JBHSR Recent Issues

The Table of Contents and abstracts for recent issues of the JBHS&R are listed below.

Volume 34, 2007

Number 1 / January 2007

Performance-based Funding of Supported Employment for Persons with Severe Mental Illness: Vocational Rehabilitation and Employment Staff Perspectives...1-16
John H. McGrew, Jason K. Johannesen, Melina E. Griss, Dennis L. Born and Colleen Hart Katuin
Abstract: Vocational rehabilitation (VR) supervisors and counselors (n = 35) as well as supported employment (SE) program managers and employment specialists (n = 26) were enrolled in a 12-month evaluation comparing two models of funding services for persons with severe mental illness: fee-for-service and results-based funding (RBF). Quantitative measures of job satisfaction and preference for funding method were obtained prospectively on a quarterly basis, and SE staff activity logs were collected monthly. Qualitative data were collected using a series of focus groups conducted at the conclusion of the study. Despite recording a substantial increase in semi-annualized VR billing charges when using RBF (45–49%), SE staff expressed less satisfaction with RBF over time. Staff raised concerns about increased financial risks and pressures to achieve job placements under RBF. Vocational rehabilitation staff were consistently more satisfied with RBF, expressing particular satisfaction with perceived effectiveness and the payment authorization process. Both VR and SE staff expressed some reservations about RBF, primarily concerning possible pressures for adverse client selection.

Long-Term Housing and Work Outcomes Among Treated Cocaine-Dependent Homeless Persons...17-33
Stefan G. Kertesz, Ashley N. Mullins, Joseph E. Schumacher, Dennis Wallace and Katharine Kirk, et al.
Abstract: Communities across the United States have initiated plans to end chronic homelessness. In many of these communities, addiction treatment programs remain the default point of entry to housing and services. This study examined the percentage of cocaine-using homeless persons (all with psychiatric distress) attaining stable housing and employment 12 months after entering a randomized trial of intensive behavioral day treatment, plus one of the following for 6 months: no housing; housing contingent on drug abstinence; housing not contingent on abstinence. Of 138 participants, the percentages with stable housing and employment at 12 months were 34.1 and 33.3%, respectively. Analyses suggested superior outcomes in trial arms that offered housing as part of the behavioral treatment. The majority of participants, however, did not achieve housing or employment, in part because of the limited capacity of the local housing programs to accommodate persons who had not achieved perfect abstinence. The findings demonstrate a helpful role for addiction treatment and suggest the need for services to support housing of persons who reduce but do not eliminate all substance use.

Predicting Future Hospital Utilization for Mental Health Conditions...34-42
Andrew Kolbasovsky, Leonard Reich and Robert Futterman
Abstract: To develop a model using administrative variables to predict number of days in the hospital for a mental health condition in the year after discharge from a mental health hospitalization. Background, index hospitalization and preindex inpatient, emergency room, and outpatient utilization information were collected for 766 adult members discharged from a mental health hospitalization during a 1-year period. A regression model was developed to predict hospitalized days for a mental health condition in the year after discharge. A regression model was created containing five statistically significant predictors: Medicare insurance coverage, preindex mental health inpatient days, index length of stay, depression diagnosis, and number of mental health outpatient visits with a professional provider. It is possible to predict future mental health inpatient utilization at the time of discharge from a mental health hospitalization using administrative data, thus allowing disease managers to better identify members in greatest need of additional services and interventions.

Effects of a Tobacco Ban on Long-term Psychiatric Patients...43-55
Grant T. Harris, Daniel Parle and Joseph Gagné
Abstract: A total ban on all tobacco products was implemented in a diverse psychiatric institution. A post hoc evaluation examined the effect of the ban on long-term patients by comparing their characteristics the year before the ban to the year after. Several variables measuring physical health, psychiatric symptomatology, feelings of well-being, and interpersonal conflict were coded with very high reliability from health records. For the majority of patients who were in the maximum security forensic division, the tobacco ban was associated with almost no detectable ill effects with some clear benefits. Among the remainder of the long-term patients, the ban might have been associated with a temporary increase in physical aggression towards staff members. It was concluded that successful implementation, and the avoidance of ill effects, depended entirely on the success staff members had in actually preventing patient access to tobacco.

