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Diagnostic Predictors of Treatment Patterns in a Cohort of Adolescents
Diagnostic Predictors of Treatment Patterns in a Cohort of Adolescents PATRICIA COHEN, PH.D. , STEPHANIE KASEN , PH.D. , JUDITH S. BROOK, ED.D. , AND ELMER L. STRUENING , PH.D. Abstract. Data on 776 American adolescents studied longitudinally were used to show treatment patterns related to psychiatric disorders. When DSM·lll·R diagnose s based on mother and youth Diagnostic Interview Schedule for Children interviews were used prospectively to determ ine subsequ ent treatment seeking, it was found that consultation with mental health speci alists. but not with pediatricians or general practitioners, was elevated in those with disorders. The specific diagnose s most associated with treatment seeking were conduct disorder and oppositionalldefiant disorder. No compensation for differences in mental health service usage between children with internalizing disorders and those with externalizing disorders in the form of help from informal or other professional sources was present. J , Am. Acad . Child Adolesc. Psychiatry, 1991, 30, 6:989-993 . Key Words: service utilization, treatment, service sources , adolescence. Epidemiological studies have provided information on certain aspects of treatment practices for children with psychopathology (Beiser and Attneave, 1982; Beitchman, 1978; Langner et aI., 1974). Among important findings are the sex discrepancies in treatment ·rates, with a predominance of boys in childhood and of girls in adolescence (Bird et aI., 1988; McCulloc et aI., 1966; Rutter and Garmezy , 1983, von Knorring et aI., 1987). Recent epidemiological studies from Canada and Puerto Rico (Bird et aI., 1988; Offord et aI., 1987) indicate that in these locations, professional consultation is obtained for only a modest minority of children with diagnosable problems. Studies to date have not provided the detail necessary to answer three important questions: 1. From whom , other than mental health professionals , do parents in the general population seek advice regarding their childrens' emotional or behavioral problems? We know little about the pattern of professionals consulted regarding children's psychiatric problems and nearly nothing about more informal sources of help and advice used by parents whose children do or do not have diagnosable disorders. A study of 50 matched pairs of clinic and nonclinic children with behavioral disorders found that parents of children attending a clinic were more likely than those not in professional care to have discussed their children's problems with the school but not more likely to have done so with the family doctor (Shepherd et aI., 1966). The Ontario Child Accepted November 7, 1990. Drs. Cohen, Kasen, and Struening are Research Scientists, New York State Psychiatric Institute ; Drs. Cohen and Struening are also Professors, Division of Epidemiology , Columbia University School of Public Health; and Dr. Kasen is also Assistant Professor, Department of Psychiatry, Columbia University College of Physicians and Surgeons. Dr . Brook is Associate Professor , Department of Psychiatry, Mt. Sinai School of Medicine, New York . This study is part of the Children in the Community Study supported by NIMH Grant No . MH3697I to Dr. Cohen as PI, by NIDA Grant No. DA03I88 to Dr. Brook as PI, and by the W.T . Grant Foundation to Dr. Cohen as PI. . Reprint requests to Dr. Cohen, Box 47, New York State Psychiatric Institute, 722 West 168 Street, New York, New York 10032. 0890·8567/9113006·0989$03.0010© 1991 by the American Academy of Child and Adolescent Psychiatry. l.Am.Acad. Child Adolesc.Psychiatry, 30 :6,November 1991
Health Study found that although families of disordered children in the community were not more likely to contact medical services, they were more likely to be heavy users of such services (Woodward et al., 1988). Generalizations of these findings to a population without a national health service are problematic. Within the United States, comparisons on consultations regarding children with clergy, school, and informal advisors of community-based cases and noncases are generally not made. This sparsity of information is due to the questions included in most epidemiological surveys being oriented toward the mental health profes sional. Nevertheless, information on the natural network of resources upon whom parents call for such advice is essential to the development of prevention efforts . 2. For which child diagnoses are families most likely to seek mental health treatment? Relevant information from epidemiological samples, using standardized diagnostic criteria, is only beginning to accumulate. Partly because of this recency, no studies were located giving predictive rather than correlational (concurrent) information on this topic. In addition , information on the effects of psychiatric comorbidity on treatment seeking is needed . 3. To what extent are informal supports used as a sub· stitute for mental health professionals by families of children with certain psychiatric diagnoses? 4. How frequently are troubled children seen by professionals who do not specifically identify or address their mental health needs? This last question addresses the issue of access; are such children being seen by potential helping professionals without actually obtaining mental health services? A final motivation for the analyses reported here is the determination of whether psychiatric diagnoses made in this manner on an epidemiological sample of children do in fact have important real world consequences. Given the current broad interest is the method and substance of child psychiatric epidemiology, such a demonstration seems particularly timely . Method Sample
Data for the current study are taken from families with adolescents, most of whom were originally randomly sam-
989
COHEN ET AL.
