Estimation Methodology for Children With a Serious Emotional Disturbance (SED)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Estimation Methodology for Children With a Serious Emotional

Disturbance (SED)

AGENCY: Center for Mental Health Services, Substance Abuse and Mental

Health Services Administration, HHS.

ACTION: Solicitation of comments.

-----------------------------------------------------------------------

SUMMARY: This notice describes the proposed methodology for identifying

and estimating the number of children with a serious emotional

disturbance (SED) within each State. This notice is being served as

part of the requirement of Public Law 102-321, the ADAMHA

Reorganization Act of 1992.

Comment Period: The Administrator is requesting written comments which

must be received on or before December 5, 1997.

Addresses: Comments should be sent to Judith Katz-Leavy, M.Ed., Senior

Policy Analyst, Office of Policy, Planning, and Administration, Center

for Mental Health Services, Parklawn Building Room 15-87, 5600 Fishers

Lane, Rockville, MD 20857. (301) 443-1563 fax.

For Further Information Contact: A detailed paper outlining the

estimation methodology described here is available from: Judith Katz-

Leavy M.Ed., Senior Policy Analyst, Office of Policy, Planning, and

Administration, Center for Mental Health Services, Parklawn Building

Room 15-87, 5600 Fishers Lane, Rockville, MD 20857. (301)443-1563 fax.

Background

Public Law 102-321, the ADAMHA Reorganization Act of 1992, amended

the Public Health Service Act and created the Substance Abuse and

Mental Health Services Administration (SAMHSA). The Center for Mental

Health Services (CMHS) was established within SAMHSA to coordinate

Federal efforts in the prevention, treatment, and promotion of mental

health. Title II of Public Law 102-321 establishes a Block Grant for

Community Mental Health Services (Block Grant) administered by CMHS,

which permits the allocation of funds to States for the provision of

community mental health services to children with a serious emotional

disturbance and adults with a serious mental illness. Public Law 102-

321 stipulates that States estimate the incidence (number of new cases)

and prevalence (total number of cases in a year) in their applications

for Block Grant funds, see 42 U.S.C. 300 (2). The statute also requires

the Secretary to establish definitions for adults with a serious mental

illness and children with a serious emotional disturbance. In addition,

the Secretary is required to develop standardized methods for the

states to use in providing the estimates required as part of their

block grant applications. See 42 U.S.C. 300 (2). As part of the process

of implementing this new block grant, definitions of the terms

``children with a serious emotional disturbance'' and ``adults with a

serious mental illness'' were announced on May 20, 1993, in Federal

Register Volume 58, No 96, p. 29422. Subsequently, a group of technical

experts was convened by CMHS to develop an estimation methodology to

``operationalize the key concepts'' in the definition of children with

a serious emotional disturbance. A similar group has prepared an

estimation methodology for adults with a serious mental illness.

Serious Emotional Disturbance (SED)

The CMHS definition is that ``children with serious emotional

disturbance'' are persons:

--From birth up to age 18;

--Who currently or at any time during the past year;

--Have had a diagnosable mental, behavioral, or emotional disorder of

sufficient duration to meet diagnostic criteria specified within DSM-

III-R

--That resulted in functional impairment which substantially interferes

with or limits the child's role or functioning in family, school, or

community activities (p.29425).

The definition goes on to indicate that, ``these disorders include

any mental disorder (including those of biological etiology) listed in

DSM-III-R or their ICD-9-CM equivalent (and subsequent revisions) with

the exception of DSM-III-R `V' codes, substance use, and developmental

disorders, which are excluded, unless they co-occur with another

diagnosable serious emotional disturbance'' (p. 29425).

Further, the definition indicates that, ``Functional impairment is

defined as difficulties that substantially interfere with or limit a

child or adolescent from achieving or maintaining one or more

developmentally-appropriate social, behavioral, cognitive,

communicative, or adaptive skills. Functional impairments of episodic,

recurrent, and continuous duration are included unless they are

temporary and expected responses to stressful events in their

environment. Children who would have met functional impairment criteria

during the referenced year without the benefit of treatment or other

support services are included in this definition'' (p. 29425).