Mental Health Services for Children in Large, Employer-Based Health Plans, 1999...56-72
Mary Jo Larson, Kay Miller, Kathleen J. Fleming and Judith L. Teich
Abstract: This study examines 1999 data from Medstat's MarketScan® database of privately insured employees of US firms and their dependents. Of enrolled children and adolescents ages 2–18, 6.6% had claims for mental health services. Average outpatient expenditures per user were $651. Of children/adolescents with claims for mental health services (MH claimants), 3.4% had inpatient MH services, with an average length of stay of 8.9 days and average MH-related inpatient expenditure per user of $7,048. One half of MH claimants who had pharmacy benefit data had claims for psychotropic medications, with average expenditures per user of $328. Whereas children/adolescent mental health users comprised 8.3% of all service users, expenditures for their care were 20.5% of all service expenditures for children/adolescents in private health plans. Results also highlight the importance of including data on psychotropic medication in analysis of children's MH services utilization, as well as the need to consider the use of psychotropic medications among children/adolescents who do not utilize other MH services.

Goal Achievement and the Accountability of Consumer-Run Organizations...73-82
Louis D. Brown, Matthew D. Shepherd, Scott A. Wituk and Greg Meissen

Abstract: This study explores how consumer-run organizations (CROs) can maintain independence while meeting the accountability needs of funding agencies. The importance of both funding agency needs for accountability and CRO needs for independence are discussed. A goal-tracking process is proposed as a potential strategy for balancing the potentially conflicting needs of accountability and independence. To demonstrate the utility of the goal tracking approach, this study analyzes goal tracking documentation in 3 years of quarterly reports from 21 CROs (also known as consumer drop-in centers and self-help agencies). Results detail the different goals of CROs. A 68% goal achievement rate suggests general organizational competence. Furthermore, CRO operations appear to be relatively cost-efficient, with an average of $11.51 spent per person per day. The analysis of quarterly reports leads to a discussion of several insights that may be useful to CROs, funding agencies, researchers, and mental health professionals.

National Estimates of Mental Health Insurance Benefits...83-95
Myles Maxfield, Lori Achman, Jeffrey A. Buck and Judith L. Teich
Abstract: This article presents estimates of the proportion of the U.S. population that had mental health benefits in 1999, of the extent of their coverage, and of the proportion that were enrolled in health plans subject to the Mental Health Parity Act of 1996 (MHPA). Findings indicate that over three-quarters (76%) of the U.S. population had mental health benefits as part of their health insurance. Approximately 18% of the population had no mental health benefits, and for the remaining 6%, mental health benefits could not be determined. Of the 18% with no mental health benefits, most (84%) had no health insurance whatsoever, while the remainder (16%) had health insurance that did not cover mental health benefits. Estimates of the generosity of coverage indicate that 44% of the population had benefits that included prescription drugs, and that provided at least 30 inpatient days and 20 outpatient visits for psychiatric care. For 12% of the population, benefit generosity could not be determined. Finally, study results suggest that the MHPA affected only 42% of the U.S. population.

Reducing Mechanical Restraints in Acute Psychiatric Care Settings Using Rapid Response Teams...96-105
David L. Prescott, Lynn M. Madden, Marilyn Dennis, Paul Tisher and Carrie Wingate
Abstract: This article describes the use of rapid response teams to reduce the use of mechanical restraints (i.e., restricting a person’s movement through the use of a mechanical device such as a backboard, net, or papoose) in an acute psychiatric care setting. Rapid response teams have proven highly effective for emergent medical patients, but have not typically been used in behavioral health care settings. Utilizing a rapid cycle process improvement approach, a response team was convened following each episode of mechanical restraint in an inpatient psychiatric treatment facility. Initial results, during a 6-week rapid cycle change process, showed that mechanical restraints were reduced by 36.4% when compared with a 6-week baseline and when compared with a 1-year baseline. Changes in hospital census during the implementation process did not appear to account for the reduction in restraints. Rapid response teams and rapid cycle process improvement are discussed as useful change vehicles for behavioral health care organizations.

