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Psychiatric Disorder, Impairment, and Service Use in Rural African American and White Youth
Adrian Angold, MRCPsych;
Alaattin Erkanli, PhD;
Elizabeth M. Z. Farmer, PhD;
John A. Fairbank, PhD;
Barbara J. Burns, PhD;
Gordon Keeler, MS;
E. Jane Costello, PhD
Arch Gen Psychiatry. 2002;59:893-901.
ABSTRACT
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Background The Caring for Children in the Community Study examined the prevalence
of DSM-IV psychiatric disorders and correlates of
mental health service use in rural African American and white youth.
Methods Four thousand five hundred youth aged 9 to 17 years from 4 North Carolina
counties were randomly selected from school databases. Parents completed telephone
questionnaires about their children's behavior problems. A second-stage sample
of 1302 was identified for recruitment into the interview phase of the study,
and 920 (70.7%) of these were successfully interviewed at home using the Child
and Adolescent Psychiatric Assessment and related measures of service use.
Results Weighted back to general population estimates, 21.1% of youth had 1
or more DSM-IV psychiatric disorders in the past
3 months. Prevalence was similar in African American (20.5%) and white (21.9%)
youth. The only ethnic difference was an excess of depressive disorders in
white youth (4.6% vs 1.4%). Thirteen percent of participants (36.0% of those
with a diagnosis) received mental health care in the past 3 months. White
youth were more likely than African American youth to use specialty mental
health services (6.1% vs 3.2%), but services provided by schools showed very
little ethnic disparity (8.6% vs 9.2%). The effect of children's symptoms
on their parents was the strongest correlate of specialty mental health care.
Conclusions In this rural sample, African American and white youth were equally
likely to have psychiatric disorders, but African Americans were less likely
to use specialty mental health services. School services provided care to
the largest number of youths of both ethnic groups.
INTRODUCTION
LITTLE IS known about the prevalence of psychiatric disorders and access
to mental health care of rural youth, especially rural minority youth.1-5
Yet, there are important reasons for paying more attention to this segment
of the population. Rural households make up about 25% of the population. Some
of the poorest regions of the United States are rural areas and areas with
a high proportion of minority residents. Poverty and minority status have
both been associated with risk for child psychiatric disorder,6-11
but these studies used urban samples and cannot elucidate the role of poverty,
independent of inner-city residence, in the emotional and behavioral development
of minority youth. Similarly, studies12 of
sex and sex by ethnicity differences in the development of different psychiatric
disorders have mainly used urban samples. Rural studies are also important
in evaluating the effect of treatment availability on use of services, because
access is generally poorer in rural areas.13
This report on the Caring for Children in the Community Study examines
the issues of need for and use of mental health services in a representative
community sample of African American and white children and adolescents living
in a largely rural area of North Carolina. The study design is similar to
that of the Great Smoky Mountains Study (GSMS),5, 14-16
which compared white and American Indian children from the same state. The
objectives of these studies include examining risk for and outcomes of DSM-IV psychiatric disorders from a developmental perspective17 and the relationship between need for mental health
care and the services provided by the various sectors that serve children
with mental health care needs: schools, primary medical care, child welfare,
juvenile justice, and specialty mental health settings.
METHODS
SAMPLE AND SETTING
The 4 counties surveyed constitute the mental health catchment area
served by a single child guidance clinic and used for the Duke University
Medical Center rural component of the Epidemiologic Catchment Area study.18 According to the 1990 census, 76% of the population
lived in rural areas, and 50% of the area's youth population (18 years and
younger) were African American. Most other youth were white, with a few American
Indian and Hispanic inhabitants. Median family income was $27 794, compared
with $35 225 for the United States and $28 280 for North Carolina.
Median family income of white families in the area was $33 788; that
of African American families was $19 914.
Basic data on the youth population living in the area were obtained
from the 4 county-wide public school districts' Schools Information Management
Systems. Because about 99% of youth in this area were on the public school
rolls, the Schools Information Management Systems provided the best information
on age and home address. The 17 117 youth aged 9 to 17 years in the Schools
Information Management Systems were sorted by households; the probability
of selection was proportional to the total number of age-eligible children
in the household. Within the selected age range, 1 youth was selected on an
equiprobability basis to generate a total screening sample of 4500 youth.
