CIm&lPsychologyRmlew, Vol. 12, pp. 791-793, 1992 Printed in the USA. All rights reserved.

0272.7358/92 $5.00 + .oo Copyright 0 1992 Pergamon Press Ltd.

THE CURRENT STATE OF CHILD AND ADOLESCENT MENTAL HEALTH SERVICES

Donald t? Oswald Nirbhay N. Singh

Cynthia R. Ellis

Medical College of Virginia

Child and adolescent treatment services is an area of mental health that has undergone marked changes in recent years. These changes are a function of competing forces in the mental health system, forces that include a relatively young but rapidly expanding re- search data base and a complicated and, at times, obstructive service delivery system suffering from increasing demands on already insufficient resources. Clinicians, research- ers, parents, and administrators frequently experience ramifications from the fact that child mental health offers challenges that are qualitatively distinct from those encountered with adults.

This issue of Clinical Psychology Review presents a snapshot view of the current state of mental health services for children and adolescents. It begins with a broad conceptual article by Kazdin that summarizes a model of dysfunctional behavior in children and sets the stage for a focus on service delivery systems that is dealt with in the remainder of the issue. Kazdin presents an overview of child psychopathology, paying particular attention to the developmental features of disturbed and disturbing behavior. In the discussion of at- risk behavior that follows, he reviews the data on child and adolescent antisocial behavior, sexual activity, substance abuse, and the environmental conditions that place children at risk for negative outcomes, including abuse and neglect, changes in family constellations, and homelessness. Finally, the author outlines several areas of research that will help guide future child mental health treatment services.

This leads to a description of the service systems involved in the provision of mental health care for children. In the next article, Cohen, Singh, Hosick, and Tremaine suggest that the current configuration of mental health services is markedly deficient, in part due to the absence of effective collaboration and coordination by professionals and advocates. At the same time, the authors note a handful of developments that show promise and that point the way toward more responsive mental health services for children and adolescents. They briefly present the features of an ideal system and the barriers that have impeded

Correspondence should be addressed to Donald P. Oswald, Department of Psychiatry, Medical

College of Virginia, P.O. Box 489, Richmond, VA 23298-0489.

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792 D. P Oswald, A? IV. Sinxh, and C. R. Ellis

progress toward that ideal. A recurring theme in their analysis is the need to develop a political constituency along with clear and effective means of communication within the political system, two skills that have often proven elusive for both clinicians and research- ers. The authors conclude by offering a set of principles that should guide efforts to redirect the child mental health system.

Trends in child mental health service utilization may be examined from many different perspectives. Frank and Dewa examine recent trends from the viewpoint of economics. They challenge common assumptions about the use of mental health services, particularly residential services, and seek to understand current usage patterns within a model of market forces.

Mental health services for children and adolescents in rural areas are among the most deficient in the entire health care system. While this conclusion has been accepted intui- tively for some time, the article by Kelleher, Taylor, and Rickert provides a stark picture of the status of these services in nonmetropol~tan areas of the country. The authors review the findings on characteristics of communities, psychiatric epidemiology, availability of men- tal health services, and barriers to adequate service delivery, all within the context of a rural setting. Although the empirical findings are relatively sparse, the data do provide the basis for developing a rural menta1 health system that would begin to address the deficien- cies. Kelieher and his colleagues have made a major contribution by spelling out the agenda for developing such a system and identifying the research questions that are most critical at the present time.

The notion of a comprehensive continuum of mental health care for children and adolescents has long been touted as the ideal toward which service delivery systems should strive. However, there have been few model implementations of such a cornprehensive continuum and there has been little research evaluating the effectiveness of such models relative to more traditionally available service networks. In the next article, Bickman, Heflinger, Pion, and Behar describe a project designed to implement and evaluate a continuum of mental health care that will allow such comparisons. In a description of the evaluation component, the authors outline a comprehensive assessment package that will gather data on children and their families, including measures of psychiatric status, behavior problems, social competence, school adjustment and achievement, family func- tioning, perceptions of stressors, and family resources. The project also includes an exten- sive cost analysis that will enable cost-benefit comparisons to be made with more tradition- al systems of care. The authors note how this voluminous data set, currently being gathered, will contribute to the understanding of children and adolescent mental health service needs and the efficacy of systems designed to meet those needs.

In the first article, Kazdin identifies the evaluation of services as a critical prerequisite for continues progress in child mental health. The final one in this issue echoes and responds to that call for a technology of evaluation. Burchard and Schaefer’s article on accountability in child mental health is based on a consumer model derived from a business context. The authors maintain that a fundamental flaw in the current service delivery system is the lack of adequate and timely information about the outcome of services provided. After reviewing some of the many barriers to useful outcome data collection, Burchard and Schaefer turn to a discussion of aspects of a model accountability program implemented in Vermont. These include a system for daily monitoring of child behavior, a system for tracking service restrictiveness, and a means of qualitatively record- ing significant events in a child’s Iife. The goa of the mode1 is to document service outcomes in terms of behavior, restrictiveness, and consumer satisfaction.

In selecting the papers for this special issue, our goal has been to reflect the current state

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of the art in child mental health service delivery and to chart a course for the development of this service delivery system. We have provided a forum for leaders in the field to speak to issues they find particularly pressing. The conclusions offered by their diverse papers achieve a convergence that is striking in view of the variety of perspectives from which the authors begin. From that common ground can come the beginnings of a reordering of mental health services that will better incorporate this knowledge into a system that is more effective and more responsive to the needs of children and their families.