Serving Children with Serious Emotional
Disturbance in a System of Care:
Do Mental Health and Non-Mental Health
Agency Referrals Look the Same?
CHRISTINE M . W A L R A T H , K I M J. NICKERSON, RAYMOND L CROWEL, A N D PHILIP J. LEAF
E
arlier reviews of the literature
(Brandenburg, Friedman, & Sil-
ver, 1990) and more recent stud-
ies (Shaffer et al., 1996) have indicated
prevalence rates for diagnosable men-
tal, emotional, or behavioral disorders
between 14% and 20% for children and
adolescents. Children with serious emo-
tional disturbance (SED) represent an
important subpopulation of those chil-
dren with diagnosable mental disorders.
These children are described as having
a diagnosable disorder coupled with sub-
stantial functional impairment in one
or more life domains (Sondheimer &
Evans, 1995). Not only do children with
SED constitute approximately 5% of
children diagnosed with mental disor-
ders (Brandenburg et al., 1990; Shaffer
et al., 1996), but a large proportion of
children with SED receive little to no
mental health intervention (Costello,
Burns, Angold, & Leaf, 1993). Over a
decade ago, commissions and experts
agreed that, because of the severity of
their emotional disturbance and the re-
sources needed to maintain them in the
community, the needs of children and
adolescents with SED could not be
adequately met by the mental health
system alone (England & Cole, 1992;
Stroul & Friedman, 1986; Tuma, 1989).
JOURNAL OF EMOTIONAL AND
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Children in need of mental health services do not constitute a homogeneous group. Important to
this discussion is an examination of the diverse presenting problems and psychosocial histories of
children referred by different service agencies. Using data from the East Baltimore Mental Health
Partnership (EBMHP), we determined whether and how children referred to the EBMHP from a
traditional mental health center differed from children referred to the EBMHP by non-mental health
agencies. Data on demography, family background, and child and family functioning were collected
on 254 children and their families. The analyses confirmed that children with serious emotional
disturbance served in a system of care and their families are not homogeneous. Children and their
families differed in terms of their sociodemographic characteristics and psychosocial adjustment
depending on their referral source. These differences are discussed in terms of service planning and
delivery, as well as theoretical implications.
In response it has been argued that To meet the many service and sup-
multidisciplinary, multiagency, child- port needs of children with SED, fed-
centered, family-focused, community- eral and private sector foundations (e.g.,
based, culturally competent systems of Child and Adolescent Service System
care are the most appropriate mecha- Program [CASSP]; Robert Wood
nisms to meet the needs of children with Johnson Foundation) have mobilized
SED. More specifically, there has been system-of-care initiatives in many com-
a call for systems of care for children munities across the United States. Be-
with SED that include not only a vari- ginning in 1993, the federal Child,
ety of mental health services—such as Adolescent, and Family Branch of the
prevention, outpatient treatment, home- Center for Mental Health Services
based care, emergency services, thera- (CMHS) of the Substance and Mental
peutic foster care, and inpatient care— Health Services Administration has
but also services and support from funded multiple demonstration sites
non-mental health agencies and sys- across the country to initiate commu-
tems—such as education, juvenile jus- nity efforts to develop and implement
tice, social welfare, health, and substance systems of care for children with SED
(England & Cole, 1992; Stroul & Fried- and their families. The East Baltimore
man, 1986; Tuma, 1989). Mental Health Partnership (EBMHP),
BEHAVIORAL DISORDERS, WINTER 1998, VOL. 6, NO. 4, PAGES 205-213
one of the 31 currently funded demon- To date, there have been several in- services and for the long-term
stration sites, is a joint community, city, vestigations into the overall character- outcomes of the children and
and state effort.to develop and imple- istics of children with SED who are families?
ment a system of care (Leaf, Bogrov, & being served in community-based and
Webb, 1997). In Baltimore, the agen- system-of-care type settings (Epstein, METHOD
cies involved in the provision of ser- Cullinan, Quinn, & Cumblad, 1994,
vices to children came together to form 1995; Landrum, Singh, Nemil, Ellis, &
Participants
a continuum of care that would work to Best, 1995; Singh, Landrum, Donatelli,
redress the fractured and inconsistent Hampton, & Ellis, 1994). There are The east Baltimore community is a
manner in which many children were obvious differences across studies with densely populated (approximately
being served and that would incorpo- regard to certain demographic charac- 70,000 inhabitants), relatively small (23
rate the majority of the key elements of teristics (e.g., ethnicity, age, diagnosis) census tracts) urban community. Ap-
systems of care (e.g., Lourie & Katz- that depend on the population being tar- proximately 20,000 children and youth
Leavy, 1991, Stroul & Friedman, 1986; geted by the system of care. However, under age 18 reside in east Baltimore.