Each youth was then allocated to 1 of 15 cohorts, corresponding to the 15
months of projected data collection.
Parents completed a brief telephone questionnaire, on the basis of which
a subsample of children was selected for intensive assessment. The goal was
to increase the number of probable mental health service users in the sample,
while retaining the capacity to generate population parameter estimates.19-20 We selected a parent-reported questionnaire
because pilot testing showed that screening both parent and child increased
refusals and incomplete data, without much improvement in case identification.
The screening measure consisted of the "externalizing" items from the Child
Behavior Checklist21-22 plus 7
items covering use of tobacco, cannabis, inhalants, etc, comprising 57 questions.
The items tap the constructs included in the DSM-IV's
"disruptive behavior disorders": conduct, oppositional, and attentional problems
and substance use. Previous studies22-24
showed that parental reports of externalizing problems best predicted most
types of psychopathologic conditions, including anxiety and depression and
service use. Other reasons for using this screen were that parents are poor
reporters on children's anxiety and depression,25-28
and we knew from the GSMS that the screen was successful in identifying children
with depressive or anxiety disorders.14 Previous
studies21, 23 have attested to
the Child Behavior Checklist's reliability and ability to identify child mental
health services users.
The telephone screens were administered by an experienced team of interviewers
maintained by the Research Triangle Institute, Research Triangle Park, NC,
using a computerized administration and response entry package. If telephone
contact could not be made after 10 attempts, the family was referred for tracing
and face-to-face screening by one of the field interviewers. Of the 4500 families
selected, 3941 (87.6%) proved eligible for the study, and 3613 (91.7%) of
these completed screens. Among the others, 559 (12.4% of 4500) had moved from
the study area or had incorrect location or age data, 120 (2.7%) could not
be located, and 208 (4.6%) refused the screen.
INTERVIEW PROCEDURES
The objective was to optimize the 2-stage design to provide the narrowest
variance estimates and maximum statistical power from a sample of fixed size,
determined by the available budget. In designing the sampling frame, we relied
on theoretical work of Erkanli and colleagues,29-32
which provides equations for determining the optimal sampling fractions from
2 or more strata generated by a screening design. Data from the GSMS and the
first 4 months of the Caring for Children in the Community Study were used
to generate measures of sensitivity and specificity.
In the first 4 months of the Caring for Children in the Community Study,
the decision rule for second-stage selection was the same as for the GSMS;
ie, 100% of those scoring 20 or higher on the screen and a 10% random sample
of the rest were invited to participate in the interviews. Analyses of these
data showed that the screen scores were almost identically distributed in
the Caring for Children in the Community Study and the GSMS, and that the
screen performed similarly in relation to the diagnostic interviews in the
2 studies.
In the second phase, separate sampling fractions were used for each
screen decile. Sampling fractions were computed based on the sensitivity and
specificity of the screen for the presence of a psychiatric diagnosis in each
screen decile.29-32
The final sampling fractions ranged from 19% of the lowest-scoring decile
to 40% of the highest-scoring decile. After each screen was completed and
scored by the computer program, it generated a random number for scores within
each decile to determine whether that family would be asked to participate
in the interview phase of the study. Of the 3613 families successfully screened,
1302 were selected to participate in the interview phase of the study. Of
these, 920 (70.7%) completed interviews.
All field interviewers had at least bachelor's level degrees and received
1 month of initial training. After training, quality control was maintained
through postinterview reviews of each schedule, weekly staff meetings to review
randomly selected audiotapes of field interviews, and regular refresher sessions
with clinical staff.
Participating parents and children met together with 2 interviewers,
who reviewed the study and obtained informed consent from parents and assent
from children. To ensure privacy, the parent and child were then interviewed
separately in different rooms, usually in the family's home. Interviews were
tape-recorded. Each parent and child was paid $15 after the interview.
MEASURES
The Child and Adolescent Psychiatric Assessment (CAPA)33-34
is a psychiatric interview for children aged 9 years and older that elicits
information about symptoms contributing to a range of DSM-IV,35 DSM-III-R,36 and ICD-1037-38
diagnoses. Like respondent-based interviews such as the Composite International
Diagnostic Interview,39 the CAPA uses a highly
structured protocol with required questions and probes. However, as in interviewer-based
interviews such as the Schedules for Clinical Assessment in Neuropsychiatry,40 the onus throughout is on the interviewer to ensure
that subjects (1) understand the question being asked, (2) provide clear information
on behavior or feelings relevant to the symptom, and (3) have the symptom
at a prespecified level of clinical severity as defined in a detailed glossary.