The first decision that was made was to focus on community

epidemiological studies done in the United States that used either the

DSM-III-R, or its predecessor, the DSM-III, and that provided

information on the prevalence of mental disorders using a structured

interview procedure. The group decided that given the relatively small

number of community epidemiological studies that had been conducted in

the United States, it would be a mistake to exclude those few studies

that had used the DSM-III, given its considerable similarity to the

DSM-III-R.

The most frequently used structured interview procedure was the

Diagnostic Interview Schedule for Children (DISC), originally developed

by A. Costello and his colleagues (A. Costello, Edelbrock, Dulcan,

Kalas, & Klaric, l984), which includes both child and parent versions.

Other interview procedures include the Diagnostic Interview for

Children and Adolescents (DICA, Herjanic & Reich, l982), the Child and

Adolescent Psychiatric Assessment (CAPA, Angold & E. Costello, l995),

and the Composite International Diagnostic Interview (CIDI, Kessler et

al, 1994).

The group elected to consider that a child met the criteria of a

diagnosable disorder either if a diagnosis was obtained from his/her

own report on the structured interview, or from the parent's report on

the structured interview, or from the combination of the youth's report

and the parent's report, even if neither one met the criteria

separately. While there are other approaches to combining data from two

or more sources that were considered and have been used (Cohen, Velez,

& Kohn, l987; Reich & Earls, 1987), the group chose to use this

``either/or'' approach because it was believed that

[[Page 52140]]

discrepant responses can be a source of valuable information.

The greater challenge for the group was operationalizing the

concept of ``functional impairment which substantially interferes with

or limits the child's role or functioning in family, school, or

community activities'' (Federal Register, l993, p. 29425). Part of the

difficulty was in identifying appropriate measures, and understanding

the inter-relationship between the different measures, but the greatest

difficulty was in determining the appropriate threshold or cut-off

point on a scale for concluding that there was functional impairment

that was ``substantially'' interfering with functioning.

After much discussion, it was decided that in the absence of any

``gold standard'' that could be used as a basis for establishing such a

cut-off point, and in the absence of any social validation process that

has established a consensus on what the threshold should be, data would

be presented for cut-off points at two levels of functional impairment.

This has the benefit of providing additional information to planners

and policy-makers to use, and to stimulate further discussion and

research to try to better establish an appropriate threshold. The

higher prevalence rate to be reported, which uses the more inclusive or

less conservative cut-off point, still meets the definition of

``seriously emotionally disturbed.'' The less inclusive and more

conservative estimate can be used for more targeted efforts to plan on

behalf of a more limited number of children whose level of functional

impairment is especially severe.

A variety of measures of impairment were used in the community

studies, and their psychometric properties were reviewed for the group

by Hodges (l994). The most frequently used measure is a global measure,

the Children's Global Assessment Scale (Bird, Canino, Rubio-Stipec, &

Ribera, 1987; Shaffer, Gould, Brasic, Ambrosini, Fisher, Bird, &

Ahwalia, 1983), on which a youngster receives a rating ranging from 0

to 100 with lower scores indicating greater impairment. Scores are

given in ten point intervals, and for each score there is a narrative

description of the meaning of the score.

The group considered several potential cut-off points on the CGAS,

and decided to use a score of 60 or lower as the cut-off point for the

less conservative definition of serious emotional disturbance. The

narrative description for 60 is:

``Variable functioning with sporadic difficulties or symptoms in

several but not all social areas. Disturbance would be apparent to

those who encounter the child in a dysfunctional setting or time but

not to those who see the child in settings where functioning is

appropriate.''

This decision was made partly on the basis of the work by Bird and

his colleagues that indicates that, ``Empirical work has demonstrated

that the optimal cut-off score on the CGAS that demonstrates definite

impairment is a score lower than 6l'' (Bird, Shaffer, Fisher, Gould,

Staghezza, Chen, & Hoven, l993, p. 103).

The score of 50 will be used as the more stringent cut-off point to

denote the more severe impairment. The narrative description for 50 is:

``Moderate degree of interference in functioning in most social areas

or severe impairment of functioning in one area, such as might result

from, for example, suicidal preoccupations and ruminations, school

refusal and other forms of anxiety, obsessive rituals, major conversion

symptoms, frequent anxiety attacks, frequent episodes of aggressive or

other anti-social behavior with some preservation of meaningful social

relationships''.

