Published online June 1, 2006
PEDIATRICS Vol. 117 No. 6 June 2006, pp. 2138-2148 (doi:10.1542/peds.2005-1531)
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Mental Health Care Services for Children With Special Health Care Needs and Their Family Members: Prevalence and Correlates of Unmet Needs

Michael L. Ganz, MS, PhD and Shalini A. Tendulkar, ScM

Harvard School of Public Health, Department of Society, Human Development, and Health, Boston, Massachusetts


   ABSTRACT
TOP
 ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVES. To estimate the prevalence and correlates of unmet needs for mental health care services for children with special health care needs and their families.

METHODS. We use the National Survey of Children With Special Health Care Needs to estimate the prevalence of unmet mental health care needs among children with special health care needs (1–17 years old) and their families. Using logistic-regression models, we also assess the independent impact of child and family factors on unmet needs.

RESULTS. Substantial numbers of children with special health care needs and members of their families have unmet needs for mental health care services. Children with special health care needs who were poor, uninsured, and were without a usual source of care were statistically significantly more likely to report that their mental health care needs were unmet. More severely affected children and those with emotional, developmental, or behavioral conditions were also statistically significantly more likely to report that their mental health care needs went unmet. Families of severely affected children or of children with emotional, developmental, or behavioral conditions were also statistically significantly more likely to report that their mental health care needs went unmet.

CONCLUSIONS. Our results indicate that children with special health care needs and their families are at risk for not receiving needed mental health care services. Furthermore, we find that children in families of lower socioeconomic status are disproportionately reporting higher rates of unmet needs. These data suggest that broader policies to identify and connect families with needed services are warranted but that child- and family-centered approaches alone will not meet the needs of these children and their families. Other interventions such as anti-poverty and insurance expansion efforts may be needed as well.

Key Words: medical home • children with special health care needs • parental mental health • mental health

Abbreviations: CSHCN—children with special health care needs • EDB—emotional—developmental—or behavioral • NS-CSHCN—National Survey of Children With Special Health Care Needs • FPL—federal poverty level • MSA—metropolitan statistical area • OR—odds ratio

Recent changes in the financing and provision of mental health services in both the private and public sectors have the potential to negatively impact children's access to mental health services. Increasing reliance on managed behavioral health organizations ("carve-out" arrangements) and reduced public funding for state-run programs may place children at risk for reduced access to needed care, especially for uninsured children.1–8 Most research on the impact of mental health–financing methods has focused on representative cross-sections of children9–11 or has focused on children with mental health care needs.12–14 However, there is little known about access to mental health care services for children with special health care needs (CSHCN) and their families. Because CSHCN are particularly vulnerable and at risk for underutilization of needed care, here we examine and describe those child, family, and environmental factors that are associated with unmet needs for mental health care services for CSHCN and their families.

CSHCN are currently defined by the Maternal and Child Health Bureau as "[children] who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally." As many as 12.8% (~9.4 million) of children in the United States under 18 years of age have a special health care need.15 As represented in the above definition, most CSHCN do exhibit some form of physical, developmental, behavioral, or emotional disability, with most of them (at least) experiencing a chronic physical condition (Newacheck et al16 reported that 31% of children experience chronic conditions of a physical nature). Above and beyond these physical conditions, ~5% to 30% of CSHCN have some type of emotional, developmental, or behavioral (EDB) disorder or condition.17–22 Irrespective of the nature of the disability, CSHCN may require mental health services to cope with stresses associated with their conditions.20, 21 In addition to the CSHCN themselves, parents and other family members may also require mental health care services.23–25 The psychological burden that parents and other family members of CSHCN may experience as they struggle to balance individual versus family health needs is a relatively understudied topic.25, 26 Understanding the health needs of CSHCN is especially important because of the potential for unmet health care needs, including unmet needs for mental health care services, in this population. The medical home concept was developed to help ensure that CSHCN receive accessible, continuous, comprehensive, family centered, coordinated,27 compassionate, and culturally effective28 care. This concept was more concretely defined recently29 and although many CSHCN are currently served by medical homes,30 having multiple health problems means that significant proportions of these children may have unmet health care needs,31 including unmet needs for mental health care services.12, 13, 33

It has been estimated that anywhere from 1.2% to 25% of these children have some type of unmet need for mental health care services.32–35 Unmet mental health care needs among other adult caregivers may place additional strains on the family; thus, it is especially important to explore the degree of need and unmet need that they may experience (for example, Gaskin and Mitchell12 report that CSHCN have higher rates of unmet medical care needs if their parents are depressed compared with caregivers that are not depressed). Because of this relationship between children's and other family members' physical health, mental health, and use of health care services, it is important to document access to care for other family members of CSHCN in addition to documenting and understanding the correlates of care for the children themselves. Such information can be important for policies aimed at helping both CSHCN and their families receive needed mental health care services. The studies reviewed above have not used large and nationally representative samples of CSHCN, have not included information on family need and access to care, and have used data that predated many important policy events such as the proliferation of managed behavioral health care plans and medical home initiatives. Here we address these gaps and update the literature by analyzing data from a recent large, nationally representative survey of CSHCN.

