Latino Disparities in Child Mental Health Services

By Lopez, Cintia Bergren, Martha Dewey; Painter, Susan G

TOPIC: Access and utilization of mental health services for Latino children. PURPOSE: As Latino children may experience higher rates of unmet needs, this article examines the current literature for the reasons for the disparity and the barriers to the utilization of mental health services for Latino children.

SOURCES: An integrative literature review was undertaken from child psychiatry and nursing.

CONCLUSIONS: The literature confirmed a pattern of underutilization of mental health services by Latino children, but did not completely address the reasons for the disparity. Suggested barriers were language and cultural issues. Gaps in the literature include a lack of agreement for definition of a mental health problem and the tools to identify these, insufficient studies into the barriers for Latino children in the access and utilization of mental health services, and cultural and language issues related to Latino research.

Search terms: Latino child mental health access, Latino child mental health disparities, Latino child mental health, Latino child mental health utilization

Health Disparities Among Latinos for Child Mental Health Services

The prevention and treatment of mental health problems in children in this country has received national attention in recent years. Mental health in children includes social, developmental, emotional, and behavioral issues and is an essential component of overall health (American Academy of Pediatrics [AAP], 2001). Factors such as physical impairments, cognitive disabilities, low birth weight, a family history of mental or additive disorders or poverty, parental separation, or child abuse or neglect place children at risk for mental health problems (U.S. Public Health Service [U.S. PHS], 2000). According to the U.S. Department of Health and Human Services (U.S. DHHS, 1999), although 1 in 10 children in the United States are estimated to have a mental health problem severe enough to cause impairment, only 1 in 5 of these children receive services.

Considering the morbidities associated with mental health problems and the possible consequences of inadequate or nonexistent treatment, it is little wonder the problem of mental illness in children has been called a national public health crisis by former Surgeon General David Satcher (U.S. DHHS, 1999). While mental health problems in children can lead to problems in school, such as learning or attention difficulties, these problems can, in turn, lead to mental health problems (DeSocio & Hootman, 2004). These problems can also develop into an increase in violence, such as suicide and homicide (AAP, 2001). In fact, the Illinois Children’s Mental Health Task Force (2003) stated that almost 70% of youths detained in the juvenile justice system suffer from a mental health problem. Mental health problems can also increase the likelihood of risky behaviors of adolescents, such as smoking and unsafe sexual practices, that can negatively impact physical health (AAP).

Utilization of mental health services remains low among all children (U.S. DHHS, 1999). Children are a particularly vulnerable group as they completely rely on adult caregivers for their healthcare needs during the early childhood and school-age years. Even as they grow older and become more independent, children still depend on their parents or guardians to a large extent to access needed services. Barriers common to children of all backgrounds in accessing mental health services include stigma, cost, insufficient coverage for services from private health insurances, and inadequately trained mental health providers (Illinois Children’s Mental Health Task Force, 2003). However, there are certain groups who have even higher rates of unmet needs. The Illinois Children’s Mental Health Task Force reports that mental health disparities exist for Hispanic and African American children. According to the U.S. PHS (2000), the difficulties in accessing mental health services can be exacerbated by cultural differences.

The elimination or reduction of racial and socioeconomic disparities by providing culturally competent care has been stressed in several reports (Illinois Children’s Mental Health Partnership, 2005; U.S. DHHS, 1999; U.S. PHS, 2000). One way to begin to eliminate health disparities is to examine affected groups and to identify and address any cultural barriers or challenges. The focus of this investigation is Latino children.

The terms Latino and Hispanic are often used interchangeably and include people of any race with a Spanish-speaking background. Latinos make up 12% of the population of the United States at 39.9 million, and are one of the fastest growing groups in the United States (U.S. Census Bureau, 2004). As with any cultural group, it is important to avoid stereotyping or assume its people are homogeneous. For instance, there are dozens of Hispanic countries and they are quite different from each other. In the United States, the largest Latino groups are Mexican Americans (58.8%), followed by Puerto Ricans (9.6%) and Cuban Americans (3.5%) (U.S. Census Bureau). However, there are similarities among cultures that can help in understanding its individual members.

In efforts to reduce the health disparity in Latino child mental health utilization, an integrative literature review was undertaken using the standards and guidelines set forth by Ganong (1987) to ensure a rigorous review that can contribute to nursing knowledge. The first step is to establish the purpose of the review and related questions to be answered. Next is to establish tentative selection criteria for the inclusion of studies. Third is to conduct a literature review. In order to gather information from the research, a questionnaire or survey tool should be developed. Next, rules of inference should be established for use in data analysis and interpretation. Inclusion criteria should be revised as necessary. Studies should be read using the tool to gather data. Then, data should be analyzed, followed by discussion and interpretation. The last step is to report the review.