Data Sources

There are no national epidemiological studies of mental disorders

for children and/or adolescents that have been conducted in the United

States. This deficit makes it difficult to derive prevalence rates that

are generalizable to the entire United States. In the absence of

national studies, the group chose to examine the results from eight

smaller, and more localized studies including, Kashani, et.al (1987),

Costello, et. al (1988) (1994), Bird, et. al (1988), Kessler, et. al

(1994), Jensen, et. al (1995), MECA (Lahey, et. al, 1996, Shaffer, et.

al, 1996), and Costello, et. al (1995). (see Table 1 for a summary of

these studies).

The group of technical experts determined that it is not possible

to develop estimates of incidence using currently available data.

However, it is important to note that incidence is always a subset of

prevalence. In the future, incidence and prevalence data will be

collected.

Table One.--Summary of Studies

----------------------------------------------------------------------------------------------------------------

SystemSample size and

Study Measure and DSM system age Measure of impairment

----------------------------------------------------------------------------------------------------------------

Kashani et al 1987................... DICA/DSMIII............ N=150, 14-16 yr. olds.. Rating of 3 or 4 by

Clinicians on 4 Point

Scale of Need for Tx

and Impairment.

Costello et al 1988.................. DISC 1.3 DSMIII........ Screened=789, CGAS 60 or less.

Interviewed=278, 7-11

yr. olds.

1994 (follow-up)..................... DISC 2.3 DSMIIIR....... Screened=789, CGAS 60 or less.

Interviewed=263, 12-18

yr. olds.

Bird et al 1988...................... DISC 1.3*/DSMIII....... n=777 first stage n=386 CGAS 60 or less.

second stage 4-16 yr.

olds

Kessler et al 1994................... CIDI/DSMIII-R (adult n=600 (about) 15-17 yr. Aggregation of 5

diagnoses). olds (Part of study of Measure.

15-54 yr. olds).

Jensen et al 1995.................... DISC2.1/DSMIIIR........ n=295 6-17 yr. old..... In tx or in

need of tx.

Internal

Impairment (1 or

more).

Internal

Impairment (2 Domains

or more).

MECA (Lahey et al, 1996 Shaffer et DISC2.1/DSMIII-R....... n=1265 9-17 yr. olds... CGAS 60 or

al, 1996). Less.

CGAS 50 or

less.

Internal

Impairment,

(3 or more),

(5 or more).

[[Page 52141]]

Costello et al 1995.................. CAPA/DSMIII-R.......... 2 stages n=4500 9, 11, Internal

and 13 yr. olds. Impairment,

(1 or more),

(2 or more),

(3 or more).

CGAS (60 or

less) CAFAS (20 or

higher).

----------------------------------------------------------------------------------------------------------------

Estimation Procedures

Based on the CMHS definition of serious emotional disturbance, and

the existing data bases which provide prevalence rates that can be

applied to this definition, it is estimated that the prevalence rate of

serious emotional disturbance in children 9-17 years of age is in the

range of 9-13 percent. Presently, the data are inadequate to estimate

prevalence rates for children under the age of nine. It is also

concluded that if a more stringent definition of impairment is desired

than was used for the estimated range of 9-13 percent, then the range

is from 5-9 percent. The difference between the two estimates is that

the measured level of functional impairment is greater in the second

estimate and has been characterized in Figure 1 as ``extreme functional

impairment.'' Children at both levels of impairment are considered to

have a ``serious emotional disturbance'' however; the group of children

falling into the range of 5-9 pecent constitutes a subset of the 9-13

percent.

It should be noted that the estimated prevalence range for 9-17

year olds is higher than the range recommended by Kessler et al. (1995)

for serious mental illness in adults (5.7 percent). The higher estimate

for 9-17 years olds is consistent with the fact that using the National

Comorbidity Study (NCS) data base, which served as the main data base

for the estimation of prevalence in adults, Kessler found that the 12

month prevalence for 15-17 year olds was 8.7 percent. The twelve month

prevalance for 18-54 year olds was 6.5 percent. To further understand

this difference, however, it is important to recognize that within the

18-54 year range there are differences associated with age. For

example, in Kessler's first article, it was reported that ``disorders

are consistently most prevalent in the youngest cohort (age range 15-24

years) and generally decline monotonically with age'' (Kessler et al.,

1994, p. 13). This was also the case with serious mental illness, as

reported by Kessler et al. (1995). This finding of highest prevalence

rates in youngest adults with rates decreasing with increasing age was

not only obtained in the NCS but also in the Epidemiological Catchment

Area study, completed in the early 1980s (Regier et al., 1988). Also,

the longitudinal research by Cohen et al. (1993), and the findings by

Reinherz et al. (1993) on 17-19 year olds point to especially high

prevalence rates for older adolescents.

