Unemployment and foster home placements: estimating the net effect of provocation and inhibition.

OBJECTIVES: This study sought, first, to explain and reconcile the provocation and inhibition theories of the effect of rising unemployment on the incidence of antisocial behavior. Second, it tested the hypothesis, implied by the provocation and inhibition theories, that the relationship between unemployment and foster home placements forms an inverted "U." METHODS: The hypothesis was tested with data from California for 137 months beginning in February 1984. RESULTS: Findings showed that the hypothesis was supported. CONCLUSIONS: Rising joblessness increases the incidence of foster home placements among families that lose jobs or income. Levels of joblessness that threaten workers who remain employed, however, inhibit antisocial behavior and reduce the incidence of foster home placements. This means that accounting for the social costs of unemployment is more complicated than assumed under the provocation theory.

Prevalence of psychopathology among children and adolescents.

OBJECTIVE: This study was done to update and expand information given in recent reviews, provide a more systematic critique of past research, identify current research trends and issues, and explore possible strategies for future research in child psychiatric epidemiology. METHOD: The authors identified and reviewed 52 studies done over the past four decades that attempted to estimate the overall prevalence of child and adolescent psychiatric disorders. RESULTS: About as many studies have been published since 1980 as were published before. Sample sizes ranged from 58 to 8,462; most were in the 500-1,000 range. Studies were carried out in over 20 countries, most frequently the United States and the United Kingdom. Subjects' ages ranged from 1 to 18 years. Rutter's criteria were the most frequently used for case definition; more recent studies were more likely to use DSM criteria. The most frequently used interview was the Rutter schedule. The most common time frame for calculating prevalence was the present, followed by 6 months and 1 year. Prevalence estimates of psychopathology ranged from approximately 1% to nearly 51% (mean = 15.8%). Median rates were 8% for preschoolers, 12% for preadolescents, 15% for adolescents, and 18% in studies including wider age ranges. CONCLUSIONS: The evidence is less informative than expected because of several problems that continue to plague research on child and adolescent disorders. These involve sampling, case ascertainment, case definition, and data analyses and presentation. Progress in understanding the epidemiology of child disorders will largely depend on whether future research successfully meets these challenges.

Screening for depression in primary care clinics: the CES-D and the BDI.

The present study was undertaken to examine the utility of the Center for Epidemiological Studies-Depression (CES-D) scale and the Beck Depression Inventory (BDI) as screening instruments for primary care clinic patients. We examined: 1) patients' willingness to complete the scales; 2) the level of agreement between the screening instruments and DSM-III diagnosis of Major Depressive Episode, based on the NIMH Diagnostic Interview Schedule (DIS); 3) the effect on detection rates of raising the cut-off score for each depression screen; and 4) the factor structure of the CES-D in our primary care sample versus findings from general population studies. The CES-D and BDI performed comparably as depression screening instruments. Both produced too many false positives when standard (low) cut-off scores were applied. However, when straight cut-off scores were used, results suggested that either the CES-D or BDI might assist physicians in reliably detecting depressed patients, without an overload of false positives. Comparison of our findings with those from other studies suggest that depression screening instruments may be particularly helpful with older primary care patients. The CES-D factor analysis highlights the need to look more closely at the relevance of positive affect to the detection, diagnosis, and treatment of depressive disorders in primary care practices.

Factor structure of a brief symptom checklist for acute psychiatric inpatients.

A 36-item symptom checklist (the HSCL-36) was assembled and assessed based on previous factor-analytic research with the Hopkins Symptom Checklist-90 (HSCL-90), which had focused on outpatients. Acute psychiatric inpatients (N = 243) completed the HSCL-36 after admission to a university hospital. The responses were factor analyzed using a principal axis extraction. Varimax rotation yielded six interpretable factors, for which factor-based subscales were derived. Five of the six subscales were found to be reliable using coefficient alpha. Results are compared with studies that used self-report symptom checklists with outpatients. Future directions for research are discussed.

