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Mental Health Service Use in a Community Head Start Population
Michelle New, PhD;
Brian Razzino, PhD;
Amy Lewin, PsyD;
Karen Schlumpf, MPH;
Jill Joseph, MD, PhD
Arch Pediatr Adolesc Med. 2002;156:721-727.
ABSTRACT
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Background Evaluating access to and delivery of mental health services for young
children was a primary objective of the national research demonstration program
Starting Early Starting Smart (SESS).
Objective To present preliminary findings on family mental health and use of services
in a community Head Start population at time of entry into a longitudinal
study as part of the SESS program.
Subjects Children enrolled for Head Start entry in 1998 and 1999 (N = 290; mean
age, 4.3 years). Of these children, 52% were boys.
Methods Data on demographic factors, child and parent mental health, and service
use were collected from the sample at baseline. Information was gathered from
primary caregivers and teachers using standardized questionnaires and structured
interviews.
Results There was low concordance between parent and teacher ratings of child
behavior. Factors predicting behavior problems in young children varied according
to whether the parent or teacher rated the child as having behavior problems.
Sex (male) and home environment were associated with teachers rating the child
as having a behavior problem. Parent mental health problems and problems in
the parent-child relationship were associated with parent ratings. Only home
environment was associated with child-focused service utilization (services
that help parents manage children's behavior).
Conclusions Demographic risk factors were not associated with child behavior problems
or use of mental health services in this group of Head Start children. Findings
suggest that children with behavioral problems have unmet mental health service
needs. Interventions designed to address both parent mental health needs and
sensitivity to the developmental needs of children may increase child-focused
mental health service utilization.
INTRODUCTION
THE MENTAL HEALTH needs of young children are of growing concern in
the field of primary care. In particular, children in the Head Start population
are considered to be at high risk for psychosocial problems due to concomitant
risk factors associated with poverty. The Head Start program was founded in
1965 to improve the social competence and school readiness of low-income children.
Incorporated into its original mission statement, mental health was seen as
the cornerstone of Head Start concepts such as prevention, outreach, early
detection, and family involvement.1-2
Providing appropriate mental health services to young children and families
in the Head Start program has remained a challenge because of increasing diversity
among families, poorly integrated service systems, resource difficulties,
and managed care restrictions.2
Service utilization research has begun to identify predictors of mental
health service use among children and adolescents; however, reviews indicate
conflicting findings about many of the variables associated with higher service
use. For example, low-income families were found to be overrepresented in
studies of referrals to mental health services in the Ontario Child Health
Study.3 Other research suggests that low income
is associated with low service use due to restrictions in access to mental
health care.4 Some research indicates that
middle-income families are also underserved because of ineligibility for subsidized
service or the inability to afford services.5
The consensus appears to be that whereas lower-income families are at higher
risk for mental health problems due to difficult social circumstances exacerbated
by poverty, low–middle-income families may not be adequately covered
by insurance. Other factors associated with lower child mental health service
use include younger age,1 minority status,4 and female sex.6 Little
research has focused on early childhood (<5 years) in terms of child mental
health service use. Studies that do include this age group indicate low rates
of service utilization for young children despite a significant rate of behavioral
and/or developmental difficulties, which places them at increased risk for
later psychiatric diagnoses.3, 7
Across multiple epidemiological studies, it is estimated that 10% to 15% of
preschool children have behavioral or emotional problems.8-9
Children from socioeconomically disadvantaged families are at higher risk
for developing behavior problems.10
Another factor related to the need for and use of child mental health
services is maternal mental health. Several studies have consistently found
that the mental health of the child's primary caregiver (usually the mother)
is a strong predictor of behavior problems in children.11
Women, and mothers in particular, are at high risk for depression, with rates
as high as 40% in mothers of preschool children.12
The purpose of this study was to examine both demographic and family
factors associated with child-focused mental health service utilization in
a group of preschool children. By understanding these variables, service needs
can be identified and potential ways to improve access and utilization by
low-income families can be devised.
SUBJECTS AND METHODS
This study investigates child-focused family mental health service utilization
by Head Start children and families enrolled in the Starting Early Starting
Smart (SESS) program. Based in Montgomery County, Maryland, this project was
conducted at one of 12 sites taking part in a national research demonstration
program funded by the Substance Abuse and Mental Health Services Administration
and the Casey Family Program. A primary objective of the SESS program was
to inform practice and policy to improve mental health and related services
for families, particularly those with low incomes.
