variation: individuals' effects on each other within each session, and the effects of different assessors on individuals in the groups. In logit analyses (Haberman, 1974) of individuals' effect on each other in each group none of the likelihood ratio statistics reached the 5% level of significance, and we concluded that these factors-size of group, sex composition, proportion of group interested in treatment, and time of assessment-were not determinants of participation in treatment. When we examined the role of the assessor in the process, however, a different picture emerged. At each session, a primary assessor conducted the proceedings and a secondary assessor assisted, generally assuming a more passive role. The assessors changed roles and partners in order to randomize assessor effects and were involved in at least 10 sessions. The primary assessors elicited different teenage responses, however, ranging from a high of 55% of teenagers assessed by one assessor, to a low of 5% of those assessed by another assessor (see the figure). When these same assessors were in the secondary role, all differences disap-
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peared. There were also no differences for same sex and opposite sex assessors. We can make two inferences from these results. First, certain assessors had an effect on the teenagers for which we had not planned: Teenagers came for help more often if they had been involved with certain assessors, and less often if with others. Second, the leadership role was a significant factor in this result. DISCUSSION
About one fourth of the Woodlawn teenagers came as far as the initial treatment interview. Such a rate suggests a considerable quantity of need or curiosity, or both, among the teenagers. Our results suggest that teenagers in this population experience a wide variety of problems such as substance use, psychiatric distress, antisocial
Effects of Assessors in Primary and Secondary Roles on Teenagers Coming for Treatment
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mdlvldua l ass ess ors
Figure I Each horizontal bar represents one of the assessors. On the left is the pen:cntage of teenagers who came Ior intake when that assessor was in the primary role; on the right is the percentage of teenagers who came for intake when that assessor was in the secondary role.
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behavior, family and school difficulties, and many others. Specific teenage problem areas, including psychological and social adaptational difficulties, seem to be generated from identifiable early conditions, and these growth patterns seem to be nonoverlapping. Thus, broadly based and varied interventions apparently should be available if we are to meet the needs of adolescents. However, teenagers with these problems may not come for help if left to their own initiative. These results were obtained in an urban, poor, black neighborhood and may not apply in different kinds of neighborhoods. Community studies allow for specific community values and social structure to be part of the design of intervention, while allowing the delivery systems to adapt to the communities' particular needs. It is important to note that our results are interpretable only in relation to such communities as Woodlawn and may not hold in other kinds of communities. On the other hand, the literature suggests that similar results may be found in communities of different ethnic and socioeconomic characteristics. Replication is required in other communities which are similar and dissimilar to Woodlawn. In Woodlawn, teenagers who appear to be in need of treatment are not more likely to seek it. This can be taken as a failure to reach those teenagers who themselves report psychological distress and social maladaptation. It appears that significant peer leaders -in this case the black college students who were the assessorsare far more important in influencing the teenager to come or not come for treatment than any other factor we have examined. If this result holds in subsequent research for other populations, it will have critical impact on the design of effective mental health services and, possibly, human services in general. A basic part of the design of such services would be a central concern with how to structure the function of peer leaders within communities. In the Woodlawn mental health project we used a three-level epidemiological model of human services in which the first level is highly integrated in the community, builds upon existing social and political structure, and serves wide varieties of populations, including not only those already in treatment but also those at risk. This first level involves identification, early intervention, and referral when necessary. A second level, staffed with more professional personnel, provides support and supervision for the first level and serves those individuals identified as being in more specialized need. The third domiciliary level offers hospitalization and highly technical diagnostic and treatment programs. Our results suggest that peer leaders operating at the first level
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are critical to the identification and involvement of those in need of treatment. We do not know how this effect occurs since we did not predict it. Unknown personal characteristics of the assessor and assignment to the primary leader role are both important. This area requires further study. We can hypothesize that at least in communities like Woodlawn the influence of peer leaders appears to be a critically important influence for aiding teenagers in seeking help. This aspect of the design of treatment services must be given increased priority. Reviewing prior literature in this area, we are struck by the relative consistency of the findings, These studies do not support the conclusion that the severity or kinds of symptoms of children or adolescents are sufficient explanation of their coming for treatment. In our Woodlawn analyses peer inHuences were vitally involved in their coming or staying away. Distress or problem behavior played no role. Again, further epidemiological studies of help-seeking among teenagers in similar and dissimilar communities must be done. Recent interest in peer intervention as a means of reaching out to teenagers stems from the failure of traditional outpatient treatment programs to engage adolescents. Particularly in the drug use area, peer counselors who could engage teenagers on street corners, in youth sites within the community, and in schools have been used. The Woodlawn model differs somewhat from most of these outreach models since it is epidemiological in the sense that it is concerned systematically with a total age-specific population of young people in a particular community. Epidemiological methods allow us to avoid the problems that arise when only clinic or hospital patients are studied. Given a total population, we can compare those teenagers who choose to come for intake to those who do not in terms of psychological distress and other factors. We can study who stays in treatment, and what kinds of treatment are used by people with what characteristics.
Epidemiological assessment also provides a strong base for designing and evaluating interventions, particularly if one accepts the three-level model of treatment that we have suggested above. The sanction for doing this research came from the community leaders of Woodlawn. The community board provided important guidance, collaboration, and long-term support. How such research and service can be integrated with each other, and with the community under study, is of fundamental importance to the curriculum of our trainees as we look forward to the next stage of the development of psychiatric treatment systems.
