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Unformatted text preview: Life Concerns and Perceptions Of Care in Adolescents with Mental Health Care Needs: A Qualitative Study In a School-Based Health Clinic Pam Gampetro, Elizabeth A. Wojciechowski, Kim Siarkowski Amer S chool-based health clinics are created to provide comprehensive care for the students they serve and are often the primary health care cornerstone for providing care for adolescents. According to the 2009 National Census by the National Assembly on School-Based Health Care (NASBHC) State Survey, there are 1,709 school-based health programs across the country. Minority and ethnic populations who have historically experienced health care access disparities comprise the majority of students in schools with school-based health clinics. Current research on comprehensive care focuses on the physical aspects of health care needs of adolescents. Few recent studies have explored the needs of adolescents with mental health disorders, particularly from the adolescent’s perspective. However, the number of children, adolescents, and their families affected by mental, emotional, and behavioral disorders is staggering. Many environmental factors affect mental health status, including exposure to violence, abuse, parental substance abuse, poverty, immigration, inadequate housing or homelessness, Pam Gampetro, MS, APRN-BC, is a Family Nurse Practitioner, Children’s Memorial Hospital, Chicago, IL. Elizabeth A. Wojciechowski, PhD, PMHCNS-BC, is a Former Associate Professor, North Park University, Chicago, IL. Kim Siarkowski Amer, PhD, RN, is an Associate Professor and Interim Director, DePaul University, School of Nursing, College of Science and Health, Chicago, IL. Acknowledgement: The research study was funded by the Shaw Nursing and Allied Health Research Grant from Children’s Memorial Hospital, and the generous donation of time and expertise by Ms. Joni Lamb, LCSW, Dr. Alberto Coll, Mr. Andrew Cubria, and Ms. Rina Ranalli. Health clinics within schools are designed to provide comprehensive care to the student population. Little research has been conducted to identify how effectively school-based health clinics are meeting the mental health needs of adolescents. This qualitative study explored the perceptions of mental health needs of 18 inner-city teens between 12 to 18 years of age with diagnosed behavioral or mental health issues. A single, face-to-face, semi-structured interview was used to examine students’ concerns and attitudes toward their health care needs and services. Results revealed concern for their personal and family relationships, education and vocational goals, health maintenance, and financial independence. Most pressing resource needs related to their ability to receive health maintenance and coping skills and to adapt to complex life challenges they faced in their urban neighborhood. Participants remarked that if the clinic did not identify their needs for mental health care, they would most likely have not received services. When mental health care needs were identified, individual counseling was used to support dialogues for optimal mental and physical health. and the loss of a significant person (Centers for Disease Control and Prevention [CDC], 2005). In addition, medical health disorders, including asthma, obesity, and diabetes mellitus, may co-exist with mental health disorders. Adolescents with altered mental health status/disorders, who may or may not have a co-existing medical problem, may be referred to as adolescents with mental health care needs. Midwest Children’s Hospital has been a leader in pediatric health care, advocacy, prevention, treatment, and research for more than 100 years. In September 2005, Midwest Children’s Hospital, in partnership with the city public schools, began staffing a school-based health clinic located in one of the city’s lowest resource communities. The goal for this schoolbased health clinic was to provide comprehensive health programs to meet the changing needs of students from middle school through high school graduation. The purpose of this study was to explore the mental health resource needs and gaps of service for adolescents who receive their care from this inner-city school-based health clinic. Learning adolescents’ perceptions of PEDIATRIC NURSING/January-February 2012/Vol. 38/No. 1 care was sought to provide the necessary information to evaluate and potentially improve current treatment standards. Having a model of care adapted to the needs of this population can provide the best opportunity for treatment success in this and other urban settings. Research objectives included: a) identify and understand the concerns of adolescents with mental health care needs, b) identify adolescents’ most pressing resource needs, c) identify helpful resources for adolescents, and d) identify the difficulties adolescents have in accessing resources for mental health care needs. Literature Review Relevant literature was reviewed to support the need for the research. Topics reviewed and addressed were 1) the prevalence of mental health disorders in adolescents, 2) surveillance data for adolescence in the U.S., 3) description of natural adolescent development and concerns, 4) mental health concerns of adolescents and their perception of needs, 5) schoolbased health centers in the U.S., and 6) ecological theory. 