Mental Health Services for Children

The State of the Art

June M. Tuma

ABSTRACT: Throughout this century, people in the

United States have been concerned about the serious deficiencies in the mental health care of our children. Despite
eloquent needs assessment and recommendations for remediation, most of the unserved needs and deficiencies of
our mental-health-care-delivery system remain the same.
This article reviews the current status of mental health
services to children, youth, and families to highlight the
necessity of an integrated system of mental health care.
The development of a continuum of care that is coordinated across the mental health and non-mental-health
systems that naturally occur in all children's lives has the
potential to vastly improve mental health services to children, youth, and families.
The United States has been concerned about the mental
health problems of children and youth throughout this
century. As early as 1909, a White House conference on
children recommended new programs to care for mentally
disturbed children. In 1930, another White House conference did likewise, proclaiming that disturbed children
have a right to develop as other children do. More recent
panels and study commissions held in 1969, 1975, 1978,
and 1981 have increasingly made detailed and specific
policy recommendations for children's mental health care.
The findings throughout the years have been consistent and are still relevant today: Most of the unserved
needs and deficiencies of our mental-health-care-delivery
system remain the same. Large proportions of disturbed
and disruptive children do not receive adequate, comprehensive services. Available services are unnecessarily
restrictive, and poor children are particularly at risk.
The recommendations have been remarkably the
same throughout the years as well. Repeatedly demanded
has been a child advocacy system to coordinate federal,
state, and local services in a comprehensive network to
meet children's mental health, physical, and social needs.
The recommended system would include establishing
preventionmfamily planning, prenatal care, and mental
health services in the schools--and remediation services-mental health services based on a child's functional level rather than on a legal or classification system--in the community.
In spite of eloquent identification of the problem
and equally eloquent and insightful recommendations
throughout the years, the President's Commission on
Mental Health (1978) indicted this nation. It found that
the recommendations of commissions and panels have
188

Louisiana State University

[
not been implemented to any significant degree. Children
and youth continued to receive inadequate mental health
care. Services were frequently unavailable, the available
scrvicvs were characterized by mental-health-manpower
shortages, and identified needs of children were too often
isolated into distinct categories, each of which was addressed separately by a different specialist, resulting in
shuttling children from service to service.
More recent analyses (e.g., one by the Children's
Defense Fund; Knitzer, 1982) emphasize shortages of
community-based services, case management, and coordination across child services systems, which are necessary to provide a comprehensive and coordinated system of mental health care. Current assessment, thus,
shows that the United States continues to have serious
deficiencies in the mental health care of our children.
The purpose of this article is to present an overview of
the current status of mental health services to children,
youth, and families and to present current efforts to improve the mental health care system. Especially highlighted will be the estimated needs for mental health services; various methods, settings, professionals, and systems of care; and, finally, the status of an exciting
coordination of systems that has the potential for vastly
improving mental health services to children in the future.

Children's Needs for Mental Health Services

Children have been referred to as one of the most negiected groups in mental health. Although it is difficult
to get accurate estimates, the latest epidemiologic data
available indicate that from 15% (9.5 million)to 19% of
the nation's approximately 63 million children and youth
suffer from emotional or other problems that warrant
mental health treatment. From 3% to 8% of these are
seriously emotionally disturbed children (those needing
intensive care; Knitzer, 1982). In addition, there are untold numbers of at-risk children who need attention and
secondary prevention services.
Children's mental health problems exist along a
continuum--from transient conditions in the child's environment to diagnosable mental illness. Besides those
children who have diagnosable disorders, many children
have subclinical mental health problems, and others are
in danger of developing a disorder. All three groups of
children and youth---clinical, subclinical, and at-risk-are in need of mental health services (remediation and
prevention) for which policies and programs should be
developed.
February 1989 American Psychologist
Copyright 1989 by the American Psychological Association, Inc. 0003-066X/89/$00.75
VoL 44, No. 2, 188-199

Clinical problems can be categorized according to

criteria of a standard diagnostic system that facilitates
communication, research, assessment, and treatment of
those affected. Not without significance, as well, is the
requirement of a diagnosis by insurance companies before
reimbursements for services are approved. The revised
Diagnostic and Statistical Manual of Mental Disorders
(DSM-III-R; American Psychiatric Association, 1987) is
the diagnostic system most frequently used in the United
States. It is a taxonomy that bases diagnoses on descriptive
information rather than causes (since little is known about
the causes of a great number of disorders).
DSM-III-R groups disorders that first become evident in infants, children, or adolescents into five general
categories on the basis of the aspect of functioning that
is most disturbed: intellectual, developmental, behavioral,
emotional, and physical (psychophysiological). DSM-IIIR also lists another major class of disorders that may
affect children as well as adults. Examples of these disorders are effective disorders, such as major depression;
adjustment disorder; and substance-use disorder. Table 1
gives the estimated prevalence rates of the most commonly
occurring DSM-III-R categories of mental health problems of children and shows that some children's disorders
occur much more frequently (e.g., conduct disorders and
enuresis) than others (e.g., pervasive developmental disorders and stereotyped movement disorders).
The table simplifies the problem, however. Children's
problems are complex--more than one DSM-III-R category, problems across general categories, and secondary
effects on other than the most affected area of functioning
are typical in any given child. In addition, patterns of
disturbance vary widely across diagnostic categories, as
does severity of disturbances. Some problems disappear
with development; others involve severe impairment and
interfere with the child's development. In addition, those
children who have disorders deriving from environmental
and psychosocial risk factors are more difficult to count
and do not appear in this table.
Some of the most severe environmental risk factors
associated with higher rates of mental health problems
in children are poverty, minority ethnic status, parental
psychopathology, physical or other maltreatment, a teenage parent, premature birth and low birthweight, parental
divorce, and serious childhood illness. Table 2 lists the
prevalence of the environmental risk factors in the U.S.
population.
Single environmental risk factors rarely occur in
isolation; more common is the occurrence of several risk
factors together, often in the context of a broad risk factor
such as low socioeconomic status. Ethnicity, social class,
and related variables have been found to profoundly influence a child's development, parental attitudes toward
child-rearing and quality of parent-child interaction, as
well as the children's cognition, motivations, personality,
Correspondence concerning this article should be addressed to June M.
Tuma, Department of Psychology, Louisiana State University, Baton
Rouge, LA 70803.