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AGRAWAL, K. C., KELLAM, S. G., KLEIN, Z. 1<:., & TURNER, RJ. (1978), The Woodlawn mental health studies. Amer. j. Pub. Hlth., 68: 139-142. ANASTASI, A. (1968), Psychological Testing, 3d edition. London: Collier-Macmillan, pp. 383-385. CONNERS, C. K. (1970), Symptom patterns in hyperkinetic, neurotic, and normal children. Child Deuelpni., 41 :667-682. DEVISE, P. (1967), Chicago's Widening Color Gafl. Chicago: Interuniversity Social Research Committee, Report No.2, Chicago Regional Hospital Study. EWALT, P., COHEN, M., & HARMATZ, J. (1972), Prediction of treatment acceptance by child guidance clinic applicants. Amer. j. Orthopsychiat., 42:857-864. HABERMAN, S. (1974), The Analysis of Frequency Data. Chicago: University of Chicago Press, pp. 352-373. KELLAM, S. G., & BRANCH, J. D. (1971), An approach to community mental health. Semin. Psychiat., 3:207-225. - - - - - - AGRAWAL, K. C., & ENSMINGER, M. E. (1975), Mental Health and Going to School. Chicago: University of Chicago Press. - - - - - - - - - & GRABILL, M. 1<:. (1972), Woodlawn mental health center. In: Handbook of Community Mental Health, cd. S. E. Golann & C. Eisdorfcr. New York: AppletonCentury-Crofts, pp. 711-727. - - - BROWN, C. H., & FLEMING, J. P. (1981 a), Longitudinal community epidemiological studies of drug use. In: Studying Drug Use and Abuse, cd. 1" N. Robins. New York: Prodist (Neale Watson Academic Publications) (in press). - - - , ENSMINGER, M. E., BRANCH, J. D., BROWN, C. H., & FLEMING, J. P. (198Ib), The Woodlawn mental health longitudinal community epidemiological project. In: Longitudinal Research in the United States, ed. S. A. Mednick & M. Harway. Hingham, Mass.: Martinus NijhofT (in press). - - - - - - SIMON, M. B. (1980), Mental health in first grade and teenage drug, alcohol, and cigarette use. Drug Alcohol Dependence, 5:273-304. - - - - - - TURNER, R. J. (1977), Family structure and the mental health of children. Arch. Gen. Psychiat., 34:1012-1022. - - - SIMON, M. B., & ENSMINGER, M. E. (1978), First-grade antecedents of teenage drug use and psychological well-being. To be published in: Origins of Psycholopathology, eel. D. Ricks & B. Dohrenwend. Also in: Prevention of Drug Abuse, Hearings before the Select Committee on Narcotics Abuse and Control, House of Representatives, Ninety-Fifth Congress, Second Session, April 18, 20, 25, May 16,25,1978. Washington, D.C.: U.S. Government Printing Office (SCNAC-95-2-4). KaHN, M., & ROSMAN, B. 1" (1972), A social competence scale and symptom checklist for the preschool child. Develpm. Psychol., 6:430--444. LAMBERT, N., & NICOLL, R. C. (1977), A conceptual model for nonintellectual behavior and its relationship to early reading achievement..J. Educ. Psychol., 69:481--490. LORD, F. M., & NOVICK, M. R. (1968), Statistical Theories of Mental Test Scores. Reading, Mass.: Addison-Wesley. LURIE, O. R. (1974), Parents' attitudes toward children's problems and toward usc of mental health services. Amer. j. Ortlwpsychiat., 44: 109-120. NOVACK, A. H., BROMET, E., NEILL, T. K., ABRAMOVITZ, R B., & STORCH, S. (1975), Children's mental health services in an inner-city neighborhood. Amer. .J. Pub. Hlth., 65:133-138. PETERSEN, A. C., & KELLAM, S. G. (1977), Measurement of the psychological well-being of adolescents. j. Youth Adol. 6:229-247. RUTTER, M. 1" (1972), Critical notice of Childhood Behaviour and Mental Health, ed. M. Shepherd, B. Oppenheim, & S. Mitchell, London: University of London Press . .J. Child Psvchol. Psychiat., 13:219-222.
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- - - '['IZARD, J., & WIlITMORE, K., cds. (1970), Education, Health, and Behainour. New York: Wiley. SHEPHERD, M., OPPENHEIM, A., & MrrCIlELL, S. (1966), The definition and outcome of deviant behaviour in childhood. Prof. Royal Soc, Med., 59:379-382. TESSLER, R., & MECHANIC, D. (1978), Factors affecting children's usc of physician services ill a prepaid group practice. Med. Care, 16:33-46.
II1
Wood law n
Sheppard G. Kellam, M .D., J eannette D. Branch, M.A ., C. H endricks B rown, Ph.D., and Gary R ussell, B .A .
Abstra ct , The fac to rs that in flu e nce people to com e for psychi atr ic treatment a rc not well kn own . Th is report comes from a lo ng-t e r m prospective stu d y of the 1966-1967 first-
grad e population of childre n and fam ilies in Woodlawn. a po or. black , u rban co m m u n ity on C hicago'S So u th Sid e, These ch ild re n, now ad olesce n ts. were rece nt ly reassessed in a l D-ycar fo llow-u p and were off ered access to a free , broad psychiatric tr ea tm en t program . Pri or and cu r re n t psych olo gical and socia l problems d id not d iscr im inate those who ca me for th e program from those who did not . However, th e black college stud e n ts who con du cted the reassessment sessions were signif ica n t in determini ng whi ch te e nagers ca me for tr eatme nt. J ou rnal of the Amaican A cad emy ofC lu ld Psychiall y , 20 :477-95 , 1981 .