A 3-month "primary period" is used rather than a longer period, because shorter
recall periods are associated with more accurate recall.41
Diagnoses and symptom scales are generated by computer algorithms. Separate
algorithms are available for child and parent reports and "combined reports,"
in which a symptom is regarded as being present if either the parent or child
reports it. In this article, we report DSM-IV diagnoses
based on combined reports. The functional impairment or incapacities section
of the CAPA, which follows the section on symptoms, relates the symptoms to
the child's ability to function at a developmentally appropriate level in
relationships with family, peers, and teachers and in activities at school,
home, and in the community.
A test-retest reliability study of the CAPA34, 42
provided  values ranging from 1.00 for substance abuse and dependence
to 0.55 for conduct disorder (CD). The intraclass correlation for incapacities
was 0.76. The construct validity of CAPA diagnoses is supported by a range
of findings.43
The Child and Adolescent Services Assessment44
is an interview about use for mental health care of specialty mental health
providers, pediatricians and other medical care providers, school counselors
and psychologists, juvenile justice staff, social services staff, self-help
groups, spiritual advisors, family, and friends. The assessment also asks
about barriers to using services for mental health care (such as distance,
lack of transportation, and stigma). The Child and Adolescent Services Assessment
has high test-retest reliability (>0.80) for the more intensive services,
such as inpatient hospitalization, and good reliability (>0.60) for
less intensive services, such as outpatient and school services.44
The parent or caregiver completed the Child and Adolescent Impact Assessment45-46 for each child, with any psychiatric
symptoms identified by the interviewer. This measure asks whether the parent
has experienced an economic burden from having a child with mental health
problems, arising from extra costs or reduced ability to work, or any effect
on family or other social relationships or perceived stigma, or personal psychological
distress caused by the child's symptoms. The intraclass correlation from a
1-week test-retest reliability study was 0.67.45
DATA ANALYSIS
Completed and coded interviews were checked by a supervisor for accuracy
and electronically verified for internal consistency and completeness. Programs
written in SAS (SAS Institute Inc, Cary, NC) created diagnoses and symptom
scales. Prevalence estimates, 95% confidence intervals (CIs), and group comparisons
were computed using the empirical option of the SAS program GENMOD, which
provided appropriately weighted parameter estimates, SEs, and 2-tailed P values ( = .05), corrected for the study's sampling
design and the response rates in the different screening strata. All reported
means, prevalences, and odds ratios (ORs) are, therefore, unbiased community
estimates of those parameters.
The principal analytic technique was logistic regression, because most
of the outcomes of interest were categorical (eg, diagnosis or use of services
in a particular sector). For the analysis of mean scores from the screening
questionnaire, Poisson regression was used, because the questionnaire data
were highly skewed. The first set of analyses compared study participants
with nonparticipants. The second set involved bivariate logistic regressions
of the probability of diagnoses on sex and ethnicity, and the third set compared
risk factors or correlates of service by sex and ethnicity. Finally, we developed
a set of multivariable logistic models of mental health service use in 4 sectors:
specialty mental health, general medical, schools, and child welfare. Too
little mental health service provision in juvenile justice settings was reported
to allow such an analysis for that sector. Age, sex, and ethnicity were forced
into the models, and all 2-way and 3-way interactions were tested, but only
the statistically significant ORs are reported.
RESULTS
DEMOGRAPHIC CHARACTERISTICS OF SCREENED AND INTERVIEWED SAMPLES
The screened sample (N = 3613) and sample selected for interview (n
= 1302) did not differ on any available demographic characteristic (Table 1). African American youth had slightly
higher mean ± SD scores on the screen than white youth (15.2 ±
13.2 vs 14.1 ± 12.7, F = 6.5, P = .01), and
were slightly more likely to have scores of 20 or higher (28.5% vs 25.5%,  2 = 4.0, P = .047). At the interview stage,
the refusers and participants were not significantly different in age distribution
or in the proportions that were male, defined themselves as living in a rural
area, were 2 or more grades behind for age, or reported using mental health
services on the screen. Interviewed subjects had higher mean scores on the
screen than refusers (21.0 vs 16.3); perhaps this group was more likely to
see the study as potentially helpful. African Americans were more likely than
white families to participate when invited (75.0% vs 64.5%, P<.001).