Within the 9-17 year age range, the data are adequate to permit

determination of gender and socio-economic differences but are not

adequate to permit determination of race differences. The comparative

analyses by Costello & Messer (l995) are particularly useful for

looking at gender and socio-economic differences. Both for global and

specific measures of impairment, they find the prevalence rates of

serious emotional disturbance in the samples already mentioned to be

about twice as high in low socio-economic groups as in high socio-

economic groups. This finding is consistent for every one of the seven

data bases included in the analysis by Costello & Messer (l995). Jensen

et al. (l995) fail to find different prevalence rates by socio-economic

status in their study. However, as they point out the socio-economic

range in their sample was limited by the fact that all of the

youngsters were military dependents.

The following steps were taken to adjust for the difference in

state socio-economic circumstances. The 1995 estimates of children and

adolescents with serious emotional disturbance by state are provided in

Table 3.

Step 1

States were sorted by poverty rates (1995), in ascending order.

Using this sort order, States were initially classified into three

groups of equal proportions, i.e., the first 17 states were put into

Group A; the next 17 States into Group B; the remaining 17 States, into

Group C. However, in reviewing the results, we noted that observations

17 and 18 differed by .01 percent. Observation number 18 was included

in group A. For this reason, Group A has 18 cases, Group B has 16

cases, and Group C has 17 cases. Group A is the group that has a

relatively low percentage of children in poverty. Group B is the mid

point, and Group C is the group with the highest percentage of children

in poverty.

Step 2

At a level of functioning of 50 (LOF=50), the number of children

and adolescents with SED is calculated to be between 5-7 percent of the

number of youth 9-17 years for Group A. For Group B, the estimate is

between 6-8 percent of the number of youth 9-17 years. The estimated

SED population for Group C is calculated to be between 7-9 percent of

the number of youth 9-17 years.

Step 3

At a level of functioning of 60 (LOF=60), the number of children

and adolescents with SED is calculated to be between 9-11 percent of

the number of youth 9-17 years for Group A. For Group B, the estimate

is between 10-12 percent of the number of youth 9-17 years. The

estimated SED population for Group C is calculated to be between 11-13

percent of the number of youth 9-17 years.

[[Page 52142]]

Table 2.--1995 Estimates of Children and Adolescents With Serious Emotional Disturbance; State Estimates

Algorithms

----------------------------------------------------------------------------------------------------------------

Estimated population

---------------------------------------------------

LOF*=50 LOF*=60

States ---------------------------------------------------

Lower limit Upper limit Lower limit Upper limit

(percent) (percent) (percent) (percent)

----------------------------------------------------------------------------------------------------------------

Group A, Lowest percent in poverty.......................... 5 7 9 11

Group B, Medium percent in poverty.......................... 6 8 10 12

Group C, Highest percent in poverty......................... 7 9 11 13

----------------------------------------------------------------------------------------------------------------

*LOF=Level of functioning from the Children's Global Assessment Scale.

Table 3.--1995 Estimates of Children and Adolescents With Serious Emotional Disturbance by State

----------------------------------------------------------------------------------------------------------------

LOF*=50 LOF*=60

State Number of Percent in ---------------------------------------------------

youth 9-17 poverty Lower limit Upper limit Lower limit Upper limit

----------------------------------------------------------------------------------------------------------------

Total...................... 33,706,204 ........... 2,118,269 2,792,391 3,466,516 4,140,636

