Study shows strengths, gaps in quality of care for kids in California’s public mental health clinics

A UCLA-led study of children’s patient records at California’s public mental health clinics identifies strengths and gaps in quality of care.

Published in the February edition of the Journal of the American Academy of Child and Adolescent Psychiatry, the study examines safety and appropriateness of care for attention deficit hyperactivity disorder (ADHD), conduct disorder and major depression in the public clinics. It is the first statewide study on quality of care for children.

The study gives high marks to the comprehensiveness of mental health evaluations, but finds moderate to poor documentation of medical monitoring psychoactive medications, child abuse screening and reporting, parent consent for medication treatment, and recommended contact with schools and other health-care providers. For example, nearly three-quarters of patient records of children receiving psychoactive medication did not document adequate safety monitoring through vital signs or laboratory studies.

“Findings from this study raise serious questions about the documentation of the child’s response to medication treatment and the adequacy of medical monitoring” said Dr. Bonnie T. Zima, principal investigator and professor in residence of psychiatry and biobehavioral sciences at the UCLA Neuropsychiatric Institute and the David Geffen School of Medicine at UCLA. “Our research team looks forward to working with the state and county mental health departments on developing programs to improve the quality of care that children receive and the documentation of that care.”

The study was sponsored by the California Department of Mental Health with additional funding provided by the National Institute of Mental Health. Institutional research partners were the National Research Center on Asian American Mental Health at the University of California at Davis; the Center for Mental Health Services Research at the University of California at Berkeley and at San Francisco; Child and Adolescent Services Research Center at Children’s Hospital in San Diego; and the UCLA/RAND NIMH Center for Research on Quality in Managed Care, led by Dr. Kenneth B. Wells. The medical record study was based at the UCLA Neuropsychiatric Institute.

With this study, the State of California Department of Mental Health is the first public agency to critically examine the quality of care provided to children in outpatient mental health clinics, funded by Medicaid. “These data will be tremendously useful in setting priority areas for improvement of care for children,” said Dr. Stephen Mayberg, director of California’s Department of Mental Health. “Safety and delivery of treatment with proven effectiveness are our highest priorities. Overall, this data is encouraging documenting that the public mental health system is using a comprehensive approach of both psychosocial and medical interventions to treat a very troubled and difficult population. This research will be useful in identifying gaps and helping us set priority areas for improvement of care for children.”
The research team scrutinized the medical records of 813 children, ages 6 to 17, from 62 clinics in 21 California counties for documentation of more than 100 indicators of quality care, based upon scientific evidence and clinical consensus by a national expert panel. The study assessed whether or not specific clinical care recommendations, from assessment to treatment to follow-up, were reported in the medical record. Documentation of the care is important because the patient chart is the main source for clinical information, treatment, and progress for the treatment team in the mental health clinic.

The study focused on care for ADHD, major depression, and conduct disorder because they are the most common disorders encountered by clinicians, and effective treatments are available.

Among specific findings:

• Children receiving care in mental health clinics have serious disadvantages:
  • About one-half of the children had moderate to severe functional impairment (or moderate to severe problems in functioning);
  • One out of every five children had at least one parent who had been incarcerated;
  • Almost 30 percent of children were reported to be victims of abuse or neglect;
  • One-half of the children had at least one parent with documented substance abuse;
  • 16 percent were living in foster care.

• The quality of care did not differ for children of color, girls, or children served in poorer or more rural counties, even when statistically considering the child’s clinical severity and high rate of psychosocial risk factors.
  Psychosocial treatments were recommended for 93 percent of children.

• Among children that required a medication evaluation, 83 percent received a referral or their record noted why it was not done, such as parent preference.
• Only 28 percent of the children’s records documented monitoring of at least one vital sign or laboratory study, as clinically recommended for the medication regimen prescribed.
• Only one-half of the children were screened for suspected child abuse, and more than one-third of the cases of documented suspected abuse noted that the legally required child abuse report was made.
• About one quarter of the records did not document informed parent consent for release of sensitive clinical information or medication treatment.

In addition to Zima and Wells, the research team included Heather Ladd, Lingqi Tang, and Naihua Duan of the UCLA Neuropsychiatric Institute; Michael S. Hurlburt and John Landsverk of Children’s Hospital in San Diego; Penny Knapp of the California Department of Mental Health and the University of California at Davis, Peggy Wallace of Santa Monica, Calif.-based RAND Corp.; and Abram Rosenblatt of the University of California at San Francisco.