pled in 1975 on the basis of geographical location in one of two upstate New York counties. Data on diagnosis and service utilization were collected in 1983 and again in 1985 to 1986 as part of the first and second longitudinal followup interviews of this cohort, which was first studied when the children were ages 1 to 10. Seventy-nine percent of the original sample of 976 were located and reinterviewed. Because families with the youngest children in areas of urban poverty were excessively lost to follow-up, the sample was supplemented with 54 newly randomly sampled families in such areas in 1983. Of families interviewed in the first follow-up, 95% were successfully interviewed in the second follow-up. For the current investigation, the sample was divided into those who were ages 16 and under as compared with those who were ages 17 to 20 at the time of the second follow-up; the investigation is confined to those 760 children whose mothers were interviewed in both follow-up waves. Table 1 provides some basic demographic characteristics about the sample at the time of the 1983 follow-up . The sample is broadly representative of children of these ages living in the northeastern section of the United States except for fewer black and Hispanic children, as is characteristic of the population of the sampled counties. At the time of the 1983 follow-up, the families lived in rural, suburban, and urban areas in some 26 different states. Family incomes ranged from levels of poverty to wealth, and marital breakups had taken place in about a third of the families, a proportion that reflects both regional and national rates. Measures
In each family, interviews were carried out with one parent, usually the mother, and the study child. These interviews included a broad range of topics relevant to understanding the origins and course of psychiatric disorder in the youth, including a structured diagnostic interview of mother and youth, the Diagnostic Interview Schedule for Children (DISC) (Costello et al. , 1984), as modified and supplemented by the authors . Responses from maternal and youth interviews were combined by computer algorithms described elsewhere (Cohen et al., 1987b) to produce DSMIll-R diagnoses at three levels-mild, moderate, and severe . Despite the orientation of the original DISC toward the DSM-llI system, the authors were able to employ information gathered elsewhere in the interviews to supplement the DISC, where demands of the revised diagnostic system had changed. Evidence of the validity of these diagnoses is provided elsewhere (Cohen et al., 1987a, 1989a, b, c; Velez et al., 1989). Diagnoses of conduct disorder (CD), oppositional defiant disorder (ODD), attention deficit hyperactivity disorder, major depressive disorder, and overanxious disorder, accompanied by high symptom levels (severe diagnoses), were employed for these analyses, which focus on diagnoses, as these conditions most unambiguously warrant professional attention . However, all findings presented here generalize completely to children diagnosed with moderate symptom levels as well. Mothers were asked a series of questions covering formal and informal consultations that were sought regarding the child's health, achievement, emotional or behavioral prob-
990
TABLE
1. Demographic Characteristics of the 1983 Sample (N = 776)
Median family income % White % Catholic % Protestant % Families intact % Rural or small town % Female % Youth with one or more severe diagnoses Maternal mean years of education
$23,000
92 55 39
68 24 50 18 12.6
lems, or for other problems or reasons. Youth were also questioned about consultations for particular diagnoses; these responses will be reported separately. Specifically, mothers were asked whether they had consulted with a pediatrician or other physician, a teacher, a psychologist, a social worker, a psychiatrist, or a member of the clergy about the child in the past year, and if so, how many times and for what problems . In addition, questions covered informal discussions with spouse, relative or friend, or another person regarding the child. The child's attendance at a mental health or other social agency was also reported. Data Analysis
Following comparisons of consultation rates with different professionals according ' to diagnostic status and age, logistic regression analyses were performed to determine the influence of diagnosis on subsequent treatment seeking. In these analyses, diagnoses made at the first follow-up were used to predict mental health service usage in the year before the second follow-up--that is, over a year later. Service usage was defined as the number of mental health professionals, including psychiatrists, psychologists, or social workers who had been consulted. By using diagnoses made prospectively, the potential bias as a result of the increased likelihood of diagnostic recognition and labelling by those currently in treatment is lessened. Confounding effects of age, sex, and urban setting of residence were removed by including these variables in the equations. Relationships of these variables totreatment are discussed elsewhere (Cohen, 1990, unpublished manuscript). Findings From Whom Is Consultation Obtained?
Table 2 presents findings regarding the base rates for consultationwith each professional for the children in younger and older age groups. The older adolescents, those ages 18 and over at the 1985 follow-up , may have been obtaining professional assistance without the awareness of their parents; thus, we might anticipate that rates and relationships would differ between these groups. In addition, both the sources of assistance and the reasons for help seeking may differ between the younger and older subsamples. As can be seen, teachers were the most likely professionals to be consulted about the child and the most likely with whom to have discussed emotional or behavioralprobl.Am.Acad. Child Adolesc. Psychiatry, 30:6, November 1991
DIAGNOSTIC PREDICTORS OF TREATMENT PATTERNS TABLE
2. Foll ow-up Total Consultations and Consultations fo r Em otional or Behavioral Problems by Age Group Younger (Ages 12-16) (N = 457) Emotional or Behavorial Problems
Any· Teacher Pediatrician! physician Psychologist Clergy Social worker Psychiatrist Mental health center Other agency
Older (Ages 17-20) (N = 303)
%
Emotion al or Behavioral Problems
Any
%
N
N
%
N
%
N
56
256
19
88
23
71
6
17
38 9 12 5 2
175 43 56 24 10
4 9 7 5 2
16 41 31 22 10
24 5 8 4 2
73 16 23 II 5
3 5 6 3 2
10 15 17 8 5
2 5
II 24
2 4
-Any reason, including academic, health, emotional or behavioral problems or consultation that was not problem-ori ented, such as a routine check-up.
