Racial and Ethnic Disparities in Receipt of Specialty Services among Children with Mental Health Need Enrolled in the Children's Mental Health Initiative

Background:  An estimated 15% to 20% of U.S. children meet diagnostic criteria for a mental disorder, yet only a small proportion of children who need mental health services actually receive them. Minority children suffer disproportionately from inadequate access to mental health services. In response to these unmet needs, the federal government launched the largest and longest funded children’s mental health program to date in 1993. The program, known as the Children’s Mental Health Initiative (CMHI), promoted community-based care for children with serious mental health needs through systems of care.  Systems of care principles specify that services should be tailored to individual needs, family-driven, community-based, integrated, easily accessible and culturally competent. Since its inception, the CMHI has funded 173 sites, which provide an array of services to children referred from multiple sources including family, mental health agencies, schools, welfare and justice systems, and physicians. The CMHI collects data from enrolled children and their caregivers through a national evaluation, representing the largest data source on children’s use of mental health services in the U.S.  Although it was not specifically designed to reduce disparities, prior research has shown that the CMHI successfully recruits minority children from socially disadvantaged areas and improves other outcomes prevalent in these communities, such as juvenile delinquency. Given its community-tailored approach, the CMHI is well positioned to improve minority access to care. If the program successfully reached minorities, then racial and ethnic differences in the utilization of children’s mental health services within sites may be significantly reduced across the communities served.

Objective: To assess racial/ethnic differences in mental health services receipt among children enrolled in “systems of care” under the CMHI.

Methods: Survey data for 3920 CMHI enrollees were used to estimate the association between race/ethnicity and the numbers of days over twelve months post-enrollment during which the child received individual, family and group therapy; medication monitoring; assessment and evaluation; case management; residential treatment; and inpatient care. Two-part regressions with fixed site effects were estimated to adjust for geography and other baseline population differences, including child and caregiver characteristics.

Results: Relative to white non-Latino children, African-Americans had lower odds of using any individual therapy (odds ratio, OR = .73; p=.019), family and group therapy (OR=.79; p=.043), and psychotropic medication monitoring (OR=.51; p<.001); among users of each service, African-Americans had lower utilization for individual therapy (incidence rate ratio, IRR=.79; p<.001), family/group therapy (IRR=.86; p=.011), and inpatient care (IRR=.75; p=.026).  Latino children had lower odds of receiving any medication monitoring (OR=.70; p=.007) and assessment and evaluation services (OR=.75; p=.027) and among users, Latinos had lower utilization for individual (IRR=.91; p=.044) and family/group therapy (IRR=.88; p=.044).  Pacific Islanders who received medication monitoring used services at a lower rate (IRR=.60; p=.009).  No other associations with race/ethnicity were significant.

Conclusions: Significant racial/ethnic disparities in children’s mental health treatment persist even within the framework of systems of care. Further work is necessary to understand the role of individual program components, their interactions with community characteristics, and how they might impact mental health services use.