Tuma, 1989). Children eligible for en- the majority of these investigations agree Of these children, 91% are African
rollment in the EBMHP are referred by that children with SED being served in American and more than one half live
1 of 4 primary participating agencies: a system of care are more often than in households with incomes below the
the Baltimore City Public Schools, the not boys, from single-parent families, poverty level. Two hundred and fifty-
Department of Social Services, the De- who present with severe child and four children and their families who were
partment of Juvenile Justice, or the Johns family risk factors, have considerable referred to the EBMHP by one of four
Hopkins Children's Mental Health Cen- service histories, and have often been agencies and who had consented to
ter. The primary goals of the EBMHP identified as having educational disabili- participate in evaluation efforts were
are (a) to develop an integrated, cultur- ties (learning or behavioral). However, included in this investigation. Intake
ally competent system of care for chil- Rosenblatt, Robertson, Wood, Furlong, information that included child demo-
dren and families faced with SED; and Sosna (1998) have found differ- graphics, history, behavior, functioning,
(b) to empower families to make deci- ences in the profiles of children referred and diagnosis and family history was
sions about the type and mix of services to a system of care depending on the collected. The sources that referred chil-
that they and their children receive; and referral source. They demonstrated that dren to the EBMHP were the Baltimore
(c) to assist agencies, community mem- factors such as age, child risk factors, Departments of Juvenile Justice (DJJ)
bers, and families in developing a com- arrests, problem behavior, and psycho- and Social Services (DSS), the Balti-
munity-based array of services for children social functioning discriminated between more City Public School System (BCPS),
whose needs run across agencies. referring agencies. and a traditional outpatient mental health
Although children with SED and their In an attempt to further identify and center for children, the Johns Hop-
families arguably can benefit most from understand differences between the chil- kins Children's Mental Health Center
system-of-care services such as those dren and families referred to a system (CMHC).
provided by the EBMHP, certain stud- of care by different agencies, we com-
ies force us to closely examine for whom pared the characteristics of children re-
Procedure
these system-of-care services are best ferred to the EBMHP by a traditional
suited (Bickman, 1996; Bickman, Sum- mental health service agency (a chil- On referral to the EBMHP, each child
merfelt & Noser, 1997; Friedman & dren's outpatient community mental and family were assigned a family re-
Burns, 1996). For example, Bickman health center) with children referred to source specialist (FRS). Family resource
et al. (1997) pointed out the need for the EBMHP by non-mental health agen- specialists are master's level mental
subgroup analyses when evaluating the cies (i.e., Department of Social Service, health clinicians who oversee and coor-
clinical effectiveness of system-of-care ( Department of Juvenile Justice, or Bal- dinate service plan development and
services. Although such analyses are timore City Public Schools). Our inves- implementation. Moreover, they provide
necessary, it is also important to iden- tigation was organized around the fol- direct service to their assigned children
tify subgroup differences at the point of lowing questions: and families in the form of individual
intake into a system of care. Subgroup and family counseling. As part of the
differences at the point of referral have 1. What are the overall characteristics standard clinical intake process, FRSs
clear implications for treatment plan- of children served by our system invited the children and family mem-
ning, which may in turn have implica- of care? bers to participate in the ongoing evalu-
tions for clinical outcomes. Communities 2. What are the agency-specific char- ation efforts of the EBMHP. Of the
must look carefully at the characteris- acteristics of children served by children and families who entered ser-
tics of the children served in order to our system of care? vices, 88% agreed to participate in the
optimally allocate and match service 3. What are the implications of these evaluation. There were no differences
to need. agency-specific differences for between those children and families who
JOURNAL OF EMOTIONAL AND BEHAVIORAL DISORDERS, WINTER 1998, VOL. 6, NO. 4

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agreed to participate in the evaluation
and those who refused in terms of de-
mographic characteristics (i.e., ethnicity,
average age, and gender) or referral
source. The FRSs served as the primary
data collectors at intake. They were in-
structed in the administration of self-
report instruments and underwent struc-
tured instrumentation training when
required. With the exception of clini-
cian-rated functional assessments, the
collected information was self-reported
by the children and families.
Child and Family Demographics
and History
Basic sociodemographic data were col-
lected for each child by the FRS at in-
take. Demographic information such as
age, gender, and ethnicity of each child
was collected and included in the analy-
ses. Information on household compo-
sition, such as the number of biological
siblings, the number of children living
in the household, and the number of
siblings in foster care were also included.
