Use of Outpatient Mental Health Services Among Children of Different Ages: Are Younger Children More Seriously Ill?

The sample included 707 children, of whom 210 (30%) were ages six or seven, 351 (50%) were users of multiple types of mental health services, and 621 (88%) screened positive for symptoms of mania. Table 1 displays sociodemographic characteristics of younger versus older children and of users of no or a single type of mental health services versus multiple types of services. Table 2 presents the children’s diagnoses and functioning measures broken out by age group and by use of mental health services.

The younger group was slightly more likely to be male, be insured by Medicaid, have two parents with mental health problems, and have elevated symptoms of mania (Table 1). Parents of younger children, however, reported less stress than parents of older children (PSS scores of 7.97 versus 9.07, p=.002). Younger and older children did not differ significantly by race-ethnicity, by parent education, and by whether the child lived with both parents.

Children who used multiple types of services were more likely than users of no or single services to be older, to have Medicaid coverage, and to be unequally distributed across the four study sites. Users of multiple types of services were less likely to live with both parents, and their parents reported more stress. Children’s sex and race-ethnicity, parent education and mental health problems, and children’s symptoms of mania were not related to service utilization.

Younger children were diagnosed as having disruptive behavior disorders more often than older children, who were more likely to have mood disorders (Table 2). Older children also had higher scores for depressive symptom severity, more stressful life events, and lower functioning/quality of life (KINDL-R scores). Notably, type of outpatient mental health treatment received at baseline, number of diagnoses, use of antipsychotic medications, and overall functioning (CGAS and A-LIFE scores) did not differ between younger and older children.

Not surprisingly, primary diagnosis (bipolar spectrum disorders), lower functioning as measured by the A-LIFE, and a lower score on the KINDL-R friends subscale were related to use of multiple types of outpatient service. Further, users of multiple types of services were much more likely to receive outpatient mental health treatment that consisted of both therapy and medication, less likely to receive therapy alone, and considerably more likely to be receiving an antipsychotic medication.

To examine further the relationship between characteristics of children of younger versus older ages and use of multiple types of mental health services, we developed logistic regression models by age group (Table 3). For younger children, study site, high depression scores, and a higher score on the physical subscale of the KINDL-R (indicating fewer minor health issues) were related to use of multiple types of mental health services, and a high score on the Stressful Life Events Schedule was associated with decreased odds of use of multiple types of outpatient mental health services. For older children, study site, higher parental stress, primary diagnosis, and poorer previous functioning (A-LIFE total scores) were related to use of multiple types of outpatient mental health services; living with both parents was related to use of a single service or of no services. Parental stress was higher in two-parent families (data not shown).

Children in both age groups first utilized outpatient mental health services at approximately three years of age (Table 4). Younger children were less likely to have seen a psychiatrist or to have used multiple types of outpatient mental health services. However, there were no differences by age group in use of school services or outpatient mental health services before being seen in a LAMS clinic. Younger and older children, however, differed dramatically in age at first inpatient hospitalization (5.54 versus 8.23, p<.001) and age at first use of a mental health service in a general medical setting (4.73 versus 6.36, p<.001).

To examine more closely differences in the timing of service use by age group, we next examined whether the proportion of children who used services before age six differed between younger and older children (Table 4). Younger children were considerably more likely than older children to have utilized services before age six (inpatient, 46% versus 16%, p=.03; specialty outpatient, 42% versus 26%, p<.001; and mental health services within general medical settings, 65% versus 40%, p<.001).

These data provide a rich, rarely available look at patients of child mental health outpatient clinics located in the community and at academic medical centers. They point to clear differences between younger and older utilizers of services. Younger children were more likely to be male, insured through Medicaid, have a disruptive behavior disorder diagnosis, come from families where both parents have mental health problems, have fewer stressful life events and fewer minor health issues, and score high for symptoms of mania and depression. Although younger children scored higher on the KINDL-R physical health measure, their overall functioning as measured by the CGAS was not statistically significantly different from older children, suggesting that although young children may have fewer minor health issues, like older children they have major deficits in functioning. Overall, these data suggest that younger utilizers of specialty outpatient services came from resource-poor families with considerable psychopathology.

For eight- to 12-year-olds in the LAMS cohort, use of multiple types of mental health services was related to characteristics commonly cited in the extant literature—diagnosis of bipolar spectrum disorders, psychosis, or depressive disorder and unfavorable family factors, such as living with one parent and parental stress. The importance of parental factors in use of services has been long identified (4) and remains an important influence. The absence of a significant association between parental stress and single parenthood and use of multiple types of services among younger children may be due to several reasons. First, it may be that stress is important only when coupled with the burden of being a single parent. Possibly the child’s problems even contribute to the parents’ separation by the time the child reaches the older age range. Second, young children’s problems may not exacerbate already existing parental stress in the same way as do older children’s problems, so that parental stress is not associated with use of multiple types of outpatient services at the younger age. Chronic exposure to the child’s problems may be necessary to finally convince parents to seek mental health help for the child and to seek multiple types of services. It could also be that stress accumulates as children age, particularly children whose functioning may predispose them to poor interactions with their peers.