T ABLE
3. Consultation Rates f or Adolesce nts with and without Curr ent Sever e Psychi atric D iagnoses
Ages 12-16 Consultation for Emotional or Behavioral Problem Physician Teacher Clergy Mental health service
Ages 17-20
No Dx Dx No Dx Dx (N = 385) (N = 72) (N = 233) (N = 44) % % % %
3 19
6 11
6 31* 12 33*
3 6 5 5
2 9 9 20*
*p < 0.05.
lems of the child. Although mothers consulted with pediatricians or other nonpsychiatric physicians regarding the child in more than a third of the sample , it was relatively rare to have discussed the child's emotional or behavioral problems. In almost all the cases in which the child's emotional or behavioral problems were discussed with a physician, it was in the context of a medical problem (data not tabled). Children were seen for some kind of counseling at a variety of other agencies , including special school programs, independent nonprofit children's agencies, and adolescent pregnancy-related and self-help groups. Of these 28 children, six were being seen in alcohol or drug abuse related programs . Six other children were seen in various juvenile justice programs. Table 3 differentiates treatment seeking according to the child's current diagnostic status. There was very little overlap between consultation s sought with a pediatrician and consultations sought with a mental health professionalamong the younger group only two youth and among the older only three youth were seen by both, and in no case was consultation with a psychiatrist reported for this group. Furthermore , of those children with emotional or behavioral l.Am .Acad. Child Adolesc .Psy chiatry , 30:6, N ovember 1991
problems for whom consultation with a primary physician but no other professional occurred, only one had previously been diagnosed with a severe psychiatric disorder, a diagnostic rate actually smaller than that of the sample as a whole. Therefore , it is reasonable to conclude that at least in this geographic area parents did not consult a primary physician when their adolescents had serious emotion al or behavioral problems. The parents did, however , go to other professionals. They were more likely to see some professional (for any reason) than when the youth did not have a serious problem (86% as compared with 71%), and in particular were twice as likely to have seen at least one professional regarding emotional or behavioral problems of the child when the child had a serious disorder than when they did not (58% as compared with 29%) . Nevertheless , 42% of those with current severe psychiatric disorders had not seen any professional for these problem s in the past year. Diagno stic Predictors of Subsequent Mental Health Service Use
The different diagnoses were by no means equally predictive of mental health service use. Table 4 presents the odds that consultation was subsequently sought as a function of the psychiatric diagnostic status 2 1/ 2 years earlier . All analyses controlled for the child's age, sex, age-sex interaction , urban setting of residence, and family socioeconomic status (effects of these variables on treatment rates are presented elsewhere [Cohen , 1990, unpublished manuscript]). Each diagnostic group used more mental health services than did the group not receiving the diagnosis: all odds ratios exceed 1.0. However , only children with CD or ODD were significantly more likely to use services than those not obtaining these diagnoses. In equations including all diagnoses, CD and ODD groups showed independent relationships to service usage; odds ratios were 3.98 and 3.62 for ODD and CD, respectively. 991
COHEN ET AL. TABLE
4. Adjusted Odds Ratios for Subsequent Professional Mental Health Consultation (N = 734)
Diagnostic Group
Odds
Major depression 2.02 Conduct disorder 3.74* Oppositional defiant 4.84* Attention deficit hyperactivity disorder 1.61 Overanxious disorder 1.11 Any severe diagnosis 2.25*
(Confidence Limits) (0.71- 5.78) (1.57- 8.93) (2.24-10.46) (0.63- 4. 10) (0.24-5.10) (1.33-3. 82)
*p < 0.01 in comparison to those not so diagnosed.