A complete psychosocial history,
including risk and exposure informa-
tion, was collected by the FRS for each
EBMHP child at intake. To adequately
assess the needs of a child and deter-
mine appropriate services, a comprehen-
sive understanding of risk and exposure
is important. Included in our analyses
were history data on family violence,
previous physical abuse of the child,
and previous sexual abuse of the
child. Risk factors related to the behav-
ior of the child included previous drug
use by the child, previous sexual abuse
by the child, and previous suicide at-
tempts by the child. Furthermore, any
history of family mental illness, previ-
ous psychiatric hospitalization of the
child or of a parent, and felony convic-
tion of a parent were included among
the child and family history variables
for analysis.
Child Behavior, Functioning,
and Diagnosis
Clinical and research instruments
used to assess child behavior and func-
tioning were administered to each child
JOURNAL OF
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and family referred to the EBMHP.
The instruments and tools administered
included the Child Behavior Checklist
(CBCL), Child and Adolescent Func-
tional Assessment Scale (CAFAS), Glo-
bal Assessment of Functioning (GAF),
diagnosis based on the Diagnostic and
Statistical Manual of Mental Disorders,
4th edition (DSM-IV; American Psychi-
atric Association, 1994), and present-
ing problem. When a clinician rating—as
opposed to a client self-report—was
required, the FRS received structured
training in order to maintain acceptable
levels of rating reliability.
Child Behavior Checklist. Parents
of EBMHP children between the ages
of 4 and 18 completed the 118-item
checklist of child problem behavior. The
CBCL is one of the most widely recog-
nized instruments used to assess prob-
lem behavior. The reliability and validity
of the CBCL have been adequately dem-
onstrated (Achenbach, 1991). The CBCL
consists of competency scale scores, a
total problem behavior score, 9 syn-
drome scales, and a subscale score
for both externalizing and internalizing
problem behaviors (Achenbach, 1991).
The internalizing and externalizing sub-
scale scores were used in this study.
Child and Adolescent Functional
Assessment Scale. The CAFAS is a cli-
nician rating scale used to assess child
functioning across five life domains: role
performance (home, community, and
school), behavior toward others, moods
and emotion (moods and self-harmful
behavior), substance use/abuse, and
thinking. The scale yields 5 subscale
scores and a total functioning score. This
investigation used only the total score.
Higher CAFAS scores indicate greater
functional impairment, and the author
(Hodges, 1994) suggests a clinical cut-
off score of 40 (range 0-150) for the
total score on the CAFAS. Interrater
reliability and validity have been dem-
onstrated in previous studies (Hodges
& Wong, 1996). Family resource spe-
cialists were trained to achieve high
correlations (> .80) between FRS rat-
ings and criterion ratings established by
the author (Hodges, 1990).
EMOTIONAL AND BEHAVIORAL
Global Assessment of Functioning.
As an additional measure of child psycho-
social functioning, each child received
a GAF score from the FRS or from an
evaluating psychologist/psychiatrist at
intake, using the guidelines of the
DSM-IV. The GAF is a subjective rat-
ing of psychosocial functioning provided
by a clinician, with higher scores indi-
cating higher functioning. The scale
ranges from 100 (indicating superior
functioning in a wide range of activi-
ties) to 1 (indicating persistent danger
of severely hurting self or others or in-
ability to maintain minimal personal
hygiene).
DSM-IV Diagnosis. As part of the
initial psychiatric evaluation provided
for each child referred to the EBMHP
for services, the DSM-IV multiaxial sys-
tem (American Psychiatric Association,
1994) was used to classify disorders
among the children. The primary diag-
noses assigned to each child were also
examined.
Presenting Problem. During the in-
take process, the FRS collected infor-
mation regarding the child's presenting
problem. These problems were coded
into 33 categories (e.g., anxious, physi-
cal aggression, poor peer interaction;
Macro International, 1995). In this study,
we used the primary presenting prob-
lem of the child, as indicated by the
FRS at intake, to determine what types
of issues were found among the chil-
dren referred to the EBMHP.
RESULTS
To compare differences in child and
family characteristics of children re-
ferred by a traditional mental health
agency (CMHC) to those referred by
non-mental health agencies (DSS, DJJ,
and BCPS), analyses of variance and
chi-square analyses were performed. A
one-way analysis of variance with four
levels (one for each referring agency)
was performed for each continuous de-
pendent variable: age, number of chil-
dren living in household, number of
biological siblings, CBCL ratings,
CAFAS ratings, and GAF rating total.