SUBJECTS
Enrollment was based on eligibility for Head Start services in Montgomery
County, a large suburban county outside of Washington, DC. The study included
290 families. Of the enrolled Head Start children, 52% were boys and 48% were
girls. Many of the families in this sample were immigrants: 43% were from
Latin America, 22% were from non-Latino (African, Caribbean, or Asian) immigrant
families, and 35% were from nonimmigrant families. At the time of data collection,
the children ranged in age from 3.2 to 5 years with a mean ± SD age
of 4.3 ± 0.3 years. Most respondents were biological mothers (91.3%)
or biological fathers (6.25%). The predominant languages spoken in the home
were English (45.1%) and Spanish (44.1%). About one quarter (27.5%) of the
respondents had completed 12th grade (n = 80). The mean household income was
$1491 per month, and 62% of the primary caregivers were employed. Although
the SESS study is longitudinal in design, preliminary data presented in this
article relate only to child and parent functioning and service use.
PROCEDURE
Intervention and comparison groups were randomized by school rather
than by individual subjects. Prior to the enrollment of the first cohort of
families, 4 schools in the county with comparable demographics were selected
to participate in the study. Two were randomly designated as intervention
schools, and the other 2 as comparison schools. All families with children
enrolled in Head Start in those 4 schools during the 1998-1999 academic year
were informed about the study and invited to participate. Caregivers who expressed
interest in participating were visited in their homes by a research assistant,
who explained the study in greater detail and obtained consent from the target
child's primary caregiver. The process was repeated with 6 schools in the
1999-2000 academic year. The families enrolled from these schools constituted
the study's second cohort. Across the 2 cohorts, 46 families were approached
but refused to participate. Most (43%) of these families cited lack of time
as their reason for not participating. Excluded from both cohorts were 17
families in which none of the adult members spoke English or Spanish well
enough to give informed consent.
Data were collected by trained research assistants during home-based
interviews. The interviews took place as close as possible to enrollment in
the Head Start program and were conducted in either English or Spanish according
to the preference of the respondent.
MEASURES
Child Behavior
The Preschool and Kindergarten Behavior Scales (PKBS)13
are a rating instrument for use in evaluating problem behavior patterns in
preschool-aged children. This norm-referenced, standardized instrument was
developed for use in assessing young children in a variety of settings and
by different informants. The PKBS is a broad-based scale that comprises a
checklist of 42 problem behaviors commonly seen in the preschool-aged group.
It is a written parent report measure designed to assess behavioral and emotional
problems in young children. The respondent is asked to rate the frequency
of each behavior on a 4-point scale ranging from "never" (0) to "often" (3).
The PKBS yields raw scores that are combined into 3 global scores: an internalizing
score for emotional problems, an externalizing score for behavior problems,
and a total problems score. Higher scores indicate greater emotional and behavioral
problems. Internalizing problems include symptoms of depression, social withdrawal,
anxious and inhibited reactions, and the development of somatic problems.
Externalizing problems include behaviors that are aggressive, defiant, disruptive,
oppositional, and hyperactive. The PKBS was completed separately by parent
and teacher. Children were considered to have clinically significant behavior
problems if they scored within the moderate-deficit or severe-deficit range
of functioning. Reliability coefficients for the PKBS Total Problem behavior
scale for this sample were 0.91 for parent-completed scales and 0.96 for teacher-completed
scales.
Parent Mental Health
Parents completed the Brief Symptom Inventory (BSI).14
The BSI is a self-report measure that asks respondents to rate the degree
of distress experienced in the past 7 days from various psychological symptoms
on a 5-point scale (0, "not at all," to 4, "extremely"). The BSI consists
of 53 items and takes about 15 minutes to complete. The primary symptom dimensions
are somatization, obsessive-compulsive, interpersonal sensitivity, depression,
anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The
BSI yields raw scores for individual scales and subscales that are then converted
to T scores (mean ± SD standard score, 50 ± 10). T scores of
63 or higher on 2 of the 6 clinical subscales meet the criteria for a clinical
case. Reliability coefficients for each subscale of the BSI for this sample
ranged from 0.69 to 0.80. The Parenting Stress Index–Short Form (PSI-SF)15 is a 36-item self-report measure of the magnitude
of stress in a parent-child system, as perceived by the parent or primary
caregiver. Because of time constraints and similarity of items with the BSI
and PKBS, only 1 subscale was analyzed (Parent-Child Dysfunctional Interaction
[P-CDI]). The PSI-SF yields percentile scores for subscales, which are then
converted into standard scores (mean ± SD, 100 ± 15) for data
analysis purposes. Parents who obtained a subscale score at or higher than
the 90th percentile were considered to be experiencing clinically significant
levels of stress within the parent-child relationship. The P-CDI subscale
focuses on the parent's perception that the child does not meet the parent's
expectations and that parent-child interactions are not rewarding for the
parent (eg, "My child seems to cry or fuss more than most children," "My child
generally wakes up in a bad mood," or "My child does not like to be cuddled
or touched"). Reliability for this subscale was 0.88 for our sample.
