Search

Objective: To determine factors influencing the use of outpatient mental health services provided by mental health professionals (OMHS) for children in foster care using a national probability sample in the United States., Method: As part of the National Survey of Child and Adolescent Well-being, detailed survey data were collected on 462 children, ages 2-15, who had been in out-of-home care for approximately 12 months at the time of sampling. A multivariate logistic regression model was used to determine how clinical need, as measured by a Total Problem, Externalizing, or Internalizing Scale T-score of 64 or greater on the Achenbach Child Behavior Checklist (CBCL), and non-clinical factors affected OSMHS use., Results: Over half of the children in the sample received at least one OMHS. Need, older age, and history of sexual abuse history all positively predicted OMHS. A history of physical neglect negatively predicted OSMHS. African-Americans used fewer services than children of Caucasian ancestry at all values on the CBCL. This finding was particularly salient at lower levels of CBCL scores; at higher levels, the discrepancy in the use of services diminished but the proportion of children receiving services remained lower for African-American children., Conclusions: This national study confirms previous findings regarding the use of mental health services based on regional data. Limitations in the use of services imposed by non-clinical factors, specifically, age, race/ethnicity and type of abuse, need to be examined in order to address implicit and explicit policies and practices that may result in inequitable distribution of services.

Objectives: To investigate rates of psychotropic medication use by youths served in public service sectors as a function of race/ethnicity., Method: Logistic regression models were used to examine racial/ethnic differences in caregiver report of psychotropic medication use for a random stratified sample of 1,342 children who were served in public service sectors during the second half of fiscal year 1996-97., Results: Race/ethnicity predicted caregiver report of past-year and lifetime psychotropic medication use when all other factors were held constant. Specifically, caregivers of African-American and Latino children were less likely to report past-year use compared to white children; caregivers of Latino children and "others" were less likely to report lifetime use. Additional factors predictive of medication use in regression models included younger age, male gender, higher household income, insurance type, active to mental health sector at time of enumeration into the study, impairment and diagnosis of mood, and anxiety or attentional disorder., Conclusions: Racial/ethnic differences in use of psychotropic medication occur in children served in public service sectors and need to be considered in clinical diagnosis and treatment.

Objectives: To 1) investigate the status of policies for comprehensive health assessments of children entering out-of-home care, 2) develop a profile for each primary sampling unit (PSU) regarding the comprehensiveness of its assessment policies with respect to physical, mental, and developmental health, and 3) examine the relationship between inclusiveness and the estimated percentage of children assessed, primary assessment location, and principal assessment provider type., Method: In collaboration with the National Survey of Child and Adolescent Well-Being, a national probability sample of 92 PSUs was identified. Detailed telephone survey data, addressing policies for the assessment of physical, mental, and developmental needs of children on entry into out-of-home care, were collected from child welfare key informants. Descriptive statistics were used for analyses, and were weighted to account for the sampling strategy., Results: Over 94% of PSUs surveyed assessed all children for physical health problems. The percentage of PSUs with inclusive policies regarding mental health and developmental assessment was much lower (47.8% and 57.8%, respectively). Only 42.6% of PSUs provided comprehensive physical, mental health, and developmental examinations inclusive of all children entering out-of-home care. Community locations and primary care providers were most often used to conduct assessments for physical and developmental problems., Conclusions: Despite the publication of national guidelines regarding assessment, many PSUs do not have comprehensive policies or routine practices that address all children entering out-of-home care. Given the high use of primary care providers, these providers must be educated regarding the prevalence and types of problems experienced by children entering foster care.

Children in the foster care system are often dependent on Medicaid for health care. These children, however, have more complex health care needs than the typical child receiving Medicaid. States are implementing Medicaid managed care programs as a way to control escalating costs while providing necessary services. This article reviews the issues surrounding delivery of managed health care services to children in foster care and describes several solutions.

Objective: To determine factors influencing outpatient mental health service use by children in foster care., Method: Detailed survey and administrative data were collected on 480 children who entered long-term foster care in San Diego County from May 1990 through October 1991. These data were linked with claims data from Medicaid and San Diego County Mental Health Services information systems. A Poisson regression model was used to determine whether the following factors influenced outpatient mental health service use: age, race/ethnicity, gender, maltreatment history, placement pattern, and behavioral problems as measured by the Achenbach Child Behavior Checklist (CBCL)., Results: Except for maltreatment history, all independent variables included in the multivariate regression model were statistically significant. The total number of outpatient mental health visits increased with age, male gender, and non-relative foster placements. Relative to Caucasians, visits were lower for Latinos, and Asian/Others, but comparable for African-Americans. Concerning maltreatment history, differences were only found in one category; children experiencing caretaker absence received fewer visits compared to children who did not experience caretaker absence. Children with CBCL Total Problem Scale T-scores of 60 or greater had significantly more visits than those with a score less than 60., Conclusions: Both clinical and non-clinical factors influence outpatient mental health service use by foster children. Limitations imposed by gender, race/ethnicity, and placement setting need to be addressed by child welfare policies. These finding suggest that guidelines are needed to systematically link children in foster care with behavioral problems to appropriate services.