DISORDERS, WINTER 1998, VOL. 6, NO. 4
Because of unequal cell size and the 200) = 13.85,/? = .003), history of fam-
with both parents, 2.5% lived alone with
relatively small number of groups be- ily mental illness (c2 (3, N = 179) =
their fathers, and the remaining 8.5%
ing compared, Fisher's Least Signifi- lived elsewhere. 12.04, p = .007), previous psychiatric
cant Difference tests (Fisher, 1935) were hospitalization of the child (c2 (3, TV =
performed for all statistically signifi- Agency-Specific Child 231) = 12.91, p < .005) and of the par-
cant F ratios (Heiman, 1998). Chi-square ent (c2 (3, N = 216) = 7.58, p = .05),
Characteristics
analysis with four levels (one for each and history of family violence (c2 (3, N
referring agency) was performed for Child and Family Demographics. = 179) = 16.97, p = .001) were signifi-
each categorical dependent variable. When comparing referrals from a tradi- cantly associated with referring agency.
With the exception of gender, ethnicity, tional mental health agency to referrals Children referred by DJJ had higher
presenting problem, and diagnosis, all originating from non-mental health reports of substance use and children
categorical variables were dichoto- agencies, there were significant differ- referred by BCPS reported lower rates.
mously coded as yes/no. These vari- ences associated with age (F(3, 250) = Children referred by CMHC and DSS
ables included number of siblings in 29.23,/? < .0001), gender (x2 (3, AT =254) were more likely to have a history of
foster care, history of family violence, = 39.83, p < . 0001), and number of sib- physical abuse than other children. In
physical abuse of the child, sexual abuse lings in foster care (x2 (3, N = 207) = contrast, referrals from DJJ and BCPS
19.63, p < .0001). Specifically, Least had lower reported rates of physical
of the child, drug use by the child, sexual
abuse by the child, suicide attempts by Significant Difference (LSD) pairwise abuse. Children referred by CMHC were
the child, history of family mental ill- assessments (Fisher, 1935) of mean age more likely to have a family history of
ness, psychiatric hospitalization of the differences indicated that children re- mental illness, and fewer children re-
child, psychiatric hospitalization of a ferred from DJJ were significantly older ferred by BCPS and DJJ had a family
parent, and felony conviction of a par- than CMHC-referred children (LSD = history of mental illness. Children re-
ent. Descriptive statistics were used to 3.35, p < .0001), BCPS-referred chil- ferred by CMHC were more likely
capture apparent differences in present- dren (LSD = 5.08, p < .0001) and DSS- than others to have had a previous
ing problems and diagnosis. A summary referred children (LSD = 3.82, p < psychiatric hospitalization. Fewer par-
of the results is presented in Table 1. .0001). Moreover, BCPS-referred chil- ents of children referred by BCPS had
The significant findings are discussed dren were significantly younger than a history of psychiatric hospitaliza-
in subsequent sections. children referred by CMHC (LSD = -1.73, tions, but more parents of children re-
p < .0001) and DSS (LSD = -1.23, p < ferred by DSS had such a history.
.0001). The lack of independence be- More children than expected had a his-
Overall Child Characteristics
tween referring agency and gender tory of family violence when referred
Regarding referral patterns, 36% (n = showed little difference between the ex- by DSS, and fewer than expected had a
91) of the children referred for services pected and observed rates for gender history of family violence when referred
were from the Baltimore City Public when referred by CMHC. In contrast, by DJJ.
School System (BCPS), 26% (n = 66) more boys than expected were referred There were no significant differences
from the Johns Hopkins Children's by DJJ and BCPS, whereas more females in the history of child sexual abuse (x2
Mental Health Center (CMHC), 22% than expected were referred by DSS. (3, N = 186) = 6.35, p = .096), sexual
(n - 56) from the Department of Social There was a significant association be- abusiveness (x2 (3, AT = 202) = 6.56,
Services (DSS), and 16% (n = 41) from tween referring agency and the referred p = .09), or suicide attempts (x2 (3, N =
the Department of Juvenile Justice (DJJ). child having siblings in foster care (an- 218) = 5.27, p = .153) as a function of
Children referred to the EBMHP for swered as yes/no). Children referred by referring agency. There were no sig-
service were predominantly African DSS more frequently had siblings in foster nificant differences in parent felony
American (93.3%), predominantly boys care, and children referred by BCPS and conviction (x2 (3> N = 1 9 8 ) = 5 - 69 >
(69%), and ranged in age at referral from by DJJ were less likely to have siblings p = .128) or family history of substance
3.8 years to 17.7 years (X = 11.03, SD in foster care. There were no signifi- abuse (x2 (3, N = 198) = 2.32, p = .526)
2
= 3.32). Sixty-seven percent of the re- cant differences by ethnicity (x (12, TV as a function of referring agency.
ferred families reported a gross income = 253) = 16.39, p = .174), number of
under $10,000 per year, 16% between biological siblings (F (3, 190) = 0.679, Diagnosis and Reason for Referral.