February 1989 American Psychologist

Table 1

Prevalence of Common Childhood

DSM-III-R Categories
DSM-III-R category
Development disorders
Mental retardation

Pervasive developmental
disorders
Specific developmental
disorders (SDD)
Disruptive behavior disorders
Attention-deficit hyperactive
disorder
Conduct disorder
Substance abuse and
dependence
Emotional disorders
Anxiety disorders of
childhood or
adolescenoe
Childhood depression
Reactive attachment
disorder of infancy
Adjustment disorder
Psychophysiological disorders
Stereotyped movement
disorders
Eating disorders
Anorexia nervosa
Bulimia
Bulimarexia
Elimination disorders
Enuresis

Encopresis

Prevalence

1%

10-15/10,000
5-10% =
3%
9% males; 2% females
NA b
Not uncommon
0.14%-1.9%
NA
Common
0.5/1,00&
1/100-800 females
5%
1/50-400 females
7% males, 3% females
(5-year-olds); 3%
males, 2% females
(lO-year-olds); 1%
males, 0% females
(18-year-olds)
1% (5-year-olds)

Obtained from Dlagnostio and Statistical Manual of Mental Disorders (3rd

ed., rev.) (DSM-III-R; American Psychiatric Association, 1987).
Varies according to type of SDD.
b Prevalence not available for children and adolescents. Prevalence in total
population of United States: 13% (alcohol), 8% (drugs).
c History of some kind of tic, not necessarily current, has been estimated to
be from 5% to 24%.
Note.

and achievement behavior. These risk factors also have

negative effects on accomplishment of important developmental tasks such as toilet training for toddlers and
developing intense peer relationships and becoming autonomous in adolescence. Even if these factors do not
necessarily result in mental disorders that meet the diagnostic criteria of DSM-III-R, they can cause maladjustment and place a child at risk for later and potentially
more serious problems. Insurance reimbursements are
not made for subclinical and at-risk problems because
they do not meet the criteria of DSM-III-R. However,
they have to be considered when one addresses children's
needs for mental health services. These problems include
those typically referred to as mental health problems and
189

Table 2

Environmental Risk Factors and Children's

Mental Health Problems
Environmental risk
faCtor

Poverty and min o r i t y status

Parental psychopathology
Affective disorders of
parents
Schizophrenic
parent
Alcoholic parent
Maltreatment
Teenage parenting ( 1 4 19-yearolds)
Premature
birth/low
birthweight
Parental divorce
Major physical
illness
Outpatient pediatdcian
visits

Prevalence of risk
factor in general
population

Prevalence of
disorders in child
population =

13.8 millionb

11.8% > average

9 % - 2 5 % females,
5%-12%
males
0.2%-1%0

40% e

10 times the average f

13% ~
1 milliong
21%h

6 % - 7 % total live
births j

3.7 million (1985) j

20% j
1/3 to 1/2 k
5%-12% =

All environmental risk factors are associated with high prevalence of mental
health problems in children, information in this column indicates more specific
information about prevalence of mental health problems in children, n U.S. Congress (1985). Gould, Wunsch-Hitzlg,& Dohrenwend (1981). a American Psychiatric Association (1987). Ovasdl~, Walssman, & Padian (1981). t Gottasman
(1978). g U.S. Department of Health and Human Services (1981). h Sugar (1984).
JNational Center for Health Statistics (1987). I U.S. Department of Commerce
(1982). ~ Wright (1975). mSchurman, Krarner, & Mitchell (1985).

children who are affected are referred to as disturbed

children.

Utilization of Mental Health Services

The magnitude of children's mental health problems is
clear. However, it is difficult to specify what types of mentel health services are needed and how many services are
available. Utilization data for 1981 show that less than
1% of the nation's children (100,000 children) receive
mental health treatment in a hospital or residential treatment center (RTC) in a given year (Taube & Barrett,
1985), and perhaps only 5% (2 million children) receive
mental health treatment in outpatient settings. Thus, from
70% to 80% of children in need may not be getting appropriate mental health services.
Services appear to be getting more appropriate,
however. There is a slight shift toward increased use of
190

less restrictive and less intensive care over a 10-year period

(from 1970 to 1980). Outpatient treatment and day treatment/partial hospitalization are more frequently used
along with a doubling of use of RTCs (a less expensive,
intensive, and restrictive inpatient treatment than hospitalization). Inpatient hospitalization of all types has
increased only slightly. The increase has been mostly in
admissions to psychiatric hospitals and psychiatric units
of general hospitals while admissions to state and county
mental hospitals, which often have inadequate services
for children, have been declining. Children also stay in
state and county mental hospitals for shorter periods, another indication that restrictive settings are used less frequently for children. How long children stay in private
psychiatric hospitals is unclear because there are reports
for both an unchanged rate and a twofold increase for a
0-year period.
Because of the wide range of settings delivering services, rates of children using outpatient treatment are
equally unclear. However, a National Institute of Mental
Health (NIMH) study indicates that 3.2% of children under 18 years of age (and 4.3% of all ages) had a mental
health visit in 1980. Others have found rates as high as
6% for all ages. Several other studies suggest that outpatient mental health services have greatly increased for all
ages.
Thus, even though there continues to be a significant
gap between the number of children identified as needing
mental health services and the number receiving them,
some gains are being made in availability and utilization
of more appropriate services (less intensive and restricfive).

Children's Mental Health Therapies

A variety of theories about human development and behavior form the basis of interventions to treat children's
mental health problems. Most of the interventions used
with children are adaptations of procedures used with
adults, although a few have been devised especially for
children. The most commonly used interventions for
children include individual psychotherapy, family therapy,
group therapy, milieu therapy, crisis intervention, and
psychopharmacological treatment.
Three broad categories of individual-treatment approaches used with children are traditional therapy, behavior therapy, and cognitive therapy. Each of these can
also be used as part of group and family therapies. Traditional therapy, usually psychodynamically oriented, is
based on the development of insight to produce changes
in cognitions and emotions, which in turn are followed
by changes in behavior. Behavior therapy is based on the
assumption that the child learns persistent pathological
behavior from experience with the social environment;
changes in behavior are made by providing new learning
experiences during therapy. Behavior-therapy methods are
based on several models of learning (operant conditioning,
reciprocal inhibition, and social modeling or observational learning). Cognitive therapy, based on findings that
disturbed children think differently from other children,
February 1989 American Psychologist