For Some Diagnoses, Could Mothers Be Using Informal Consultations to Substitute for Mental Health Consultations for Their Children? It is reasonable to hypothesize that discussions about the child with nonprofessionals may be used in some cases as a substitute for discussions with mental health professionals. In particular, it may be that advice regarding children with internalizing disorders may be more likely to be obtained from the parent's informal network, because it is clear that they are less likely to reach mental health professionals. In order to answer this question, the authors examined the total number of kinds of nonprofessionals with whom the mother reported having discussed emotional or behavioral problems of the youth . For the total sample, 26% had not discussed the child with anyone, 23% had talked about the child with one person, and 51 % with more than one person. As noted, psychiatric comorbidity was quite common in this sample, as has been found in other epidemiological samples of youth (Bird et aI., 1988; Kashani et aI., 1987; Offord et al., 1987). In order to improve the statistical power for these comparisons, five groups of children were examined: those with no severe diagnosis, those with only internalizing diagnoses, those with one externalizing diagnosis, those with more than one externalizing diagnosis, and those with both internalizing and externalizing diagnoses . Because the group of children with multiple externalizing diagnoses studied longitudinally was small (23 children) , none of the differences between them and the group with a single externalizing diagnosis was significant. Therefore , the authors present data on the pooled externalizing group. Group means may be seen in Table 5. The analysis of covariance controlling for age and sex differences was not significant (F = 1.51). The trend was for mothers of children with externalizing disorders to use more informal as well as mental health professional help. Therefore , it is concluded that informal supports are not used as a substitute for formal supports . For Some Diagnoses , Could Mothers Be Using Other Professionals as a Substitute for Mental Health Consultations for Their Children ? Although informal supports do not follow a clear diagnostic pattern, it is theoretically reasonable that parents consult other professionals regarding the child for certain disorders. Therefore, the mean numbers of professionals
992
consulted by the parent regarding the child's emotional or behavioral problems were examined . These professionals include, in addition to the mental health professionals , teachers, clergy, and physicians. As shown in Table 5, no such compensating tendency was evident, and diagnostic differences in professional consultation , other than mental health professionals , were not significant (F = 1.50). Summary and Conclusions This epidemiological study has shown the following patterns of professional contact by mothers regarding troubled adolescents: 1. In agreement with findings of epidemiological studies conducted at other times and locations, many children with serious problems were not being seen by anyone regarding these problems. 2. Teachers were the professionals with whom parents most commonly discussed the emotional or behavioral problems of their offspring, followed by clergy and psychologists. It is, of course , not possible to generalize about these consultations as if they were mental health treatment. In fact, it is likely that in a number of cases, teachers initiated contacts because they wanted the parents to control the behavior of their children, without providing any advice or joint plan of action. However , this high level of contact suggests an opportunity for constructive professional input. 3. Although a very high proportion of teen-agel's did see a physician during the course of a year , it was rare that emotional and behavioral problems were discussed with them, and when they were, it was generally in the context of medical problems . Mothers who did discuss the problems of their adolescents with a physician generally did not discuss them with any mental health professional. The authors conclude that, in general , physicians did not make referrals to mental health specialists. On the other hand, the problems discussed with physicians may have been trivial or transitory on the whole, as indicated by the low psychiatric diagnostic rate in these children. The fact that the diagnoses were made prospectively rules out the alternative inference that once a parent has discussed these problems with a pediatrician, she is so reassured that she no longer considers-and therefore no longer reports-that the child has a problem. 4. Diagnoses made over a year earlier were strong predictors of treatment seeking, and this was particularly true of CD and ODD. Treatment rates for depressive and anxiety disorders were not statistically significantly elevated. CD and ODD effects on treatment seeking were cumulative rather than redundant. This finding reinforces the advisability of keeping separate these diagnostic groups, despite the considerable comorbidity found. These findings also suggest that children with internalizing problems are underidentified or referred. 5. There was no " balancing" tendency for mothers to seek advice regarding children with internalizing disorders from informal sources, such as her spouse, a relative, or a friend. On the whole, advice from informal sources tended to follow the same pattern as advice from mental health professionals. 6. There was also no evidence that parents of children J. Am. Acad. Child Adolesc . Psychiatry, 30:6, November 1991
DIAGNOSTIC PREDICfORS OF TREATMENT PATTERNS TABLE
5. Number of Informal Supports and Total Professionals Consulted Regarding Emotional or Behavioral Problems of Adolescence by Prior Diagnostic Status Infonnal Supports
No severe diagnosis One or more internalizing One or more externalizing Internalizing and externalizing
Total Professionals
N
X
(SO)
N
X
(SO)
593 47 47 20
1.79 1.81 2.04 1.79
(0. 80) (0.82) (0.75) (0.7 1)
593 47 47 20
1.06 1.11 1.49 1.15
(1.08) (1.20) (1.41) (1.27)
with internalizing disorders tended to consult professionals outside the mental health system as a substitute for mental health consultation. Nevertheless, the vast majority of all families with disordered children had consulted at least one professional, and, therefore, showed at least partial access to professional help. Several important limitations of the current study should be noted. Data are confined to maternal reports of those consulted for health, academic, emotional, or behavior problems of the youth. Although these data cover more professional disciplines and settings than most previous reports, they do not necessarily indicate that treatment was actually being sought. Moreover, mothers may well not correctly identify the professional discipline of some mental health professionals with whom they have talked. No information is available about referral patterns for the various consultations . Referral source tends to be information that is hard to obtain reliably, even in clinical settings. Partially counteracting these limitations are the strengths of the current study , including its population-based sample , the availability of prospective longitudinal diagnostic information from two sources, and considerable detail on consultation sources and reasons.
