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Comparative Effectiveness ReviewNumber 181Strategies ToImprove Mental HealthCare for Children andAdolescentse

Comparative Effectiveness ReviewNumber 181Strategies To Improve Mental Health Care for Childrenand AdolescentsPrepared for:Agency for Healthcare Research and QualityU.S. Department of Health and Human Services5600 Fishers LaneRockville, MD 20857www.ahrq.govContract No. 290-2012-00008-IPrepared by:RTI International–University of North Carolina Evidence-based Practice CenterResearch Triangle Park, NCInvestigators:Valerie L. Forman-Hoffman, Ph.D., M.P.H.Jennifer Cook Middleton, Ph.D.Joni Lynn McKeeman, Ph.D.Leyla Faw Stambaugh, Ph.D.Robert Bourke Christian, M.D., FAAPBradley Neil Gaynes, M.D., M.P.H.Heather Lynne Kane, Ph.D.Leila C. Kahwati, M.D., M.P.H.Kathleen N. Lohr, Ph.D.Meera Viswanathan, Ph.D.AHRQ Publication No. 16(17)-EHC035-EFDecember 2016

This report is based on research conducted by the RTI International–University of NorthCarolina Evidence-based Practice Center (EPC) under contract to the Agency for HealthcareResearch and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00008-I). The findingsand conclusions in this document are those of the authors, who are responsible for its contents;the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, nostatement in this report should be construed as an official position of AHRQ or of the U.S.Department of Health and Human Services.None of the investigators have any affiliations or financial involvement that conflicts withthe material presented in this report.The information in this report is intended to help health care decisionmakers—patients andclinicians, health system leaders, and policymakers, among others—make well-informeddecisions and thereby improve the quality of health care services. This report is not intended tobe a substitute for the application of clinical judgment. Anyone who makes decisions concerningthe provision of clinical care should consider this report in the same way as any medicalreference and in conjunction with all other pertinent information, i.e., in the context of availableresources and circumstances presented by individual patients.This report is made available to the public under the terms of a licensing agreement between theauthor and the Agency for Healthcare Research and Quality. This report may be used andreprinted without permission except those copyrighted materials that are clearly noted in thereport. Further reproduction of those copyrighted materials is prohibited without the expresspermission of copyright holders.AHRQ or U.S. Department of Health and Human Services endorsement of any derivativeproducts that may be developed from this report, such as clinical practice guidelines, otherquality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.This report may periodically be assessed for the currency of conclusions. If an assessment isdone, the resulting surveillance report describing the methodology and findings will be found onthe Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on thetitle of the report.Persons using assistive technology may not be able to fully access information in this report. Forassistance contact EffectiveHealthCare@ahrq.hhs.gov.Suggested citation: Forman-Hoffman VL, Cook Middleton J, McKeeman JL, Stambaugh LF,Christian RB, Gaynes BN, Kane HL, Kahwati LC, Lohr KN, Viswanathan M. Strategies ToImprove Mental Health Care for Children and Adolescents. Comparative Effectiveness ReviewNo. 181. (Prepared by the RTI International–University of North Carolina Evidence-basedPractice Center under Contract No. 290-2012- 00008-I.) AHRQ Publication No. 16(17)EHC035-EF. Rockville, MD: Agency for Healthcare Research and Quality; December l.cfm.ii

PrefaceThe Agency for Healthcare Research and Quality (AHRQ), through its Evidence-basedPractice Centers (EPCs), sponsors the development of systematic reviews to assist public- andprivate-sector organizations in their efforts to improve the quality of health care in the UnitedStates. These reviews provide comprehensive, science-based information on common, costlymedical conditions, and new health care technologies and strategies.Systematic reviews are the building blocks underlying evidence-based practice; they focusattention on the strength and limits of evidence from research studies about the effectiveness andsafety of a clinical intervention. In the context of developing recommendations for practice,systematic reviews can help clarify whether assertions about the value of the intervention arebased on strong evidence from clinical studies. For more information about AHRQ EPCsystematic reviews, see .cfm.AHRQ expects that these systematic reviews will be helpful to health plans, providers,purchasers, government programs, and the health care system as a whole. Transparency andstakeholder input are essential to the Effective Health Care Program. Please visit the Web site(www.effectivehealthcare.ahrq.gov) to see draft research questions and reports or to join anemail list to learn about new program products and opportunities for input.If you have comments on this systematic review, they may be sent by mail to the Task OrderOfficer named below at: Agency for Healthcare Research and Quality, 5600 Fishers Lane,Rockville, MD 20857, or by email to epc@ahrq.hhs.gov.Andrew Bindman, M.D.DirectorAgency for Healthcare Research and QualityArlene S. Bierman, M.D., M.S.DirectorCenter for Evidence and PracticeImprovementAgency for Healthcare Research andQualityStephanie Chang, M.D., M.P.H.DirectorEvidence-based Practice Center ProgramCenter for Evidence and Practice ImprovementAgency for Healthcare Research and QualityChristine Chang, M.D., M.P.H.Task Order OfficerCenter for Evidence and PracticeImprovementAgency for Healthcare Research andQualityiii