23 Life Concerns and Perceptions of Care in Adolescents with Mental Health Care Needs: A Qualitative Study in a School-Based Health Clinic Prevalence of Mental Health Disorders in Adolescents Mental health is important at every stage of life because it affects how one views oneself, others, and the world, and it influences coping and decision-making. Merikangas et al. (2010) conducted a study of the prevalence of mental disorders in children based on data from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2004. In a sample of 3,042 participants ranging from 8 to 15 years of age, 12-month prevalence data revealed that 8.6% had attention deficit hyperactivity disorder, 3.7% had mood disorders, 2.1% had conduct disorder, 0.7% had panic disorder, and 0.1% had eating disorders. According to Merikangas et al. (2010), “only one-half of those diagnosed with mental disorders sought treatment with a mental health professional” (p. 75). African Americans and Mexican Americans were less likely to seek treatment than Caucasians, highlighting the need to make mental health treatment more accessible to these youth. With this in mind, the American Academy of Pediatrics (AAP) (2010a) provided a report on evidence-based child and adolescent psychosocial interventions for educators, families, youth, and primary providers. Interventions with the best evidence for support included cognitive behavior therapy, cognitive behavior therapy and medication, assertive training, family therapy, group therapy, and social skills training, to name a few. Key elements of success were directly related to the early identification of health care issues, with prompt access to mental health care. If left untreated, childhood mental disorders may continue into adulthood. The National Institute of Mental Health (NIMH) estimates that 57.7 million (26.2%) American adults suffer from a mental health disorder (Kessler, Chui, Demler, & Walters, 2005). Adolescence Surveillance Data In the United States The 2009 National Youth Risk Behavior Survey monitors six categories of priority health risk behaviors that contribute to unintentional injuries and violence, including tobacco use, alcohol and other drug use, sexual behaviors and unintended pregnancies, STDs, and unhealthy dietary and physical activity behaviors (CDC, 2010). The sampling frame 24 consists of all public and private schools with students in grades 9 through 12 in all 50 states, and the survey is conducted every two years. Findings show that 74% of all deaths among individuals 10 to 24 years of age result from four causes: motor vehicle accidents, other unintentional injuries, homicides, and suicides (CDC, 2010). Other key findings were: • 9.7% had never or rarely worn a seatbelt. • 17.5% carried a weapon to school. • 5.0% had not gone to school because they felt unsafe. • 28.3% had ridden in a car with someone who had been drinking. • 46.0% had sexual intercourse. • 19.5% had smoked cigarettes within the past 30 days before the survey. • 77.7% had not eaten five servings of fruits or vegetables one week prior to the survey. • 23.1% had not met the recommend levels of physical activity. The survey findings are significant because many risky behaviors in adolescence contribute to morbidity and mortality in adulthood. Environmental influences, such as poverty, abuse, and unsafe housing, can contribute to and compound risky behaviors. Such findings guide policy and interventions to improve health behaviors and outcomes among all adolescents. Natural Adolescent Development and Concerns An appreciation of normal development is vital to understanding mental health in adolescents and the risks they face. According to the AAP (2010b), adolescence is defined as 11 through 21 years of age. During the period of adolescence, the major interrelated developmental tasks include a) developing a sense of identity, b) adjusting to body changes, c) developing abstract thought, d) acquiring interpersonal skills, e) establishing autonomy, f) acquiring a value system, g) establishing and negotiating a new relationship with family, h) setting goals for future achievement, and i) choosing a vocation (Blos, 1979; Callaghan, 2006; Flay, 2002; Monasterio, 2002). The intensity of this transitional time often requires medical and mental health resources, which correlate with their respective special health care needs (Wojciechowski, 2003; Wojciechowski, Cichowski, & Torres, 2001). The American Academy of Child and Adolescent Psychiatry (AACAP) (2010) corroborates that all adolescents face many developmental tasks during middle