A method for comparing two systems of acute 24-hour psychiatric care.

A quasi-experimental method was developed to evaluate the cost-effectiveness of a public system of 24-hour acute psychiatric care in Santa Clara County, California, before and after a new treatment setting was introduced. The original system relied on a 54-bed psychiatric unit in a county general hospital; the new system consisted of a 20-bed unit in the general hospital plus a 45-bed nonhospital psychiatric health facility. The study demonstrated that the per diem cost of the psychiatric health facility was approximately 60 percent that of the original general hospital unit, but the average difference in cost per episode between the two systems was only about +25, primarily due to longer lengths of stay in the new system. In addition, patients treated in the new, combined system appeared sicker at discharge than those treated in the old system. The findings suggest the importance of simultaneously evaluating both cost and treatment effectiveness to make sure that one element does not dominate program direction at the expense of the other.

Characteristics of useful evaluation data: an example from community mental health centers.

The results of an empirical study of the use of evaluation data in community mental health centers are reported. A mailed survey on evaluation use was conducted among the directors of 164 community mental health centers in 19 states; 140 completed questionnaires were returned. Results indicate that certain types of data have important impacts in a majority of centers. Systems resources management data were most highly used, followed by need assessment data, and client utilization data. Least used were data on outcomes of intervention and community impact. Data use appears closely tied to the utility of the data in carrying out priority management tasks in a center. Findings have important implications for community psychologists who plan, administer, or evaluate mental health services. The broader role of evaluation in community psychology is also discussed.

Restrictiveness of care among the severely mentally disabled.

Restrictiveness of care was assessed among 286 severely mentally disabled individuals known to an urban community mental health center. By examining clinical records, the authors rated each subject for each month during a period of up to 85 months on four dimensions of restrictiveness: physical freedom, time constraints, legal status, and conservatorship. The maximum restrictiveness experienced by most of the subjects was high, reflecting periodic involuntary hospitalization. The average restrictiveness they experienced, however, was well below the level represented by state hospital care. Thus the authors suggest that the average restrictiveness experienced by this population has been reduced since the initiation of deinstitutionalization.

The use of reception checks in client pretherapy orientation research.

The psychotherapy research literature abounds with evidence of the problems of premature termination and unsatisfactory outcome, especially among low-SES clients. In attempting to enhance the success rate of therapeutic services, some researchers have instituted pretherapy orientation procedures that convey information to clients with regard to the goals and processes of therapy. Although research in this area has continued for two decades, the efficacy of such procedures has not been established firmly. Even when orientations have demonstrable positive effects, the processes through which these results are achieved usually remain unknown. In order to gain an understanding of these mechanisms, researchers must employ measures to assess directly the immediate effects of the orientation. In a recent study, the authors developed a questionnaire to determine whether clients had attended to and understood a pretherapy videotape presentation and whether they recalled the material 1 month later. The results obtained on this measure facilitated the interpretation of the overall research findings.

Defining the severely mentally disabled.

A definition of the "known target population of severely mentally disabled" in community mental health centers is examined. Criteria include intensive treatment contact and persistent, severe disability, but not diagnosis. Feasible and reliable screening procedures are demonstrated. In the identified population, most subjects at some time had received a diagnosis of schizophrenia and had been on public assistance. These criteria apply to catchmented treatment systems and should be useful in services research.

Enhancing the utilization of outpatient mental health services.

This article describes two sets of field studies undertaken by the program evaluation unit of a community mental health center. These studies analyzed clients' utilization of service and assessed service impact in the process of testing procedural variations in service delivery. In the first set of studies, a procedure for ensuring verbal client-therapist contact prior to the first appointment was developed and tested. This procedure reduced the no-show rate for initial appointments from 22 to 12%. In the second set of studies, a brief pretherapy orientation nearly eliminated dropout during the first month of therapy. Orientation had both short- and long-range impact on the amount of services used by clients as well as on their outcomes. Therapist's global ratings of client functioning reflected more change for oriented clients, who reported greater short-term symptom reduction as well. Non-oriented clients were more likely to drop out early and to impress their therapists less favorably. The results of these studies suggest that a combination of pretherapy orientation and verbal client-therapist contact prior to the initial appointment might greatly reduce the failure to complete treatment.