The Conflict Tactics Scale16 (CTS) is
a 19-item self-report instrument that measures individual responses to conflict
within the family. The scales are intended to measure physical aggression
in the marital or adult relationship. A dichotomous variable (physical aggression)
was created indicating the presence or absence of violence in the adult relationship.
Violence was considered to be present if affirmative responses were given
to 1 or both of the following criteria: (1) 3 or more incidents of any violent
act, and/or (2) 1 incident of severe violence as defined in the CTS manual.
The reliability coefficient for the CTS Violence scale was 0.79 for this sample.
The Home Observation for Measurement of the Environment17
(HOME) is a 45-item interview and observation measure. Home visits were made
to assess subjects according to the HOME Inventory, which includes the following
domains: parental affection (responsivity), presence of materials to facilitate
or stimulate learning, and emotional and verbal reciprocity in the child's
home environment. Subscales of the HOME include learning material, language
stimulation, physical environment, academic stimulation, modeling, variety,
and acceptance. The reliability coefficient for the HOME scale was 0.82 for
this sample. Scores on the HOME were dichotomized into the categories "at
risk" and "other" for our study. Families with a score at or below the lowest
quartile of the total SESS sample (n = 82) were considered to be within the
clinically "at risk" range.
Instruments and their administration (eg, the use of short forms) were
selected by consensus of the SESS cross-site steering committee to ensure
national uniformity in measures across all subsites.
Mental Health Service Utilization
The Services Access and Utilization Scale (SAUS) was developed for the
SESS cross-site study to evaluate social and behavioral health service use.
The SAUS is a semistructured interview that includes questions about service
need and use for the respondent and target child in the past 12 months.
Child-Focused Family Mental Health Service Use.
Families were considered to have received child-focused services if
a positive response to 1 or both of the following items was obtained: (1)
use of parent education groups, and/or (2) consultation with a professional
to receive help specifically on parenting or managing child behavior.
Parent-Focused Mental Health Service Use.
Parents were considered to have received services if a positive response
to any 1 or more of the following items was obtained: (1) attended sessions
with a professional for problems with emotions or stress; (2) participated
in a support group to help with emotions or stress; (3) attended a substance
abuse treatment program (such as Alcoholics Anonymous); and/or (4) was admitted
to a psychiatric facility for mental health and/or substance use issues.
Demographic Risk
Risk factors for psychosocial adversity were identified using criteria
from the Annie E. Casey Family Risk Index18
based on data collected during the SAUS interviews. The Family Risk Index
comprises 6 demographic factors: (1) child is not living with 2 parents; (2)
household head did not complete high school; (3) family income is below the
federal poverty line; (4) child is living with parents who do not have steady,
full-time employment; (5) family is receiving welfare benefits; and (6) child
does not have health insurance. Whereas adjustment to 1 of these risk factors
may be challenging, prior research indicates that children living in families
with 1 risk factor are not likely to differ significantly on behavioral outcomes
from those with none. Except for a maximum of 10%, all children in Head Start
live in families whose income is below the state poverty line. Although likely,
it was not certain that many of the children in this sample would meet the
federal poverty line cutoff because of the more stringent (ie, lower income
level) federal poverty criteria. The federal cutoff was therefore included
as a potential risk factor. In combination, the presence of multiple risk
factors can have an additive and damaging effect on child development. For
this investigation, each family was given a cumulative risk factor score by
summing each risk factor present (1-6) to form a composite index. Given the
relatively small number of families (n = 21) with 4 or more risk factors,
our study deviated slightly from the methods used by the Annie E. Casey Foundation
by considering families with 3 or more risk factors to be at significant risk.