The purpose of this paper is to examine past research on Latino child mental health access and utilization in an effort to expand the current knowledge base and determine areas for further research. The following questions-“Why is there a greater rate of unmet need among Latinos for mental health services?” and “What are the barriers facing Latinos in accessing and utilizing services for child mental health problems?”-were used to focus this investigation.

Method

In efforts to begin to understand these issues, a literature search was undertaken. The computerized databases CINAHL (1982 to August 2005), Ovid MEDLINE (1964 to August 2005), and PsycINFO (1872 to August 2005) were searched using the keywords “children mental health” and “child mental health” combined with “Latino” and “Hispanic.” Titles were screened and all relevant abstracts reviewed. Additionally, citations in relevant articles led to more articles to review. A total of 43 articles were reviewed. All research articles having to do with access and utilization of mental health services for children were selected for inclusion if Latinos were included. An exclusion criterion was not including Latinos or not specifying whether Latinos were included under the categories of White or Black. Articles that excluded children or that focused on specific treatment interventions were excluded. A total of 5 research articles were selected for review in the first search wave.

Due to the scarcity of available research in the initial search, Ovid MEDLINE (1966 to third week of September 2005), CINAHL (1982 to fourth week of September 2005), and PsychINFO (1806 to fourth week of September 2005) were again utilized in a second search wave. This time the search words “Latino mental health,””Hispanic mental health,””pathways into mental health services,””help-seeking for child mental health,””access to mental health care,””barriers to mental health services,” as well as the combination of “child mental health” and “access to care” were used for a yield of 228 research articles to review. Using the link “find similar” in the University of Illinois online library for the most relevant of these articles resulted in an additional 360 articles. Additionally, the online journal Psychiatric Services (http:// psychservices.psychiatryonline.org/cgi/content/full/ 54/1/60) was searched using the term “access to service” for a result of 121 articles. The titles of all these articles were screened for relevance to the topic with the most relevant ones selected for abstract review. Once again the inclusion criterion was to select all articles pertaining to the access and utilization of mental health services for children if Latino children were included. Articles on specific treatment interventions were excluded, as were those that focused on mental health access and utilization for adults in general or that did not specify Latino ethnicity. In the second search wave, 3 articles were selected for review.

Results

In all, a total of 8 research articles were selected for review. To aid in analyzing the research, the suggestion by Ganong (1987) to develop a survey tool was followed. See Appendix A for the survey tool, which was used to gather key elements of the studies and to take notes on their strengths and weaknesses. The 8 articles selected were examined for relevance to the topic of Latino child mental health access and utilization of services. Specifically, answers as to whether a health disparity exists and, if so, why it exists and what are the factors leading to this disparity were sought by reviewing the literature.

All of the studies reviewed were quantitative in nature and none were experimental. To aid in evaluating the current knowledge base on access and utilization of child mental health services for Latinos in the United States, the studies are examined by themes beginning with the studies relating to mental health service needs and utilization of services, followed by those examining service entry points and pathways, and ending with studies that focused on access issues and barriers.

National Surveys: Mental Health Service Needs and Utilization

Two studies analyzed data from national surveys with large samples representative of the U.S. population (Kataoka, Zhang, & Wells, 2002; Simpson, Bloom, Cohen, Blumberg, & Bourdon, 2005). In the Kataoka et al. study, secondary analysis of 3 national data sets- the National Health Interview Survey, the National Survey of American Families, and the Community Tracking Survey-from 1996 to 1998 was done for a total sample size of 48,736 randomly selected children. Parents were questioned about their children’s mental health. Unmet need was defined as not having been seen by a mental health professional in the past for those children in need of a mental health evaluation based on a screening tool that used selected items from the Child Behavior Checklist. The Simpson et al. study was based on the 2001, 2002, and 2003 National Health Interview Surveys, with a total of 29,278 randomly selected children. Parents or a knowledgeable adult were questioned using the Strengths and Difficulties Questionnaire to determine parental perception of having a definite or severe difficulty in emotions, concentration, behavior, or in getting along with others. The Kataoka et al. study found the need for mental health services to be much higher at 15.2-20.8% for 6- to 17-year-olds, with nearly 80% not receiving services compared to the Simpson et al. study, which estimated the need to be 5% for 4-to 17-year-olds with 55-60% not having contact with a mental health professional. Furthermore, Kataoka et al. found a significantly greater unmet need among Latinos as compared to White children, but did not explore the possible reasons for this disparity. On the other hand, the Simpson et al. study actually found that Hispanic children had a lower percentage of mental health issues compared to African Americans and Caucasians but does not speculate the rate of unmet need for specific groups. One possible reason for the discrepancy in findings is the manner in which mental health needs are measured. The Kataoka et al. study used selected items from the Child Behavior Checklist to determine need and had a much larger sample size than the Simpson et al. study. Furthermore, the Simpson et al. study was based on 3 years of a single survey and, despite being a later version of one of the surveys used by Kataoka et al., used a different tool, the Strengths and Difficulties Questionnaire, to determine need.