Assessment of patient satisfaction: development and refinement of a service evaluation questionnaire.

A series of seven studies was conducted by the authors and their colleagues to produce an efficient measure of service satisfaction that can easily be related to symptom level, demographic characteristics, and type and extent of service utilization. The resulting measure, the Service Evaluation Questionnaire (SEQ) is a brief, global index that has excellent internal consistency and solid psychometric properties. Data from an extensive SEQ field study can be used as a comparison base for future applications of the two SEQ component scales, the CSQ-8 and the SCL-10. A new hypothesis has emerged from this series of studies that will guide future research: Service recipients may find if difficult to formally express dissatisfaction in the face of significant caring--however ineffectual--when the technical capacity to offer definitive treatment is not yet fully developed and when criteria for evaluating the efficacy of treatment are not yet crystal clear.

The evaluation ranking scale: a new methodology for assessing satisfaction.

Most patient satisfaction scales produce high, undifferentiated levels of reported satisfaction that fail to detect program areas that consumers do not like. Methodological problems apparently contribute to these results. An alternative procedure, the Evaluation Ranking Scale (ERS), was formulated and tested. A 2 X 3 design was employed with 246 public health center patients randomly assigned to one of two measurement techniques (ERS vs. a global measure) and one of three informational sets. A secondary group of subjects was a convenience sample of 26 staff members, which allowed comparisons of staff evaluations of the health center to patients' evaluations of the health center. Compared to the global measure, the ERS provided more specific information about particular program components, was more discriminating, and resulted in mean satisfaction scores that were significantly lower. This new approach may be a more effective technique for assessing the psychosocial effectiveness of human service programs.

Comparison of indirect and direct approaches to measuring patient satisfaction.

One indirect (PSQ) and two direct (CSQ-18B and ERS) measures of patient satisfaction were compared across a series of psychometric, acceptability, and concurrent validity criteria. None of the three measures was significantly related to health status or demographic characteristics. Each measure performed as expected from prior research on their psychometric properties. The scales contrasted, however, in regard to acceptability, with the PSQ being much less acceptable to patients than the other two. The PSQ also produced more missing data. The results on the PSQ reflected patient inconsistency on cross-check items and patients tended to be uncertain in their responses to many items. In multivariate analyses the three measures were used as predictors of patient-rated indices of global service satisfaction. The CSQ-18B and the ERS were significant predictors of patient-rated indices of global service satisfaction, whereas the PSQ was unrelated to these indices. It was concluded that the direct and indirect approaches measure different satisfaction domains. The PSQ likely assesses more generalized attitudes about health services while the CSQ-18B and the ERS efficiently reflect opinions about the specific setting in which they are administered.

Relationship of service satisfaction to life satisfaction and perceived well-being.

Two procedures for gaining patients' evaluations of health services were compared: (a) the Client Satisfaction Questionnaire (CSQ-18B), a direct approach assessing the setting and services actually encountered, and (b) the Patient Satisfaction Questionnaire (PSQ), an approach that indirectly assesses satisfaction with service by inquiring about general health care attitudes. Results from 148 public health patients indicated that the PSQ produced the most acceptability problems and was tapping aspects of life satisfaction other than service satisfaction. However, the PSQ produced significantly lower reports of satisfaction. Additional comparison and interpretation of typical responses generated from the two approaches suggested, on the whole, that the CSQ-18B data provided clearer, more efficient, and more useful information for program planning and evaluation. In this study, service satisfaction measured by the CSQ-18B did not have any significant relationship to global or multidimensional (LDQ-30) measures of life satisfaction and well-being. In contrast, over a third of the variance in PSQ scores was accounted for by measures of life satisfaction. It appears that the PSQ elicits attitudes toward the more generalized health care delivery system as well as aspects of life satisfaction rather than reactions to specific services actually received.