1 New Hampshire.............. 147,695 4.07 7,385 10,339 13,293 16,246

--------------------------------------------------------------------------------

2 Alaska..................... 90,955 8.96 4,548 6,367 8,186 10,005

3 New Jersey................. 932,671 9.60 46,634 65,287 83,940 10,259

4 Utah....................... 349,086 9.76 17,454 24,436 31,418 3,839

5 Minnesota.................. 643,892 11.30 32,195 45,072 57,950 70,828

6 Colorado................... 491,930 11.34 24,597 34,435 44,274 54,112

7 Nebraska................... 231,037 11.62 11,552 16,173 20,793 25,414

8 Missouri................... 709,439 11.74 35,472 49,661 63,850 78,038

9 Kansas..................... 354,722 12.55 17,736 24,831 31,925 39,019

10 Wisconsin.................. 706,004 12.56 35,300 49,420 63,540 77,660

11 Hawaii..................... 143,901 13.97 7,195 10,073 12,951 15,829

12 North Dakota............... 91,443 14.13 4,572 6,401 8,230 10,059

13 Virginia................... 790,359 14.38 39,518 55,325 71,132 86,939

14 Nevada..................... 186,695 14.41 9,335 13,069 16,803 20,536

15 Indiana.................... 758,633 15.24 37,932 53,104 68,277 83,450

16 Rhode Island............... 115,176 15.36 5,759 8,062 10,366 12,669

17 Delaware................... 85,396 15.56 4,270 5,978 7,686 9,394

18 Maine...................... 160,434 15.57 8,022 11,230 14,439 17,648

19 Vermont.................... 76,500 15.79 4,590 6,120 7,650 9,180

20 Maryland................... 608,209 15.80 36,493 48,657 60,821 72,985

21 Wyoming.................... 75,106 16.21 4,506 6,008 7,511 9,013

22 Georgia.................... 942,161 16.30 56,530 75,373 94,216 113,059

23 Massachusetts.............. 680,101 17.12 40,806 54,408 68,010 81,612

24 Iowa....................... 385,583 17.39 23,135 30,847 38,558 46,270

25 Washington................. 714,567 17.81 42,874 57,165 71,457 85,748

26 Connecticut................ 378,473 18.03 22,708 30,278 37,847 45,417

27 Pennsylvania............... 1,462,731 18.07 87,764 117,018 146,273 175,528

28 Oregon..................... 411,543 18.22 24,693 32,923 41,154 49,385

29 Michigan................... 1,275,452 18.36 76,527 102,036 127,545 153,054

30 Ohio....................... 1,451,220 19.33 87,073 116,098 145,122 174,146

31 Idaho...................... 183,829 20.57 11,030 14,706 18,383 22,059

32 South Dakota............... 108,855 20.74 6,531 8,708 10,886 13,063

33 North Carolina............. 879,091 21.06 52,745 70,327 87,909 105,491

34 Kentucky................... 504,373 21.25 30,262 40,350 50,437 60,525

35 Illinois................... 1,517,182 22.14 106,203 136,546 166,890 197,234

36 Tennessee.................. 658,573 22.23 46,100 59,272 72,443 85,614

37 Montana.................... 126,834 22.39 8,878 11,415 13,952 16,488

38 Arkansas................... 337,718 22.44 23,640 30,395 37,149 43,903

39 Texas...................... 2,623,654 24.53 183,656 236,129 288,602 341,075

40 California................. 3,968,950 24.97 277,827 357,206 436,585 515,964

41 Oklahoma................... 457,496 24.98 32,025 41,175 50,325 59,474

42 Arizona.................... 542,019 25.31 37,941 48,782 59,622 70,462

43 Florida.................... 1,623,697 25.50 113,659 146,133 178,607 211,081

44 New York................... 2,141,435 25.51 149,900 192,729 235,558 278,387

45 West Virginia.............. 231,390 26.93 16,197 20,825 25,453 30,081

46 Alabama.................... 547,671 27.50 38,337 49,290 60,244 71,197

47 Louisiana.................. 639,158 29.69 44,741 57,524 70,307 83,091

48 South Carolina............. 470,875 32.11 32,961 42,379 51,796 61,214

49 Washington, DC............. 48,365 35.33 3,386 4,353 5,320 6,287

50 New Mexico................. 251,231 36.59 17,586 22,611 27,635 32,660

51 Mississippi................ 392,694 37.03 27,489 35,342 43,196 51,050

----------------------------------------------------------------------------------------------------------

[[Page 52143]]

Analyses show very similar prevalence rates for girls and boys in

the seven sites. The absence of gender differences is also apparent in

the findings of Jensen et al. (1995). Kessler (1995), however, reports

a higher prevalence rate in females than males using the adult

diagnostic categories, and an older adolescent sample (15-17 year

olds). There is no indication that overall prevalence rate of serious

emotional disturbance differs by gender within the 9-17 year age range

although there clearly are gender differences in prevalence of

particular diagnoses, such as conduct disorder and depression, and

there are suggestions that the rates may diverge in later years of

adolescence.