Unprecedented transformations in the financing and organization of child health care are driving change in the practice of pediatrics at a remarkably fast pace. The health care needs of children also are evolving, reflecting changing disease patterns, new technologies, and shifting socioeconomic and demographic characteristics of children and families. Changes in the financing and organization of child health services catalyzed by managed care and legislative initiatives need to be responded to proactively by the pediatric community. Yet, the anticipated health care needs of children also must be addressed as models for both pediatric training and practice in the future are developed. This article summarizes briefly these changes in health care services and in child health needs, addresses training implications, and discusses several initiatives the pediatric community is undertaking to develop guidelines for training pediatricians for the 21st century.

Managed care involves the linkage of service delivery and financing. One of the outgrowths of the rapid expansion of managed care over the past decade has been an increasing consensus that the generalist of the future will need to manage more of the patients traditionally cared for by subspecialists. Subspecialty education for pediatric residents becomes increasingly important as the role of the pediatric generalist enlarges to include independent outpatient management of some less complex but traditional subspecialty patients as well as collaborative management of more complex patients. To prepare for this role, a balanced exposure to subspecialty problems in outpatient as well as inpatient settings is required. At the same time, however, the growth of managed care has led to certain barriers for providing this enhanced training. This article describes the effects of managed care on the role and scope of the pediatric subspecialist as well as on educational strategies for coping with these changes while reshaping the roles of both generalists and subspecialists for maximal effectiveness in meeting the health care needs of children.

Seven herpes simplex virus mutants which have been previously shown to be resistant to arabinosyladenine were examined for their sensitivities to four types of antiviral drugs. These drugs were a pyrophosphate analog, four nucleoside analogs altered in their sugar moieties, two nucleoside analogs altered in their base moieties, and one altered in both. The seven mutants exhibited five distinct phenotypes based on their sensitivities to the drugs relative to wild-type strain KOS. All mutants exhibited resistance to acyclovir and arabinosylthymine, as well as marginal resistance to iododeoxyuridine, whereas all but one exhibited resistance to phosphonoformic acid. The mutants exhibited either sensitivity or hypersensitivity to other drugs tested--2'-nor-deoxyguanosine, 5-methyl-2'-fluoroarauracil, 5-iodo-2'-fluoroarauracil, and bromovinyldeoxyuridine--some of which differed only slightly from drugs to which the mutants were resistant. These results suggest ways to detect and treat arabinosyladenine-resistant isolates in the clinic. Antiviral hypersensitivity was a common phenotype. Mutations conferring hypersensitivity to 2'-nor-deoxyguanosine in mutant PAAr5 and to bromovinyldeoxyridine in mutant tsD9 were mapped to nonoverlapping regions of 1.1 and 0.8 kilobase pairs, respectively, within the herpes simplex virus DNA polymerase locus. Thus, viral DNA polymerase mediates sensitivity to these two drugs. However, we could not confirm reports of mutations in the DNA polymerase locus conferring resistance to these two drugs. All of the mutants exhibited altered sensitivity to two or more types of drugs, suggesting that single mutations affect recognition of the base, sugar, and triphosphate moieties of nucleoside triphosphates by viral polymerase.

We have isolated a human cytomegalovirus mutant that is resistant to the antiviral drug 9-([2-hydroxy-1-(hydroxymethyl)ethoxy]methyl)guanine (BW B759U), yet exhibits wild-type sensitivity to inhibitors of herpesvirus DNA polymerases such as phosphonoformic acid and aphidicolin. Cells infected with the mutant accumulate approximately equal to 1/10th the amount of drug triphosphate as do those infected with the wild-type parent. This reduction in drug triphosphate could not be attributed to altered drug uptake or to reduced stability of the triphosphate, once formed. The induction of normal nucleoside and deoxynucleoside triphosphates and certain cellular nucleoside kinases was comparable in mutant and wild-type virus infections. These results provide strong evidence for the importance of phosphorylation in the selectivity of this antiviral compound and raise the possibility that human cytomegalovirus encodes a nucleoside kinase. The mutant may identify the existence of a cytomegalovirus function whose properties could facilitate genetic analysis of this important pathogen.