References Beiser, M. & Attneave, C. L. (1982), Mental disorders among Native American children: rates and risk periods for entering treatment. Am . J. Psychiatry, 139:193-198 . Beitchman, J . (1978), Social class , system type and the utilization of children's psychiatric services: some comparative Canadian data. Can. Psychiat. Assoc. J., 23:297-302 . Bird, H. R. , Canino, G., Rubio-Stipec, M. et al. (1988), Estimates of the prevalence of childhood maladjustment in a community survey in Puerto Rico. Arch. Gen . Psychiatry, 45: 112~1128 . Cohen, P. O'Connor, P., Lewis, S. A. & Malachowski, B. (1987a), A comparison of the agreement between DISC and K-SADS-P interviews of an epidemiological sample of children. J. Am . Acad. Child Psychiatry, 26:662-667. - - Velez, C. N., Kohn, M., Schwab-Stone, M. & Johnson, J. (1987b), Child psychiatric diagnosis by computer algorithm: theoretical issues and empirical tests. J. Am . Acad. Child Psychiatry, 26:631-638 .
J .Am. Acad. Child Adolesc .Psychiatry, 30:6, November 1991
- - Johnson, J ., Lewis, S. A. & Brook, J. S. (1989a), Single parenthood and employment: double jeopardy? In: Stress between Work and Family, eds. J. Eckenrode & S. Gore. New York: Plenum. pp. 117-131. - - - - Struening, E. L. & Brook, J. S. (1989b), Family mobility as a risk factor for psychopathology in childhood . In: Epidemiology and the Prevention of Mental Disorders , eds. B. Cooper & T. Helgason. London: Routledge, pp. 145-156. - - Velez, C. N. , Brook, J. S. & Smith, 1. (1989c) , Mechanisms of the relationship between perinatal problems, early childhood illness, and psychopathology in late childhood and adolescence. Child Dev. , 60:701-709 . Costello, A. J. , Edelbrock, C. S. , Dulcan, M. K. & Kalas, R. (1984). Testing of the NIMH Diagnostic Interview Schedule for Children (DISC) in a Clinical Population. (Contract No. RFP-DB-81-0027). Rockville, MD: Center for Epidemiological Studies, National Institute of Mental Health. Kashani, J. H., Beck, N. C., Hoeper, E. W. et al. (1987), Psychiatric disorders in a community sample of adolescents. Am . J . Psychiatry, 144:584-589. Langner, T ., Gersten, J. C., Greene , E. L., Eisenberg, J . G. , Herson, J. H. & McCarthy, E. D. (1974), Treatment of psychological disorders among urban children. J. Consult . Clin. Psychol . , 42:17~ 179. McCulloc, J. W. , Henderson , A. S. & Philip , A. E. ( 1966), Psychiatric illness in Edinburgh teenagers. Scott . Med. J., 11:277-281. Offord, D. R., Boyle, M. H., Szatmari, P. et al. (1987), Ontario Child Health Study: II . Six-month prevalence of disorder and rates of service utilization. Arch. Gen. Psychiatry, 44:832-836. Rutter, M. & Garmezy, N. (1983); Developmental psychopathology. In: Handbook of Child Psychology, 4th edition, Socialization, personality and social development, ed. E.M . Hetherington. pp. 775911, New York: Wiley. Shepherd, M. , Oppenheim , A. N. & Mitchell, S. (1966), Childhood behaviour disorders and the child-guidance clinic: an epidemio logical study. J. Child PsychoI. Psychiatry, 7:39-52. Velez, C. N., Johnson, J. & Cohen , P. (1989), Longitudinal analyses of selected risk factors for childhood psychopathology : the Children in the Community Study. J . Am . Acad . Child Adolesc. Psychiatry, 28:861-864. von Knorring, A., Andersson, O. & Magnusson , D. (1987), Psychiatric care and course of psychiatric disorders from childhood to early adulthood in a representative sample. J. Child Psychol . Psychiatry, 28:329-341. Woodward, C. A., Boyle, M. H., Offord, D. R. et al. (1988), Ontario Child Health Study: patterns of ambulatory medical care, utilization, and their correlates . Pediatrics. 82:425-434 .
993
Health Study found that although families of disordered children in the community were not more likely to contact medical services, they were more likely to be heavy users of such services (Woodward et al., 1988). Generalizations of these findings to a population without a national health service are problematic. Within the United States, comparisons on consultations regarding children with clergy, school, and informal advisors of community-based cases and noncases are generally not made. This sparsity of information is due to the questions included in most epidemiological surveys being oriented toward the mental health profes sional. Nevertheless, information on the natural network of resources upon whom parents call for such advice is essential to the development of prevention efforts . 2. For which child diagnoses are families most likely to seek mental health treatment? Relevant information from epidemiological samples, using standardized diagnostic criteria, is only beginning to accumulate. Partly because of this recency, no studies were located giving predictive rather than correlational (concurrent) information on this topic. In addition , information on the effects of psychiatric comorbidity on treatment seeking is needed . 3. To what extent are informal supports used as a sub· stitute for mental health professionals by families of children with certain psychiatric diagnoses? 4. How frequently are troubled children seen by professionals who do not specifically identify or address their mental health needs? This last question addresses the issue of access; are such children being seen by potential helping professionals without actually obtaining mental health services? A final motivation for the analyses reported here is the determination of whether psychiatric diagnoses made in this manner on an epidemiological sample of children do in fact have important real world consequences. Given the current broad interest is the method and substance of child psychiatric epidemiology, such a demonstration seems particularly timely . Method Sample
Data for the current study are taken from families with adolescents, most of whom were originally randomly sam-
989
COHEN ET AL.