E p idem iology is t he stud y of t he q ua nt ity and distribu tion of illness, d isorder, o r d ysfu nct ion in po pulations and of t he enviro nmental factors t ha t play im po r tant r ole s in the ir origins a nd conti n uation . A co ncern wit h to ta l d efinabl e populations , alo ng D r. Kellam is Projessor oj Psychiatry and D irector of th e S ocial Psychiat ry St udy Center, Department of Psychiatr », University of Chicago (58 1 I S outh K emoo od A venue, Ch icago, JL 6 063 7) , iohere reprint" //lay be requested. M1'.I. Branch is Field W ork Associate Professor in Psychia try and SCIlior R escarcli Analyst, C. H endricks B m wn is Chief Statistician , a nd M r. Russell uiasjormerl» a statistician, all at th e Soc ia l Psyrh iatrv Sl nrfy (;",,11'>', t i; authors wish to acknowledge th e cru cial con tribu tions of th e fa mi lies, chi ldren, and com mu nity board 1II1'lIIbas of Woodlawn, w ho ova the last seventeen yea1'.l have p rouid ed su/JIJO rt and g nida n ce / in' thi s research and ola v ice enterprise . Th e teachers, principa ls, and district superintenden ts of the Chicago public schools an d the Chicago Archd iocesan schools were also essential con tributors, Dr, Curtis M elnick, [ormerls Associa te S up erin tendent , and Mr. Geo rge Flo res oI th e Chicago B oard oI Education were eS!JI,cially important. Ou r [i as! am i current colleagues at the Soci al VI )'I'hiatl y Study Center ha ve provided essen tia l hd!J. W e 1'''!Jecia lly unsh to thank Margaret Ensminger, Ph .D ., and Georg» Bohrnstedt, Ph .D . Till ' folloioi ng g ran ts iULVe suppor ted these studies : State of I ll i nois Department oj' M l'llta l I l eallh giants 17 -2 2 '1, 17-332 , and DI'vlH 820-0 2 ; 1'. 1I.S. grant M H-1 5760 ; the M al/ria Falk Medical Fund ; Nation a l I nstitute on D ru g Abuse grants J>A -()0 78 7 a nd 1/ 8 1 -DA 0 1730 ; and most reccn tls i/lOlp fro m OlJia of Human D eoelopm ent Services g ra nt 90 C W 6 43 . 000 2-7 I fl HtH I/2 003-0477 SO1.58 I() I!l8 1 Am eri can Acad em y o f C h ild l'sychiatry.
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with the social and physical environments in which these populations live, is a key characteristic of the field. Because of this orientation to total populations of healthy and ill, functional and dysfunctional, epidemiology is strategic for the determination of differences between sick and healthy individuals. Epidemiological research is also in a good position to study helpseeking behavior by the ill, the dysfunctional, and even the normal members of the total population. The questions "Who becomes a patient?" and "Under what circumstances?" are amenable to study in epidemiological research precisely because the denominator includes healthy as well as ill, functioning as well as non functioning individ uals. In this paper we will review the literature and describe data on the importance of symptoms or psychological distress and other factors in the help-seeking of a total population of adolescents who, when they were in first grade, lived in Woodlawn, a black ghetto community on Chicago's South Side. Our population consists of the total first-grade cohort of 1966-67, whom we periodically assessed in first grade, again in third grade, and recently at age 16
or 17, when they were also offered an opportunity to seek help in a broad treatment program addressing the psychosocial needs of adolescents. The program was offered free and included transportation to and from the home, thus providing an opportunity to study helpseeking among this important population of teenagers without confounding the problem of lack of funds or difficulties in transportation. We will examine factors as far back in the life course of the teenagers as first grade. Early family characteristics, school success and failure, and psychological well-being will be examined, as well as current social structural, social adaptational, and psychological conditions which hypothetically might influence their coming for help in the treatment program. The measure of outcome used here is whether or not the teenager came in for the initial interview session of the treatment program. Since its beginning in 1963, the Woodlawn project has combined the study of mental health and illness with the provision of services. Throughout the project we have received the support of a community board composed of leaders from the community's larger citizen organizations. The board has played an advise and consent role in the design of service and research and has spec-
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ified that research be coupled with service (Kellam and Branch, 1971; Kellam et al., 1972). All the teenagers whom we are studying spent their first-grade year in the same community. Age-specific and community-specific studies such as this one are necessary complements to broader studies of social and psychological function, such as those on national probability samples. Because community studies focus on defined populations, they may reveal higher or lower rates of illness or of seeking help than such rates in other communities or in less homogeneous samples (Kellam et al., 1975). Community studies are also necessary because national scale planning cannot be based on nationwide statistics, which do not reflect the different needs of different areas (Rutter et al., 1970). Mental health and illness have been shown to vary considerably from one community to another, and therefore warrant attention from studies within specific kinds of communities. The relationships among social, psychological, and biological variables and seeking help may indeed vary from one kind of community to another. Woodlawn is a community on the South Side of Chicago. Between 1955 and 1966 it became black and substantially overcrowded with low median income and high unemployment (DeVise, 1967). It ranked among the four most impoverished Chicago neighborhoods by 1966, though some sections of Woodlawn have higher median income and more home ownership than others. Between 1963 and 1969 we studied all first-graders in Woodlawn three times each year and reassessed those who remained in the community in their third-grade years. We gathered extensive information on the families of two cohorts-half of the 1964-65 first-graders (randomly selected) and all of the 1966-67 firstgraders-by interviewing their mothers or mother surrogates during their first-grade years. These data include household composition, income and welfare status, geographic and social mo-
bility, social interaction within and outside the household, the psychological well-being and value orientation of the mother, and the mother's ratings of how well her child was doing. The target population for long-term study was the first-graders of 1966-67, particularly the 1,242 families whose children were present in Woodlawn first-grade classrooms during the entire school year. By the time of the 10-year follow-up more than two thirds of that population no longer lived in Woodlawn. However,