BOOK REVIEW...106-107
The Impact of Welfare Reform: Balancing Safety Nets and Behavior.Modification
Christopher R. Larrison and Michael Sullivan (editors)
292 Pages. ISBN: 0-7890-3160-4
Heather M. Butts

Number 2 / April 2007

The Concept of Recovery as an Organizing Principle for Integrating Mental Health and Addiction Services...109-120
Larry Davidson and William White
Abstract: Despite a range of long-standing historical, political, ideological, professional, structural, and practical barriers, there has been, and continues to be, a clear consensus that integration between mental health and addiction services is sorely needed and long overdue. This paper focuses on one dimension of the challenge of integration from among the several – the conceptual – and proposes the construct of recovery as an organizing principle for bridging the divide between the two domains. After reviewing briefly the parallel history of the two traditions and their shared need for transformation to a recovery orientation, the authors offer an integrated model of recovery for persons with co-occurring disorders. They then derive from this model the underlying values, guiding principles, key strategies, and essential ingredients of recovery-oriented systems of care that comprise a common approach across both addictions and mental illness, offering a strengths-based solution to achieving integration where pathology-focused approaches have failed.

Service Delivery in Substance Abuse Treatment: Reexamining “Comprehensive” Care...121-136
Lori J. Ducharme, Heather L. Mello, Paul M. Roman, Hannah K. Knudsen and J. Aaron Johnson
Abstract: Substance abuse treatment clients present with an array of service needs in various life domains. Ideal models of addiction treatment incorporate provision or linkages to services to meet clients’ multiple needs; in turn, these wraparound and supportive services are associated with improvements in client retention and treatment outcomes. Using data from large samples of specialty addiction treatment providers in the public and private sectors, this article examines the extent and organizational correlates of the comprehensiveness of service delivery. Multivariate models indicate that private sector treatment facilities offer more “core” medical and treatment services, whereas public sector programs offer more wraparound and supportive services. However, both sectors fall short of the ideal model of service comprehensiveness in terms of absolute number of services offered. These findings raise concerns regarding the quality and availability of needed services for treatment of addiction.

Is Readmission a Valid Indicator of the Quality of Inpatient Psychiatric Care?...137-150
Janet Durbin, Elizabeth Lin, Crystal Layne and Moira Teed
Abstract: Early return to hospital is a frequently measured outcome in mental health system performance monitoring yet its validity for evaluating quality of inpatient care is unclear. This study reviewed research conducted in the last decade on predictors of early readmission (within 30 to 90 days of discharge) to assess the association between this indicator and quality of inpatient psychiatric care. Only 13 studies met inclusion criteria. Results indicated that risk is greatest in the 30-day period immediately after discharge. There was modest support that attending to stability of clinical condition and preparing patients for discharge can protect against early readmission. A history of repeated admission increases risk, suggesting that special efforts are required to break the revolving door cycle. The authors identified a need for more standardization in measurement of client status at discharge and related care processes, more intervention studies on discharge practices, and studies of the effect of community care on early readmission.

Group and Organizational Involvement Among Persons with Psychiatric Disabilities in Supported Housing...151-167
Yin-Ling Irene Wong, Sara B. Nath and Phyllis L. Solomon
Abstract: This study examined the patterns and correlates of group and organizational involvement among persons with psychiatric disabilities using a cross-sectional, probability sample of 252 residents in supported independent housing (SIH). Groups and organizations were classified according to whether or not they have a behavioral health focus. Demographic, clinical, and service use characteristics were examined as potential predictors of membership using Poisson regression models. Findings indicated that 60% of the sample was involved in some kind of behavioral or nonbehavioral health organization. Similar to the findings from the general population, higher rates of membership were found among older persons, Blacks, those with more years of education, and those with higher incomes. Other correlates specific to the SIH sample included prior homelessness, perceived discrimination, substance abuse history, psychiatric symptoms, psychiatric diagnosis, and contact with service providers. Implications of study findings for developing intervention strategies to enhance organizational membership and for future research are discussed.