pled in 1975 on the basis of geographical location in one of two upstate New York counties. Data on diagnosis and service utilization were collected in 1983 and again in 1985 to 1986 as part of the first and second longitudinal followup interviews of this cohort, which was first studied when the children were ages 1 to 10. Seventy-nine percent of the original sample of 976 were located and reinterviewed. Because families with the youngest children in areas of urban poverty were excessively lost to follow-up, the sample was supplemented with 54 newly randomly sampled families in such areas in 1983. Of families interviewed in the first follow-up, 95% were successfully interviewed in the second follow-up. For the current investigation, the sample was divided into those who were ages 16 and under as compared with those who were ages 17 to 20 at the time of the second follow-up; the investigation is confined to those 760 children whose mothers were interviewed in both follow-up waves. Table 1 provides some basic demographic characteristics about the sample at the time of the 1983 follow-up . The sample is broadly representative of children of these ages living in the northeastern section of the United States except for fewer black and Hispanic children, as is characteristic of the population of the sampled counties. At the time of the 1983 follow-up, the families lived in rural, suburban, and urban areas in some 26 different states. Family incomes ranged from levels of poverty to wealth, and marital breakups had taken place in about a third of the families, a proportion that reflects both regional and national rates. Measures
In each family, interviews were carried out with one parent, usually the mother, and the study child. These interviews included a broad range of topics relevant to understanding the origins and course of psychiatric disorder in the youth, including a structured diagnostic interview of mother and youth, the Diagnostic Interview Schedule for Children (DISC) (Costello et al. , 1984), as modified and supplemented by the authors . Responses from maternal and youth interviews were combined by computer algorithms described elsewhere (Cohen et al., 1987b) to produce DSMIll-R diagnoses at three levels-mild, moderate, and severe . Despite the orientation of the original DISC toward the DSM-llI system, the authors were able to employ information gathered elsewhere in the interviews to supplement the DISC, where demands of the revised diagnostic system had changed. Evidence of the validity of these diagnoses is provided elsewhere (Cohen et al., 1987a, 1989a, b, c; Velez et al., 1989). Diagnoses of conduct disorder (CD), oppositional defiant disorder (ODD), attention deficit hyperactivity disorder, major depressive disorder, and overanxious disorder, accompanied by high symptom levels (severe diagnoses), were employed for these analyses, which focus on diagnoses, as these conditions most unambiguously warrant professional attention . However, all findings presented here generalize completely to children diagnosed with moderate symptom levels as well. Mothers were asked a series of questions covering formal and informal consultations that were sought regarding the child's health, achievement, emotional or behavioral prob-
990
TABLE
1. Demographic Characteristics of the 1983 Sample (N = 776)
Median family income % White % Catholic % Protestant % Families intact % Rural or small town % Female % Youth with one or more severe diagnoses Maternal mean years of education
$23,000
92 55 39
68 24 50 18 12.6
lems, or for other problems or reasons. Youth were also questioned about consultations for particular diagnoses; these responses will be reported separately. Specifically, mothers were asked whether they had consulted with a pediatrician or other physician, a teacher, a psychologist, a social worker, a psychiatrist, or a member of the clergy about the child in the past year, and if so, how many times and for what problems . In addition, questions covered informal discussions with spouse, relative or friend, or another person regarding the child. The child's attendance at a mental health or other social agency was also reported. Data Analysis
Following comparisons of consultation rates with different professionals according ' to diagnostic status and age, logistic regression analyses were performed to determine the influence of diagnosis on subsequent treatment seeking. In these analyses, diagnoses made at the first follow-up were used to predict mental health service usage in the year before the second follow-up--that is, over a year later. Service usage was defined as the number of mental health professionals, including psychiatrists, psychologists, or social workers who had been consulted. By using diagnoses made prospectively, the potential bias as a result of the increased likelihood of diagnostic recognition and labelling by those currently in treatment is lessened. Confounding effects of age, sex, and urban setting of residence were removed by including these variables in the equations. Relationships of these variables totreatment are discussed elsewhere (Cohen, 1990, unpublished manuscript). Findings From Whom Is Consultation Obtained?