This step was taken to include a larger sample of families while maintaining
the sensitivity of the Annie E. Casey Family Risk Index.
Statistical Analysis
Frequency distributions and the mean and SD of the measures were examined.
An exploratory analysis was performed to identify potential variables that
might act as mediators of service use. Users of services were compared with
nonusers on categorical variables with the Fisher exact test.
Univariate odds ratios (ORs) between predictors (demographic risk, child
characteristics [sex], and family measures [HOME, BSI, PSI-SF, and CTS]) and
child- and parent-focused mental health utilization outcomes were computed
using logistic regression analyses. Univariate ORs were computed to analyze
the relationship between predictors for the following variables: (1) demographic
predictors and PKBS outcome variables (parent and teacher ratings of internalizing
and/or externalizing behavior problems); (2) demographic adult and child mental
health predictors of child-focused family mental health service utilization;
and (3) demographic adult and child mental health predictors of parent-focused
mental health service utilization. Subsequent to univariate regression analyses,
variables meeting the following criteria (P<.001)
were included in multivariate logistic regression equations to determine which
ones most effectively predicted scores on measures of internalizing and externalizing
behavior problems. Data were analyzed using SAS version 8.1 (SAS Institute
Inc, Cary, NC) and SPSS version 10.0 (SPSS Inc, Chicago, Ill) statistical
software.
RESULTS
SOCIODEMOGRAPHIC CHARACTERISTICS OF SAMPLE
Data were collected on 290 children enrolled in the SESS study at school
entry in 1998 and 1999 in 8 schools in Montgomery County. Of the total sample,
133 children (45.8%) were Latino, 73 (25.1%) were African American, and 15
(5.2%) were white. The children ranged in age from 3.2 to 5 years (mean ±
SD age, 4.3 ± 0.3 years). Most respondents were biological mothers
(91.3%) or biological fathers (6.25%). The predominant languages spoken in
the home were English (45.1%) and Spanish (44.1%). With regard to parent educational
level, 80 caregivers (27.5%) had completed 12th grade. Risk factors for psychosocial
adversity were identified using criteria from the Annie E. Casey Family Risk
Index based on data collected during the SAUS interviews. Frequency counts
for the 290 children on whom these data were collected were as follows: (1)
child is not living with 2 parents (n = 166; 57%); (2) household head did
not complete high school (n = 7; 2%); (3) family income is below the federal
poverty line (n = 140; 48%); (4) child is living with parents who do not have
steady, full-time employment (n = 83; 29%); (5) family is receiving welfare
benefits (n = 87; 30%); and (6) child does not have health insurance (n =
49; 17%).
CHILD BEHAVIOR PROBLEMS
As indicated in Table 1,
29% of this sample of children entering Head Start met the criteria for behavioral
problems, as rated by their parents (n = 84). For teachers, the rate was much
lower (12%; n = 32). Prevalence rates for internalizing and externalizing
diagnoses were similar (22% and 17%, respectively, for parent report, and
9% and 5%, respectively, for teacher report).
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Table 1. Children Identified as Having Behavior Problems and Their
Use of Child-Focused Family Mental Health Service*
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There was low concordance between parents' and teachers' ratings of
child behavior problems ( = 0.02; P = .75)
(Table 2 and Table 3). Differences between parent and teacher externalizing and
internalizing behavior rating scores were not significant, indicating that
differences in behavioral ratings were not attributed to the severity of behavior
problems observed (ie, teachers rating only very severe problems as clinically
elevated). Low parent-teacher concordance on child behavior ratings appears
to be consistent with previous research.19-20
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Table 2. PKBS Total Problem Behavior and Subscale Raw Scores*
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Table 3. Means and SDs for Clinically Significant Parent and Teacher
PKBS Ratings*
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PARENT MENTAL HEALTH
As presented in Table 4,
43% of the sample met the criteria for caseness on the BSI. Caseness is defined in the BSI manual as 2 or more elevated scales
and refers to the value or score on the screening measure that defines a positive
case (ie, the presence of parental mental health problems). Prevalence rates
for individual scales were as follows: paranoid ideation (46%), interpersonal
sensitivity (38%), obsessive-compulsive (28%), depression (27%), anxiety (21%),
and hostility (21%). As indicated in Table
5, 16% of the sample were in the clinically elevated range on the
P-CDI subscale of the PSI-SF.