Behavioral Health Problems as Barriers to Work: Results from a 6-year Panel Study of Welfare Recipients...168-185
Denise Zabkiewicz and Laura A. Schmidt
Abstract: Over the course of welfare reform, behavioral health problems have emerged as significant issues. Welfare time limits have added urgency to recipients’ efforts to obtain economic self-sufficiency and have raised new concerns about mental health and substance abuse problems as barriers to work. However, there is limited research on how behavioral health problems operate to impede the employability of welfare recipients. This analysis draws on data from a 6-year panel study of welfare recipients (n = 341) to examine how a broad spectrum of mental health and substance abuse problems impact efforts to obtain work while on aid and subsequent transitions from welfare to work. Recipients who reported symptoms of depression at baseline were less likely to actively search for work while on aid compared to others. However, they were no less likely to leave welfare for work within a 2-year time frame. In contrast, other problems – including hostility, interpersonal sensitivity, psychoticism, and heavy drug use – had significant effects on work exits from welfare but little association with job search activities. Overall, these results suggest that behavioral health problems do not operate in the same manner to inhibit transitions from welfare to work. Welfare-to-work programs should direct interventions towards the unique constellations of problems that recipients face.

Stigmatization in Different Mental Health Services: A Comparison of Psychiatric and General Hospitals...186-197
Mieke Verhaeghe, Piet Bracke and Kevin Bruynooghe
Abstract: The earliest studies about stigmatization of persons receiving professional mental health care date from the time when psychiatric hospitals constituted the predominant facilities. The landscape of care has changed enormously since. Current research reveals that stigmatization still exists and has detrimental outcomes, not only for clients of psychiatric hospitals, but also for clients of so-called alternative settings. Studies that explicitly compare stigma experiences between different organizations are very scarce, however. This article compares clients from psychiatric and general hospitals according to three dimensions of stigmatization, using data from structured questionnaires (n = 555). The results reveal that when background characteristics are taken into account clients of psychiatric wards of general hospitals report less stigma expectations and social rejection experiences in comparison with their counterparts in psychiatric hospitals. Concerning self-rejection, no differences are found. These results suggest that more attention should be paid to specific characteristics of mental health services themselves in discussions about stigmatization and destigmatization of mental health care.

Pretrial Court Diversion of People with Mental Illness...198-205
Kathleen Hartford, Robert Carey and James Mendonca
Abstract: Court diversion is a method of administering justice compassionately for persons with mental illness (PMI). Evidence-based practices of this intervention were identified by reviewing the existing literature. Findings suggest that: (a) formal case finding procedures are important for the early identification of mentally ill offenders in need of services, (b) stable housing enhances the possibility that the divertee will remain in regular contact with her or his treatment provider, and (c) active case management improves compliance and reduces the likelihood of recidivism. In summary, research has not yet yielded generalizable knowledge about diversion and thus, it is suggested that evaluations should involve well-defined indicators, benchmarks, and outcomes.

Evaluation of a Summer Research Institute in Behavioral Health for Undergraduate Students...206-218
Amber Gum, Kalah Mueller, Daryl Flink, Shaila Siraj and Catherine Batsche, et al.
Abstract: Because of the need for additional researchers in the interdisciplinary field of behavioral health services research, the Florida Mental Health Institute at the University of South Florida developed and pilot tested a summer research institute for undergraduate students. Participants completed a 6-week program in which they developed a research project with a mentor and participated in a research seminar. The long-term objectives of the program were to attract promising students to the field and encourage them to pursue careers in behavioral health services research; short-term goals of the program were to strengthen participants’ research skills and knowledge, provide an intensive and enjoyable learning experience, and positively impact participants’ intentions to pursue graduate education in behavioral health. These goals were evaluated using a pre–post design with 6-month follow-up. Findings suggested that short-term goals were met. Suggestions for future improvements and implementation at other research settings are discussed.