Table 2 presents findings regarding the base rates for consultationwith each professional for the children in younger and older age groups. The older adolescents, those ages 18 and over at the 1985 follow-up , may have been obtaining professional assistance without the awareness of their parents; thus, we might anticipate that rates and relationships would differ between these groups. In addition, both the sources of assistance and the reasons for help seeking may differ between the younger and older subsamples. As can be seen, teachers were the most likely professionals to be consulted about the child and the most likely with whom to have discussed emotional or behavioralprobl.Am.Acad. Child Adolesc. Psychiatry, 30:6, November 1991
DIAGNOSTIC PREDICTORS OF TREATMENT PATTERNS TABLE
2. Foll ow-up Total Consultations and Consultations fo r Em otional or Behavioral Problems by Age Group Younger (Ages 12-16) (N = 457) Emotional or Behavorial Problems
Any· Teacher Pediatrician! physician Psychologist Clergy Social worker Psychiatrist Mental health center Other agency
Older (Ages 17-20) (N = 303)
%
Emotion al or Behavioral Problems
Any
%
N
N
%
N
%
N
56
256
19
88
23
71
6
17
38 9 12 5 2
175 43 56 24 10
4 9 7 5 2
16 41 31 22 10
24 5 8 4 2
73 16 23 II 5
3 5 6 3 2
10 15 17 8 5
2 5
II 24
2 4
-Any reason, including academic, health, emotional or behavioral problems or consultation that was not problem-ori ented, such as a routine check-up.
T ABLE
3. Consultation Rates f or Adolesce nts with and without Curr ent Sever e Psychi atric D iagnoses
Ages 12-16 Consultation for Emotional or Behavioral Problem Physician Teacher Clergy Mental health service
Ages 17-20
No Dx Dx No Dx Dx (N = 385) (N = 72) (N = 233) (N = 44) % % % %
3 19
6 11
6 31* 12 33*
3 6 5 5
2 9 9 20*
*p < 0.05.
lems of the child. Although mothers consulted with pediatricians or other nonpsychiatric physicians regarding the child in more than a third of the sample , it was relatively rare to have discussed the child's emotional or behavioral problems. In almost all the cases in which the child's emotional or behavioral problems were discussed with a physician, it was in the context of a medical problem (data not tabled). Children were seen for some kind of counseling at a variety of other agencies , including special school programs, independent nonprofit children's agencies, and adolescent pregnancy-related and self-help groups. Of these 28 children, six were being seen in alcohol or drug abuse related programs . Six other children were seen in various juvenile justice programs. Table 3 differentiates treatment seeking according to the child's current diagnostic status. There was very little overlap between consultation s sought with a pediatrician and consultations sought with a mental health professionalamong the younger group only two youth and among the older only three youth were seen by both, and in no case was consultation with a psychiatrist reported for this group. Furthermore , of those children with emotional or behavioral l.Am .Acad. Child Adolesc .Psy chiatry , 30:6, N ovember 1991
problems for whom consultation with a primary physician but no other professional occurred, only one had previously been diagnosed with a severe psychiatric disorder, a diagnostic rate actually smaller than that of the sample as a whole. Therefore , it is reasonable to conclude that at least in this geographic area parents did not consult a primary physician when their adolescents had serious emotion al or behavioral problems. The parents did, however , go to other professionals. They were more likely to see some professional (for any reason) than when the youth did not have a serious problem (86% as compared with 71%), and in particular were twice as likely to have seen at least one professional regarding emotional or behavioral problems of the child when the child had a serious disorder than when they did not (58% as compared with 29%) . Nevertheless , 42% of those with current severe psychiatric disorders had not seen any professional for these problem s in the past year. Diagno stic Predictors of Subsequent Mental Health Service Use
The different diagnoses were by no means equally predictive of mental health service use. Table 4 presents the odds that consultation was subsequently sought as a function of the psychiatric diagnostic status 2 1/ 2 years earlier . All analyses controlled for the child's age, sex, age-sex interaction , urban setting of residence, and family socioeconomic status (effects of these variables on treatment rates are presented elsewhere [Cohen , 1990, unpublished manuscript]). Each diagnostic group used more mental health services than did the group not receiving the diagnosis: all odds ratios exceed 1.0. However , only children with CD or ODD were significantly more likely to use services than those not obtaining these diagnoses. In equations including all diagnoses, CD and ODD groups showed independent relationships to service usage; odds ratios were 3.98 and 3.62 for ODD and CD, respectively. 991
COHEN ET AL. TABLE
4. Adjusted Odds Ratios for Subsequent Professional Mental Health Consultation (N = 734)
Diagnostic Group
Odds
Major depression 2.02 Conduct disorder 3.74* Oppositional defiant 4.84* Attention deficit hyperactivity disorder 1.61 Overanxious disorder 1.11 Any severe diagnosis 2.25*
(Confidence Limits) (0.71- 5.78) (1.57- 8.93) (2.24-10.46) (0.63- 4. 10) (0.24-5.10) (1.33-3. 82)
*p < 0.01 in comparison to those not so diagnosed.