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Table 1. Characteristics of Screened Subjects, Participants, and Refusers*
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THREE-MONTH PREVALENCE OF PSYCHIATRIC DIAGNOSES
Table 2 gives the 3-month
prevalence estimates and 95% CIs for DSM-IV diagnoses
for the whole sample and separately by sex and ethnicity. A total of 21.1%
of subjects had 1 or more DSM-IV diagnoses. Disruptive
behavior disorders (attention-deficit/hyperactivity disorder, CD, or oppositional
defiant disorder) were more common than affective or anxiety disorders. Among
the specific diagnoses, the most common were CD (particularly childhood-onset
CD), anxiety disorders (of which the most common was separation anxiety),
and substance abuse or dependence. Among the depressive disorders, minor depression
(defined as an experimental category by DSM-IV) was
the most common. One third of patients with oppositional defiant disorder
were comorbid with CD; excluding this group, the prevalence of pure oppositional
defiant disorder was low. Among individuals with attention-deficit/hyperactivity
disorder with onset before age 7, more were of the combined subtype than of
the predominantly hyperactive and impulsive subtype or the purely inattentive
subtype. Six percent of youth (29.8% of those with a disorder) had more than
1 diagnosis. Of these, 31.0% had an affective or anxiety disorder and a disruptive
behavior disorder. There were too few individuals with obsessive-compulsive
disorder, pica, hypomania or mania, anorexia, bulimia, schizophrenia, posttraumatic
stress disorder, or Tourette disorder for CIs to be reliable.
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Table 2. Three-Month Prevalence of DSM-IV
Diagnoses*
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EFFECTS OF ETHNICITY, SEX, AND AGE ON PREVALENCE OF DSM-IV DIAGNOSES
There was little ethnic difference in the prevalence of psychiatric
disorder in general (Table 2).
A significantly higher prevalence of depressive disorder (OR, 3.4; 95% CI,
1.6-7.4), oppositional defiant disorder (OR, 2.5; 95% CI, 1.1-5.5), and any
affective or anxiety disorder (OR, 1.8; 95% CI, 1.0-3.0) was found in white
youth.
Boys had more attention-deficit/hyperactivity disorder than girls (OR,
5.0; 95% CI, 2.0-11.3) and more disruptive behavior disorders, mainly childhood-onset
CD (OR, 4.2; 95% CI, 1.8-9.7). However, rates of adolescent-onset CD were
almost identical in boys and girls. Functional enuresis and encopresis were
also more common in boys than in girls.
The effect of age on disorders varied among diagnoses, but the prevalence
of any psychiatric disorder showed a U-shaped distribution, falling from 26.4%
at age 9 to 16.8% at age 12, then rising to 31.2% by age 17. Through age 13,
the prevalence of any psychiatric disorder was significantly higher in boys
than in girls (OR, 2.1; 95% CI, 1.3-3.5), largely as a result of their higher
levels of disruptive behavior disorders. From age 14 onward, there was no
overall difference between the sexes (OR, 1.0; 95% CI, 0.5-1.7), largely because
the prevalence of affective or anxiety disorders increased with age in girls.
Substance abuse and dependence increased in both sexes. Age patterns were
similar for both ethnic groups.
RELATIONSHIP BETWEEN SCREEN SCORE AND DIAGNOSIS BY ETHNICITY
Youth with any psychiatric diagnoses had mean ± SD screen scores
almost twice as high as those without (23.4 ± 14.9 vs 13.1 ±
11.5, z = 8.61, P<.001).
Youth with a disruptive behavior disorder only had a somewhat but not significantly
higher score than those with affective or anxiety disorders only (24.6 ±
15.7 vs 19.8 ± 12.6, z = 1.63, P = .10). Although comorbid youth had the highest mean ± SD
screen score (30.3 ± 18.2), it was not significantly different from
that of youth with only disruptive behavior disorders (z = 0.91, P = .37) or those with only anxiety
or depression (z = 1.79, P
= .07). There were no ethnic differences in screen scores for youth with and
without anxiety or depression, disruptive behavior disorder, or both (Figure 1). There was thus no evidence that
the diagnostic rates of white or African American youth were differentially
affected by response to the screen.