Child Welfare in the Legal Setting: A Critical and Interpretive Perspective. Thomas M. O’Brien...219-220
302 Pages. ISBN: 0-7890-2351-2
Heather M. Butts

Number 3 / July 2007

Case Management and Client Access to Health and Social Services in Outpatient Substance Abuse Treatment---221-236
Jeffrey A. Alexander, Harold Pollack, Tammie Nahra, Rebecca Wells and Christy Harris Lemak
Abstract: A primary goal of case management is to coordinate services across treatment settings and to integrate substance abuse services with other types of services offered in the community, including housing, mental health, medical, and social services. However, case management is a global construct that consists of several key dimensions, which include extent of case management coverage, the degree of management of the referral process, and the location of case management activity (on-site, off-site, or both). This study examines the relationship between specific dimensions of case management and the utilization of health and ancillary social services in outpatient substance abuse treatment. In general, results suggest that more active case management during the referral process and providing case management both on-site and off-site are most consistent with our predictions of greater use of health and ancillary social services by substance abuse clients. However, these effects are specific to general health care and mental health services. Case management appears to have little effect on use of social services or aftercare plans.

The Sustainability of Systems of Care for Children’s Mental Health: Lessons Learned...237-259
Beth A. Stroul and Brigitte A. Manteuffel
Abstract: The federal Comprehensive Community Mental Health Services for Children and Their Families Program was initiated in 1992 to provide grants to states, communities, territories, and Indian tribes to develop systems of care to serve children and adolescents with or at risk for emotional disorders and their families. As part of the national evaluation of this program, a study was undertaken to assess the ability of funded sites to sustain their systems of care beyond the federal grant period. The study involved a web survey and telephone interviews with local and state respondents to examine the extent to which key components of systems of care were maintained during the period in which federal funds were phasing out and during the postgrant period. Study results demonstrate positive and negative changes that occurred in the communities which are included in the sample, with respect to maintaining the availability of each service included in the broad service array, the implementation of system of care principles, the system of care infrastructure, and the achievement of system of care goals. In addition, results identify factors that contribute to or impede the ability to sustain systems of care, and the effectiveness of various strategies for sustainability. Study findings offer guidance not only to federally funded system of care communities but also to nonfunded communities engaged in system of care development to enhance their ability to sustain systems of care for this population over time. Findings will also assist federal, state, and local policymakers, technical assistance providers, family members, advocates, and other key stakeholders to more effectively support the development of viable, sustainable systems of care.

Consistent Adherence To Guidelines Improves Opioid Dependent Patients’ First Year Outcomes...260-271
Jodie A. Trafton, Keith Humphreys, Alex H. S. Harris and Elizabeth Oliva
Abstract: Clinical practice guidelines for opioid substitution treatment (OST) for opioid dependence recommend that patients receive at least 60 mg daily methadone and have access to a broad array of psychosocial services. However, there is still wide variation in clinical practice in OST clinics. In real-world settings, patients could receive lower methadone doses and less psychosocial care because they require less intensive care for recovery; alternatively, barriers to delivery of guideline concordant care could limit treatment received and impair recovery. The Multisite Opioid Substitution Treatment (MOST) study examines the impact of more consistent adherence to guideline recommendations in eight Veterans Affairs OST clinics. While patients at all clinics demonstrated improvements in substance use over the first year in treatment, patients at clinics that more consistently adhered to guidelines had greater reductions in heroin and cocaine use and greater improvement in mental health. These results suggest that efforts to increase guideline adherence in OST will improve patient outcomes.