school and high school. These tasks mirror adolescent mental health concerns. Mental Health Concerns Of Adolescents’ and Their Perception of Needs A literature review on the terms “community mental health services,” “adolescents,” and “English language for the years of 1998-2008” revealed several studies that examined adolescent support and services with a variety of positive reports of resources. The most common form of youth involvement in their community is through youth groups, and apart from these groups, youth participation is largely absent (Gyamfi, KeensDouglas, & Medin, 2007). Another study demonstrated a lack of consensus among adolescents interviewed on desired outcomes, which ultimately limited engagement in the treatment and effectiveness of care (Garland, Lewezyk-Boxmeyer, Gabayan, & Hawley, 2004). Based on this review, the status of research on client perceptions of mental health services remains in a formative stage that includes a variety of outcome measures. Literature reviewed revealed that over that past 10 years, few research studies represented perceptions of adolescents receiving mental health care and the assessment of whether their mental health needs are being met. Future research is needed to understand firsthand accounts of adolescents’ mental health concerns and to offer ideas for the delivery of mental health care at school-based health clinics. School-Based Health Centers In the United States School-based health centers are defined as partnerships created by schools, communities, and health organizations to provide onsite medical care and mental health services that promote the health and educational success of underserved schoolaged children and adolescents (Juszczak, Schlitt, & Odlum, 2003; Scully & Hackbarth, 2005). The goal is to provide comprehensive care. In 2007-2008, the NASBHC (2009) surveyed 1,909 clinics connected with schools. Sixty-four percent (1,226 clinics) responded to the survey. Findings illustrated: • 1,026 provide at least primary care services. • All programs provide some type of mental health promotion and prevention. PEDIATRIC NURSING/January-February 2012/Vol. 38/No. 1 • 96% are located in the school building. • 57% are located in urban communities. • 80% serve adolescents (grade 6th or higher). • Almost three-quarters of students served are from minority or ethnic populations. • 82% have a school-employed mental health provider (licensed clinical social worker, substance abuse counselor, or psychologist). • Mental health services provided range from crisis intervention, referral, and on-going counseling. In addition, outcome data related to mental health showed that schoolbased health clinics enhanced children’s and adolescents’ access to care. Data revealed that adolescents are 10 to 21 times more likely to receive mental health services at the schoolbased health clinic than at a health maintenance organization (HMO), depressed and suicide-prone students were more willing to go to the schoolbased health clinic for counseling, and students who received mental health services had an 85% decline in school discipline problems (Allison et al., 2007; Juszczak, Melinkovich, & Kaplan; 2003; NASBHC, 2009). The AAP’s Policy Statement on School-Based Mental Health Services (2004) advocates for a school-based health clinic as a means for improving access and diagnosis for mental health problems. The term “underserved population” implies inadequate resources. Lacking adequate resources is an environmental stressor, implying that adolescents seen by a school-based health clinic either have or are at risk for mental health care needs. Inevitably, the schoolbased health clinic may be the only place where underserved children and adolescents access health care. Theoretical Framework: An Ecological Perspective The ecological perspective underscores the individual and the contextual system (environment), and the interrelationship between the two (McLaren & Hawe, 2005; NewesAdeyi, Helitzer, Caulfield, & Bronner, 2000). This ecological perspective provides structure and a framework to guide practice. According to this perspective, an individual’s capacity to remain healthy depends on this interdependence (Bronfenbrenner, 1979; 2004). Inherent in this perspective is the individual’s capability to relate to interactions with key elements in the environment, such as the family, community, culture, and society. Recent literature reveals the utility of the theory in addressing mental health problems with adolescents (Cooper, Lezotte, Jacobellis, & DiGuiseppi, 2006; Frankford, 2007; Garcia & Saewye, 2007). When an adolescent has stressors (such as limited social or economic resources, or a chronic illness), the capacity to remain healthy is much more challenging. Methods This study used qualitative exploratory design (Holloway & Wheeler, 2002) through interviews focused on perceptions of the mental health care of adolescents within a school-based health clinic in Chicago. Institutional Review