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. However, when child mental health need is high, social support may facilitate caregiver access to needed services. We have assessed social support in broad terms, including indicators of emotional support and support expressed in practical ways.
Studies of caregiver psychological distress have yielded similarly mixed results. Psychological distress includes such symptoms as trouble sleeping and depressed mood and may arise from psychopathology, chronic stress, or other factors. The assessment of psychological distress and of psychopathology frequently overlap (Coyne, 1994). Parental distress has consistently been linked with greater child mental health need (Horwitz, Gary, BriggsGowan, & Carter, 2003). However, the relationship between distress or psychopathology and child mental health service use is less clear. Farmer, Stangl, Burns, Costello, and Angold (1999) found that caregiver distress predicted increased likelihood of children receiving mental health services. Other research, however, has found caregiver psychopathology is related to unmet mental health needs of children (Flisher et al., 1997). Children whose parents are suffering from psychopathology or distress may show both increased need and increased service use, compared to other children. At the same time, levels of service use for these children may still fall short of meeting the actual level of need, because parents dealing with psychopathology or distress may have trouble recognizing their children's need for services and obtaining such services (Hoberman, 1992). Because the presence of caregiver psychopathology is difficult to assess comprehensively, this research focused on psychological distress. This approach is common in services research (e.g., Horwitz et al., 2003).
Finally, the limited research available on family functioning is also mixed. Family functioning refers to relationships (the degree to which family members feel close to each other and are free of serious conflict) (Beavers, Hampson, & Hulgus, 1990). Some research has found that good family functioning is associated with early identification and treatment of child mental health problems and with low rates of treatment dropout (Carpentier & White, 2002). In their study of depressed adolescent boys, however, Lindsey and colleagues (2006) found that close ties among family members were actually associated with reduced likelihood of seeking mental health services for children. Our assessment of family functioning relies on parent self-report (Beavers et al., 1990).
In addition to the family factors noted above, several demographic factors have been found to influence the likelihood of receipt of services. First, race/ethnicity appears to strongly influence children's likelihood of receiving mental health services. In general, ethnic minority children are less likely than white children to receive mental health services, and this disparity is particularly pronounced for African American children (Flisher et al., 1997). In particular, African American children are roughly half as likely as white children to receive mental health services (Angold et al., 1998). This disparity persists when mental health needs and socioeconomic status are taken into account (Flisher et al., 1997).
Socioeconomic status also appears to be related to mental health service use, although the research here is somewhat mixed. First, children from poor families are much more likely to be in the child welfare system, which is one key process by which children receive mental health services (Lyons & Rogers, 2004). On the other hand, after controlling for other demographic factors, it appears that poor children are actually less likely than other children to receive mental health services (Thompson, 2005).
Finally, household composition may exert some influence on mental health service use. For example, children in foster care are more likely than other children to receive mental health services (Lyons & Rogers, 2004), although this may be because of the substantially higher mental health needs among foster care children (Kerker & Dore, 2006). There is some evidence that children in single-parent homes are more likely to receive services (Zahner & Daskalakis, 1997), but this may also be due to increased need.
Recently, several models have emerged that include family environment in understanding child mental health service use (e.g., Costello, Pescosolido, Angold, & Burns, 1998; Long & King, 2001). These models typically indicate a sequence by which children with mental health needs come to receive services. For example, a model proposed by Costello et al. (1998) proposes that child mental health service use occurs as a result of the following sequence: 1) child expresses emotional or behavioral problems; 2) caregivers or other adults identify these problems and see them as indicative of need; 3) social network members offer suggestions for coping; and 4) network members actively facilitate or delay service use (Costello et al.). The Costello model suggests a focus on the role of social support, but other sequential models emphasize the role of caregiver distress and of family functioning (e.g., Long & King).
Study Overview and Participants
The Longitudinal Studies on Child Abuse and Neglect (LONGSCAN) is a consortium of longitudinal studies designed to investigate the risk factors for and consequences of child maltreatment (Runyan et al., 1998). LONGSCAN is a consortium of studies operating under common protocols at five sites in different regions of the United States: the South, the East Coast, the Midwest, the Northwest, and the Southwest. At each site, a sample of children (4 years old or younger) who had been maltreated or were at risk of maltreatment was recruited. Risk of maltreatment was defined in a variety of ways, varying by site, including demographic risk factors, such as extreme poverty and very young maternal age at birth, and clinical factors, such as children treated in Failure to Thrive clinics or caregivers receiving substance abuse treatment. Children were defined as maltreated if there had been a report to Child Protective Services regarding the child as a victim of maltreatment.