attempts to alter the way children think about their behavior and environment.
Group therapy combines the elements of individual
therapies with interactional processes. Group members
are the primary agents of change: New ways of relating
are developed within the groups, strong children serve as
models for others, and the entire group can help an individual child with a weakness. Oftentimes, group therapists are interested in the processes of group behavior
rather than the dynamics, as, for example, when group
therapy is used primarily to provide mutual reinforcement
for improved behavior or peer modeling. Group therapy
is often used as an adjunct to other modalities (e.g., individual or family).
Unlike individual and group therapists, family therapists reject the notion of the identified patient; rather,
they believe that problems are manifestations of disturbed
interactions within a family. The goal of family therapy
is to change the system. Three models of family therapy
are dynamic, systemic, and behavioral family therapies.
They are based, respectively, on the goals of developing
insight, changing the family's psychosocial organization,
and teaching parents techniques of social-learning-based
child management. Milieu therapy occurs only within
the context of a hospital, RTC, or a day treatment center.
Every aspect of daily life is designed to help the child
recover by teaching the child social and educational skills,
to explore the child's emotional life and patterns in relating to others, and to provide the child with ongoing
support. Crisis intervention applies techniques to defuse
threatening situations and provide family members with
coping resources during periods of acute mental health
problems and stress. Interventions are typically offered
intensively on an as-needed, off-hours basis. Contact is
maintained with the family after the crisis until other
services are arranged.

Effecdveness of Therapy With Children

Therapeutic treatment of children has recently been
shown to be as effective as therapy with adults. A recent
review of child psychotherapy studies in general--when
a variety of treatments and problems are mixed--yielded
positive evidence for effectiveness. Even though years ago
Levitt (1957, 1963) found no difference between treated
and untreated children, a recent recta-analytic review of
most variationsof individual,group, and family therapies
by Cascy and Berman (1985) found that the average
treated child had an outcome that was betterthan those
of two thirdsof untreated children,regardlessof the category of treatment.
Casey and Berman's (1985) analysis indicated that
the therapiesproduced improvements in high percentages
of treated children over untreated children: 55% treated
with behavior therapy (96% including therapylikeactivities)and 8 I% treated with cognitivetherapy. Casey and
Berman also found that psychodynamic, group, and
family therapieswere as effectiveas the other modalities.
More recently,traditional psychotherapy has been reFebruary 1989 American Psychologist

viewed and found to be effective in 62% of studies reviewed (Tuma, in press).

At present, it is not known which therapies are the
most effective for treating certain kinds of problems, but
some information is forthcoming. For example, behavior
therapy is effective in treating phobias and enuresis. Positive effects have been found for fears, hyperactivity, disruptive behavior, and general self-control, but aggression
appears to be especially resistant to cognitive methods.
Group therapy is effective with delinquent adolescents
and apparently yields positive effects for various measures
(anxiety, academic performance, antisocial behavior), selfconcept, and feelings about parents and peers in adolescents. Behavior family therapy is effective with conductdisordered and delinquent children in reducing aggressive
and antisocial behavior both in the home and in the classroom, and it leads to improvement in family interaction
and decreases recidivism. More severely disadvantaged,
troubled families have benefited much less than other
families, however. Some therapies appear to be more effective when combined with others. For example, improvements in children treated with cognitive therapy do
not continue once therapy is concluded unless it is combined with operant-conditioning methods.
There are no indications that milieu therapy and
crisis intervention are effective when separated from the
context in which treatment is embedded, leaving the
question of their effectiveness open.

Drug Treatment
Although drug treatment is not used with children as
frequently as with adults, its use with a range of child
mental disorders has increased over the past decade, particularly with children whose disruptive or destructive
behavior is uncontrollable otherwise. Three kinds of psychoactive medication are used with children: stimulants,
neuroleptics (antipsyehotic drugs), and antidepressants.
Drug treatment is usually combined with other treatments
because medication cannot contain the problem sufficiently alone, and combined treatments appear more effective than any treatment alone.
Stimulants used on children suffering from attentiondeficit hyperactive disorder (ADHD) are effective in correcting attention deficits but not in improving academic
achievement. Stimulants also improve social behavior, but
long-term results are less impressive. Research has shown
that side effects (e.g., possible retardation of physical
growth, negative effects on learnin~ drug dependence or
later drug abuse, and euphoriant effects) are either minor,
equivocal, or not a problem.
Neuroleptics produce positive effects for managing
psychotic children and hyperactivity in children with
ADHD (although not as well as stimulants) and for reducing ties. Because they do not reverse or cure severe
disorders, neuroleptics are considered to be useful adjuncts to psychotherapy and other treatments. Short- and
long-term side effects do not appear to be serious, and
those that are occur infrequently only with high doses or
prolonged use.
191

None of the more rigorous studies have shown antidepressants to be better than placebos across samples
of depressed children (some subgroups have responded
well, however). Antidepressants have been used to treat
other disorders, notably enuresis, ADHD, separation
anxiety, and school phobia--all with some success. However, of all the drugs used with children, tricyclics call for
the greatest caution, especially with suicidally depressed
children.
The most recent evaluations of treatment methods
point to a diverse array of approaches to treating child r e n - a l l of which work fairly well. However, with few
exceptions, our knowledge is sketchy at this time about
what specific method of treatment in what kind of setting
is best for what kind of child with what kind of mental
health problem.

Human Resources for Mental Health Services

to Children
Trained statf are needed to design and provide responsive
mental health services for children and adolescents. The
many commissions and panels throughout this century
have pointed to manpower shortages as one of the reasons
for underservice to children in need of mental health services. A little more than 10% of psychiatrists (Knitzer,
1982) and less than 1% of psychologists are devoted primarily to serving children (VandenBos et al., 1979). There
are approximately 3,000 child psychiatrists, 5,000 clinical
child psychologists, 7,000 child/family-oriented social
workers, and 1,000 child/family-oriented mental health
nurses (Knitzer, 1982). The need is estimated to be much
higher.
Other human resources shortages also exist. In 1979,
states estimated that they could meet only 5% to 50% of
the need for teachers. The number of specially trained
people working with children and adolescents in residential settings has increased, but not enough to meet the
demand. To complicate matters, some trained providers
choose not to work with seriously emotionally disturbed
children, or they may be trained only in the most traditional mental health services. Moreover, children under
the care of public agencies are seldom brought to these
trained professionals.
Producing professionals to serve children takes special training facilities because those working with children
require special skills. However, training programs to train
clinical child psychologists have been scarcemabout 12
existed in the late 1960s and 30 in the late 1970s. The
scarcity is so severe that I predicted earlier (Tuma, 198 l)
from rates at which programs could train clinical child
psychologists, that by 1989 the number produced would
fall short by about two thirds the need projected by
VandenBos et al. (1979). One road-block to producing
psychologists to serve children has been the lack of guidelines for training. To address this need, the Section on
Clinical Child Psychology sponsored a training conference
in 1985 and made a number of recommendations that
have since been used to guide training programs (Tuma,
1985).
192