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Table 4. BSI Total and Subscale Scores for Primary Caregivers*
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Table 5. Parenting Stress Index-Short Form Subscale Scores
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PREDICTORS OF CHILD BEHAVIOR PROBLEMS
Using univariate logistic regression to predict the risk of behavior
problems reported by parents, the significant variables were parent mental
health (caseness on the BSI), physical aggression between parents (CTS), and
elevated P-CDI scores on the PSI-SF. Elevated HOME scores and demographic
risk were significant at P = .10. Using multivariate
logistic regression, the only significant predictors of parent ratings were
BSI caseness (OR = 3.7; 95% confidence interval [CI], 2.1-6.5; P<.001) and P-CDI score (OR = 4.3; 95% CI, 2.1-8.5; P<.001) (Table 6). Significant
variables predicting teacher behavior problem ratings were child's sex (male)
(OR = 2.7; 95% CI, 1.2-6.0; P = .02) and elevated
HOME scores (OR = 2.8; 95% CI, 1.3-5.8; P = .01)
in a multivariate model.
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Table 6. Univariate and Multivariate Odds Ratios for Predictors of
PKBS Internalizing and Externalizing Behavior*
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PREDICTORS OF CHILD-FOCUSED MENTAL HEALTH SERVICE UTILIZATION
Using multiple logistic regression to predict child-focused family mental
health utilization, the significant variables were parent-focused mental health
use and clinically elevated HOME scores (Table 7). Child behavior problems (parent- or teacher-rated) were
not associated with child-focused family mental health utilization.
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Table 7. Univariate Odds Ratios for Predictors of Child-Focused Family
Mental Health Service Utilization*
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COMMENT
LIMITATIONS OF THIS STUDY
The design of this study was limited in several ways. Like most studies
of this type, much of the data collected were from a single source: the primary
caregiver (>90% were mothers). The use of teacher ratings lessens this problem;
however, further supportive data would be helpful, especially considering
the low rate of agreement between parents and teachers regarding what constitutes
problem behavior. Whether this is due to real-life situational differences
or differences in perception is a question that has long been asked in developmental
research. Although the cross-sectional design of this study is appropriate
for generating and testing preliminary hypotheses, a prospective longitudinal
design is required to fully explore how the parent-child relationship, child
behavior problems, and child-focused mental health service use are causally
related. Given the high rate of parent-reported behavioral problems in this
age group, it is possible that these difficulties are transient and/or within
normal limits for this population.
IMPLICATIONS FOR PRACTICE
Findings from this study underscore the importance of evaluating parent
mental health because of its central role in both the development and identification
of behavioral problems in young children. Screening tools that can be easily
administered during an office visit are most likely to be useful to community
providers.21-22
Although not new to this field, these findings emphasize the fact that
many children have unmet mental health needs before they enter elementary
school. In this Head Start population, nearly 1 in 3 children were identified
as having clinically significant behavioral problems by their parents. However,
almost 80% of identified children did not receive child-focused mental health
services. A similar picture emerged when examining teacher ratings. Whereas
nearly 1 in 8 children were rated as having clinically significant behavioral
problems, more than 90% of these children did not receive services. In part,
these unmet needs may be due to low concordance between a child's key caregivers
regarding behavior problems. For example, in this Head Start population, parents
and teachers frequently disagreed on whether a child truly had behavioral
problems. This may be partially explained by situational differences in the
behavior of young children. Moreover, different factors may influence parents'
opinions about their child's behavior. Whereas teacher ratings appear to be
related to sociodemographic factors (eg, sex or home environment), those of
parents were linked to their own emotional distress and parent-child relationship
factors. Thus, some of the difficulty concerning adequate access to and delivery
of child-focused mental health services may be due to different perceptions
of a child's behavior by critical gatekeepers.
PARENTAL STRESS AND MENTAL HEALTH PROBLEMS
The literature suggests that one of the predictors of adult mental health
service use is internal distress,23 which acts
as a powerful motivator to access and utilize services. Similarly, parental
motivation to make and keep appointments for mental health services would
seem to be motivated by the level of distress or burden they feel as a result
of their child's behavior. Future research is needed to operationalize the
concept of parental stress and its relationship with access to and utilization
of services.
