The Influence of Family Environment on Mental Health Need and Service Use among Vulnerable Children
Thompson, Richard, Lindsey, Michael A., English, Diana J., Hawley, Kristin M., Lambert, Sharon, Browne, Dorothy C., Child Welfare
Children in child welfare are especially likely to have unmet mental health needs. The role of family factors in children's use of mental health services was examined in a longitudinal sample of 1,075 maltreated or at-risk children. Vulnerable family environment (poor family functioning, low social support, and caregiver psychological distress) is an important predictor of children's mental health needs. It also predicts them not having these needs met.
Psychopathology in childhood is widespread, with 12-17% of children in the United States suffering from emotional or behavioral disorders that impair their functioning (Institute of Medicine, 1989; Costello, Egger, & Angold, 2005). Less than half (6-12%) receive services for these mental health needs (Achenbach, Dumenci, & Rescorla, 2003; Angold, Messer, Stangl, & Burns, 1998). This widespread presence of unmet mental health needs extends to the child welfare system, where the rate of child mental health need is much higher than in the general population (Lyons & Rogers, 2004), but only one-quarter of children with mental health needs receive services to address these needs (Burns et al., 2004). Such unmet needs can represent substantial additional burden for fami lies already in need of child welfare services (Burns et al., 2004).
The purpose of the current research was to examine the relationship between family environment, child mental health needs, and child mental health services use in a large sample of children who had either experienced child welfare involvement or were at risk of such involvement. Specifically, we examined three hypotheses: 1) vulnerable family environment predicts child mental health need (because there are more stressors for children), 2) vulnerable family environment predicts decreased use of mental health services (because this environment allows less responsiveness to child needs), and 3) vulnerable family environment predicts decreased mental health service use (after controlling for mental health needs).
In understanding why most children who need mental health services do not receive them, the role of family environment has received some attention. Children rarely self-refer; instead, they typically receive treatment as a result of decisions made by adults in their lives (Hawley & Weisz, 2005; Thompson, 2005). Even in child welfare, where children often have nonfamilial adult decision makers, family factors may play a significant role in determining which children receive mental health services. In particular, three aspects of family environment may be important: social support, caregiver psychological distress, and family functioning. Good functioning in each of these areas (high social support, low distress, high cohesion) can be characterized as a positive family environment. Poor functioning in these areas indicates a generally vulnerable family environment.
Social support includes not only advice and emotional support from others, but also practical (or instrumental) support (Broadhead, Gehlbach, DeGruy, & Kaplan, 1988). One might expect social support to be important, but findings have been mixed. On one hand, Bussing and colleagues (2003) found that support reduced strain among caregivers of children with behavioral problems, which in turn reduced the likelihood that children received formal mental health services for ADHD. Other studies, however, indicate that social support may facilitate service use (Harrison, McKay, & Bannon, 2004). Finally, some research has found no effect of social support on service use (e.g., Brannan, Heflinger, & Foster, 2003). These inconsistent findings could be driven by differences in the form of social support assessed and in the level of mental health need. Social support may be generally helpful for both caregiver and child, in some situations leading to a decrease in child mental health problems such that service needs are actually reduced and accompanying service use is appropriately lessened. …