The evaluation ranking scale: clarification of methodological and procedural issues.

Compared with CSQ-8, a typical questionnaire approach to assessing global patient satisfaction, the Evaluation Ranking Scale (ERS) had equally good patient acceptability, yielded more normally distributed satisfaction scores, and results allowed comparative information about patients' evaluation of specific service dimensions. The study also addressed key questions that have emerged about the ERS procedure. Patients apparently do not distinguish conceptually between "importance" of dimensions and "satisfaction" with dimensions in the first phase (ranking) of the ERS. Results did confirm that the ERS sequence of ranking and then rating the dimensions is essential to achieving optimal utility of results. The ranking task seems to have an organizing effect on patients' approach to the rating task. This effect does not work to dictate results in the rating phase but rather seems to familiarize patients with the dimensions to be rated thereby yielding greater potential discriminative capacity for the ERS. Finally, results indicate that the ERS can be administered in a flexible fashion that yields additional information about the absolute importance of the six dimensions without loss of desired operating characteristics for the measure.

Assessing client satisfaction among Hispanics.

Data from two studies using community health center clients are analyzed to assess how a measure of client satisfaction operates when used with different ethnic populations. The eight-item version of the Client Satisfaction Questionnaire (CSQ-8) is a measure of general satisfaction with services that was developed to provide a brief, standard assessment procedure suitable for use in a wide variety of service settings. Based on the results of this survey, the CSQ-8 seems to operate about the same, whether administered to Anglos, blacks, persons of Mexican descent, or persons of other Hispanic origin, or whether in English or Spanish. There were essentially no differences among the various ethnic groups across statistical criteria of internal consistency reliability, central tendency, dispersion, item intercorrelation, or missing values. These results suggest that the CSQ-8 is a measure of general satisfaction with services suitable for use with a variety of client populations, including Hispanics.

The client satisfaction questionnaire. Psychometric properties and correlations with service utilization and psychotherapy outcome.

An 18-item version of the Client Satisfaction Questionnaire (CSQ-18) was included in an experimental study of the effects of pretherapy orientation on psychotherapy outcome. The psychometric properties of the CSQ-18 in this study were compared with earlier findings. In addition, the correlations of the CSQ-18 with service utilization and psychotherapy outcome measures were examined. Results indicated that the CSQ-18 had high internal consistency (coefficient alpha = .91) and was substantially correlated with remainer-terminator status (rs = .61) and with number of therapy sessions attended in one month (r = .54). The CSQ-18 was also correlated with change in client-reported symptoms (r = -.35), indicating that greater satisfaction was associated with greater symptom reduction. Results also demonstrated that a subset of items from the scale (the CSQ-8) performed as well as the CSQ-18 and often better. The excellent performance of the CSQ-8, coupled with its brevity, suggests that it may be especially useful as a brief global measure of client satisfaction.

Artifact in client satisfaction assessment: experience in community mental health settings.

Artifact in client satisfaction assessment is discussed and the results of a study of three factors thought to mediate client satisfaction ratings; (a) general life satisfaction, (b) mode of administration, and (c) psychological symptomatology, are reported. A standard client satisfaction questionnaire (CSQ) was modified to yield parallel forms and was administered orally and in writing to 92 clients in two mental health day treatment programs. Satisfaction ratings obtained from these clients were quite similar to out-patient ratings obtained in previous studies conducted in this setting and using the same measures. Oral administration of the CSQ produced 10% higher satisfaction ratings than written administration (p less than .05) and less missing data (p less than .01). Satisfaction ratings were also obtained using a simple graphic instrument. Graphic ratings were comparable to CSQ ratings. Satisfaction with life in general and level of psychiatric symptoms together accounted for 25% of CSQ variance. The implication of these findings for future client satisfaction research is discussed.