A second problem in producing psychologists was

not addressed until very recently. Although the NIMH
has supported clinical training of mental health professionals for many years, no funds were earmarked for
training mental-health-service providers for children.
Since 1983, however, a portion of NIMH clinical-training
funds were specifically allocated to train those professionals serving underserved populations, including children. A recent conference held by the NIMH outlined
guidelines for tying training funds to integration of mental
health and other systems of care for seriously emotionally
disturbed children, indicating that at least some federal
support of training will continue.

Mental Health Treatment Settings

Mental health treatment for children occurs in two major
kinds of systems: in the traditional mental health service
system--hospitals, RTCs, day treatment programs, and
outpatient settings such as community mental health
centers (CMHCs)---and in non-mental-health systems-preventive services and mental health care integrated into
other systems (such as educational, health care, welfare,
and juvenile justice systems).
A wide range of settings has been developed to treat
children's mental health problems. These treatment settings are often conceptualized as occupying specific places
along a continuum of intensiveness of care. At one end
of this continuum is inpatient hospital treatment (24hour-a-day care for extended periods of time); outpatient
treatment (only 1 or 2 hours per week, sometimes for
only a few weeks) is at the other end, with day treatment
in an intermediate position.
The entire continuum of services must be available
to properly serve children. In this country, children are
often inappropriately served because many services are
unavailable (Knitzer, 1982). Various commissions and
panels, noting that facilities for children are almost nonexistent, have consistently recommended an increase in
development of residential treatment facilities and community-based services for children who do not need inpatient care. However, disproportionate funding and development of state and county inpatient facilities to the
detriment of less restrictive settings has characterized
mental-health-service development to date. All mental
health authorities agree that it is desirable to provide appropriate treatment in the least restrictive setting possible.
In fact, federal legislation (Education for All Handicapped
Children Act, Public Law 94-142) and judicial decisions
(Willie M. et al. v. Hunt, 1980; Behar, 1984) require that
the principle be followed. How to achieve a proper balance
among all levels of care to ensure that children are appropriately served in the least restrictive setting is a major
problem facing this nation.
Several factors influence the treatment and treatment
setting of choice for each mentally disturbed child.
Symptoms and the severity of the child's disorder are
obviously important, but other important factors include
the child's developmental status, availability of family
support, social and environmental conditions, availability
February 1989 American Psychologist

of financing for services, and geographic availability of

certain services. In this section, mental health settings are
presented in order from most to least intensive and restrictive: hospitalization, RTCs, and outpatient services.

Psychiatric Hospitalizatlon
Psychiatric hospitalization is regarded as the most intensive of care because the child is removed from the home
environment and placed in the hospital for provision of
total care--food, lodging, medical care, recreational
needs, and education. Hospitals use a number of interventions, including individual, family, and group therapies; medication; milieu therapy; and, perhaps, behaviormodification procedures.
Children can be hospitalized for mental health care
in various types of facilities, including free-standing psychiatric hospitals for all ages (state and county mental
hospitals and private psychiatric hospitals), separate children's hospitals or units, chemical-dependency units, and
psychiatric units of general hospitals. Psychiatric hospitals
must be licensed as hospitals according to state law, and
many must also be accredited as hospitals by the Joint
Commission on the Accreditation of Hospitals. Various
types of hospitals are available to children, varying in
kinds of facilities, staff, and cost.
There are 30 publicly funded state and county mental hospitals and some CMHCs that have separate psychiatric units for children (National Institute of Mental
Health, 1986). Typical of these facilities are a lack of fiscal
resources, limited numbers of beds for children, and less
weil-trained staffs than private facilities. During the past
20 years, the number of children placed in inpatient units
of these hospitals has declined considerably because of
the deinstitutionalization movement.
Private psychiatric hospitalization is an option for
some. Various organizations (private corporations, universities, and religious organizations) own and operate
private psychiatric hospitals, most for profit. Services offered by these organizations are increasing, and because
they typically have more resources to devote to treatment
than do public hospitals, they tend to provide more hours
of ancillary treatment per week per patient, have a higher
staff-to-patient ratio, and have a greater number of, as
well as a more experienced, professional treatment staff.
Private psychiatric hospitalization is, however, the most
expensive children's mental health treatment.
Children's psychiatric hospitals and units specialize
in treating youth and do not admit adults. These hospitals
and hospital units provide three kinds of care: short-term
care for crisis situations and long-term care for chronically
disturbed children. Intermediate-term (60 days to 2 years)
psychiatric hospitals are the most frequently appearing
inpatient psychiatric facility for children. A substantial
amount of the inpatient psychiatric care for children is
provided by general hospital units--separate psychiatric
units with treatment programs similar to those offered
by free-standing psychiatric hospitals. In addition, general
hospitals admit psychiatric patients to medical wards under some circumstances.
February 1989 American Psychologist

Chemical Dependency Units (CDUs), specialty

treatment centers that treat substance abuse and dependence (e.g., alcohol and illicit drugs), sometimes admit
and specialize in treating children and adolescents. CDUs
may be public or private, free standing or part of a general
hospital.

RTCs
RTCs are an alternative to hospitals when intensive and
restrictive care is needed. RTCs are 24-hour care facilities
(not licensed as hospitals) that offer mental-health-treatment programs for mentally disturbed children. These
facilities range from highly structured institutions closely
resembling psychiatric hospitals to those that are indistinguishable from group homes, halfway houses, or fostercare homes. Although RTCs typically have a more limited
number of medical professionals than do psychiatric hospitals, they are more selective, often not admitting highly
aggressive, suicidal, or overtly psychotic (delusional or
hallucinating) children. RTCs can be set up to house only
a few children or hundreds; most serve adolescents (75%).
Services offered range from custodial care to the full range
of possible services; milieu therapy is usually central. Most
RTCs serve children with short-term needs (up to 2 years).
About 15% are designed for long-term treatment of severely emotionally disturbed children (e.g., infantile autism, severe mental retardation, and neurological disorders) for whom there is no cure nor possibility for normal
development.