$10,000 and $14,999 per year, 12% p = .566), or number of children living Descriptive analyses were performed on
between $15,000 and $24,999 per year, in household (F(3, 188) = 1.46, p = presenting problem and diagnosis for
and the remaining 5% reported an an- .228) as a function of referring agency. children referred by the four different
nual gross income of $25,000 or more. sources. The most frequently docu-
The majority of referred children lived Child and Family History. Previ- mented reason for referral across refer-
alone with their mothers (56%); how- ous substance use by the child (c2 (3, N ring agencies was found to be physical
ever, 24% lived with a guardian (mostly = 179) = 16.97, p = .001), previous aggression (30.5%, n = 233). When
extended family guardianship), 9% lived physical abuse of the child (c2 (3, N = analyzed by agency, physical aggres-

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sion remained the most likely reason
for referral regardless of referring agency
(CMHC = 34%; DSS = 25%; BCPS =
36%; DJJ = 19%). For DJJ referrals,
police contact (19%) was equally likely
to be documented as the reason for re-
ferral as physical aggression.
In contrast, there was evidence of diag- referred by DJJ was conduct disorder
nostic differences as a function of re- (44%, n = 18), by BCPS was attention-
ferring agency. The most common di- deficit disorder (19%, n = 42), and by
agnostic category for children referred DSS was depression (12.5%, n = 24)
by CMHC was oppositional defiant dis- and adjustment disorder (12.5%,
order (23%, n = 39). However, the most n = 24). Diagnostic differences between
frequently used diagnosis for children referring agencies are based on a sub-

TABLE I
Summary of Results: Differences in Child and Family Characteristics as a Function of Referral Source

Referral source
Characteristic CMHC BCPS DSS PJJ Statistic

Demographics
African Americans 88% 97% 94% 93% X 2 (I2, N = 253) = 16.39
Boys*** 68% 83% 40% 85% X2(3, N = 254) = 39.83
Age* * *
M 11.25 9.52 10.78 14.60 F(3,250) = 29.23
SD (2.97) (2.65) (3.36) (2.35)
Number of biological siblings
M 2.79 2.88 3.30 3.00 F(3,190) = 0.679
SD (1.91) (2.12) (1.79) (1.33)
Number of children living in house
M 3.27 3.45 3.98 3.32 F(3,I88)= 1.46
SD (1.80) (1.80) (1.67) (1.36)
Siblings in foster care*** 12% 5% 31% 7% X2(3, N = 207) = 19.63
Child history
Substance use*** 4% 1% 4% 20% X2(3, N = 179)= 16.97
Physically abused** 33% 17% 42% 13% X 2 (3,N = 200) = 13.85
Sexually abused 24% 14% 27% 7% X2(3, N = 186) = 6.35
Sexually abusive 6% 3% 2% 14% X2(3, N = 202) = 6.56
Psychiatric hospitalizations** 36% 16% 11% 22% X2(3, N = 23l)= 12.91
Suicide attempts 11% 14% 4% 16% X 2 (3,N = 218) = 5.27
Family history
Family mental illness** 64% 34% 51% 33% X2(3, N = 179)= 12.04
Family violence*** 55% 48% 66% 24% X2(3, N = 179)= 16.97
Parent psychiatric hospitalization* 8% 5% 19% 9% X 2 (3,N = 216) = 7.58
Parent felony conviction 8% 15% 22% 6% X2(3, N = 198) = 5.69
Family history of substance abuse 81% 74% 81% 70% X2(3, N = 198) = 2.32

Child behavior & functioning

CAFAS**
M 58.57 53.21 45.68 74.70 F(3,I4I) = 5.68
SD (26.91) (22.08) (25.99) (25.77)
CBCL - Externalizing
M 68.38 64.63 61.12 63.70 F(3,I52) = 1.52
SD (12.21) (14.19) (15.13) (11.14)
CBCL - Internalizing***
M 61.23 60.87 52.59 52.77 F(3,I52) = 6.I7
SD (14.07) (11.93) (10.90) (11.60)
Global Assessment of Functioning
M 55.46 55.00 60.11 54.00 F ( 3 , I I 4 ) = 1.17
SD (11.65) (11.55) (8.31) (11.79)

Note. CMHC = Children's Mental Health Center; BCPS = Baltimore City Public Schools; DSS = Department of Social Services; DJJ = Department of Juvenile
Justice; CAFAS = Child and Adolescent Functional Assessment Scale (Hodges, 1990); CBCL = Child Behavior Checklist (Achenbach, 1991).
*f> < .05. **p < .01. ***p < .001.