Measuring Clinically Meaningful Change Following Mental Health Treatment...272-289
Susan V. Eisen, Gayatri Ranganathan, Pradipta Seal and Avron Spiro
Abstract: Assessment of clinically meaningful change is useful for treatment planning, monitoring progress, and evaluating treatment response. Outcome studies often assess statistically significant change, which may not be clinically meaningful. Study objectives are to: (1) evaluate responsiveness of the BASIS-24© using three methods for determining clinically meaningful change: reliable change index (RCI), effect size (ES), and standard error of measurement (SEM); and (2) determine which method provides an estimate of clinically meaningful change most concordant with other change measures. BASIS-24© assessments were obtained at two time points for 1,397 inpatients and 850 outpatients. The proportion showing clinically meaningful change using each method was compared to the proportion showing change in global mental health, retrospectively reported change, and clinician-assessed change. BASIS-24© demonstrated responsiveness at both aggregate and individual levels. Regarding clinically meaningful improvement and decline, SEM was most concordant with all three outcome measures; regarding no change, RCI was most concordant with all three measures.

Substance Abuse Treatment Participation and Employment Outcomes for Public Disability Beneficiaries with Substance Use Disorders...290-308
Debra L. Brucker
Abstract: Quantitative research methods are used to examine the interaction among public disability benefit receipt, substance abuse, participation in substance abuse treatment, and employment among US adults. Using cross-sectional data from the 2002 and 2003 Survey on Drug Abuse and Health, the results demonstrate that disability beneficiaries who have substance use disorders are more likely to access treatment than persons with substance use disorders who are not beneficiaries. Results could not confirm, however, that those beneficiaries who access treatment are more likely to return to employment than those who do not access treatment.

Does State Certification or Licensure Influence Outpatient Substance Abuse Treatment Program Practices?...309-328
Jamie F. Chriqui, Yvonne Terry-McElrath, Duane C. McBride, Shelby Smith Eidson and Curtis J. VanderWaal
Abstract: In the United States, state governments legally authorize outpatient substance abuse treatment programs. In some states, programs are certified or accredited (ideal standards). Other states license programs (minimal standards). Additionally, some states authorize programs through “deemed status”, which is afforded to programs attaining accreditation from a national accrediting body. Primary legal research and the National Survey of Substance Abuse Treatment Services’ (N-SSATS) data were used to examine the relationships between state authorization type (certification/accreditation vs licensure with and without deemed status) and outpatient treatment program practices. Programs in certification/accreditation (vs licensure) states had significantly higher odds of offering wrap-around and continuing care/after care services associated with better long-term treatment outcome. Programs in states that allowed for certification/accreditation with deemed status had significantly lower odds of infectious disease testing, but higher odds of providing group and family counseling. Results suggest that state authorization type may impact services offered by outpatient treatment programs.

Discontinuation of Antidepressant Medication Among Latinos in the USA...329-342
Dominic Hodgkin, Joanna Volpe-Vartanian and Margarita Alegría
Abstract: Despite recent growth in the variety of antidepressant medications available, many patients discontinue medication prematurely for reasons such as nonresponse, side effects, stigma, and miscommunication. Some analysts have suggested that Latinos may have higher antidepressant discontinuation rates than other US residents. This paper examines Latino antidepressant discontinuation, using data from a national probability survey of Latinos in the USA. In this sample, 8% of Latinos had taken an antidepressant in the preceding 12 months. Among those users, 33.3% had discontinued taking antidepressants at the time of interview, and 18.9% had done so without prior input from their physician. Even controlling for clinical and other variables, patients who reported good or excellent English proficiency were less likely to stop at all. Patients were also less likely to stop if they were older, married, had public or private insurance, or had made eight or more visits to a nonmedical therapist.

Mental Health Benefits in Employer-sponsored Health Plans, 1997–2003...343 - 348
Judith L. Teich and Jeffrey A. Buck
Abstract: Data drawn from the Mercer National Survey of Employer-sponsored Health Plans in 1997 and 2003 indicate that a large majority of employers continue to provide some level of coverage for mental health (MH) services in their primary plans. However, a majority of plans continue to impose different benefit limitations for MH than for other medical treatment. Among plans with limitations on MH coverage, there was a sharp increase in the use of limits on inpatient days and outpatient visits between 1997 and 2003. The proportion of employers providing coverage for some MH services decreased; e.g., among small employers, 88% provided coverage for inpatient MH care in 2003, compared with 94% in 1997. These results suggest that parity legislation has had a noticeable but limited effect, but that, at least in the short-term, it is unlikely that universal parity in employer-based plans will be achieved through a legislative strategy.