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we located and reinterviewed 939 (75%) of the mothers or mother surrogatcs of the 1,242 families in the follow-up (Agrawal et al., 1978). The mothers' refusal rate was 5.9%. The additional 18.5% could not be reinterviewed because the families had moved from Chicago, or, in a few cases, because the child from the study population had died. Of the 939 teenage children of the reinterviewed mothers, 705 (75%) participated in the reassessments, 14.5% refused to participate, and 10.4% could not be found, had moved out of Chicago, were in an institution, or had run away. The study population for this paper consists of 685 of the 705 teenagers whom we reassessed. Twenty teenagers were needed for pilot work in the early phases of the treatment program and were excluded from analysis. To study differences between those reassessed and those not reassessed we compared three groups from the original population, including: (1) children who participated in the follow-up as teenagers, all of whose mothers or mother surrogates had participated; (2) children who did not participate but whose mothers had; and (3) children who did not participate and whose mothers also
had not. We found no differences among the groups of children's or mothers' early psychological well-being, early family income, family type, or welfare status. Young mothers refused to participate somewhat more often than older mothers. The third group was somewhat more mobile before and during first grade, and was more likely to have been in parochial school in first grade. It was harder to trace parochial school students because these schools lacked the centralized, computerized records that the Chicago public school system maintains. We found significant differences in only 3 of 21 first-grade performance measures. We conclude thus far that the population we were able to reassess in the 10-year follow-up differs from the cases not reassessed only in terms of early mobility, age of mother, and parochial school enrollment. (For an overview of the Woodlawn project and the areas that have been investigated, see Kellam et al., 1981 b.) 'THE
FOLLow-U P
ASSESSMENT AND THE
INVITATION TO TREATMENT
In 1966-67 and in 1975-76 we interviewed the mothers or mother surrogates in their homes. In the earlier period the students were assessed in the schools that they attended, but in 1976 teenage as-
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sessments took place at our program offices in Woodlawn. Free transportation was provided. The teenagers were assessed in groups, usually of 5 to 8. Two instruments were administered by black college students in one 2-hour session in a standardized process that emphasized hearing the concerns of the teenagers, engendering trust, and assuring confidentiality. The assessment instruments, "How I Feel" and "What's Happening," were presented simultaneously on slides and on an audiotape that had been prepared by a black actor, a procedure which corrected for reading difficulty and helped to standardize the pace (Petersen and Kellam, 1977). Since the assessments took place at the program offices, where both the assessment and service staff were housed, each small group of teenagers was invited after the assessment session to tour the facilities. The treatment program was described to them. After the tour the teenagers returned to the assessment room and were asked to check a box on the "What's Happening" instrument if they wanted further contact. After each assessment session, the names of the teenagers requesting further contact were given to the treatment staff, who then contacted the teenager by telephone or, if necessary, by a home visit. The staff person invited the teenager to attend an initial session in which his or her needs and interests would be explored and aspects of the program would be determined as appropriate for initial participation. This method of making contact permitted the staff to engage with the teenager and his or her parents. THE TREATMENT PROGRAM
The treatment program, which had been described to the teenagers at the end of the assessment session, included two interrelated levels of care and access to a third. The first level was peer intervention. The staff consisted of peer leaders who were one year older than the study teenagers and peer counselors who were black college students. The peer leaders worked with the study teenagers mainly in the teenagers' neighborhoods, linking teenagers to significant others, including schools and neighborhood agencies. They also functioned as leaders in the rap sessions which were held every week for about two hours. The peer counselors coordinated the work of the peer leaders with the supervision and support of professional staff, and also did some individual counseling.
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The second level of intervention provided professional services as a backup to peer intervention. These services included skill training and psychotherapy. Skill training primarily involved the enhancement of the teenagers' skills in reading, mathematics, and communication. Psychotherapy included individual and group therapy. The team providing these second-level services was composed of a psychiatrist as consultant, a social worker, two teachers at the master's degree level, and a trained community worker. The social worker, in addition to meeting clinical responsibilities, supervised the peer counselors and leaders and maintained the linkage between the staffs of first and second levels. The second level of intervention generally was aimed at the needs of those whose troubles were more severe. In some cases it was useful to support a teenager's participation at both levels. In addition to the two levels of intervention described, daily 24-hour crisis response was offered in the form of home visits and access to the University of Chicago Hospitals and to a state mental health center polydrug unit for inpatient care. Our aim was to develop a therapeutic program which would enable teenagers to resolve feelings of distress and problems with drugs, school, and peers; and develop self-esteem in an atmosphere which would likely make them feel reasonably free to attend. OTHER STUDIES ON SEEKING TREATMENT
In studies of issues that persuade children and adolescents to come for psychiatric help, investigators have most often concluded that factors other than symptoms or problem behaviors of the child played major roles. Opinions on the exact role of symptoms or problem behaviors range from those who think it is not a factor to those who think it is one of many factors that bring a child to a clinic. Lurie's (1974) epidemiological survey of 3- to 18-year-olds in Westchester County, New York-a socially, economically, and ethnically diverse area-found that the mother's attitude was more significant than the severity of the child's disturbance in determining whether help was sought. Composition of household and sex of child were also important; male children were more often brought for treatment, particularly from homes headed by females.
