Outcomes associated with clinical profiles of children in psychiatric crisis enrolled in intensive, in-home interventions.

Little is known about the characteristics of children and youth presenting at emergency settings in psychiatric crisis, and virtually nothing is known about their outcomes. The purpose of this study is to describe the clinical profiles of 238 children presenting at two psychiatric emergency settings and enrolled in a randomized controlled trial of three intensive in-home interventions. A second purpose is to examine child mental health outcomes, based on clinical profile and to suggest the utility of using a clinical-profiles approach.

CpG methylation as a mechanism for the regulation of E2F activity.

Regulation of gene expression in mammals through methylation of cytosine residues at CpG dinucleotides is involved in the development and progression of tumors. Because many genes that are involved in the control of cell proliferation are regulated by members of the E2F family of transcription factors and because some E2F DNA-binding sites are methylated in vivo, we have investigated whether CpG methylation can regulate E2F functions. We show here that methylation of E2F elements derived from the dihydrofolate reductase, E2F1, and cdc2 promoters prevents the binding of all E2F family members tested (E2F1 through E2F5). In contrast, methylation of the E2F elements derived from the c-myc and c-myb promoters minimally affects the binding of E2F2, E2F3, E2F4, and E2F5 but significantly inhibits the binding of E2F1. Consistent with these studies, E2F3, but not E2F1, activates transcription through methylated E2F sites derived from the c-myb and c-myc genes whereas both E2F1 and E2F3 fail to transactivate a reporter gene that is under the control of a methylated dihydrofolate reductase E2F site. Together, these data illustrate a means through which E2F activity can be controlled.

The impact of managed care on mental health services for children and their families.

For more than a decade, the philosophy of community-based systems of care has guided the delivery of mental health services for children and adolescents served by publicly funded agencies. This philosophy supports system attributes that include a broad array of services; interagency collaboration; treatment in the least-restrictive setting; individualized services; family involvement; and services responsive to the needs of diverse ethnic and racial populations. The notion of systems of care emerged in an era when managed health care also was gaining popularity. However, the effect of managed care on the delivery of mental health and substance-abuse services--also known as behavioral health services--has not been widely studied. Preliminary results from the nationwide Health Care Reform Tracking Project (HCRTP) inform discussions about the impact of managed behavioral health care on services for children and adolescents enrolled in state Medicaid programs. Most states have used some type of "carve-out design" to finance the delivery of behavioral health services, and there is a trend toward contracting with private-sector, for-profit companies to administer these benefits. In general, managed care has resulted in greater access to basic behavioral health and community-based services for children and adolescents, though access to inpatient hospital care has been reduced. Under managed care, it also has been more difficult for youths with serious emotional disorders, as well as the uninsured, to obtain needed services. With managed care has come a trend toward briefer, more problem-oriented treatment approaches for behavioral health disorders. A number of problems related to the implementation of managed behavioral health care for children and adolescents were illuminated by the HCRTP. First, there is concern that ongoing efforts to develop systems of care for youths with serious emotional disorders are not being linked with managed care initiatives. The lack of investment in service-capacity development, the lack of coordination with other agencies serving children with behavioral health problems, and cumbersome preauthorization requirements that may restrict access to appropriate service delivery were other concerns raised by respondents about managed care. As the adoption of managed behavioral health care arrangements for Medicaid beneficiaries expands rapidly, the HCRTP will continue to analyze how this trend has affected children and adolescents with behavioral health problems and their families.

Assessing the outcomes of parent-and provider-designed systems of care for children with emotional and behavioral disorders.

There is a paucity of research on the outcomes associated with involving parents of children with emotional and behavioral problems as partners with professionals in designing and implementing a system of care. This study examines the systems, child, and family outcomes associated with providing flexible funds to two counties, one engaged in strengthening its provider-designed system and the other in developing and implementing a parent-designed system. This article describes the qualitative, network, and treatment outcome studies comprising the research.

Developing new certificate-of-need regulations for inpatient care of children in New York State.

In 1988 New York State imposed a moratorium on the development of new psychiatric beds for children because the state's certificate-of-need law lacked objective criteria for evaluating applications. The following year the department introduced revised certificate-of-need regulations that incorporated more specific program criteria, based on the department's policies, as well as a quantitative methodology for estimating the number of children's beds needed in general hospitals and private specialty hospitals. The methodology led to a planning figure of 10,000 admissions of children to acute care for 1995. It disaggregated the expected admissions to each of the state's 15 children's service areas and also established expected average lengths of stay for each service area. The authors outline the program criteria, the bed-need methodology, and results of the calculations.

Chronic home care in ontario: five year follow up.

The first 218 patients admitted to the Kingston Chronic Home Care program (CHC) after its inception in October, 1975 were followed to March 31, 1981. Their average number of admissions to CHC was 2.3, and they averaged 16 months in CHC. Twenty-eight percent died before any admission to a longterm care institution; 44% were admitted to such an institution at or after last separation from CHC. The study suggests that CHC results in a significant degree of prevention or delay of admission to institutions.

Effect of chronic home care on admission to institutions providing long-term care.

Home care programs are operating throughout Ontario. In October 1975 pilot-test chronic home care (CHC) programs were added in three areas. Whether the Kingston CHC program prevented or delayed admission to an institution providing long-term care was studied in the 218 patients admitted to the program up to mid-March 1976. Forms were completed for all 218 patients admitted, for the 109 still in the program 6 months later, and for the 131 who had left the program by August 1976. Of the 218 patients 20% had applied for admission to an institution providing long-term care before applying for CHC, and another 22% had seriously considered applying to such an institution. The CHC staff judged that 61% would have needed institutional care without CHC. Only 12% of the 218 patients left the CHC program to enter an institution, only 1 of the 48 patients discharged to self-care at home was considering a move to an institution, and only 2 receiving CHC for 6 months applied to an institution during that time. CHC therefore seems to delay greatly admission to an institution providing long-term care for a substantial group of patients.