Consistent with previous research, parent mental health problems were
strongly related to parent perceptions of child behavioral problems. In this
Head Start population, a relatively large proportion (43%) of caregivers surveyed
met the criteria for clinically elevated levels of distress as measured by
the BSI. In part, this seemed to be due to a significant number (46%) of caregivers
with elevations on the paranoid ideation and interpersonal sensitivity subscales
of the BSI. The paranoid ideation scale represents paranoid behavior including
suspiciousness, hostility, grandiosity, and fear of loss of autonomy. The
interpersonal sensitivity dimension focuses on feelings of personal inadequacy
and inferiority. Items on this scale are based on concepts such as self-deprecation,
self-doubt, and marked discomfort during interpersonal interactions.
These subjective feelings, in particular, may add to caregivers' perceptions
of behavioral and emotional problems in their children and may be related
to a greater sense of inadequacy and alienation. In turn, this may influence
parents to seek out assistance (parent- or child-focused) from mental health
professionals.
HOME ENVIRONMENT
Another interesting finding in this preliminary study was the role of
the child's home environment as measured by the HOME scale. Both teacher ratings
of child problem behavior and utilization of child-focused mental health services
were predicted by the quality of the home environment. Children living in
a home with parental affection (responsivity), materials to facilitate or
stimulate learning, emotional and verbal reciprocity, and developmentally
appropriate stimulation were nearly twice as likely not to be rated by teachers
as having clinically significant behavior problems. Moreover, children living
in these homes were twice as likely to receive child-focused mental health
services. These findings suggest that increased parental sensitivity to the
developmental needs of their children at home is associated with utilization
of child-focused mental health services and reduced behavioral problems in
preschool.
CONCLUSIONS
In conclusion, even though parents identified mental health problems
in themselves and their children in this study, the gap between need and use
remains. Pediatricians in primary care are in a unique position in terms of
being able to address education regarding early identification of behavior
problems, appropriate referrals for treatment, and issues of restrictions
in access to behavioral health, mental health, and substance use services.
This leads to a challenging corollary for many community physicians. As research
highlights the need for community level screening of mental health problems
in children and their parents, the health service community is lacking in
qualified professionals to meet the identified need.
| What This Study Adds
Pediatricians are becoming aware of the disparity between the mental
health needs and mental health service use of young children. This study focuses
on the unique needs of younger children (<5 years old) and the importance
of their home environment, relationships with their primary caregivers, and
parents' mental health. Understanding the behavioral health needs of children
as they are commonly seen in general pediatric practice is essential to primary
care physicians. The context of Head Start and other community preschool programs
represents a potential venue for collaboration between primary care physicians
and school-based programs. Suggestions from this study include adding screening
instruments for use by community physicians as a tool in the identification
of behavioral problems in young children. Developing appropriate services
to meet the referral needs of these children and families is an urgent policy
matter.
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AUTHOR INFORMATION
Accepted for publication March 15, 2002.
This study was supported by grant 5 U1H SPO7983 (Jill Joseph, MD, PhD)
from the US Department of Health and Human Services (DHHS), Washington, DC;
the Substance Abuse and Mental Health Services Administration (SAMHSA) and
its 3 centers—the Center for Mental Health Services, the Center for
Substance Abuse Prevention, and the Center for Substance Abuse Treatment,
Rockville, Md; and Casey Family Programs, Seattle, Wash.
This study would not have been possible without the contributions of
staff from DHHS, the Office on Early Childhood at SAMHSA, and Casey Family
Programs; the SESS principal investigators, project directors, and researchers;
and the parent representatives who helped design and supervise the data collection.
We thank Children's National Medical Center for institutional support and
the following individuals for help with the preparation of this manuscript:
Cheng Shao, MPH, Carolin Frey, PhD, Juanita Wiley, BA, Melissa Rocklen, BA,
Wendy Albright, BA, Erin Anne Smith, BA, Mara Kailin, BA, Maia Coleman, BA,
Katherine Marshall, BA, and Carla Jenkins, BA. Thanks are also extended to
2 anonymous reviewers for their helpful comments.
The content of this publication does not necessarily reflect the views
or policies of DHHS or Casey Family Programs, nor does mention of trade names,
commercial products, or organizations imply endorsement by the US government.
Responsibility for the content of this report rests solely with the named
authors.
Corresponding author and reprints: Michelle New, PhD, Department
of Psychology, Children's National Medical Center, 111 Michigan Ave NW, Washington,
DC 20010-2970 (e-mail: mnew{at}cnmc.org).
From the Center for Health Services and Clinical Research, Children's
National Medical Center, Washington, DC.
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