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Similar conclusions were reported at a child guidance center in eastern Massachusetts. Ewalt et al. (1972) studied which of the children brought by their parents for evaluation actually began treatment. The center served children from birth to age 18 in a population of diverse socioeconomic backgrounds. The mother's attitude, rather than the child's symptoms, was a major predictor. If the mother was worried about her child's problem or if she characterized the child as stubborn, she was likely to seek treatment for the child. Mothers with at least a high school education were more likely to continue with treatment. Shepherd et al. (1966) did a cross-sectional epidemiological survey of the mental health of school children in Buckinghamshire County, England. This study first involved a large representative sample of children between the ages of 5 and 16, followed by a comparison of 50 of these children who were matched by symptom status to a group of 50 children attending child guidance clinics. The mental health and reaction of the parents, especially of the mothers, distinguished clearly between the clinic and nonclinic children. Mothers of clinic children were more likely to be anxious, depressed, and easily upset by stress, less able to cope with their children, and more prone to discuss their problems and to seek advice. Rutter (1972) discussed the Shepherd et al. study and pointed out that the design did not allow the inference that symptoms could be discounted from influencing clinic attendance. We can infer that other factors were also im portant and that other children in the community with comparable levels of symptomatology did not come to the clinic. At the Hill Center in New Haven, Connecticut, Novack et al. (1975) examined the use of children's mental health services by persons under 20 over a 3-year period. This health center is located in an inner-city neighborhood and serves a low-income population of blacks, Spanish-speaking whites, and other whites. The group receiving mental health services was compared to all children under 20 who were registered for general medical care during the same period, and to all children under 20 years of age living within the census tract served by the center. Males were predominant as patients regardless of ethnic origin. Children from female-headed households were significantly more likely to come for treatment than children from two-parent families. Approximately two thirds of the children receiving mental health services
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were from families on public assistance. On the other hand, symptoms did not distinguish those who received mental health services from those who did not. In another study, Conners (1970) compared clinic and nonclinic children and found certain symptom items discriminated the two grou ps. He factor-analyzed parent symptom ratings of 316 psychiatric clinic patients and 365 nonclinic black and white children between the ages of 5 and 16. Conners found that similar symptom patterns appear in clinic and nonclinic children, but that symptoms were more severe in the clinic children. We compared Conners's data to our Woodlawn data. Mothers' ratings of their first-grade children's symptoms in our population were based on the discriminating items used by Conners. The Woodlawn symptom levels proved to be generally similar to those of Conners's nonclinic group and less severe than those of his clinic children (Kellam et al., 1975). The importance of factors other than patient's symptoms in help-seeking may not be limited to mental health services. Tessler and Mechanic (1978) studied factors affecting children's use of physicians' services in a prepaid group practice. In this study of 175 mothers and their 336 children under 12 years old, the psychological distress of the mother (rather than the child's symptoms) was a predictor of the amount of use of physicians by the child. Although these studies differ in methodology (and in purpose in some cases), most of them indicate that the mother's mental wellbeing and values and attitudes about seeking help were related to her bringing her child for help. Whether the mother was the only adult, the sex and age of the child, and factors in addition to or instead of the presence or severity of symptoms discriminate between those who came and those who did not. Several of these studies, when assessing the importance of ethnicity, found similar results within all groups. DEFINING AND MEASURING MENTAL HEALTH
In the Woodlawn studies (Kellam et al., 1975) we conceptualize mental health in two dimensions: psychological well-being and social adaptational status (SAS). Psychological well-being is the primary component of the traditional psychiatric view of mental health-how the individual feels about himself or herself-assessed by means of self-reports or of psychiatric indicators. Social adaptational status is how a significant other-a natural rater-in a par-
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ticular social field rates the individual's performance on the tasks that the natural rater sets for him or her. Examples of natural raters in social fields are the parent in the child's home, the student's teacher in the classroom, particular individuals in the teenager's peer group, and the foreman on the job. On a broader societal level, illicit drug use and delinquency are SAS matters, judged by the courts and the police. We have defined SAS and psychological well-being as separate concepts and have measured them independent of each other so that we may study their long-term interrelationships as well as the outcome of each. In 1966-67 the first-graders' teachers and mothers assessed the first-graders' social adaptational status using structured standardized interviews and scales. IQ and readiness test scores were used as additional measures, since they are tasks that children are expected to perform. Both the clinicians and the mothers of the first-graders reported on the children's psychological well-being. In the l Ovyear follow-up self-reports were feasible. Mothers and teenagers reported on the teenagers' psychological well-being and on the teenagers' social adaptational status in a variety of social fields. First-Grade Social Adaptational Status