AcknowledgmentsThe authors gratefully acknowledge the following individuals for their contributions to thisproject and deeply appreciate their considerable support, commitment, and contributions:Christine Chang, M.D., M.P.H., our AHRQ Task Order Officer; Denise Dougherty, Ph.D.,AHRQ Senior Advisor; Charlotte Mullican, M.P.H., AHRQ Senior Advisor; Richard A. Epstein,Ph.D., M.P.H., our Associate Editor; RTI International–University of North Carolina EPCstaff—Carol Woodell, B.S.P.H., EPC Project Manager; Daniel Jonas, M.D., M.P.H., EPC CoDirector; Christiane Voison, M.S.L.S., Librarian; Heather Ringeisen, Ph.D., Scientific Reviewer;Emmanuel Coker-Schwimmer, M.P.H., research assistant; Catherine Grodensky, M.P.H.,research assistant; Claire Baker, B.S., research assistant; Sharon Barrell, M.A., editor; LauraSmall, B.A., editor; and Loraine Monroe, publications specialist.Key InformantsIn designing the study questions, the EPC consulted several Key Informants who representthe end-users of research. The EPC sought the Key Informant input on the priority areas forresearch and synthesis. Key Informants are not involved in the analysis of the evidence or thewriting of the report. Therefore, in the end, study questions, design, methodological approaches,and/or conclusions do not necessarily represent the views of individual Key Informants.Key Informants must disclose any financial conflicts of interest greater than 10,000 and anyother relevant business or professional conflicts of interest. Because of their role as end-users,individuals with potential conflicts may be retained. The TOO and the EPC work to balance,manage, or mitigate any conflicts of interest.The list of Key Informants who provided input to this report follows:Kenneth S. Fink, M.D., M.G.A., M.P.H.Med-QUEST Division, State of HawaiiDepartment of Human ServicesKapolei, HIKelly Kelleher, M.D., M.P.H.The Research Institute at NationwideChildren’s HospitalColumbus, OHDarcy Gruttadaro, J.D.National Alliance on Mental IllnessArlington, VABryan Samuels, M.P.P.Chapin Hall Center for Children at theUniversity of ChicagoChicago, ILKimberly Eaton Hoagwood, Ph.D.Department of Child and AdolescentPsychiatryNew York UniversityNew York, NYMark Weist, Ph.D.Department of PsychologyUniversity of South CarolinaColumbia, SCLouise Johnson, M.S.Division of Children, Adolescents and TheirFamiliesSouth Carolina Department of MentalHealthColumbia, SCiv

Technical Expert PanelIn designing the study questions and methodology at the outset of this report, the EPCconsulted several technical and content experts. Broad expertise and perspectives were sought.Divergent and conflicted opinions are common and perceived as healthy scientific discourse thatresults in a thoughtful, relevant systematic review. Therefore, in the end, study questions, design,methodologic approaches, and/or conclusions do not necessarily represent the views ofindividual technical and content experts.Technical Experts must disclose any financial conflicts of interest greater than 10,000 andany other relevant business or professional conflicts of interest. Because of their unique clinicalor content expertise, individuals with potential conflicts may be retained. The TOO and the EPCwork to balance, manage, or mitigate any potential conflicts of interest identified.The list of Technical Experts who provided input to this report follows:Jeffrey A. Buck, Ph.D.*Center for Clinical Standards & QualityCenters for Medicare & Medicaid ServicesBaltimore, MDKelly Kelleher, M.D., M.P.H.*The Research Institute at NationwideChildren’s HospitalColumbus, OHKimberly Eaton Hoagwood, Ph.D.Department of Child and AdolescentPsychiatryNew York UniversityNew York, NYMichael P. Kelly, Ph.D., Hon FRCP,FRCPE, FFPH*Institute of Public HealthUniversity of CambridgeCambridge, UKAaron T. Hogue, Ph.D.National Center on Addiction and SubstanceAbuseNew York, NYDouglas K. Novins, M.D.*Division of Child & Adolescent PsychiatryDepartment of PsychiatryUniversity of Colorado School of MedicineAurora, COLouise Johnson, M.S.Division of Children, Adolescents and TheirFamiliesSouth Carolina Department of MentalHealthColumbia, SC*Provided input on Draft Report.v

Peer ReviewersPrior to publication of the final evidence report, EPCs sought input from independent PeerReviewers without financial conflicts of interest. However, the conclusions and synthesis of thescientific literature presented in this report do not necessarily represent the views of individualreviewers.Peer Reviewers must disclose any financial conflicts of interest greater than 10,000 and anyother relevant business or professional conflicts of interest. Because of their unique clinical orcontent expertise, individuals with potential nonfinancial conflicts may be retained. The TOOand the EPC work to balance, manage, or mitigate any potential nonfinancial conflicts of interestidentified.The list of Peer Reviewers follows:Embry Howell, Ph.D.The Urban Institute, Health Policy CenterWashington, DCMarc S. Atkins, Ph.D.Departments of Psychiatry and PsychologyInstitute for Juvenile ResearchDissemination and Implementation Researchand Policy ProgramUIC Center for Clinical TranslationalScienceUniversity of Illinois at ChicagoChicago, ILMark Weist, Ph.D.Department of PsychologyUniversity of South CarolinaColumbia, SCLeonard Bickman, Ph.D.Psychological SciencesVanderbilt UniversityNashville, TNTumani Coker, M.D., M.B.A.Assistant Professor of Pediatrics, DavidGeffen School of Medicine and MattelChildren's Hospital at UCLAAssociate Director of Health ServicesResearch, UCLA Children's Discovery andInnovation InstituteNatural Scientist, RANDLos Angeles, CAvi