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Mean screen scores of white and African American youth by DSM-IV diagnostic category.
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SERVICE USE BY SECTOR
Table 3 gives the 3-month
prevalence of service use by sector. In the 3 months before the interview,
13.3% of the sample (including 36.0% of those with a DSM-IV study diagnosis) had used 1 or more professional service sectors for
mental health care. The school system was the single most widespread provider
of mental health services to children and adolescents in this area. The only
service sector in which use of mental health care showed a strong effect of
ethnicity or sex was the specialty mental health sector. White youth were
twice as likely as African American youth to use such services (OR, 2.0; 95%
CI, 1.1-3.5). The ethnic difference in specialty mental health service use
was greater in boys (9.0% vs 4.4%; OR, 2.2; 95% CI, 1.1-4.5) than in girls
(3.2% vs 2.2%; OR, 1.5; 95% CI, 0.5-4.4).
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Table 3. Use of Services for Mental Health Care in the Past 3 Months*
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FACILITATORS AND BARRIERS TO MENTAL HEALTH CARE
Table 4 gives the distribution
of key variables selected for their potential to affect service use for the
whole sample and by ethnicity and sex. Almost half of African American children
came from families living below the federal poverty line, compared with 16.0%
of white children. Poverty was reflected in the ethnic difference in private
health insurance coverage: most white youth, but only half of African American
youth, had some private health insurance. On the other hand, one third of
African American youth, compared with 1 in 5 white youth, had some form of
public health insurance (mainly Medicaid). As a result, the difference in
proportions not covered by any health insurance was small.
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Table 4. Risk Factors and Correlates of Mental Health Service Use*
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Table 5 gives the final
results of a series of logistic regression analyses of service use by sector,
using the combined set of correlates and their 2-way and 3-way interactions.
Only the variables that remained significant in at least one of the models
are included there.
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Table 5. Risk Factors and Correlates of Service Sector Use for Children's
Mental Health Problems*
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The strongest correlate of access to specialty mental health care was
the impact of the child's problems on the family, especially on the family's
income, as reported by the parent. Having a DSM-IV
disorder did not increase the chance of specialty mental health care once
impairment and parental impact were entered into the model. In African American
and white children, the presence of parental impact made a dramatic difference
in the probability of receiving care. Medicaid coverage increased specialty
mental health service use, but private insurance did not. (The increased likelihood
of access with Medicaid compared with no insurance approached significance: z = 1.8, P = .07.)
The general medical care sector was more often used by younger children,
children with a DSM-IV disorder, and those whose
parents reported experiencing psychological problems because of the child's
symptoms. Ethnicity, functional impairment, and availability of health insurance
did not affect the likelihood of using primary medical care as a resource.
In the case of school mental health services, psychiatric diagnosis
increased the likelihood of service use. School services were used by children
with functional impairment, barriers to care, and those whose parents were
experiencing a psychological burden caused by the child's problems. African
American and white youth were equally likely to receive treatment provided
by school mental health services.
The mental health services provided through child welfare went mainly
to younger children with psychiatric diagnoses, from both ethnic groups.
COMMENT
The prevalence of DSM-IV disorders was similar
to estimates from other studies1-2,47-56
using a range of DSM and ICD
taxonomies and assessment tools, including the GSMS.14
The study's 2-stage design, with samples for interview drawn with different
probability from different strata of screen scores, produced rates of disorders
comparable to those found using both single-stage51-53
and multistage14, 54-56
designs.
Few studies, however, provide information that permits a comparison
of the prevalence of psychiatric disorders for white and African American
youth. A recent review57 of 9 studies of serious
emotional disturbance (psychiatric diagnosis accompanied by significant functional
impairment) showed only small, statistically nonsignificant differences by
ethnicity, and other studies1-3,58-60
found only minor disparities when other risk factors, especially poverty and
inner-city residence, are controlled for. This finding goes back to pioneering
work by Lapouse and Monk61 in which ethnicity
alone was associated with small differences on a scale score of behavior problems
reported by mothers. The present study is, to our knowledge, the first to
provide a full range of DSM-IV diagnoses in a large
population-based sample of rural African American youth for whom a direct
comparison with a white sample is possible.