Board approval was obtained from the Office for the Protection of Human Subjects at the children’s hospital and DePaul University. Setting The school-based health clinic is located within one of the city’s lowest resource communities, with more than 96% of students from lowincome and working poor families. Health center staff included a medical director and physician certified in adolescent medicine, a family nurse practitioner, a certified medical assistant, an office manager, a licensed clinical social worker (LCSW), a dietitian, and a community advocate. The student population was diverse: 64% African American or African; 22% Latino; 7% Asian/Pacific Islander; 4% Caucasian; and 3% mixed ethnicity. More than 20% of students lived in homeless shelters or Department of Children and Family Services facilities, and almost 22% had a form of physical or learning disability. Many students lived in single-parent, foster-parent, or blended households. For students who had insurance, Medicaid was the most common source. Many students and their families experienced insurmountable problems, such as illiteracy, poverty, lack of transportation, and/or housing necessitating a referral to the schoolbased health clinic’s LCSW. Preliminary data showed that 428 students visited the clinic, for a total of 1,465 visits. During a six-month period, the social worker saw 84 (17%) adolescents out of 480 enrolled in the 2007-2008 school year. PEDIATRIC NURSING/January-February 2012/Vol. 38/No. 1 Sample Selection And Recruitment Process Clinic personnel conducted a medical chart review to determine whether or not the subject met the criteria. Criteria for an adolescent to participate in the study included having a current consent for treatment signed by his or her parents, were between the ages of 12 and 18 years, and who had a minimum of two sessions with the LCSW at the clinic. The adolescent also had to have received a DSM-IV-TR diagnosis during the oneyear period data were being collected. A convenient purposive sample of 18 adolescents with Axis I diagnoses was used for this study. The sample was chosen selectively from the 84 students who were receiving mental health services based on their DSM diagnosis. All participants were selected through a purposive sampling process using the following steps: • Obtain a list of all adolescents 12 through 18 years of age with an Axis 1 diagnosis who were seen by the school-based health clinic’s LCSW. • Stratify the sample into subgroups by age group (12 to 14 years old, 15 to 16 years old, 17 to 18 years old) and gender. • Place each sub-group in alphabetical order. • Draw a sample of male and female students, starting with the top of the alphabet in descending order. Demographic characteristics of the sample can be found in Table 1. The LCSW provided a DSM IV-TR diagnosis (American Psychiatric Association [APA], 2000). The majority of students were diagnosed with adjustment reaction with mixed emotions, mixed disturbance of emotions, and conduct disorder (see Table 2). Procedure Prior to the onset of the study, parent(s) provided written permission/ consent for their adolescent to participate in the research, and each adolescent participant also provided written assent/consent. Each participant completed a demographic information survey. The researchers conducted 18 individual, face-to-face interviews with adolescents within the age groups of 12 to 14 years, 15 to 16 years and 17 to 18 years old. Adolescents were interviewed once in a private room at the school-based health clinic. Interviews, which were scheduled for one hour, ranged in length between 7 and 50 minutes, and were audiotape recorded. All participants 25 Life Concerns and Perceptions of Care in Adolescents with Mental Health Care Needs: A Qualitative Study in a School-Based Health Clinic Table 1. Characteristics of Adolescents (N = 18) Percentagea N Gender Male 8 45 Data Analysis 10 55 12 64 Asian 0 0 Hispanic 5 26 Native American 1 5 Caucasian (non-Hispanic) 1 5 12 to 14 3 17 15 to 16 8 44 17 to 18 7 39 Audiotapes were transcribed by a transcriptionist into Microsoft Word©. Demographic data were analyzed with descriptive techniques and are presented in table form in the findings section (see Table 3). To maintain anonymity and protect each participant’s confidentiality, the researchers de-identified each participant by giving him or her an acrostic name. Content analysis was used to analyze data, and responses for each interview were categorized by research objective topics: a) concerns of adolescents with mental health care needs, b) most pressing resource needs, c) helpful resources for adolescents, and d) difficulties in accessing resources for mental health care needs. Within each category, common issues/themes were identified and coded. After codes were identified, the researchers explored the interviews for conceptual themes. A constant comparison technique was used to develop ...
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