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209

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sample of 123 children (out of 254 par-
ticipating children) who received diag-
noses while receiving services from their
referring agency prior to entering the
EBMHP. Because of the time required
to schedule and complete diagnostic as-
sessments for the children who had been
psychiatrically evaluated for this study,
the number of children included in the
descriptive analysis of diagnosis is sub-
stantially smaller than the total number
of children participating in this study.
Behavior and Functioning. Sig-
nificant differences were found for
total CAFAS rating (F(3,141) = 5.68,
p = .001) as well as for the internalizing
subscale of the CBCL (F(3,152) = 6.17,
p - .001) as a function of referring
agency. Specifically, Least Significant
Difference pairwise assessments in
CAFAS scores indicated that children
referred by CMHC were rated as sig-
nificantly less functionally impaired
(LSD = -16.13, p = .029) than children
referred by DJJ and significantly more
impaired than children referred by DSS
(LSD = 12.89, p = .029). Moreover,
DJJ-referred children were rated more
functionally impaired than children re-
ferred by BCPS (LSD = 21.49,/? = .002)
or DSS (LSD = 29.03, p = .001).
Least Significant Difference pairwise
assessments in CBCL internalizing
subscale scores indicated that children
referred by CMHC were rated as hav-
ing more internalizing behavior prob-
lems (LSD = 8.09, p = .009) than
children referred by DJJ or DSS (LSD
= 8.64, p = .005). Children referred by
BCPS were rated as having significantly
more internalizing behavior problems
than children referred by DSS (LSD =
8.28, p = .005). There were no signifi-
cant differences for the CBCL external-
izing subscale scores (F(3,152) = 1.52,
p = .640) or the GAF ratings (F(3,l 14)
= 1.17, p = .323) as a function of refer-
ring agency.
DISCUSSION
The results of this investigation support
those of Rosenblatt et al. (1998). They
demonstrate that children with SED
served in a system of care and their
T i n JOURNAL OF EMOTIONAL AND
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families are not homogeneous. Children
and their families differ in terms of their
sociodemographic characteristics and
psychosocial adjustment as a function
of their referral source. In other words,
children served in a system of care,
despite sharing a common label of SED,
may not share mental health profiles
and histories. Researchers and provid-
ers must be aware of these differences
in order to effectively match services to
need.
Service and Practice Implications
Using the East Baltimore Mental Health
Partnership system of care, we demon-
strated that children and families dif-
fer depending on the agency by which
they are referred. Comparing traditional
mental health agency referrals to non-
mental health agency referrals, we found
notable differences in the demograph-
ics, psychosocial histories, diagnoses,
and functioning of children served in
this system of care. The different men-
tal health profiles and histories of chil-
dren referred to the EBMHP from a
traditional mental health center, the De-
partment of Juvenile Justice, the Depart-
ment of Social Services, and the Bal-
timore City Public Schools are discussed
below. Furthermore, we describe how
we have used our understanding of these
differences to tailor services to meet
individual children's needs.
Children referred to the EBMHP by
the traditional mental health outpatient
center (CMHC) were predominantly
African American, and approximately
two thirds were boys. These children
typically had suffered physical abuse
themselves, had histories of psychiatric
hospitalizations, and had families with
histories of mental illness and violence.
They presented with problems of phys-
ical aggression, significant levels of
psychosocial dysfunction, internalizing
problem behaviors, and oppositional de-
fiant disorders. To engage and sustain
these families in traditional mental health
treatment, a home-based specialist or a
home-based case manager was neces-
sary. A strong coordination and referral
system between the outpatient center,
an area emergency room, and an inpa-
BEHAVIORAL DISORDERS,
tient unit had been established, as well
as respite services to help prevent un-
necessary hospitalizations or shorten the
length of required inpatient admissions.
We found that children referred by
the Department of Juvenile Justice were
older, predominantly African American,
and more likely to be boys. Children
referred by DJJ presented with higher
levels of substance use, sexually abu-
sive behavior and suicide attempts than
children referred by other agencies, and
their family histories included higher
incidences of substance abuse; they pre-
sented with lower reported histories of
family violence and family mental ill-
ness. Clinically, these children showed
higher levels of psychosocial dysfunc-
tion, conduct disorder, and—predict-
ably—higher levels of police contact.
However, lower than expected levels of
violence and abuse reported in the fam-
ily histories of these children should be
interpreted with caution, because fami-
lies involved with the juvenile justice
system may under-report such incidents
in view of the perceived legal conse-
quences. For these children, mental
health service planning teams included
input from representatives of the juve-
nile justice system, probation office, and
courts, as well as from parents and
mental health specialists. Given that
these children tended to be older boys
with conduct problems, it was impor-
tant for clinical and support services to
include age-appropriate mentoring and
group therapy, alternative educational
and prevocational opportunities, and
transitional living or respite care.