Day Treatment~Partial Hospitalization

Day treatment is intermediate in intensity between outpatient and 24-hour care. It is used both as a less restrictive
alternative and as a transition from inpatient to outpatient
care. The number of day treatment centers has increased
dramatically from 10 in 1961 to more than 350 in 1980.
Day treatment centers offer extended treatment for a
number of hours a day. Some are psychoeducational day
treatment programs and operate more like schools with
a therapeutic component; others include the full range of
mental health intervention, including individual therapy,
group therapy, family therapy, vocational counseling, and
other vocational programs. Within these programs, educational and recreational activities are designed to further the child's development. Partial hospitalization refers
to the use of a psychiatric hospital setting for less than
24-bout-a-day care. Children in these programs return
to their homes at night.

Outpatient Settings
Outpatient treatment is the least intensive treatment setring and is appropriate for children who can function in
their natural environments. It is the most prevalent treatment for children. Many fa"cdities---CMHC outpatient
departments, private outpatient clinics, and private mental health practices--offer all treatment modalities (individual therapy, group therapy, family therapy, etc.).
Publicly supported CMHCs were established in 1963
as a national mental health system to provide compre193

hensive mental health services to all residents of catchment areas regardless of their ability to pay. Outpatient
treatment is by far the most common form of service
provided. The CMHCs never developed as a nationwide
mental health system and were especially deficient in
serving the needs of children. The insufficiencyof services
offered by CMHCs results in denying children from lowincome families, who depend on public services, access
to outpatient care.
Many private clinics provide outpatient services to
children. These services are similar to CMHC outpatient
services in many ways, but private clinics vary more in
size, scope, and treatment philosophy. Some are nonprofit
and have sliding scales for payment, whereas others provide services only at standard fees.
Private mental health practices are an option for
some children. Many mental health professionals (psychiatrists, psychologists, social workers, psychiatric nurses,
and mental health counselors) provide outpatient treatment in private practices. Although the number of children cared for by these providers is unknown, it is believed
to be lower than the need. Private practitioners provide
all the outpatient treatments offered by organizational
settings but charge fees affordable only by families with
middle incomes and above, who are often reimbursed by
insurance companies. Although some private care is accessible to most families owing to the widespread availability of health insurance, policies vary greatly in their
coverage of outpatient mental health care.

Effectiveness of Mental Health Services

Despite the rhetoric about appropriate care and the least
restrictive care principle, definitive research to compare
treatment settings has not been done. To determine which
settings are the most effective, one would have to randomly assign disturbed children with similar diagnoses
and life circumstances to a hospital, an RTC, a CMHC,
or other outpatient setting that gives similar treatment
and then compare treatment outcomes. Because this has
not been done, it is difficult to separate effects due to
particular treatment modalities from effects due to the
setting in which either treatment or no treatment occurs.
It is also difficult to assess the degree to which alternative
treatments or alternative settings would have achieved
similar or different therapeutic outcomes. We do have a
number of studies (often uncontrolled), however, to determine whether certain settings are effective in producing
improvements in children treated.
Although effects of settings~hospitalization, RTC,
day treatment, outpatient treatment~have not been
compared with one another and with no treatment, follow-up studies generally show that children improve with
treatment. Positive outcomes of hospitalization are primarily associated with the severity of disorder---diagnoses
of neurotic or personality disorders are associated with
long-term positive outcomes, and diagnoses of psychosis
or neurologically impaired are associated with fewer positive outcomes. Positive outcomes of hospitalization are
also associated with other patient variables (e.g., intelli194

gence and parental psychopathology) and, to some extent,

treatment variables (e.g., aftercare and length of stay),
implying that a continuum of care and coordination of
services leads to more efficacy. Research on RTCs indicates that most children improve during treatment and
that their long-term outcomes may be less positive, depending on the involvement of the family in treatment,
the amount of stress in the environment, and the availability of social support. These findings suggest that effectiveness of RTC treatment must be evaluated only in
conjunction with the quality of follow-up care--coordination between RTCs, community agencies, and the
family. Day treatment appears not only to lower the
probability of children being placed in inpatient settings
but also to improve functioning while in treatment. Although definitive conclusions about the effectiveness of
day treatment cannot be made, reports of positive outcomes are encouraging.
Treatment obtained through outpatient settings has
not been compared with other settings treating the same
kinds of problems (e.g., hospitals and day care) to determine efficacy. Reviews of controlled outcome research
show that outpatient treatment modalities ofail types are
effective (Casey & Berman, 1985; see the earlier section
on therapy modalities). To date, treatment modalities used
in outpatient settings have been more highly researched
than have the effects of settings in which treatments a r e
delivered.
The available research fails to indicate what elements
of the inpatient treatment contribute to successful outcomesmor if children treated as inpatients would have
fared better, worse, or similarly if treated with nonhospital
treatment. If children are to be served appropriately, more
controlled research that compares treatment settings is
needed. Information about specific treatment settings for
specific problems is also needed to develop an effective
system of care for children and adolescents.
In this section, the diverse mental health settings for
children were presented and the effectiveness of those settings was briefly reviewed. Research shows that children
improve with treatment in all settings in the continuum
of care, from the most intensive and restrictive of settings
to the least intensive and restrictive. What is not known
at present are the specifics of the improvement: What
part of the child's improvement is due to the setting, to
the modality of treatment, and to the professional delivering the intervention?

Non-Mental-Health Systems of Care

Other systems of caremthe educational, health care, child
welfare, and juvenile justice systems---are also involved
in preventing and treating children's mental health problems. These systems, naturally involved in the lives of
most children, are potent forces in early identification
and remediation of at-risk, subclinically, and clinically
disturbed children. Because disturbed children are the
most likely to fail in school, to be involved with the criminal justice system, and to manifest a variety of medical
problems, these settings are often the first to identify chilFebruary 1989 American Psychologist

dren who are having problems. In addition, treatment

offered within a natural environment is less disruptive
than treatment that removes the child to an unknown
setting such as a clinic or hospital. Non-mental-health
systems have always been important mental health resources and, as all the study groups in this century have
noted, should be more strongly integrated with mental
health systems.