Children and caregivers participated separately in annual interviews administered by trained interviewers over the course of the longitudinal study. Families were compensated financially for their participation. The same child-caregiver dyads took part in interviews at several time points: ages 6, 8, 9, and 10. These dyads continue to participate in the longitudinal research.
The baseline LONGSCAN sample consisted of 1,354 childcaregiver dyads. Only those who had completed interviews at each of the target ages are included in these analyses. This resulted in a sample size of 1,075 (79.4% of the baseline sample). The participants in this sample are described in detail in Table 1. More than half of the families were African American, and two-thirds were single-parent families. Nearly two-thirds had been reported to Child Protective Services for child maltreatment allegations. Mean scores on the Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977) and Brief Symptom Inventory (BSI) (Derogatis, 1993) suggested that most caregivers had elevated psychological distress but did not meet clinical cut points for disturbance.
Family environment. Three different indicators of family environment were used in these analyses: family social support, family functioning, and caregiver psychological distress.
Family social support. At the age 6 interview, family social support was measured by a version of the Duke-UNC Functional Social Support Scale (FSS) (Broadhead et al., 1988) that was modified by LONGSCAN investigators (Hunter et al., 2003). This version has three subscales: Confidant Support, Affective Support, and Instrumental Support. These scales were summed to produce the index of family social support used here. There is substantial evidence for the reliability and validity of this scale (Broadhead et al., 1988; Hunter et al., 2003). At age 8, the Social Provisions Scale (SPS) (Cutrona & Russell, 1987), administered to caregivers, measured family social support. The SPS has demonstrated both validity and reliability (Cutrona & Russell, 1987).
Family functioning. At both age 6 and age 8 interviews, the Self-Report Family Inventory (SFI) (Beavers et al., 1990) was administered to caregivers. The SFI is a 36-item assessment of functioning in five domains of family functioning that were summed to produce a global estimate of family functioning: Family Health/Competence, Conflict, Cohesion, Expressiveness, and Directive Leadership. The scale has good reliability and correlates predictably to other indices of family functioning (Beavers et al.).
Caregiver psychological distress. At age 6, caregiver psychological distress was measured by the CES-D. The CES-D is a 20-item self-report measure of psychological distress. The CES-D has been extensively validated (Radloff, 1997). At age 8, caregiver psychological distress was measured by the global severity index of the BSI. The BSI is a 53-item scale assessing psychological symptomatology, which is strongly related with other measures of psychological distress (Derogatis, 1993).
Demographics and socioeconomic status. At the age 6 and 8 interviews, caregivers were asked several questions about demographics and socioeconomic status. The demographic and socioeconomic variables assessed included the ethnic background of the target child (White, African American, or Other), family composition (intact family, single/cohabiting parent, and foster /substitute family), caregiver education (in years), and caregiver age (in years). Single and cohabiting parent family composition was combined because of the difficulty in determining whether and how frequently partners lived with unmarried parents.
Child mental health need. At the age 6 and 8 interviews, child mental health need was assessed by caregiver report using the Child Behavior Checklist (CBCL) (Achenbach, 1991). The CBCL is one of the most widely used and extensively validated caregiver reports of child emotional and behavior problems. The analyses presented here used the Internalizing Problems scale, which comprises the Anxious/Depressed, Withdrawn/Depressed, and Somatic Complaints scales, and the Externalizing Problems scale, which comprises both Delinquent and Aggressive behavior scales.
Mental health service use. An assessment of child mental health care utilization was administered to caregivers at each of the age 8, 9, and 10 interviews. In it, caregivers were asked whether in the past year they had received "any type of counseling or therapy for their child, outside of school, for a psychological or behavioral problem."