The children referred to EBMHP by
the Department of Social Services were
predominantly African American and
more likely to be girls of late elemen-
tary school age. Family histories of these
children were characterized by high lev-
els of parental psychiatric hospitaliza-
tion and family violence, including
physical abuse of the child. These chil-
dren often presented with histories of
physical aggression and suffered from
depression and adjustment disorders.
Given the profile of children referred
by the Department of Social Services,
the system-of-care service team included
input from a Department of Social Ser-
WINTER 1998, OL. 6, NO. 4
vices case manager, a mental health
specialist for the family and the child,
and a representative of the adult mental
health system to assist parents with
emotional disturbances in obtaining the
help they need. Because of the high
percentage of DSS-referred children with
siblings in foster care, the clinical is-
sues related to loss, separation, and po-
tential reunification were addressed in
treatment and planning. The EBMHP
also provided advocacy training and
support for parents via referral and link-
age to Families Involved Together (FIT),
a family advocacy agency. A strengths-
based approach (i.e., structured assess-
ment of family and child strengths at
intake into service) was especially im-
portant for these children because fam-
ily reunification or placement stability
depends on identification and develop-
ment of the family's capacity to care
for its members.
Children referred to the EBMHP by
the public school system (BCPS) tended
to be younger, predominantly African
American, and more likely to be boys.
Family and child histories included
moderate levels of family mental ill-
ness and violence and lower than ex-
pected levels of physical abuse and
substance use. Clinically, these children
had more internalizing behavior prob-
lems and often presented with physical
aggression and a diagnosis of attention-
deficit disorder. In the system of care,
we found that the issues involving chil-
dren referred by the school system
required a team that included school
staff—most importantly the teacher—a
school-based mental health clinician, and
an in-home specialist to work with the
child and family. A psychologist or psy-
chiatrist who specialized in school-
related evaluation was needed to ade-
quately assess the child's attention
problems and make recommendations
on medications and therapy. Much of
the clinical work was addressed in the
school setting and focused on the over-
arching goals of prosocial skill devel-
opment and academic achievement.
Furthermore, ongoing family support,
including advocacy, was often required
to help the family understand their rights
in the school system. Before referral to
JOURNAL OF
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our system of care, parents and schools
less often worked together to meet the
child's educational needs. We found it
useful for the work in the home to
complement the ongoing school-based
activities, assisting the family in devel-
oping a stronger presence in the school
and sustaining their involvement in the
development and implementation of
school plans.
These comparisons of children by
referring agency are obviously not ex-
haustive or representative of every child
referred to the EBMHP. These descrip-
tions are meant to stimulate discussion
of the depth and breadth of the service
arrays that would be most beneficial for
serving these children and families.
Although individually tailored services
are a cornerstone of system-of-care ap-
proaches, it is important to develop re-
source pools based on unique group
characteristics to will meet the needs of
children. As our analyses show, each
referring agency provides services to
children with distinct characteristics—
and consequently distinct service needs.
Understanding these differences will
allow system developers to allocate re-
sources that optimally serve the various
distinct populations of children they may
encounter.
Clearly, systems of care must con-
sider the global characteristics of the
communities, the families, and the chil-
dren they serve when determining the
types and combinations of services to
provide. For example, the EBMHP
serves a primarily urban, poor, African
American population. Recent calls for
cultural competency in the design and
delivery of mental health services (Isaacs
& Benjamin, 1991) should not go un-
heeded in systems of care such as the
EBMHP. Systems of care should invest
the resources to ensure that the organi-
zation of the services delivered reflects
the racial and ethnic culture of the chil-
dren and families being served. This
includes programming that is culturally
relevant and appropriate and argues
against a "one size fits all" approach to
developing and implementing programs.
Another global characteristic of chil-
dren referred to the EBMHP is the com-
mon behavioral manifestation of their
EMOTIONAL AND BEHAVIORAL
behavioral and emotional problems (i.e.,
the reason for referral). Despite the fact
that diagnostic patterns differed depend-
ing on the referral source, the most com-
mon primary presenting problem was
physical aggression. This is extremely
important given the national interest in
violence prevention programs, conflict
resolution programs, and other initia-
tives aimed at reducing the alarming
number of assaults and homicides in
cities such as Baltimore.