Educational System
Mental health problems interfere with a child's ability to
learn and interact with peers. In the 1920s and 1930s,
schools referred children to child-guidance clinics for
treatment. At present, some schools have their own mental health professionals (school psychologists, social
workers), and some rely heavily on special education,
which was specifically developed to serve the educational
needs of children with learning disabilities and psychological and physical handicaps. Others still refer children
to various resources for treatment. Overall, mental health
interventions within schools are not widespread, nor are
they coordinated with other systems of care.
Schools have recently been mandated to become
more active in the mental health care of children. Public
Law 94-142 requires schools to provide the educational
and related services needed by physically and mentally
handicapped children. Prior to the law's enactment, children with handicapping conditions were often denied
schooling, and parents had no resources to compel schools
to serve such children. Implementation of the law has
been hindered by confusion over the definition of "related
services" and by the fiscal responsibility for payment of
treatment and residential care if obtained outside the
school system. The interpretation that psychotherapy is
one of those related services has been made by several
court decisions (e.g., In rethe "A" Family, 1979; Papacoda
v. State of Connecticut, 1981 ). Four million students (ages
3 to 21) received mental health services under Public Law
94-142 in 1984 (Dougherty, Saxe, Cross, & Silverman,
1987), but it is unclear how many of these children were
handicapped.

General Health Care System

Many mental health problems are detected by physicians
while delivering primary health care to children with
physical problems, behavior problems, or chronic physical
illness. About 11% to 12% of pediatrician and family
practitioner office visits are by children with psychological
disorders, and from one third to one half of child hospital
patients have significant behavioral concomitants of their
physical illness---the effects of hospitalization, surgery,
and dentistry. Several surveys have found that chronically
ill children are at greater risk for developing behavioral
or emotional problems than are healthy children.
Physicians age the first professionals consulted about
young children's developmental and psychological problems. They provide counseling, advice, or medication to
50% of those children, yet they are not well informed
about mental health issues, and when physicians and
February 1989 American Psychologist

mental health professionals concurrently treat a child,

treatment lacks coordination. Better care can be provided
by primary-care providers if they either obtain mental
health training or consult with mental health specialists.
For the past 20 years, increasing numbers of pediatric
psychologists, variants of clinical child psychologists, work
in pediatric departments, hospitals, private practices, and
clinics, and considerable research has been accomplished
in health care settings, mostly showing successful interventions with children who have psychological problems
associated with physical problems. Some involve early
intervention programs, and others aim at helping physically ill children manage their illnesses without undue
mental health consequences. Systematic mental health
intervention in physical-care settings is routine only in
health maintenance organizations (HMOs), however.

Child Welfare System

Some of the most serious problems affecting children are
seen by the child welfare system. Parental abuse and neglect and other situations in which parental care is lacking
(e.g., during parental illness) are handled by child welfare.
The child welfare system offers a number of services to
children, including foster placement, therapeutic foster
care, respite care, and group home care. Coordination of
mental health and child welfare systems is generally poor.
One of the major interventions of child welfare systems is foster placement. An estimated 270,000 children
are in foster care. Children are removed from their homes
because of abuse, neglect, or abandonment and are either
adjudicated "dependent" by the court or are voluntarily
placed by the family. Placements are made in foster-family
homes, group homes, group child care facilities, and
RTCs.
The number of children being placed is increasing
at an accelerating rate, and children remain in foster care
for long periods without benefit of long-term planning.
Although foster placement is intended to be a temporary
measure, an alarming 66% of children and 88% of adolescents were found to be in foster care until the age of
majority. This "foster care drift" (temporary placements
becoming permanent through lack of planning) has led
to the development of permanency planning, which refers
to the process of taking prompt, decisive action to mainrain children in their own homes or to place them permanently with other families. The permanency planning
movement, in turn, led the U.S. Congress in 1980 to pass
the Adoption Assistance and Child Welfare Act (Public
Law 96-272), designed to provide incentives for permanency planning by states.
Children requiring foster placement come from
homes characterized by a number of risk factors, yet there
has been little research to determine their mental health
needs. One study found that children in long-term foster
care typically had severe psychosocial problems at entry
as well as 5 years later, but 85% received inadequate mental health treatment.
When it is recognized that a child needs therapeutic
components to foster care, several kinds of placements
195

can be made: respite care for emergency situations, therapeutic foster care in individual family settings, or therapeutic care in group homes administered by social service agencies that take 10 to 12 children. In respite care
and therapeutic foster care, the child is cared for by spcdally trained parents, whereas trained staff either live in
or work in shifts in the group homes. Both group homes
and therapeutic foster-care settings commonly involve
concurrent treatment in a mental health setting. Children
are placed in these settings for 1 month to several years.
Respite care can occur for two kinds of situations:
as a planned or unplanned relief for parents or foster
parents from caring for a difficult child or as an emergency
measure. The emergency respite-care arrangement is
brought about by some kind of crisis---an emotional
breakdown of parents or escalating conflict between children and other family members. Care is usually provided
for a few days to several weeks, until the child can return
home or is placed in another appropriate setting.
Placement in these foster settings is considered to
be a less intensive alternative to psychiatric hospitals or
RTCs. Foster parents are carefully selected to take disturbed children into their homes and to provide some
therapeutic work for a finite period of time. The foster
parents undergo training prior to therapeutic foster-care
placements and subsequently are supervised and supported by professionals who also arrange for other needs
of the children and provide emergency professional care.
Many states have levels of therapeutic foster care
available to cover a range of impairment in children. Intensive levels of care require more treatment-specific
training, greater involvement of the foster parents, and
greater availability of adjunct services. Most children in
therapeutic foster care receive mental health treatment
in addition to that provided by foster parents. Depending
upon the particular child's needs and availability of services, some children receive outpatient psychotherapy,
whereas others attend day treatment programs. It is apparent that this service demands a great deal of coordination between mental health and child welfare systems.

