NURSES, PHYSICIANS, AND other health providers in inner-city ambulatory settings often care for many children who are ethnic minorities, from low-income families, and enrolled in publicly insured programs like Medicaid or the State Children’s Health Insurance Program (SCHIP). Many of these children have special health care needs (CSHCN), defined by the Maternal and Child Health Bureau as “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally (McPherson, Arango, Fox, et al., 1998, p.138).” CSHCN are estimated to make up from 13% to 17% of all children in the United States population (Bethell et al 2002; McPherson and Honberg 2002; Neff et al 2002 and Stein, R.E.K. and Silver, E.J., 2002. Comparing different definitions of chronic conditions in a national data set. Ambulatory Pediatrics 2 1, pp. 63–70. Abstract | Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (29)Stein and Silver 2002). Although publicly insured programs provide a comprehensive array of health services for all enrolled CSHCN, there are disparities in the utilization of mental health services for many low-income and ethnic minority children. CSHCN who are from low-income families and who also are ethnic minorities have consistently been found to have higher rates of mental health problems and more severe illnesses than their higher-income counterparts ( Kerlman and Perloff 1997; Samaan 2000 and Walder and Drotar, 2000). Further, children from low-income or poor families are less likely to receive mental health care when needed (Cunningham & Friedman, 1996). Early identification of mental health problems in children can greatly aid in prompt diagnosis, referral, and treatment by mental health providers.

Population-based surveys of the prevalence of mental health disorders, using a variety of multimethod and multistage approaches, have documented that 15% to 22% of United States children have symptoms diagnosable (DSM-III or DSM-IV diagnostic criteria) for at least one mental disorder (Bean et al 2000; Briggs-Gowan et al 2000; Halfon and Newacheck 1999 and Hoberman 1992). While the prevalence of mental health disorders in community samples is well documented, we know little about the status of mental health functioning in publicly insured, low-income, or ethnic minority CSHCN who live in inner-cities. Moreover, among this group of children, it is not known if behavioral and mental health problems differ by race.

Knowledge of the rates of behavioral and mental health problems in low-income, minority, and publicly insured CSHCN, as well as identifying what causes access and treatment disparities among these children, are areas of national need. Targeting CSCHN for a comprehensive array of services, including mental health, is part of a national plan of the Maternal and Child Health Bureau 2001 and McPherson and Honberg 2002. The United States (U.S.) Surgeon General’s Report on Mental Health (United States Surgeon General, 2000) and the Department of Health and Human Services (USDHHS, 2000) Healthy People 2010 Objectives for the Nation indicate that identification of mental health problems in children can greatly aid in early referral, diagnosis, and treatment by mental health providers that will improve their mental health functioning.

Early diagnosis and treatment for mental and behavioral health problems depend to a significant degree on parents identifying, accessing, and accepting services for their children. Therefore, it is important to understand parents’ perceptions of their children’s behavioral problems and the need for mental health services. In national studies, parent reports of mental health and behavior problems in children have ranged between 3% and 20%, depending on the severity and disabling impact of the condition being studied (Halfon & Newacheck, 1999). A few studies have described mental health needs in general pediatric settings (Briggs-Gowan, Horwitz, Schwab-Stone, Leventhal, & Leap, 2000). However, in CSHCN who are publicly insured, no studies have compared the parents’ perceptions of their child’s behavioral and mental health status and the need for mental health treatment and counseling.

The aims of this study were to describe mental health status in a sample of low-income, publicly insured CSHCN and to determine caregiver perceptions of the need for mental health counseling and treatment. Specific research questions were:

1. How does behavioral and mental health status in a sample of low-income publicly insured CSHCN compare to published norms for a general pediatric population?
2. Are there differences in behavioral and mental health status in low-income publicly insured CSHCN by race, gender, age, and caregiver demographics?
3. What is the prevalence of behavioral and mental health problems in a sample of publicly insured CSHCN based on caregivers’ perceptions?
4. Are there racial differences in caregivers’ perceptions of mental health treatment and counseling needs after controlling for sociodemographic variables?

Method

Sample and setting

Randomly selected primary caregivers (N = 1220) were asked to complete a CSHCN Screener (Bethell et al 2002 and Van Dyck et al 2002) and a demographic questionnaire when they brought their children for primary health care visits at one of six urban Midwestern community health centers between September 2001 and May 2002. The CSHCN Screener consists of five sequenced questions related to the child’s functioning, need for health care, service use, and/or use of prescriptions. Follow-up questions asked whether the child’s condition, service use, or use of medications was expected to last more than 12 months (Bethell et al 2002 and Van Dyck et al 2002). Only caregivers of children with positive responses to one or more questions on the CSHCN Screener were invited to participate in this study. Children were excluded if they were not African American or Caucasian, 2 to 18 years old, or enrolled in the State Medicaid Program. Other exclusions were inability of caregivers to speak English or no telephone.