Theoretical Implications
and Conclusions
Many providers and researchers have
argued that systems of care represent
the "best practice" service delivery
modality for children with serious emo-
tional disturbances. Multidisciplinary,
multiagency, child-centered, family-
focused, community-based, culturally
competent systems of care that offer an
array of mental health and non-mental
health services and support have been
deemed most appropriate for children
with serious and complex clinical prob-
lems (England & Cole, 1992; Stroul &
Friedman, 1986; Tuma, 1989). Recent
outcome and effectiveness studies have
forced program funders, developers, and
researchers to question which children
and families could, would, and do ben-
efit most from such a comprehensive
service approach (Bickman, 1996;
Bickman et al., 1997; Friedman & Burns,
1996). To understand differential out-
come as a function of subgroup, we must
first identify and understand subgroup
differences in sociodemographic char-
acteristics and functioning at the point
of service initiation. Characteristic dif-
ferences at the start of services have
implications for planning and delivery,
which in turn may have implications
for differential outcome. This investi-
gation, in conjunction with Rosenblatt
et al. (1998), provides initial support
for the notion that all children with SED
referred to a system of care are not alike.
These studies have demonstrated that
children referred by different public
sector agencies present with different
life histories, psychosocial functioning,
and diagnostic patterns. In other words,
DISORDERS WINTER 1998, VOL. 6, NO. 4 T i l
children from different referral sources
have differing profiles. Not only do these
differing child and family profiles in-
fluence service planning and delivery,
they also lay the empirical groundwork
for subgroup analyses to investigate the
effectiveness of system-of-care service
delivery.
Finally, an alternative implication of
these agency-related differences must
be considered. Glisson (1996), in a study
of mental health and non-mental health
system children's service needs in Ten-
nessee, found that the psychosocial func-
tioning of children served in mental
health and non-mental health agencies
had little impact on the mental health
service decisions being made. He found
that a great many children served by
these agencies were in need of mental
health services, but that their docu-
mented need seemed to be unrelated to
their referral for service. The success of
the system-of-care initiative depends on
the identification and referral of chil-
dren with SED both in mental health
and in non-mental health agencies. If
individual agencies continue to serve
as primary providers for children with
SED, ways to improve identification of
needs and access to systems of care or,
alternatively, ways to improve the ef-
fectiveness of each individual agency
in an effort to improve mental health
outcomes for these young people must
be considered.
Some study limitations must be ac-
knowledged. First, this investigation has
not considered the strengths of the chil-
dren and families referred to the EBMHP.
A thorough investigation of the charac-
teristic differences of children and fami-
lies should consider both their strengths
and their challenges. Second, the degree
to which these findings are generaliz-
able is unknown, given the unique or-
ganization and structure of the EBMHP
and the population demographics of the
children and families it serves. Third,
children were identified and referred for
service within each of the primary ser-
vice agencies. Agency staff selected chil-
dren for referral to the EBMHP. Al-
though these children had to meet basic
eligibility requirements (e.g., multiple
JOURNAL OF EMOTIONAL AND
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agency involvement, residency require-
ments), not all eligible children were
referred; hence there was room for selec-
tion bias. Finally, the within-agency sam-
ple sizes were relatively small. In spite
of these potential limitations, these find-
ings lay the groundwork for further ex-
amining whether differences in children
and family characteristics are related to
differences in outcomes.
About the Authors
CHRISTINE M. WALRATH, PhD, MHS,
is a research associate in the Department of
Mental Hygiene at the Johns Hopkins Uni-
versity School of Hygiene and Public Health
and the lead evaluator for the East Balti-
more Mental Health Partnership. KIM J.
NICKERSON, PhD, is an assistant profes-
sor in the Department of Mental Hygiene at
the Johns Hopkins University School of Hy-
giene and Public Health and leads the cul-
tural competency training efforts of the East
Baltimore Mental Health Partnership. RAY-
MOND L. CROWEL, PsyD, is a research
associate in the Department of Mental Hy-
giene at the Johns Hopkins University School
of Hygiene and Public Health and is the
project director for the East Baltimore Men-
tal Health Partnership. PHILIP J. LEAF,
PhD, is a professor in the Department of
Mental Hygiene at the Johns Hopkins Uni-
versity School of Hygiene and Public Health,
the principal investigator of the East Balti-
more Mental Health Partnership, and the
director of the Johns Hopkins Prevention
Research Center. Address: Christine Walrath,
Johns Hopkins School of Public Health, 624
N. Broadway, Room 803, Baltimore, MD
21205.
Authors' Note
This research was funded through the Mary-
land Mental Hygiene Administration by the
federal Substance Abuse and Mental Health
Services Administration's Center for Men-
tal Health Services Comprehensive Com-
munity Mental Health Services for Children
and their Families demonstration grant
(CMHS 5 44SM51392) and a grant from
the National Institutes of Mental Health to
support the Children's Mental Health
Services Research Center (MH 19545 07).
The contents of this article do not neces-
sarily reflect the opinions of the funding
organizations.
BEHAVIORAL DISORDERS, WINTER
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