We chose the child's classroom for the primary measurement of first-grade social adaptational status and used the teacher as natural rater because of the importance of that social field and that natural rater at that point in the child's life cycle. The Teacher Observation of Classroom Adaptation is comprised of six global rating scales to measure SAS: social contact (sitting alone, having few friends); authority acceptance (fighting, breaking rules); maturation (clinging, not working independently); cognitive achievement (not learning up to ability as the teacher perceives it); concentration (short attention span); and an overall, global scale of how well the child is performing as a student. Each teacher rated all of her students in this standardized interview on 4-point scales ranging from adaptive to severely maladaptive behavior (Kellam et al., 1975). Teachers made these ratings early in the first-grade school year, at midyear, and at its end. In the first-grade family interview the mothers or mother surrogates of the first-graders rated them on the same scales. The Metropolitan Readiness Test Scores and KuhlmannAnderson IQ scores serve as quasi-SAS measures. The Metropolitan Readiness Test measures a child's readiness for school learning
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(Anastasi, 1968). The readiness test was administered ea rly in first grad e a nd the Kuhlm ann-Anderson IQ Test toward the middle of first grade by the teachers o r staff of the public scho o ls that the first-graders attended. Both tests have been show n to correlate sig nifica n tly with other SAS mea sures; reliability a nd valid ity studies o f the first-grad e m easures can be found in Kellam et. £11. (1975) . First-Grade Psychological Well-Being
Two measures of the psychological well -being o f the first-grad ers are used in this paper. Direct Clin ical Observation is a r ating of the ch ild re n made early in fir st gr ad e and at its e nd by pairs of clinicians on scales of flatn ess, d epression, anxiety, hyp erkinesis, bizarre behavior, and a global scale of whether (or how severely) the child was symptomatic. The second measure is th e Mother Symptom Inventory (MSI) co m ple te d by the mothers o r mother surroga tes in the family interview during the first-g rade year. The MSI is a 38-item inventory adapted from previous inv esti gations of the e p ide m io lo gy of symptoms among child re n (Conners , 1970; Kellam e t al. , 1975). T eenage Psychological W ell-Being and Social Adaptational Stat us
As had been the ca se with the first-grade famil y interview s, trained a nd ex pe r ienced bla ck females interviewed th e mo th ers or mother surro gates of the teenagers in th eir homes. The fa m ily interviews included , among o t he r thin gs, ratings by the mo ther of the teenager's ps ychological well-be ing on several sca les, ratings of the teenager's social adaptati onal stat us on a scale esse n tially sim ila r to th e scal e us ed in the firs t-grad e famil y interview , r atings of the mother's perception o f her own psychologi cal we ll-be in g, and fam ily a tmosp he re variabl es. Self-reports on teenagers' psychological well -being were made in the" How I Feel" instrument, a measure designed to ass ess psychiatric symptoms, self- esteem, body satisfaction, and se lf-pe rce p tio n of social adaptational status a nd satisfaction with it. The other selfr eport instrument, the " Wha t's Happening," included questions about drug use, antisocial behavior, social involvement, and problems in school. VALIDITY OF TH E MEASURES OF MENTAL H EALTH
We will report briefly o n so me resu lts of th e IO-year follow-up to show th e relationships o f important measures in first grade to
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teenage outcomes. We do this to show the considerable strength and the specificity of prediction of these early variables to teenage psychological distress and problem behaviors, outcomes that one might think would be associated with coming for help. The teenage psychological and social behavioral measures can be viewed, then, as having developmental importance in the sense of having evolved over at least this segment of the child's life. The 'reacher Observation of Classroom Adaptation is our primary measure of first-grade social adaptational status. In prior analyses of these ratings, shyness (having few friends, sitting alone), aggressiveness (breaking rules, fighting with other children), and learning problems proved to be strong predictors of teenage substance use and psychiatric symptoms (Kellam et al., 1980; Kellam et al., 1981a). "Learning problems" refers to the three social tasks assessed by teachers in addition to social contact (shyness) and authority acceptance (aggressiveness), They are maturation (acting with sufficient independence to accomplish first-grade tasks), cognitive achievement (learning up to ability as the teacher perceives it), and concentration (paying attention for a sufficient span of time to allow for teaching and learning). For similar concepts of learning problems, see Kohn and Rosman (1972) and Lambert and Nicoll (1977). First-grade males with learning problems were roughly twice as likely to be among the more severely symptomatic teenagers 10 years later as other first-graders, whether or not the other firstgraders were seen as shy or aggressive (Kellam et al., 1978, 1980, 1981a). Few teenage males who were symptomatic, however, were also heavy users of drugs, alcohol, or cigarettes. Shyness and aggressiveness in first grade, not learning problems, were important predictors of teenage substance use for males. Shy first-grade males were far less frequent substance users 10 years later than aggressive first-grade males. First-grade males with adapting or learning problems were in the middle in regard to teenager substance use. For both males and females, first-grade IQ and Metropolitan Readiness Test scores also predicted teenage substance use. The better-scoring students used more drugs than the worse-scoring students (Kellam et al., 1978, 1980, 1981a). Measurements of psychological well-being made during first grade were related to teenage symptoms among females but not males. The Mother Symptom Inventory (MS1), completed by the mother while the child was in first grade, had a positive correlation with females' symptoms 10 years later (Kellam et al., 1981 a).
