This article examined the relationship between 2 contextual variables and specialty mental health service use, controlling for other predictors of service use, in a nationally representative sample of children referred to the child welfare system who were subsequently removed from their homes or who remained with their families but had a child welfare case opened.
At a broad level, our analyses confirm findings that rates of mental health need are exceptionally high in this population.3,28
At the time of the first interview wave, 42.4% of children had clinical-level CBCL scores. Within approximately 1 year of the child welfare investigation, 28.3% of children had received specialty mental health services. Despite large increases in specialty mental health service use during this time, these analyses demonstrate that many children with strong clinical indications of need for service continue not to receive such services, consistent with our earlier work examining service use among children shortly after contact with the child welfare system.1
The present study extends that earlier work by focusing on how contextual predictors moderate service use patterns among children open to child welfare during a full year after contact with child welfare. Results from this study revealed that child- and contextual-level variables serve as powerful predictors of rates and patterns of specialty mental health services. At the child level, out-of-home placement status and older age predicted increased service use, even after controlling for level of need in multivariate models. At a minimum, these findings raise questions about the degree to which counties and child welfare agencies are missing opportunities to address menial health concerns that are already substantial among younger children and children remaining in their homes of origin. In addition, race/ethnicity and CBCL scores contribute to patterns of specialty mental health service use.
Child-level variables must be examined jointly with county-level contextual variables. The 2 most significant results of this analysis concern the interactions of CBCL score and race/ethnicity with the strength of interagency linkages between the local child welfare and mental health service systems. First, our data suggest that child welfare systems are responsive to the level of emotional and behavioral problems that children experience but that local interagency linkages increase the focus of specialty mental health service delivery to children with clinical levels of need. Whether targeting specialty mental health services to children with the most substantial levels of clinical need represents the most efficient and effective allocation of mental health resources is unclear. Some might argue that given the overall high levels of need and the comparatively low rates of specialty mental health service use, it is critical to increase rates of specialty mental health service use by all children. Others might argue that specialty mental health services should focus primarily on children with the most significant levels of need, paired with appropriate prevention approaches for children and families with lower risks. Regardless, the results of this study suggest that interagency coordination may have important effects on the patterns of children receiving services.
The strength of interagency ties also seems to affect racial/ethnic disparities in service use. Without taking county contextual variables into account, we found that African American and Hispanic children are markedly less likely to receive specially mental health services than white children, replicating findings from other local studies29–31
of children in the child welfare system. Increased interagency linkages, however, seem to decrease disparities for African American children but not for children from other minority groups. A variety of potential mechanisms have been proposed to explain lower use rates by racial/ethnic groups, such as language barriers, knowledge of services, concerns about stigma, and differences in beliefs about the nature of mental health problems. Although this study does not directly identify specific mechanisms that contribute to lower use rates, efforts by child welfare and mental health agencies to coordinate around the mental health needs of children maybe able to prevent disparities in mental health care use among African American children, who are heavily overrepresented in the child welfare system.
These results are in accord with other studies that show the importance of specific linkage mechanisms (eg, providers’ knowledge of and connection with mental health service resources) to increased identification of children’s need for services.18
However, system integration efforts emphasize a broader array of mechanisms designed to streamline the identification and referral process. Items in the linkage construct exemplify these mechanisms. It is important to note that the linkage construct items are not highly correlated. This poses no theoretical problem because the linkage indicators are best conceptualized as cause indicators.32
However, if interagency linkage is causally related to patterns of service use, a pragmatic implication is that communities may need to focus on multiple aspects of coordination to make significant changes in the way services are targeted to children in the child welfare system.
The other contextual variable studied herein, total supply of mental health providers in a county, does not seem to have a strong relationship with specialty mental health service use among children in the child welfare system. Using an approximation of federal methods for defining mental health care supply, only a relatively weak and non-significant trend was found for increased use of services in areas with greater relative provider supply.
STRENGTHS AND LIMITATIONS
This study has 2 major strengths: it includes a nationally representative sample of children involved with child welfare systems from 92 PSUs and thus allows for the unique opportunity to study how contextual characteristics of counties and service systems relate to service delivery rates and patterns.
These strengths suggest some inherent limitations. First, there have been few opportunities to formally develop and test measures of some constructs of interest, such as interagency linkage and provider supply. However, the measure of interagency linkage used is the most concrete operationalization we are aware of. Likewise, the provider supply variable is an approximation of a federal approach to assessing mental health resource adequacy, although it does not take into account other master’s-level providers who make up large segments of the mental health care system. Second, although associations between linkages and service use were identified in this study, it was not possible to evaluate the causality of the observed relationships. Despite these limitations, this study is the first to explore contextual predictors of specialty mental health service use among children in the child welfare system, and it reveals potentially important associations.
These results confirm previous findings regarding child- and family-level variables that affect specialty mental health service use in children served by child welfare agencies. In addition to these findings, 2 new primary messages emerged from this study. First, counties and child welfare systems may largely be missing several important opportunities to improve the well-being of children and reduce the likelihood of families’ reinvolvement with child welfare. Specifically, counties and child welfare agencies may want to evaluate opportunities for addressing the high rates of clinically significant emotional and behavioral problems among young children and children who remain in their homes of origin that currently are not adequately addressed.
Second, the degree of linkage between the local child welfare and mental health service systems may have important effects on the pattern of children receiving specialty mental health services. Increasing coordination between the 2 agencies at the local level may facilitate targeting of scarce service resources to those children with the greatest levels of need. Furthermore, it may help mitigate the effects of other forces that frequently lead to disparities in service use by African Americans. The specific mechanisms by which these effects occur are not known and may be multiple. Future research is warranted to understand whether increased collaboration between agencies can improve the targeting of resources and minimize inappropriate disparities.