Latino Children: Mental Health Service Needs and Utilization

Other studies reviewed were not based on a national representative sample but specifically looked at Latino children and mental service utilization. Similar to the findings of Kataoka et al. (2002), Latino children were found to have significantly less utilization of mental health services as compared to White children (Hough et al., 2002; Snowden, Evans Cuellar, & Libby, 2003; Yeh, McCabe, Hough, Dupuis, & Hazen, 2003). Two of these studies were based on the same data set of over 1,000 randomly selected high- risk Latino, White, and African American children receiving services from 1 or more of 5 public sectors of care (mental health services, alcohol and drug programs, public school programs for the emotionally disturbed, child welfare programs, and the juvenile justice system) from San Diego County, California (Hough et al.; Yeh et al.). Both share the same limitation of excluding most primarily Spanish speakers due to a lack of instruments in Spanish. The study by Snowden et al. examined Medicaid claims for foster children and compared utilization of services among African American, Hispanic, and White children in areas starting Medicaid capitated managed care from September 1994 to June 1997 in 2 managed care sites and 1 fee- for-service site in Colorado. While all groups had a decline in services under managed care, Hispanic children had the lowest level of use under both models. Again, the reasons for this disparity were not explored.

Additionally, Alegria et al. (2004) found a high rate of unmet need, which limits the investigation of children in Puerto Rico in terms of their need, utilization of services, and the location of services. Here, need was assessed for the randomly selected sample of 1,890 children with the use of the Computerized Diagnostic Interview for Children (Version IV) to determine psychiatric disorders, while impairment was assessed by interviewing the parents using the Parent Interviewer Children Global Assessment Scale. This study found that 22% of children had significant mental health impairment and a majority of these children (87.8%) did not receive services in the previous year. These findings are striking since there would be no language barriers or incongruity in culture in Puerto Rico among parents, their children, and the mental health providers.

Service Entry Points and Pathways

A crucial aspect of accessing mental health services is the process of seeking help and the actual initiation of services. One study compared Latinos with African Americans and Caucasians in their sources of help leading to utilization of mental health services for children (McMiller & Weisz, 1996). The sample consisted of 192 families conveniently chosen from seven community mental health clinics in central and southern California. Latinos and African Americans were found to differ from Caucasians in that initial help tended to come from nonprofessional sources such as family and community members versus sources such medical or school personnel. Another study looked at the court system as an entry point for mental health services for foster children, a group expected to have a greater need (Garland & Besinger, 1997). Here the sample size was 142 children aged 2-16 years randomly selected from a larger study of children placed in foster care. While there were no differences among ethnicities for court recommendations for services, Whites were found to have a significantly higher rate of court-mandated services as compared to Latinos and African Americans. Although the sample size is small at 142, this finding is important as a court mandate is likely to elicit compliance for initiation of mental health services and also carries a financial responsibility for coverage.

Parental Perceptions: Access Issues and Barriers

When examining access issues, some researchers have highlighted parental perception of a possible problem or concern over the child’s mental health. The study by Alegria et al. (2004) was based only on parents and children in Puerto Rico, and found that 30% of the caregivers were concerned about their child’s mental health but only 12.2% of the children had received services in the previous year. Generalizability is limited as Latinos in the U.S. mainland were not included.