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The Dir ect Clinical Observation had no significan t rel ationships ; th ere were only a few fir st- grad ers who were r at ed as symptomatic by thi s method (Ke lla m e t al., 197 8). Children whose mothers we re the only adult in the household did not ad apt as well as o the r child r e n to ex pecte d performance fr om fir st to third grad es (Ke llam e t al ., 1977). T he presence of ce r ta in other adults in the home, for example, the ch ild' s father or grandmother, was associated with a higher frequ ency of adaptation durin g th ese early school years. The effects o f family typ e (i.e ., the co m bina tio n of adults in the home) seem to operate indirectly and diminish over time, havin g had their direct effect o n males as well as o n females early in th e schoo l years. Early learnin g problems in schoo l are associated with a high incidence of sym pt oms 10 years lat er for males and to a lesser extent for femal es. For females, the mother's own early and e vo lving psychological well-being and expectations of her daughter's ed uca tion were r elated to the daughter's sym p tom status (Kellam e t al., 1978, 1981a). PREDI CTORS 01" SEl~KIN G HELP
Our measure of outcome in this report is whe t he r or not a teenager ca me for the initial sess ion of the tr eatment program. A bo ut 20 % of the 332 males a nd 25 % of the 35 0 females did co me for treatment ; the difference is not significa nt. In or de r to identify the factors leading to treatm ent , we first examin ed the three major d om ain s: psychological we ll-be in g, social ada pta tio nal status, and fa m ily a tm osp he r e. All th ree were measured in first grade and at age 16 to 17. Along with the cha r acte ristics of th e assessment sessions themselves , these d omains form a fairl y broad array of influences hypotheticall y likel y to predispose the teenager toward co m ing for help . A mother's ratings for her child 's symptoms in first grade did not predict coming for trea tment. The teenagers' self-r atings of psychological well-being, whi ch included psy ch opathology (49 items) , sel f-estee m (7 item s), a nd body satisfaction (10 items), had no relationship to co m in g for treatment. These tests were Pearson ian chi-sq ua re s calculated on two-way tables o f ps ychological well-being ver sus pati ent status. One se t of scales for these three co ns tr uc ts was ge ne ra te d by Rasch model scaling, a technique used exte ns ively in ed ucatio nal testing (Lo rd and No vick, 1968). Sin ce the Rasch sca le is a monotone transformation o f a total morbidity sco re it is useful when a
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single underlying factor exists. This score showed no relationship to coming for treatment. Six factors were also examined within the psychopathology items: anxious, angry, depressive, bizzare peculiar, bizarre paranoid, and obsessive/compulsive feelings. The scales were examined categorically in a test for independence and continuously in a multivariate logistic mode (Lord and Novick, 1968) for a relationship with coming in for an intake interview. No relationship was found for either sex. Neither self-perception of teenage social adaptational status in any of several social fields nor satisfaction with it was related to coming for treatment. Similarly, the mother's evaluation of the teenager's psychological well-being in the areas of anxiety, depression, bizarreness, and self-esteem did not show a relation to coming for help. We have described the strong lingering effects of first-grade SAS on teenage symptoms and substance use. The following domains were examined in detail and none had any relationship with coming for help: early and late first-grade teacher ratings of SAS, the first-grade Metropolitan Readiness Test and IQ scores, self-reports by teenagers of lifetime substance use, antisocial behavior, and the quantity and intensity of teenage social involvement. An appraisal by the mother of the child's social adaptational status was taken at both time periods. She was asked to rate the child on the same scales as used by the teacher. In all of these tests only one rating was predictive of coming for intake. Males and females who were rated as more aggressive by their mothers in the follow-up interviews were more likely to come for treatment. This is a possibly interesting result with doubtful validity, given the multitude of insignificant results in this domain. The family variables were studied in terms of change and stability between first grade and follow-up. By cross-classifying responses to identically worded questions in the two mother interviews, we ascertained whether a quality or level of family atmosphere had been maintained, had changed for the better, or had changed for the worse by the time the child was a teenager. The categories for family type included being reared by a mother who was the only adult at home, mother and father, and mother living with an adult other than the child's father. Other family related change measures included income, geographic or social mobility, the mother's psychological well-being, and her expectations regarding how far her child would go in school. No significant relationships were found for either males or fe-
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males between any of the family atmosphere variables and treatment intake. To measure the influence of family characteristics on coming for treatment, we performed Pearson chi-square tests separately for each family variable. Since the mother's permission was necessary before a child in this study could be contacted, we cannot evaluate the interest in treatment of teenagers whose mothers did not give their permission. However, for those teenagers who were contacted, the mother's interest in treatment for herself did not influence the child's coming for help. Similarly, mothers who showed deep concern for their children's psychological distress or social maladaptation had little effect on their child's coming for treatment, aggressiveness being the single exception. The clear inability of family, social adaptational, and psychological measures to predict patient status led to the consideration of factors associated with the assessment session itself. We established that the rate of intake differed from session to session. By comparing the data with a model that assumed equal possibilities of intake for all individuals, we found that sessions often had much higher or much lower proportions of teenagers coming for treatment than expected (p < 0.001). In seeking an explanation for the discrepancies, we considered a number of characteristics of the assessment session. These factors were designed to tap two potential sources of variation: individuals' effects on each other within each session, and the effects of different assessors on individuals in the groups. In logit analyses (Haberman, 1974) of individuals' effect on each other in each group none of the likelihood ratio statistics reached the 5% level of significance, and we concluded that these factors-size of group, sex composition, proportion of group interested in treatment, and time of assessment-were not determinants of participation in treatment. When we examined the role of the assessor in the process, however, a different picture emerged. At each session, a primary assessor conducted the proceedings and a secondary assessor assisted, generally assuming a more passive role. The assessors changed roles and partners in order to randomize assessor effects and were involved in at least 10 sessions. The primary assessors elicited different teenage responses, however, ranging from a high of 55% of teenagers assessed by one assessor, to a low of 5% of those assessed by another assessor (see the figure). When these same assessors were in the secondary role, all differences disap-