Juvenile Justice System

Children who fight, steal, lie, and run away from home
can be classified as having a conduct disorder by DSMIII-R criteria, but often they are in the juvenile justice
system. These children are not always formally diagnosed,
and the number of juveniles who have mental disorders
in addition to criminal or status offenses (e.g., truancy
and running away from home) is not known. Determination of the extent of the mental health problems of this
population of children is complicated by use of different
criteria to define the problems; the child can enter either
the mental health or the juvenile justice system, depending
on whether the particular behavior is characterized as a
symptom or as a violation of the law.
Coordination of the mental health and juvenile justice systems is rare. Because juvenile offenders are sometimes dangerous and disruptive, mental health agencies
are reluctant or unable to take responsibility for inter196

vention with them. Children often move back and forth

between these two systems, and frequently, children for
whom original interventions have failed or have been exhausted are sent from one system to the other, creating
other problems. Several models of coordinated mental
health and juvenile justice interventions have been developed. Some private mental health agencies have state
contracts to provide comprehensive services to disturbed
juvenile offenders, and other programs provide mental
health consultation directly to juvenile justice facilities.
Infrequently, case management has been used to resolve
some of the problems of serving disturbed children who
are wards of the juvenile justice system (Behar, 1984).

Effectiveness of Non-Mental-Health Systems

There is generally a paucity of evaluation studies of interventions in non-mental-health settings; therefore the
evaluation of their effectiveness is rudimentary, at best.
Only a few interventions delivered in educational systems
have been evaluated, so no definitive conclusions can be
reached about effectiveness. However, one study found
that at the end of treatment, 18 months, and 3 years, all
treatments led to improvement on at least some measures,
that emotionally disturbed children did better than behavior-disordered children, and that improvements increase over time. Conclusions are better with regard to
mental health services delivered in the general health care
system. Findings indicate that various interventions can
be administered as crisis interventions for children who
are treated for acute physical disorders and that collaboration between mental health professionals and pediatricians leads to earlier identification and intervention of
mental health problems in children. Some research delivered in the juvenile justice system has shown that practical, atypical interventionspjob counseling and placement, remedial education, aid in managing moneymare
effective both in the setting and at follow-up, but more
traditional methods of treatment (behavioral treatment),
although effective when the child is in the setting, do not
improve behavior when the child returns to the community. Because of the importance of these settings in
early identification and treatment of mental health problems of children and adolescents, it is crucial to conduct
more research on their efficacy.
Prevention of Children's M e n t a l H e a l t h
Problems
Two types of efforts have been used to prevent behavioral,
social, emotional, and academic difficulties in children.
Primary prevention strategies are aimed at reducing the
incidence of new problems; secondary prevention strategies are directed at reducing the severity and duration
of disorders through early identification, diagnosis, and
treatment. Both have the common goal of reducing the
incidence of mental health problems in the population
and of reducing the need for more intensive and costly
treatment services such as psychiatric hospitalization and
other residential treatment.
Primary prevention efforts for children are aimed at
February 1989 American Psychologist

teachers and parents of high-risk children. Programs have

been developed for particular at-risk groups (e.g., teenage
mothers, poor women) and parents in general--those not
known to have children at-risk. Examples include development of training manuals on child management techniques, videotapes for inexperienced mothers, and parent
education groups, such as parent effectiveness training.
These programs have been popular, but they may not
meet the needs of low-income families. Prevention efforts
in schools take many forms. Examples include alcoholeducation programs, mental health consultation to
teachers, and specific programs aimed at decreasing specific behaviors that predispose children to later problems
in school adjustment.
Head Start and similar preschool child-development
programs are examples of primary prevention. Established in 1965, Head Start was designed to provide enriched early childhood education for low-income children.
Other services, including health, nutrition, and social services, are also provided, and parent and community involvement in the development and operation of the program is an effective feature of it.
Family support programs (FSPs) recognize that
families--often thought to be primary contributors to
mental illness in children--are a principal source of
mental health and adaptation, as well. FSPs are characterized by their focus on family strengths rather than deficits, parents' need for information and support for their
roles, attempts to foster self-reliance, and emphasis on
relationships between children and parents and between
families and support systems in the community. FSPs
range from center-based programs resembling traditional
mental health services to practices such as corporate flex
time and daycare. A number of FSPs target at-risk families
and typically offer support and guidance to parents in a
series of steps that emphasize progressively greater peer
support and progressively less staff involvement.
Some secondary prevention efforts are aimed at
training parents (or school personnel) to deal directly with
their children's problems. Programs aimed at parents
train them to use behavioral methods to modify a range
of behaviors in their preschool children--reducing
aggression and tantrums; increasing eye contact, imitation, and vocalization; and enhancing children's prosocial
behavior and language skills.
School-based secondary prevention programs involve delivery of individually based remediation efforts
to primary-grade children who have been identified as
having behavioral and academic difficulties--typically
acting-out, withdrawal, and learning problems. Teacher's
aides meet regularly with children during the school year,
working on individually determined goals. Mental health
professionals serve as consultants to teachers and other
school personnel.

Effectiveness of Prevention Efforts

Research on prevention has a number of difficulties: the
low base rate of some disorders, the large cost and effort
involved in long-term follow-up studies, and the wide
February 1989 American Psychologist

range of target problems and interventions included.

However, a number of prevention strategies have been
found to be effective in preventing mental disorders and
promoting mental health and adaptation.
Prevention efforts with teenage mothers and their
preterm infants produced improvements in both infants
(physical, cognitive, social, and temperamental improvements) and mothers (lower rates of subsequent pregnancy
and higher rates of school enrollment and employment
1 year after intervention; however, many benefits were n o
longer apparent 2 years after intervention).
Evaluations of early education and child-development programs, especially Head Start, make clear that
the most effective interventions are often those that actively involve parents as well as children. Outcome studies
of FSPs that aim to support effective functio~aing of highrisk families have been found to be effective. For example,
mothers in the Yale Child Welfare Research Program
(Seitz, Rosenbaum, & Apfel, 1985) were more likely to
be employed, to have fewer total children, to live in improved socioeconomic circumstances, to have higher levels of education, and to display self-initiated involvement
with children's schooling. Their children had better school
attendance, required fewer costly special services, and
showed better social and school adjustment.
Evaluations of family-based prevention--FSPs that
target child maltreatment--show that families had fewer
incidents of child abuse, experienced less stress, and had
developed better parent-child interaction and child-care
conditions by the end of the program. Greater involvement in the program correlated with better outcomes.
Preliminary work shows that school-based secondary
prevention is also effective. Several outcome studies show
that school-based secondary prevention is effective in reducing problem behaviors and enhancing competence in
high-risk groups. Outcome research on prevention programs for specific mental disorders is very undeveloped,
however.
The rigorous studies that exist are on efforts to prevent more broadly defined maladjustment. These studies
suggest that effective interventions can be offered through
any of several existing systems, including the family,
schools, and health care programs. Prevention programs
have led to positive changes in social, emotional, and academic measures and are effective in preventing future
problems.