The most striking differences between younger and older users of child mental health services was their use patterns. Although younger children first started using outpatient services around the same time as older children (around age three) and they were somewhat less likely to have been hospitalized for a mental health problem (6% versus 11%, p=.06), when they were hospitalized it occurred at a much younger age than among older children (5.54 versus 8.23 years, p<.001), suggesting that their symptoms and functioning were quite concerning. A similar pattern was seen for age at first use of mental health services and of a general medical setting for a mental health problem. Thus, for most specialized services, younger utilizers started their service itineraries at much younger ages.

Furthermore, these data speak to the importance of the general medical system as a provider of mental health services to preschool children. The fact that 65% of young children and 40% of older children in the LAMS cohort received mental health care in a general medical setting before age six speaks loudly for integration of general medical and mental health care, particularly for young children, and for improving primary care providers’ identification, management, and referral of these problems.

These data had limitations. The cohort was screen-enriched for symptoms of mania and thus is not representative of all users of outpatient child mental health services. In fact, 57% of children visiting the nine outpatient clinics did not score high enough for manic symptoms to qualify for study inclusion. That 43% of children scored high for symptoms of mania is not surprising, given that high rates of mania among clinically referred children have been reported previously (32–34). Similarly, participants were recruited in four Midwestern cities, and the results may not be generalizable to the entire United States. Indeed, even within that limited geographic area, some site differences were found. All data were parent and child reports; no attempts were made to verify service utilization. Thus reporting biases may have been present. Diagnosis may be more difficult among young children than among older children, and the diagnoses may be less stable. Perhaps the most important limitation is that this was a cross-sectional snapshot that involved a comparison of age cohorts. To determine whether differences in the diagnostic evolution and use of high-end mental health services between younger and older utilizers of service continued, prospective LAMS data will need to be examined.

The findings present a picture of very early use of multiple types of services for mental health problems among six- and seven-year-olds at nine outpatient clinics in four Midwestern cities. The six- and seven-year-olds began using services at an average age of three years, and 6% had been hospitalized, on average, at age six. A total of 46% who had had an inpatient hospitalization had been hospitalized before six years of age. In addition, their functioning suggests that they had considerable and persistent impairment, despite longstanding, substantial, and multiple interventions, and that they came from resource-challenged families with considerable parental psychopathology. All of these factors argue strongly for focusing attention on the emotional, behavioral, and service use issues for very young children, given that their problems and use of services appear to be persistent even at a very young age.

This research was supported by the National Institutes of Health (RO1 MH073967; RO1 MH073801; RO1 MH73953; and RO1 MH073816). The authors thank the National Institute of Mental Health (NIMH) for the support but acknowledge that the findings and conclusions in this manuscript are those of the authors and do not necessarily reflect the opinions of the NIMH.

Dr. Youngstrom has received travel support from Bristol-Myers Squibb and has consulted with Lundbeck. Dr. Frazier has received funding or research support from, acted as a consultant to, received travel support from, or received a speaker’s honorarium from the Simons Foundation, Ingalls Foundation, Forest Laboratories, Ecoeos, IntegraGen, Shire Development, Bristol-Myers Squibb, and the Brain and Behavior Research Foundation. Dr. Fristad receives royalties from Guilford Press, American Psychiatric Press, and Child and Family Psychological Services, Inc. Dr. Arnold has received research funding from CureMark, Forest, Lilly, and Shire; advisory board honoraria from Biomarin, Novartis, Noven, Roche, Seaside Therepeutics, and Shire; consulting honoraria from TrisPharma; and travel support from Noven. Dr. Birmaher receives royalties from Random House, Inc., UpToDate, and Lippincott Williams & Wilkins. Dr. Kowatch is a consultant for Forest Pharmaceuticals, Astra-Zeneca, and the REACH Foundation. Dr. Findling receives or has received research support from or acted as a consultant or served on a speaker's bureau for Alexza Pharmaceuticals, American Psychiatric Press, AstraZeneca, Bracket, Bristol-Myers Squibb, Clinsys, Cognition Group, Forest, GlaxoSmithKline, Guilford Press, Johns Hopkins University Press, Johnson & Johnson, KemPharm, Lilly, Lundbeck, Merck, Novartis, Noven, Otsuka, Oxford University Press, Pfizer, Physicians Postgraduate Press, Rhodes Pharmaceuticals, Roche, Sage, Seaside Pharmaceuticals, Shire, Stanley Medical Research Institute, Sunovion, Supernus Pharmaceuticals, Transcept Pharmaceuticals, Validus, and WebMD. The other authors report no competing interests.