For Some Diagnoses, Could Mothers Be Using Informal Consultations to Substitute for Mental Health Consultations for Their Children? It is reasonable to hypothesize that discussions about the child with nonprofessionals may be used in some cases as a substitute for discussions with mental health professionals. In particular, it may be that advice regarding children with internalizing disorders may be more likely to be obtained from the parent's informal network, because it is clear that they are less likely to reach mental health professionals. In order to answer this question, the authors examined the total number of kinds of nonprofessionals with whom the mother reported having discussed emotional or behavioral problems of the youth . For the total sample, 26% had not discussed the child with anyone, 23% had talked about the child with one person, and 51 % with more than one person. As noted, psychiatric comorbidity was quite common in this sample, as has been found in other epidemiological samples of youth (Bird et aI., 1988; Kashani et aI., 1987; Offord et al., 1987). In order to improve the statistical power for these comparisons, five groups of children were examined: those with no severe diagnosis, those with only internalizing diagnoses, those with one externalizing diagnosis, those with more than one externalizing diagnosis, and those with both internalizing and externalizing diagnoses . Because the group of children with multiple externalizing diagnoses studied longitudinally was small (23 children) , none of the differences between them and the group with a single externalizing diagnosis was significant. Therefore , the authors present data on the pooled externalizing group. Group means may be seen in Table 5. The analysis of covariance controlling for age and sex differences was not significant (F = 1.51). The trend was for mothers of children with externalizing disorders to use more informal as well as mental health professional help. Therefore , it is concluded that informal supports are not used as a substitute for formal supports . For Some Diagnoses , Could Mothers Be Using Other Professionals as a Substitute for Mental Health Consultations for Their Children ? Although informal supports do not follow a clear diagnostic pattern, it is theoretically reasonable that parents consult other professionals regarding the child for certain disorders. Therefore, the mean numbers of professionals
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consulted by the parent regarding the child's emotional or behavioral problems were examined . These professionals include, in addition to the mental health professionals , teachers, clergy, and physicians. As shown in Table 5, no such compensating tendency was evident, and diagnostic differences in professional consultation , other than mental health professionals , were not significant (F = 1.50). Summary and Conclusions This epidemiological study has shown the following patterns of professional contact by mothers regarding troubled adolescents: 1. In agreement with findings of epidemiological studies conducted at other times and locations, many children with serious problems were not being seen by anyone regarding these problems. 2. Teachers were the professionals with whom parents most commonly discussed the emotional or behavioral problems of their offspring, followed by clergy and psychologists. It is, of course , not possible to generalize about these consultations as if they were mental health treatment. In fact, it is likely that in a number of cases, teachers initiated contacts because they wanted the parents to control the behavior of their children, without providing any advice or joint plan of action. However , this high level of contact suggests an opportunity for constructive professional input. 3. Although a very high proportion of teen-agel's did see a physician during the course of a year , it was rare that emotional and behavioral problems were discussed with them, and when they were, it was generally in the context of medical problems . Mothers who did discuss the problems of their adolescents with a physician generally did not discuss them with any mental health professional. The authors conclude that, in general , physicians did not make referrals to mental health specialists. On the other hand, the problems discussed with physicians may have been trivial or transitory on the whole, as indicated by the low psychiatric diagnostic rate in these children. The fact that the diagnoses were made prospectively rules out the alternative inference that once a parent has discussed these problems with a pediatrician, she is so reassured that she no longer considers-and therefore no longer reports-that the child has a problem. 4. Diagnoses made over a year earlier were strong predictors of treatment seeking, and this was particularly true of CD and ODD. Treatment rates for depressive and anxiety disorders were not statistically significantly elevated. CD and ODD effects on treatment seeking were cumulative rather than redundant. This finding reinforces the advisability of keeping separate these diagnostic groups, despite the considerable comorbidity found. These findings also suggest that children with internalizing problems are underidentified or referred. 5. There was no " balancing" tendency for mothers to seek advice regarding children with internalizing disorders from informal sources, such as her spouse, a relative, or a friend. On the whole, advice from informal sources tended to follow the same pattern as advice from mental health professionals. 6. There was also no evidence that parents of children J. Am. Acad. Child Adolesc . Psychiatry, 30:6, November 1991
DIAGNOSTIC PREDICfORS OF TREATMENT PATTERNS TABLE
5. Number of Informal Supports and Total Professionals Consulted Regarding Emotional or Behavioral Problems of Adolescence by Prior Diagnostic Status Infonnal Supports
No severe diagnosis One or more internalizing One or more externalizing Internalizing and externalizing
Total Professionals
N
X
(SO)
N
X
(SO)
593 47 47 20
1.79 1.81 2.04 1.79
(0. 80) (0.82) (0.75) (0.7 1)
593 47 47 20
1.06 1.11 1.49 1.15
(1.08) (1.20) (1.41) (1.27)
with internalizing disorders tended to consult professionals outside the mental health system as a substitute for mental health consultation. Nevertheless, the vast majority of all families with disordered children had consulted at least one professional, and, therefore, showed at least partial access to professional help. Several important limitations of the current study should be noted. Data are confined to maternal reports of those consulted for health, academic, emotional, or behavior problems of the youth. Although these data cover more professional disciplines and settings than most previous reports, they do not necessarily indicate that treatment was actually being sought. Moreover, mothers may well not correctly identify the professional discipline of some mental health professionals with whom they have talked. No information is available about referral patterns for the various consultations . Referral source tends to be information that is hard to obtain reliably, even in clinical settings. Partially counteracting these limitations are the strengths of the current study , including its population-based sample , the availability of prospective longitudinal diagnostic information from two sources, and considerable detail on consultation sources and reasons.
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