Integration of Mental Health and Other

Services
All commissions and panels have consistently pointed to
inadequate and inappropriate services to children with
mental health needs. Some of the lack of service, however,
is not due to the number of facilities available but to how
they work together. It has been consistently documented
that children obtain fragmented services because of lack
of communication between parts of a system and between
systems. Children are shuttled from one system to the
other and in other ways are inappropriately served, especially by the use of more restrictive and intensive care
197

than is warranted by the case. Fragmentation of services

offered by the various systems that now characterize our
mental-health-delivery system often contributes to both
undertreatment and overtreatment of children in need
(e.g., outpatient services delivered to children in need of
more intensive treatment and vice versa; Dougherty et
al., 1987; Knitzer, 1982).
Currently, there is little integration of services between the mental health and non-mental-health systems
partly because of different goals and philosophies of care,
but most important, because of the types of administration of mental health services within state governments.
In his review of state administrative structures for provision of coordinated services, Isaacs (1984b) found a
number of models, but state education and health departments, which have the most frequent contact with
children, were almost always excluded from coordination
programs. In addition, in many states, implementation
often depends on the efforts of individual staff members
rather than on established systems and structures.
Treatment and prevention of children's mental
health problems can and do occur in many diverse settings, including educational and other settings outside the
mental health care system. Since children often enter
multiple systems, simultaneously or sequentially, an effective delivery of care demands that services be integrated
across modalities, providers, settings, and systems. To
achieve an integrated model of mental health care, a single
agency should take responsibility and promote early
identification of problems and provide care that supports
a nurturing relationship with adults while integrating
mental health with other services (physical, mental, social,
intellectual) within the child's normal environment and,
if not possible, within the least restrictive setting.
Models of integration have been advanced at the
level of the system or at the level of the individual child
(Isaacs, 1983a, 1983b). An example of systems integration
would involve joint efforts by state departments in developing policy, initiating programs jointly, sharing management and support services, and staffing service programs by representatives from all systems. Integration at
the individual child level would require agency collaboration on most stages of the treatment process from case
findings and evaluation to follow-up. Specialized services
offered by different agencies would be coordinated by periodic presentation at case conferences or through the use
of case teams or case consultation. Central to integrated
care is the concept of "case manager" or case advocate
(Knitzer, 1984). A case manager or case advocate is an
individual or a team representing the mental health system who assumes responsibility for ensuring that all the
appropriate combinations of services from all service systems are provided to a client. A sophisticated model of
case management has been developed in North Carolina
(Behar, 1985).
Recent developments have spurred a great deal of
federal incentives to develop technical assistance and research aimed at assisting states in the development of a
continuum of care coordinated within a system of care
198

(Isaacs, 1984a; S~oul & Friedman, 1986). Today, the

thrust is to develop services that are balanced along a
continuum of restrictiveness and intensity, services that
are integrated and coordinated among all services and
systems. Although it is too soon to evaluate at this point,
the federal government has responded with some support.
The Federal Child and Adolescent Service System Program (CASSP) was established in 1984 to help state mental health agencies coordinate care for one segment of the
population with mental health problems--seriously
emotionally disturbed children. In 1984 and 1985,
through CASSP, the NIMH funded 22 states to create a
state-level focal point for services to seriously emotionally
disturbed children, to conduct interagency planning and
needs-assessment activities, and ultimately to develop
more effective systems of services (Friedman, 1986).
There is also a thrust by the NIMH to connect support
for training mental health professionals within models of
integration of services to children. In addition, the State
Comprehensive Mental Services Plan Act of 1986 will
institute another grant program to assist states in dev~eloping comprehensive services for the chronically mentally
ill of all ages.
Conclusions
Despite the fact that delivery of mental health care to
children in need in the United States is not that noticeably
different today from what it was at the turn of the century
(15% to 19% of the nation's 63 million children are in
need of mental health treatment, whereas 70%-80% may
not be getting appropriate care), there are indications that
a direction has been found to promote improvements.
Significant attention and financial support from the federal government has been focused on developing a continuum of care coordinated across mental health and nonmental-health systems that naturally occur in all children's lives. There is already evidence that at least 22
states, financed by CASSP, are developing systems that
will coordinate and make more efficient all the systems,
facilities, human resources, and methods that are available
while also creating systems and services that will fill out
the continuum of care needed. Other states have available
considerable assistance to develop as well (Stroul &
Friedman, 1986).
The available research appears to indicate that we
have the appropriate facilities, methods of treatment, human resources, and systems of care (both mental health
and non-mental-health)--albeit in deficient amounts at
present--to treat children in need. Outcome research indicates that the various therapies work, that the various
facilities along the continuum of intensiveness and restrictiveness work, and that prevention services work, and
even preliminary amounts of research indicate that mental health care delivered in other systems works. We do
not yet have all the answers that will show exactly the
best way to treat each child in need. We eventually need
to answer the very complex question: What specific psychotherapy is effective, under what conditions; for which
children, at which developmental level; with which probFebruary 1989 American Psychologist

lems; under what environmental conditions; and with

w h i c h c o n c o m i t a n t p a r e n t a l , family, e n v i r o n m e n t a l , or
systems i n t e r v e n t i o n ? To a n s w e r those questions, we n e e d
research that systematically compares the t r e a t m e n t of
s i m i l a r c h i l d r e n w i t h different m o d a l i t i e s o f t r e a t m e n t s
i n settings along the c o n t i n u u m o f care t o s i m i l a r c h i l d r e n
n o t treated. I n t h e m e a n t i m e , as researchers are a t t e m p t i n g to a c c u m u l a t e a n s w e r s to these q u e s t i o n s - - a n d this
is a t i m e - c o n s u m i n g e n t e r p r i s e - - t h e available i n f o r m a t i o n is sufficient to implicate the careful coordination and

integration of services along the entire continuum of care

as t h e best possible u s e o f r e s o u r c e s at t h e p r e s e n t t i m e .

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