Mental Health Disorders in Childhood:
Assessing the Burden on Families
Susan Busch
Colleen Barry
Yale University
We gratefully acknowledge support from the RWJ Foundation through the
HCFO initiative (Grant no 56465).
Motivation
In 2001 approximately 13 percent of US children
had special health care needs (van Dyck, 2004)
Caring for a sick child places a burden on
families
– The full cost of Special Health Care Needs may not
be covered by health insurance
– Re-allocation of parent time to sick child
– Labor market participation/hours may increase or
decrease (Salkever, 1982; Powers, 2002)
Little evidence on differential burden by
mental/general health diagnoses
Research Question
Do families of children with mental health
disorders experience a greater burden
than families with general health
conditions?
– Financial outcomes (OOP spending)
– Labor Market (participation, hours)
– Parent time devoted to child’s health care
needs (arranging or providing care)
Physical and mental health conditions
may create differential burden
Private health insurance covers mental
health conditions less generously
– Lack of parity in benefit design
Children with MH disorders may have less
predictable needs (Gould, 2004)
– Difficulty planning for expenses or scheduling
time away from work
Differential burden (cont.)
Fragmented MH system may require more
time arranging care (New Freedom
Commission Report)
MH diagnosis may be viewed as more
subjective
– Reduces acceptability of time away from work
Stigma
– May reduce in-kind support from family
members
Data
2000-2002 SLAITS National Survey of CSHCN
Large nationally representative sample of
children (N=38,856)
– Limited to children whose parents report the child has
more health care needs than average, and that the
condition is expected to last at least 12 months
– All SHCN children
Single cross-section
Analytic Approach
Concern that children with mental
disorders may be different than children
with general health disorders on other
dimensions
– Use propensity score methods to model the
effect of mental versus general health care
need on family burden
– Use propensity score (rather than regression)
due to concern that some data is ‘off support’
Methods
Run logistic regression to estimate
propensity to need mental health care
Use these coefficients to predict the
propensity to need mental health care for
each child (yhat)
Match children with need for mental health
care with SHCN child with no need for
mental health care (by propensity score)
Compare on outcome measures
Outcome Measures
Financial
– Out-of-pocket spending > $500 during past 12 months
– Whether a family reported :
that a child’s health care has caused financial problems
needing additional income for a child’s medical expenses
Labor Market
– Any family member quit work to care for child?
– Any family member reduce work hours to care for
child?
Time burden
– Any family member spend more than 4 hours per
week arranging care?
– Any family member spend more than 4 hours
providing care?
Measures
Mental health
– Did child need mental health care in past 12 months?
Demographics
– Age, gender, race, language, mother’s education,
family income, number of adults in the household
Insurance coverage (private, public, uninsured)
Disease severity
– Parents ranking of child’s disability (1-10)
– Parent report of time the child is affected by the
condition (never, sometimes, usually, always)
State fixed effects
– Account for state-level differences in labor market
opportunities or public benefits
Descriptive Statistics (Unadjusted)
CSHCN
needing
mental health
care
CSHCN not
needing
mental health
care
42 %
26 %
Child’s HC caused financial problems
30
15
Family needed add’l inc to care for child
25
12
12 %
10 %
Child’s HC caused financial problems
29
22
Family needed add’l inc to care for child
23
19
Children with private coverage
OOP spending >$500
Children with public coverage
OOP spending >$500
Unadjusted Outcomes (cont.)
CSHCN
needing
mental health
care
CSHCN not
needing
mental health
care
Cut work hours
37 %
22 %
Quit work
17 %
10 %
>4 hrs/wk providing care
19 %
15 %
>4 hrs/wk arranging care
17 %
10 %
Labor Market
Time Burden
Adjusted Financial Outcomes
45
42
40
Private Coverage
Public Coverage
35
30
30
***
29
28
25
27
23
20
20
23 22
***
No Mental Health Care Need
17
***
15
11
12
10
5
0
Out-ofpocket
spending
greater than
$500
Child's
health care
has caused
financial
problems
Mental Health Care Need
Family
Out-ofneeded
pocket
additional
spending
income to
greater than
care for child
$500
Child's
health care
has caused
financial
problems
Family
needed
additional
income to
care for child
Adjusted Labor Market Outcomes
40
35.8
35
30
26.5
***
25
Mental Health Care Need
20
No Mental Health Care Need
16.2
15
12.1
***
10
5
0
Family members have cut work Family members have stopped
hours to care for child
working due to child’s health
Adjusted Time Burden
25
20.1
20
18
16.2
15
12.2
***
Mental Health Care Need
No Mental Health Care Need
10
5
0
Spends greater than 4
hours providing care
Spends greater than 4
hours arranging care
Limitations
Making causal inferences is difficult with
cross sectional data
Measures are self-report
No information on specific diagnosis
Conclusion/Implications
On average, families of children with
mental disorders bear a greater burden
Design of public policies
– Children’s SSI eligibility for those with mental
health condition has changed over time
– Multiple outcomes considered
Ideal program would mitigate all these concerns
Just providing services will not alleviate all the
burden – argues for other types of assistance
Parity
– Requiring equivalent insurance coverage
currently being debated in US Congress