The study by Yeh et al. (2003) specifically looked at the barriers, or rather the endorsement of barriers, faced by ethnic minority parents in accessing mental health care for their children. Parents were not asked to name barriers but instead were asked to rate a total of 54 questions representing different possible barriers, including content of services, helpfulness of services, provider characteristics, effects of service, economic/ financial constraints, accessibility, language problems, and a lack of need for services. The questions were comprised of 15 items adapted from the Service Assessment of Children and Adolescents, 14 items adapted from other research deemed appropriate for children’s mental health services (namely, that of Alegria et al.), and 25 items created by two of the investigators. Surprisingly enough, the parents of the ethnic minorities, including Latinos, surveyed reported significantly fewer barriers in accessing care despite a significantly greater rate of unmet needs when compared to Whites. A notable exception for Latinos was language issues, which was endorsed as a barrier. Another intriguing finding was that greater acculturation was positively associated with barrier endorsement, even after controlling for symptoms severity. Since this study looked at an at-risk group already receiving services in a public health sector, the findings are not generalizable to the general population for whom barriers may have prevented receiving care altogether. Another consideration is whether the 54 items representing barriers captured all the possible barriers Latino parents may face in seeking mental health services for their children.

Aside from language and cultural issues, a frequently mentioned barrier for Latinos in healthcare access includes insurance issues. However, only one study included ethnicity when investigating the impact of insurance in the mental health access for children (Snowden et al., 2003). As described earlier, this study compared Medicaid-managed care to the traditional fee-for-service model and did find a decline in utilization under the fee-for-service model for Hispanic children. In addition, while Hispanics were found to have the lowest utilization rates as compared to African Americans and Whites, there was an increase in the use of residential treatment centers in managed care for both Hispanics and African Americans. Discussion

Clearly, there are gaps in the literature to date. The problem of underutilization of mental health services among all children with mental health problems has been documented (Kataoka et al., 2002; Simpson et al., 2005; U.S. DHHS, 1999). Furthermore, most of the studies examining issues of disparities in utilization of mental health services found that Latino children have a lower rate of utilization as compared to White children (Hough et al., 2002; Kataoka et al; Snowden et al., 2003; Yeh et al., 2003). However, it should be noted that the two national studies differed in terms of the prevalence of mental health issues among Latino children. While Kataoka et al. suggest that there is an increased prevalence of mental health problems among Latino youth as compared to Whites, another national study by Simpson et al. had the conflicting finding of a lower percentage of mental health issues among Hispanic children as compared to African Americans and Caucasians but does not differentiate the rate of unmet needs for specific groups.

The crucial questions as to why there is an unmet need and what barriers exist among Latino children for mental health service access and utilization remain only partially answered. During the literature search, most of the studies on Latino barriers to healthcare access centered on adults, with only a few investigations exclusive to Latino children and only one focusing specifically on mental healthcare access for Latino children (Yeh et al., 2003). This single study looked at children already receiving services when assessing parental perceptions of barriers. The puzzling findings that Latino parents do not report as many barriers as White parents do and yet Latino children have a lower rate of utilization suggest that there may be some cultural factors influencing parental perceptions of what constitutes a barrier or of recognizing that their child may require mental health services or even in voicing complaints about accessing services.

Aside from the issue of quantity or, rather, the insufficient number of studies investigating barriers specifically for Latino children and mental health services, other serious problems are apparent in the literature.

Perhaps the most critical problems are related to cultural issues in research. One such issue is the lack of validated Spanish language instruments. Due to the lack of an instrument, Spanish speakers were excluded from some studies on Latino child mental health access and utilization (Hough et al., 2002; Yeh et al., 2003). This is a major omission as it effectively excludes from the study Latinos who are likely among the most vulnerable and most at risk for health disparities due to language barriers. Another problem, which led to the exclusion of many articles in the literature search, is not including or specifying whether Latinos are included in the sample. Since Latinos can be of any race, simply categorizing the sample as White or Black does not clarify whether Latinos are being included. Since Latinos are not only of different races, but also originate from various Spanish-speaking countries and are in differing degrees of acculturation to the United States, they should not be treated or grouped as a homogeneous group. To be fair, it may be difficult, if not impossible, to have a large enough sample of Latinos to distinguish findings by country of origin, including U.S. born, or by degree of acculturation. However, indicating these differences among the Latinos in a sample can assist one in generalizing the findings.

Another basic issue is the lack of consensus as to what defines a mental health need, impairment, or actual diagnosis and how these are determined. Across the studies, various instruments were utilized to determine mental health need or impairment. For instance, one study used the Strengths and Difficulties Questionnaire (Simpson et al., 2005) while another used selected items from the Child Behavior Checklist to determine impairment (Kataoka et al., 2002). Yet another study used the Parent Interviewer Children Global Assessment Scale and the Computerized Diagnostic Interview for Children (Version IV) (Alegria et al., 2004). With such a wide variety among researchers as to what constitutes an impairment or a diagnosis, it is difficult to compare findings from study to study.