Gain Is Not Always Good...349
Leonard Bickman and E. Warren Lambert

MHSPY: Intentional Integrated System of Care Associated with Improved Youth Outcomes...350-351
Katherine E. Grimes and Brian O. Mullin

Number 4 / October 2007

Special Issue: Qualitative Methods in Children's Mental Health
Guest Editor, Sharon Hodges, PhD, MBA

Quality as the Cornerstone of Behavioral Health: Four Critical Issues...353-356
Linda Rosenberg
Abstract: The author emphasizes the need to focus on quality in mental health and addictions treatment. High-quality care means care that is personalized, prevention-oriented, and based on evidence about the benefits, costs, and the desires of each person. Whereas the challenges to improving quality are formidable, four critical issues can and must be addressed: focus on whole health, clinical excellence, workforce, and information technology. With strong leadership, commitment, and persistence, we can have a system that supports recovery and ensures a meaningful life in the community for our sickest and poorest citizens.

Challenge and Opportunity in Children’s Mental Health Research...357-360
Sharon Hodges
Without Abstract

The Use of Qualitative Methods in Systems of Care Research...361-368
Sharon Hodges, Mario Hernandez, Allison Pinto and Caitlin Uzzell
Abstract: In an effort to understand the impact of qualitative methods on the field of children’s mental health, a review of the proceedings of the University of South Florida’s Research and Training Center for Children’s Mental Health (RTC) conferences from 1988 through 2003 was conducted. One hundred presentations published in the proceedings were identified as meeting criteria for inclusion as qualitative research. Data regarding title, topic, researchers, funders, methodology, and results were collected and reviewed across studies to identify patterns and themes. Results revealed that the number of qualitative studies presented at the conference and included in the proceedings since the inception of the conference in 1988 has increased. Understanding stakeholder perspectives and system and service delivery descriptions were among the most common topics of study. Most studies did not specify research design independently of describing methods used and did not specify the method used to analyze data. Recommendations are provided to improve future qualitative research to advance knowledge in children’s mental health.

Studying Family Participation in System-of-care Evaluations: Using Qualitative Methods to Examine a National Mandate in Local Contexts...369-381
Pauline Jivanjee and Adjoa Robinson
Abstract: With the rapid pace of policy and practice changes in children’s mental health, there is a need for research to examine, describe, and disseminate information about the translation of policy directives into practice innovations at the local level. National policy mandates for children’s mental health have placed expectations on local communities to involve families as partners in the development, implementation, and evaluation of systems of care with little guidance about how to implement program requirements locally. Consequently, there is a gap in the knowledge base regarding how innovations are actually implemented in local community contexts. This article reports on a qualitative study to gain understanding of family participation in evaluations of systems of care from the perspectives of evaluators and family members working together. Findings provided rich examples of the experiences and perceptions of evaluators and family members working on evaluation teams, the challenges they encountered, and effective strategies to meet those challenges.

Youth and Youth Coordinators’ Perspectives on Youth Involvement in Systems of Care...382-394
Phyllis Gyamfi, Anika Keens-Douglas and Eva Medin
Abstract: To increase understanding of the current status of youth involvement in Substance Abuse and Mental Health Services Administration-funded system-of-care communities, focus groups with youth and youth coordinators were conducted as part of the national evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. Using focus group discussions as the primary qualitative data analysis method, these discussions addressed the ways in which youths are involved in their communities, the role of youth coordinators, the challenges that hinder youth participation, and strategies for overcoming these challenges. Discussions revealed that the most common form of youth involvement is through youth groups, and that apart from these groups, youth participation is largely absent. Key challenges to youth involvement include stigma and lack of support from system-of-care administrators and staff.