The primary analyses were a set of structural equation models (SEM) designed to examine the relationship between family environment, child mental health needs, and child mental health service use. First, to ensure that cases with small amounts of missing data were not excluded, multiple imputation was conducted on the data (Schafer, 1997). Then, the models were tested. A measurement model was created, testing the fit of eight latent constructs and three second-order constructs. Once the measurement models were confirmed, the main hypotheses of the study (structural hypotheses) were tested. For simplicity, only the results of the analyses focused on structural hypotheses are reported.
A single measurement model was tested for all analyses presented here. A first-order confirmatory factor analysis (CFA) was conducted to test this measurement model. In this analysis, we hypothesized that 21 measured variables would reflect eight latent constructs: family environment (family functioning, caregiver distress, and social support) at ages 6 and 8 years, mother-defined need at ages 6 and 8 years, child-defined need at age 8, mental health services use, and socioeconomic status (SES) at ages 6 and 8. The resulting model fit the data well according to all criteria, _2 (132) = 228.38, _2/df = 1.73, CFI = .99, NFI = .98, RMSEA = .03. A second CFA was conducted to test the hypothesis that the same concepts measured at ages 6 and 8 would be reflected in secondorder constructs. This was supported; family environment at age 6 and at age 8 reflected one second-order construct (Family Environment), mother-defined need at age 6 and at age 8, and childdefined need at age 8, reflected one second-order construct (Mental Health Needs), and SES at age 6 and age 8 reflected one secondorder construct (SES). This model fit the data well, _2 (134) = 228.78, _2/df = 1.71, CFI = .99, NFI = .98, RMSEA = .03.
Structural Hypothesis Testing
Hypothesis 1: Vulnerable family environment predicts child mental health need. A structural equation model (SEM) was built upon parts of the measurement portion of the model described above. This model posited that vulnerable family environment would predict children's mental health needs. The resulting structural model is shown in the first panel of Figure 1. The model fit the data well according to all criteria, _2 (45) = 49.46, _2/df = 1.10, CFI = 1.00, NFI = .99, RMSEA = .01. The structural path was highly significant.
Hypothesis 2: Vulnerable family environment predicts decreased use of mental health services use. An SEM was built upon parts of the measurement portion of the model described above. The model posited that a vulnerable family environment would predict decreased mental health services use. The resulting model is shown in the second panel of Figure 1. The model fit the data well according to all criteria, _2 (11) = 14.19, _2/df = 1.29, CFI = 1.00, NFI = .99, RMSEA = .02. However, the estimate for the structural link between family environment and mental health services use was nonsignificant and very modest (.04), suggesting little direct link between family environment and mental health services use.
Hypothesis 3: Vulnerable family environment predicts decreased mental health service use, after controlling for mental health needs. Because of past research findings showing that vulnerable family environment predicts both increased mental health needs and decreased service use, we posited that child mental health need might be suppressing the link between family environment and mental health service use. An SEM was tested to determine whether vulnerable family environment would predict decreased service use, after taking mental health needs into account. The resulting model is shown in the third panel of Figure 1. The model fit the data well according to all criteria, _2 (75) = 84.41, _2/df = 1.13, CFI = 1.00, NFI = .99, RMSEA = .01. All paths in the model were significant. After taking into account the link between mental health needs and mental health services use, the link between family environment and mental health services use was found to be negative and highly significant.
Follow-up analyses. We also examined whether SES, ethnicity, and family structure influenced the relationships described above. After taking into account SES, all relationships between family environment, mental health need, and mental health service use remained significant and in the same direction as noted above, suggesting little influence of SES.
Differences between the models were tested for each of the three ethnic groups (White, African American, Other). Although the model fit the data in each case, there was an overall significant difference between African American and other families, _ _2 (3) = 7.93, p < .05. The link between family environment and mental health service use was much stronger in African American families than in families that were not African American.
Finally, the difference between the models for each of the three family structures (intact family, single /cohabiting parent, and foster/substitute family) was tested. There was a marginally significant difference between foster families and other family structures, _ _2 (6) = 12.65, p = .05. For foster families, the links between family environment and both child mental health need and services use were not significant. Thus, for children in foster or substitute homes, family environment exerted a weaker influence on child mental health need and use.
There was general support for the main hypotheses of the study. Vulnerable family environment (poor family functioning, low social support, and parent psychological distress) strongly and directly predicted children's mental health needs. These findings are consistent with a large body of literature, which has found that children whose families grapple with family conflict or chaos, social isolation, or mental illness are at risk for a host of negative psychosocial outcomes, including mental health problems (Rice, Harold, Shelton, & Thapar, 2006).