Overall, there is support for the use of socio-economic status as a

correction factor in developing a methodology for the estimation of the

prevalence of serious emotional disturbance. There is no empercial

basis at this point for using other correction factors.

Conclusions

Of the 33 million children and adolescents between the ages of 9-17

in the United States, 9-13 percent or 3.5-4 million of these youngsters

have a serious emotional disturbance at a score of 60 or lower on the

Children's Global Assessment Scale. A more stringent definition of

impairment, representing a score of 50 or lower on the Children's

Global Assessment Scale shows a range of 5-9 percent or 2.1-2.8 million

youngsters with a serious emotional disturbance (see Figure 1).

Currently there are not sufficient studies to determine the prevalence

rate in very young children ages birth--8. Therefore the estimated

number of children with serious emotional disturbance presented here is

a low estmate since it only included data for 9-17 year olds.

Limitations

There are several limitations for these estimates. First, it must

be recognized that these estimated ranges are based on the findings

from many modest-sized studies which varied not only in population but

often in instruments that were used (particularly for measurement of

impairment), methods that were used to collect the data, and even the

diagnostic system that was used.

Second, there are only two studies that include youngsters under

the age of nine, and these studies are not adequate to provide a base

for any estimate of the prevalence of serious emotional disturbance for

children under the age of nine. The estimate presented here is intended

for children between nine and 17 years of age.

Third, the data are also inadequate to determine prevalence

estimates for children of different racial and ethnic backgrounds.

Several of the studies included youngsters of color in their sample and

two studies were done exclusively on Hispanic youngsters in Puerto Rico

(Bird et al., 1988, & one of the MECA sites). However, the sample sizes

are too small and not sufficiently representative of African-American,

Hispanic, Asian American, or native American populations to permit

estimates to be made.

Fourth, with the absence of any large national studies, it is not

possible to determine whether rates differ in urban versus rural areas,

or different regions of the country.

Scope of Application

Inclusion in or exclusion from the definition is not intended to

confer or deny eligibility for any service or benefit at the Federal,

State, or local levels. Only a portion of children with a serious

emotional disturbance seek treatment in any given year. Due to the

episodic nature of serious emotional disturbance, some children and

adolescents may not require mental health service at any particular

time. Additionally, the definition is not intended to restrict the

flexibility or responsibility of the State or local government to

tailor publicly funded service systems to meet local needs and

priorities. However, all individuals whose services are funded through

Federal Community Mental Health Services Block Grant funds must fall

within the criteria set forth in these definitions. Any ancillary use

of these definitions for purposes other than those identified in the

legislation is outside the purview and control of CMHS.

It is anticipated that additional work will be done in future years

to refine and update the estimation methodology. CMHS will keep States

apprised as this work develops.

References

Achenbach, T.M., & Edelbrock, C. (1983). Manual for the Child

Behavior Checklist and Revised Child Behavior Profile. Burlington,

VT: Queen City Printers.

Angold, A., & Costello, E.J. (1995). A test-retest reliability study

of child-reported psychiatric symptoms and diagnoses using the Child

and Adolescent Psychiatric Assessment (CAPA-C). Psychological

Medicine, 25, 755-762.

Bird, H.R., Canino, G., Rubio-Stipec, M., Gould, M.S., Riobera, J.,

Sesman, M., Woodbury, M., Huertas-Goldman, S., Pagan, A., Sanchez-

Lacay, A., & Moscoso, M. (1988). Estimates of the prevalence of

childhood maladjustment in a community survey in Puerto Rico.

Archives of General Psychiatry, 45, 1120-1126.

Bird, H.R., Canino, G., Rubio-Stipec, M., & Ribera, J. C. (1987).

Further measures of the psychometric properties of the children's

global assessment scale. Archives of General Psychiatry, 44, 821-

824.