A Qualitative Study of Programs for Parents with Serious Mental Illness and Their Children: Building Practice-Based Evidence...395-413
Joanne Nicholson, Beth R. Hinden, Kathleen Biebel, Alexis D. Henry and Judith Katz-Leavy
Abstract: The rationale for the development of effective programs for parents with serious mental illness and their children is compelling. Using qualitative methods and a grounded theory approach with data obtained in site visits, seven existing programs for parents with mental illness and their children in the United States are described and compared across core components: target population, theory and assumptions, funding, community and agency contexts, essential services and intervention strategies, moderators, and outcomes. The diversity across programs is strongly complemented by shared characteristics, the identification of which provides the foundation for future testing and the development of an evidence base. Challenges in program implementation and sustainability are identified. Qualitative methods are useful, particularly when studying existing programs, in taking steps toward building the evidence base for effective programs for parents with serious mental illness and their children.

A Participatory Study of School Dropout and Behavioral Health of Latino Adolescents...414-430
Teresa M. Nesman
Abstract: The dropout of Latino adolescents from public schools has been linked to behavioral health issues such as delinquency and family conflict. Greater understanding is needed about the interplay of cultural, social, and developmental factors in this process. This article reports the findings of 14 group interviews conducted using a participatory approach with Latinos in a large school district in the southeastern USA. Findings support the need for comprehensive school-based interventions along the continuum from early intervention to intensive treatment for Latino adolescents who are at risk of dropping out. Participatory research is recommended for identifying strategies that integrate culturally and developmentally appropriate adaptations into existing behavioral health and dropout prevention services.

Issues Encountered in a Qualitative Secondary Analysis of Help-Seeking in the Prodrome to Psychosis...431-442
Brenda M. Gladstone, Tiziana Volpe and Katherine M. Boydell
Abstract: Primary data are rarely used explicitly as a source of data outside of the original research purpose for which they were collected. As a result, qualitative secondary analysis (QSA) has been described as an “invisible enterprise” for which there is a “notable silence” amongst the qualitative research community. In this paper, we report on the methodological implications of conducting a secondary analysis of qualitative data focusing on parents’ narratives of help-seeking activities in the prodrome to psychosis. We review the literature on QSA, highlighting the main characteristics of the approach, and discuss issues and challenges encountered in conducting a secondary analysis. We conclude with some thoughts on the implications for conducting a QSA in children’s mental health services and research.

Grounded Theory and Backward Mapping: Exploring the Implementation Context for Wraparound...443-458
Janet S. Walker and Nancy Koroloff
Abstract: Within children’s mental health, there is an increasing demand for wider implementation of wraparound and other interventions that can provide comprehensive, individualized, family-driven care. Unfortunately, implementation has proven difficult because these approaches do not necessarily flourish within traditionally organized agencies and systems. This has highlighted the need for information about how mental health agencies and systems must evolve if they are to provide a hospitable implementation environment for these interventions. A first step in developing this information is through research that advances conceptual and theoretical understanding of the impact of contextual factors on implementation. At the same time, there is an immediate need for practical information to guide decision making and policy development in settings where implementation is being undertaken. This article describes a study of wraparound implementation that used a combination of qualitative strategies to meet both of these needs simultaneously. It is argued that these strategies are particularly well suited to the study of emerging practices that reflect—and help drive—transformation in mental health systems.

Linking Data to Decision-Making: Applying Qualitative Data Analysis Methods and Software to Identify Mechanisms for Using Outcomes Data...459-474
Vaishali N. Patel and Anne W. Riley
Abstract: A multiple case study was conducted to examine how staff in child out-of-home care programs used data from an Outcomes Management System (OMS) and other sources to inform decision-making. Data collection consisted of thirty-seven semi-structured interviews with clinicians, managers, and directors from two treatment foster care programs and two residential treatment centers, and individuals involved with developing the OMS; and observations of clinical and quality management meetings. Case study and grounded theory methodology guided analyses. The application of qualitative data analysis software is described. Results show that although staff rarely used data from the OMS, they did rely on other sources of systematically collected information to inform clinical, quality management, and program decisions. Analyses of how staff used these data suggest that improving the utility of OMS will involve encouraging staff to participate in data-based decision-making, and designing and implementing OMS in a manner that reflects how decision-making processes operate.