Implications

Advanced practice nurses in child mental health services have little empirical evidence to direct them to explain the phenomenon of low utilization of services or to assist in developing appropriate interventions for increasing access to care for Latino children. The current literature highlights the need for further studies to investigate barriers in Latino child mental health service access and utilization. Areas in need of further study for Latino children include the investigation into the impact of poverty and insurance issues, such as managed care versus public aid, and versus no insurance. The perception of barriers to mental health care must be evaluated from both the parent and child perspective and assessed as to whether any differences exist. Another necessity is the consensus among mental health experts as to what constitutes a mental health need and what instruments determine impairment, problems, or diagnosis.

It is essential that research into child mental health issues include Latino children and reflect the diversity within the Latino community, identifying Latinos from all countries of origin and regardless of English language skills. To investigate access to child mental health services between the various Latino subgroups, national studies should oversample Latinos to allow the measurement of differences between subgroups. Spanish language measurement tools must be developed and validated for Latino children and their parents. Based on previously identified barriers of language and cultural issues, research teams should include bilingual and bicultural members. Addressing these issues will result in research that can guide advanced practice nursing priorities and intervention efforts.

While community, poverty, and insurance issues have been examined in healthcare access for Latino adults and occasionally for children, these possible barriers have yet to be fully explored in the access and utilization for child mental health services. Future studies should include community samples for a complete picture of the barriers that may be preventing Latino children from initial entry into the mental health system. It is also imperative that advance practice nurses become politically involved in bringing these issues to the forefront in support of funding mental health issues for our nation’s children.

Until the gaps in the literature are narrowed, mental health providers in both private and public arenas must investigate strategies to reduce health disparities for Latino children in mental health service access and utilization. Careful consideration of the evidence indicating that all children, in particular minority groups, such as Latinos, underutilize mental health services is a first step. Advanced practice nurses must examine language and cultural sensitivity in their own settings and decrease possible bias in their own practice. For instance, providers can take steps to reduce the language barrier by ensuring that materials are available in Spanish and English, that at least some staff members are bilingual or that qualified translators are available at all times, and to provide services in the language of choice (keeping in mind that this may be different for parent and child). Certainly, ongoing education of staff on issues of cultural competency can alleviate cultural barriers, as would the inclusion of bilingual and bicultural staff. To increase the numbers of culturally competent mental health advanced practice nurses, Latino nurses should be actively recruited and supported to enter the mental health advanced practice specialties. Advance practice nurses must continue to support minorities who practice and who receive services in the mental healthcare system.

Advanced practice nurses can also improve the sensitivity of those who refer clients to mental health services to the health disparities among Latino children. Community and school providers can be alerted to the criteria for referring child clients for services, and be given strategies for ensuring that Latino families can locate and avail themselves of mental health care for their children. Providing services where the children are, either as a school-based service or in their neighborhoods, will decrease some of the barriers faced.

Conclusion

This integrative literature review found that Latino children experience a higher rate of unmet needs and mental health underutilization compared to White children. The current literature does not fully explore the reasons for the disparity, although suggested barriers include language and cultural issues. Further study is clearly needed to close the current gaps in the literature and must continue in order to support minorities in the mental healthcare system. Research into how mental health issues are addressed within the Latino culture would also benefit the advance practice nurse in practice. Advance practice nurses need to understand and support how mental illness impacts children’s lives within the Latino community, in order to build a foundation to narrow the gaps within a community.

Answers as to whether a health disparity exists and, if so, why it exists and what are the factors leading to this disparity were sought.

Aside from language and cultural issues, a frequently mentioned barrier for Latinos in healthcare access includes insurance issues. This integrative literature review found that Latino children experience a higher rate of unmet needs and mental health underutilization compared to White children.

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Cintia Lopez, RN, MS, ILCSN, is a School Nurse, Chicago Public Schools, Chicago, IL; Martha Dewey Bergren, DNS, RN, NCSN, ILCSN, FNASN, is Clinical Assistant Professor, College of Nursing, University of Illinois at Chicago, Chicago, IL; and Susan G. Painter, APRN, BC, is a Clinical Instructor, College of Nursing, University of Illinois at Chicago, Chicago, IL. This article was written as part of the requirements for Master’s in Nursing at the University of Illinois at Chicago.

Author contact: [email protected], with a copy to the Editor: [email protected]

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