Bird, H.R., Shaffer, D., Fisher, P., Gould, M.S., Staghezza, B.,

Chen, J. Y., & Hoven, C. (1993). The Columbia Impairment Scale

(CIS): Pilot findings on a measure of global impairment for children

and adolescents. International Journal of Methods in Psychiatric

Research, 3, 167-176.

Brandenburg, N.A., Friedman, R.M., & Silver, S. (1990). The

epidemiology of childhood psychiatric disorders: Recent prevalence

findings and methodologic issues. Journal of the American Academy of

Child and Adolescent Psychiatry, 29, 76-83.

Canino, G. (1994). Personal communication.

Cohen, P., Cohen, J., Kasen, S., Velez, C.N., Hartmark, C., Johnson,

J., Rojas, M., Brook, J., & Streuning, E.L. (1993). An

epidemiological study of disorders in late childhood and

adolescence: 1. Age and gender-specific prevalence. Journal of Child

Psychology and Psychiatry, 34, 851-867.

Cohen, P., Velez, C.N., Kohn, M., Schwab-Stone, M., & Johnson, J.

(1987). Child psychiatric diagnosis by computer algorithm:

Theoretical issues and empirical tests. Journal of the American

Academy of Child & Adolescent Psychiatry, 26, 631-638.

Costello, E.J. (1989). Developments in chidl psychiatric

epidemiology. Journal of the American Academy of Child and

Adolescent Psychiatry, 28, 836-841.

Costello, A.J., Edelbrock, C.S., Dulcan, M.K., Kalas, R., & Klaric,

S.H. (1984). Report on the NIMH Diagnostic Interview Schedule for

Children (DISC). Pittsburgh, Pa.: Department of Psychiatry,

University of Pittsburgh.

Costello, E.J., Angold, A., Burns, B.J., Erkanli, A., Stangl, D., &

Tweed, D. (1995). The Great Smoky Mountains Study of Youth: II.

Functional impairment and severe emotional disturbances. Unpublished

manuscript, Department of Psychiatry, Duke University.

Costello, E.J., Edelbrock, C., Costello, A.J., Dulcan, M.K., Burns,

B.J., & Brent, D. (1988). Psychopathology in pediatric primary care:

The new hidden morbidity. Pediatrics, 82, 415-424.

Costello, E.J., & Messer, S.C. (1995). Rates and correlates of

serious emotional disturbance: Secondary analysis of epidemiologic

data sets. Paper prepared for Center for Mental Health Services,

Rockville, Md.

[[Page 52144]]

Costello, E.J., & Tweed, D.L. (1994). A review of recent empirical

studies linking the prevalence of functional impairment with that of

emotional and behavioral illness or disorder in children and

adolescents. Paper prepared for the Center for Mental Health

Services, Rockville, Md.

Friedman, R.M., Kutash, K., & Duchnowski, A.J. (1996). The

population of concern: Defining the issues. In B. A. Stroul (Ed.),

Children's Mental Health: Creating Systems of Care in a Changing

Society. Paul H. Brookes, Baltimore, p. 69-95.

Hernjanic, B., & Reich, W. (1982). Development of a structured

psychiatric interview for children: Agreement between child and

parent on individual symptoms. Journal of Abnormal Child Psychology,

10, 307-324.

Hodges, K. (1990). Manual for the Child and Adolescent Functional

Assessment Scale. Unpublished manuscript, Ann Arbor, Michigan.

Hodges, K. (1994). Measures for assessing impairment in children and

adolescents. Paper prepared for the Center for Mental Health

Services, Rockville, MD.

Jensen, P.S., Watanabe, H.K., Richters, J.E., Cortes, R., Roper, M.,

& Liu, S. (1995). Psychopathology among children and adolescents

living on a military base. Journal of the American Academy of Child

and Adolescent Psychiatry, 34, 1514-1524.

Kashani, J.H., Beck, N.C., Hoeper, E.W., Fallahi, C., Corcoran,

C.M., McAllister, J.A., Rosenberg, T.K., & Reid, J.C. (1987).

Psychiatric disorders in a community sample of adolescents. American

Journal of Psychiatry, 43, 255-262.

Kessler, R.C. (1995). Personal communication.