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peared. There were also no differences for same sex and opposite sex assessors. We can make two inferences from these results. First, certain assessors had an effect on the teenagers for which we had not planned: Teenagers came for help more often if they had been involved with certain assessors, and less often if with others. Second, the leadership role was a significant factor in this result. DISCUSSION
About one fourth of the Woodlawn teenagers came as far as the initial treatment interview. Such a rate suggests a considerable quantity of need or curiosity, or both, among the teenagers. Our results suggest that teenagers in this population experience a wide variety of problems such as substance use, psychiatric distress, antisocial
Effects of Assessors in Primary and Secondary Roles on Teenagers Coming for Treatment
c:uming f. 1.'fccnt t r ea tm ent Dr
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mdlvldua l ass ess ors
Figure I Each horizontal bar represents one of the assessors. On the left is the pen:cntage of teenagers who came Ior intake when that assessor was in the primary role; on the right is the percentage of teenagers who came for intake when that assessor was in the secondary role.
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behavior, family and school difficulties, and many others. Specific teenage problem areas, including psychological and social adaptational difficulties, seem to be generated from identifiable early conditions, and these growth patterns seem to be nonoverlapping. Thus, broadly based and varied interventions apparently should be available if we are to meet the needs of adolescents. However, teenagers with these problems may not come for help if left to their own initiative. These results were obtained in an urban, poor, black neighborhood and may not apply in different kinds of neighborhoods. Community studies allow for specific community values and social structure to be part of the design of intervention, while allowing the delivery systems to adapt to the communities' particular needs. It is important to note that our results are interpretable only in relation to such communities as Woodlawn and may not hold in other kinds of communities. On the other hand, the literature suggests that similar results may be found in communities of different ethnic and socioeconomic characteristics. Replication is required in other communities which are similar and dissimilar to Woodlawn. In Woodlawn, teenagers who appear to be in need of treatment are not more likely to seek it. This can be taken as a failure to reach those teenagers who themselves report psychological distress and social maladaptation. It appears that significant peer leaders -in this case the black college students who were the assessorsare far more important in influencing the teenager to come or not come for treatment than any other factor we have examined. If this result holds in subsequent research for other populations, it will have critical impact on the design of effective mental health services and, possibly, human services in general. A basic part of the design of such services would be a central concern with how to structure the function of peer leaders within communities. In the Woodlawn mental health project we used a three-level epidemiological model of human services in which the first level is highly integrated in the community, builds upon existing social and political structure, and serves wide varieties of populations, including not only those already in treatment but also those at risk. This first level involves identification, early intervention, and referral when necessary. A second level, staffed with more professional personnel, provides support and supervision for the first level and serves those individuals identified as being in more specialized need. The third domiciliary level offers hospitalization and highly technical diagnostic and treatment programs. Our results suggest that peer leaders operating at the first level
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are critical to the identification and involvement of those in need of treatment. We do not know how this effect occurs since we did not predict it. Unknown personal characteristics of the assessor and assignment to the primary leader role are both important. This area requires further study. We can hypothesize that at least in communities like Woodlawn the influence of peer leaders appears to be a critically important influence for aiding teenagers in seeking help. This aspect of the design of treatment services must be given increased priority. Reviewing prior literature in this area, we are struck by the relative consistency of the findings, These studies do not support the conclusion that the severity or kinds of symptoms of children or adolescents are sufficient explanation of their coming for treatment. In our Woodlawn analyses peer inHuences were vitally involved in their coming or staying away. Distress or problem behavior played no role. Again, further epidemiological studies of help-seeking among teenagers in similar and dissimilar communities must be done. Recent interest in peer intervention as a means of reaching out to teenagers stems from the failure of traditional outpatient treatment programs to engage adolescents. Particularly in the drug use area, peer counselors who could engage teenagers on street corners, in youth sites within the community, and in schools have been used. The Woodlawn model differs somewhat from most of these outreach models since it is epidemiological in the sense that it is concerned systematically with a total age-specific population of young people in a particular community. Epidemiological methods allow us to avoid the problems that arise when only clinic or hospital patients are studied. Given a total population, we can compare those teenagers who choose to come for intake to those who do not in terms of psychological distress and other factors. We can study who stays in treatment, and what kinds of treatment are used by people with what characteristics.
Epidemiological assessment also provides a strong base for designing and evaluating interventions, particularly if one accepts the three-level model of treatment that we have suggested above. The sanction for doing this research came from the community leaders of Woodlawn. The community board provided important guidance, collaboration, and long-term support. How such research and service can be integrated with each other, and with the community under study, is of fundamental importance to the curriculum of our trainees as we look forward to the next stage of the development of psychiatric treatment systems.
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