Despite the widely held belief that CD is more prevalent in African
American youth,60 we found no such result in
our study. In a recent review, Robins62 pointed
out that the only community-based study to show higher rates of CD in African
American children is the 1975 study by Rutter et al63
of children aged 10 to 11 living in central London, which found that the higher
prevalence of psychiatric problems in West Indian immigrant children was accounted
for by the higher level of stress under which they were living.64
In a recent meta-analysis of predictors of serious and violent adolescent
offending, Lipsey and Derzon65 found that ethnicity
fell to a "third-rank" predictor for children aged 6 to 11 and a "fifth-rank"
predictor for those aged 12 to 14, carrying much less weight than sex, aggression,
family and peer environment, and history. In the adult population, the National
Comorbidity Survey found the lifetime prevalence of any psychiatric disorder
in African Americans to be half that of whites, while the 12-month prevalence
was 30% lower.66-67 The difference
was most marked in the case of affective and substance abuse disorders. The
Epidemiologic Catchment Area multisite investigation of adult populations68 found a modestly higher lifetime and active prevalence
of psychiatric disorder in African American than white participants, but the
difference was restricted to the older (>45 years) segment of the sample and
to cognitive impairment and somatization disorders. There were no ethnic differences
in self-reports of childhood disruptive behavior symptoms.69
Epidemiologic studies15, 70-73
of rural youth in North America are rare but consistent in finding rates of
psychiatric disorder that mirror those of suburban and urban children, once
income is controlled for. (The relationship between inner-city residence and
criminal behavior appears to be a separate issue.65, 74)
In the adult population, the Epidemiologic Catchment Area study18
and National Comorbidity Study66 also found
no dramatic differences in rates of disorder between urban and rural participants.
On the other hand, it is possible that rural residence was a barrier to care,
as has been reported for the United States,75
although not for Canada.70
Like other recent studies3, 76-77
in the United States, this study identifies a large gap between mental health
service use and need for services, whether identified by psychiatric disorder,
functional impairment, or both. Only 1 youth in 3 with a current psychiatric
disorder had received any mental health care from any professional during
the past 3 months, and only 14.6% of those with a disorder had seen a mental
health care specialist. It is also disconcerting to document once again3-5,78 that
the gap between need and specialty mental health services is exacerbated in
ethnic minorities. However, the present study demonstrates that, in analyses
including insurance status, ethnicity, and income, Medicaid coverage gave
youth of both ethnic groups greater access to specialty mental health care.
Barriers to accessing service use were commonly reported by both ethnic
groups. Unfortunately, the number of barriers reported increased with the
need for care. This finding of earlier research79-80
is replicated in this study; exposure to the mental health care system tends
to increase, rather than decrease, patients' awareness of the problems involved
in gaining access to needed care. The strongest facilitator of service use
for children with treatment needs was also common to both ethnic groups, namely,
the impact of the child's psychiatric problems and functional impairment on
parents' lives, whether through economic or psychological strain or by disruption
of relationships with family and friends. Children, unlike adults, can rarely
obtain care by their own efforts; they rely on parents to make appointments,
transport them, and pay for treatment.81 The
role of parental concerns in children's access to care deserves more attention.
The prevalence of psychiatric disorders in this community and the rates
and correlates of service use bore striking similarity to those found in the
GSMS, a study of a rural community some 480 km away. Also striking was the
finding in both studies that minority youth had equal access to mental health
services provided by the school system (the biggest provider of mental health
services in both areas), although they were only half as likely as white youth
to use specialty mental health services. This suggests that system disparities
in mental health care delivery can be overcome.
AUTHOR INFORMATION
Submitted for publication March 12, 2001; final revision received November
5, 2001; accepted December 11, 2001.
This study was supported in part by cooperative agreement MH54279 and
center grant MH57761 from the National Institutes of Health, Bethesda, Md.
Corresponding author and reprints: Adrian Angold, MRCPsych, Center
for Developmental Epidemiology, Department of Psychiatry and Behavioral Sciences,
Duke University Medical Center, Campus Box 3454, Durham, NC 27710 (e-mail: adrian.angold{at}duke.edu).
From the Center for Developmental Epidemiology, Department of Psychiatry
and Behavioral Sciences, Duke University Medical Center, Durham, NC.
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