Although the relationship between family environment and children's mental health services use appears more complex, the basic findings are clear. First, family environment did not predict mental health services use overall. However, among children with significant mental health need, vulnerable family environment predicted lowered rates of mental health services use. This may help explain some earlier mixed findings regarding service use (e.g., Harrison et al., 2004). Our research suggests that when there are significant family problems, children are more likely to have mental health needs, but parents are less likely to have the resources or motivation to seek help for their children (Harrison et al.). In homes characterized by family problems and child mental health need, two opposing processes may be at work: child mental health needs cause additional burdens for parents, motivating them to seek help for children (Angold et al., 1998), but family problems may make parents less sensitive to child need and less capable of effectively seeking help (Harrison et al.).
Both race/ethnicity and family structure influenced the model described in this research. The link between family environment and mental health services use was much stronger for African American families than for other families. The reasons for this discrepancy are unclear; it is possible that either bias or barriers to access for African American families make parent initiative even more important. There were few differences between single-parent and two-parent families, but family environment did not appear to affect needs or services in foster families. Although the family environment of foster families is undoubtedly important, foster families typically have better access to mental health services than do other families served by child welfare (Lau, Litrownik, Newton, & Landsverk, 2003). In short, these findings suggest that greater attention to child needs and family functioning is especially critical for child welfare families where the child has not been removed from the home.
It is important to keep in mind several limitations of the research and analyses. First, the sampling for this research focused on children likely to be served by child welfare and the results should not be seen as necessarily indicative of families in general. In addition, most of the sampling sites for this research were urban or suburban. Other limitations relate to the assessments used in this research. All of the assessments used were pen-and-pencil instruments or structured interviews, and did not involve direct observation or diagnostic assessments. The assessment of psychological distress as a proxy for parent psychopathology is commonly used, but is at best a crude proxy and is unlikely to have captured adequately such problems as substance abuse, relational disorders, or cognitive/intellectual deficits of the caregivers (Coyne, 1994). Although SEM is a robust way of combining several different sources of information, it provides a rather broad-brush approach. Further research should examine the processes underlying the links between family factors (especially parent psychopathology) and child mental health and services use in a more detailed way.
Increased screening and improved access to treatment are important for children in child welfare settings. It is important not to rely solely on parent initiative in seeking help for children. Our research shows that children in a vulnerable family environment are at increased need of mental health services, but many are not receiving such services.
Given the importance of vulnerable family environment for children's development, our research also suggests that careful assessment of parent and family functioning is warranted. Child welfare workers can serve as important conduits to mental health services for families whose children are experiencing mental health problems. These workers may be especially important referral sources and aides for children whose caregivers are themselves experiencing significant family dysfunction, social isolation, or distress. In such situations, the assistance of a child welfare worker to help locate and contact appropriate referral sources may be just the added support that caregivers need in order to access needed services for their children and themselves.
Acknowledgements: This research was supported by gra?its from the Office of Child Abuse and Neglect to the Consortium of Longitudinal Studies on Child Abuse and Neglect (LONGSCAN). Dr. Rowley's work was supported by San Diego State University's Oscar Kaplan Postdoctoral Fellowship. The authors are grateful to the LONGSCAN Coordinating Center at the University of North Carolina-Chapel Rill for administrative and data management support.
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Richard Thompson PhD is Director of Research, Juvenile Protective Association, Chicago, Illinois. Michael A. Lindsey PhD MSWMPH is Assistant Professor, School of Social Work & School of Medicine, University of Maryland, Baltimore, Maryland. Diana J. English PhD is Investigator, Child Welfare Research Group, School of Social Work, University of Washington, Seattle, Washington. Kristin M. Hawley PhD is Assistant Professor, Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri. Sharon Lambert PhD is Assistant Professor, Department of Psychology, George Washington University, Washington, DC. Dorothy C. Browne MSW MPH DrPH is Director, Center for Health Disparities Solutions, Morgan State University, Baltimore, Maryland.
Address reprint requests to Richard Thompson, Juvenile Protective Association, 1707 North Hoisted Street, Chicago, IL 60614. E-mail RThompson@juvenile.org.