Kessler, R.C., Berglund, P.A., Leaf, P.J., Kouzis, A.C., Bruce,

M.L., Friedman, R.M., Grosser, R.C., Kennedy, C., Kuehnel, T.G.,

Laska, E.M., Manderscheid, R.W., Narrow, B., Rosenbeck, R.A.,

Santoni, T.W., & Schneier, M. (1995). Estimation of the 12-month

prevalence of serious mental illness (SMI). Unpublished manuscript.

Center for Mental Health Services, Rockville, MD.

Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M.,

Eshleman, S., Wittchen, H.U., & Kendler, K.S. (1994). Lifetime and

12-month prevalence of DSM--III--R psychiatric disorders in the

United States: Results from the National Comorbidity Study. Archives

of General Psychiatry, 51, 8-19.

Lahey, B.B., Flagg, E.W., Bird, H.R., Schwab-Stone, M., Canino, G.,

Dulcan, M.K., Leaf, P.J., Davies, M., Brogan, D., Bourdon, K.,

Horwitz, S.M., Rubio-Stipec, M., Freeman, D.H., Lichtman, J.,

Shaffer, D., Goodman, S.H., Narrow, W.E., Weissman, M.M., Kandel,

D.B., Jensen, P.S., Richters, J.E., & Regier, D.A. (1996). The NIMH

methods for the epidemiology of child and adolescent mental

disorders (MECA) study: Background and methodology. Journal of the

American Academy of Child and Adolescent Psychiatry. 35, 855-864.

Leaf, P.J., Alegria, M., Cohen, P., Goodman, S.H., Horwitz, S.M.,

Hoven, C.W., Narrow, W.E., Vaden-Kiernan, M., Regier, D.A. (1996).

Mental health service use in the community and schools: Results from

the four-community MECA study. Journal of Child and Adolescent

Psychiatry 35, 889-897.

National Advisory Mental Health Council. (1993). Health care reform

for Americans with severe mental illnesses. American Journal of

Psychiatry, 150, 1447-1465.

Regier, D. A., Boyd, J. H., Burke, J. D., Jr., Rae, D. S., Myers, J.

K., Kramer, M., Robins, L. N., George, L. K., Karno, M., & Locke, B.

(1988). One-month prevalence of mental disorders in the United

States. Archives of General Psychiatry, 45, 977-986.

Reich, W., & Earls, F. (1987). Rules for making psychiatric

diagnoses in children on the basis of multiple sources of

information. Journal of Abnormal Child Psychology, 14, 601-616.

Reinherz, H. Z., Gianconia, R. M., Lefkowitz, E. S., Pakiz, B., &

Frost, A. K. (1993). Prevalence of psychiatric disorders in a

community population of older adolescents. Journal of the American

Academy of Child & Adolescent Psychiatry, 32, 369-377.

Robins, L. N. (1985). Epidemiology: Reflections on testing the

validity of psychiatric interviews. Archives of General Psychiatry,

42, 918-924.

Shaffer, D. Personal communication. July & August, 1994.

Shaffer, D., Fisher, P., Dulcan, M., Davies, M., Piacentini, J.,

Schwab-Stone, M., Lahey, B. B., Bourdon, K., Jensen, P., Bird, H.,

Canino, G., & Regier, D. (1996). The NIMH Diagnostic Interview

Schedule for Children (DISC 2): Description, acceptability,

prevalences, and performance in the MECA study. Journal of the

American Academy of Child and Adolescent Psychiatry, 35, 865-877.

Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P.,

Bird, H., & Aluwahlia, S. (1983). A children's global assessment

scale (CGAS). Archives of General Psychiatry, 40, 1228-1231.

Substance Abuse and Mental Health Services Administration (1993).

Final notice establishing definitions for (1) Children with a

serious emotional disturbance, and (2) adults with a serious mental

illness. Federal Register, 58(96), 29422-29425.

BILLING CODE 4160-20-U

[[Page 52145]]

[GRAPHIC] [TIFF OMITTED] TN06OC97.002

BILLING CODE 4160-20-C

Dated: September 22, 1997.

Richard Kopanda,

Executive Officer SAMHSA.

[FR Doc. 97-26372 Filed 10-3-97; 8:45 am]

BILLING CODE 4160-20-U