In selecting those factors to include in our analyses, we relied on the Andersen36 model of health services utilization that articulates how health services use is determined by individual, family, environmental/health services system, and societal factors. Given the availability of the data in the survey that we use, we focused mainly on individual factors, which are composed of enabling, need, and predisposing factors. Enabling factors such as income, insurance coverage, and site of usual source of care measure financial resources related to access and use of care are included in this analysis. Need factors including condition severity, stability, and presence of an EDB condition measure the perceived and evaluated need for care and reflect expectations of how helpful care will be. Predisposing factors such as age, education, and race/ethnicity measure the biological and social resources related to access and use of services and are largely predetermined. To capture environmental and health systems factors, we include measures of residence in a metropolitan area and the availability of health care providers who specialize in children. An inclusive model should incorporate not only family demographic and socioeconomic measures but family health measures as well. Family-level health measures are difficult to articulate and operationalize, especially given the structure of the National Survey of Children With Special Health Care Needs (NS-CSHCN), but we include a measure of family unmet needs for mental health care services in the child regression model and child unmet needs for mental health care services in the family regression model in an effort to tap this dimension.36

On the basis of the Andersen model, we expect to find a negative association between unmet need and most of the enabling and predisposing factors that are associated with access to resources. For example, children in higher-income families, insured children, children with a usual source of care, and children with more educated mothers should be expected to have their mental health care needs met. (Although children in lower-income families qualify for publicly provided insurance and, as a result, should have access to care, we do not observe such a nonlinear relationship between income and unmet needs.) Among the need factors, we expect that more severely affected or more unstable children should have higher levels of unmet needs, as would children with EDB problems.

However, our expectations about the relationships between these factors and unmet need among other family members are unclear, because it is difficult to hypothesize how some child characteristics are related to other family members. For example, family poverty level or the child's condition severity are expected to be related to family unmet mental health care needs in the same manner as for the target child's unmet needs, but it is less clear how the target child's gender or usual-source-of-care arrangements are related to other family members' unmet needs. Given no other guidelines, we expect the child and family factors to be related to family unmet need in the same manner as for child unmet need.

Using this framework as a guide, the goals of this article, therefore, are to (1) estimate the prevalence of EDB conditions among CSHCN in the United States, (2) estimate the prevalence of unmet need for mental health care services for both CSHCN and other family members, and (3) estimate the relationships between child and family demographic and child health factors and the probability of an unmet need for mental health care services among children and other family members.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We use the NS-CSHCN, which was fielded from April 2000 to October 2002, to estimate the prevalence of unmet mental health care needs among CSHCN (1–17 years of age) and their families.27, 37, 38 This survey uses the State and Local Area Integrated Telephone Survey (SLAITS), a random-digit-dialing telephone survey that is conducted jointly by the National Center for Health Statistics and the Centers for Disease Control and Prevention and sponsored by the Maternal and Child Health Bureau (Health Resources and Services Administration) and the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services. The NS-CSHCN initially sampled and interviewed 372174 children (living in 196888 households) in the United States; data were collected in 3 phases. First, demographic information on children <18 years of age was collected. This was followed by a Foundation for Accountability screener to identify CSHCN.39, 40 A child with a condition that lasted or was expected to last at least 1 year and matched at least 1 of 5 criteria (using or needing more medical care, mental health services, or educational services than are provided for other children of the same age; using or needing prescription medication; having a limitation in the ability to do things most children of the same age do; using or needing special therapy; or using or needing EDB treatment or counseling) was classified as having a special health care need. The Foundation for Accountability screener identified 48690 CSHCN, 38866 of whom (1 per household) were later interviewed in depth. Using questions from the screener, we identified children as having an EDB condition lasting for >12 months (ie, has a special need arising from an EDB condition) if the following 2 questions were answered in the affirmative: "Does your child have any kind of emotional, developmental, or behavioral problem for which he needs treatment or counseling?" and "Has that child's emotional, developmental or behavioral problem lasted or is it expected to last 12 months or longer?" We define "unmet need" as reporting a need for mental health care services in the past 12 months and reporting not having received all needed services. CSHCN and/or their families who reported no need were considered to have no unmet need. Although this definition is sensitive, it is not specific: the definition of "unmet need" will also include those who are still receiving care and those on waiting lists. However, these situations are unlikely to influence our results. For both CSHCN and other family members the prevalence rates of reporting still receiving ongoing care and/or difficulty obtaining an appointment are <0.25%.

We operationalize enabling factors (income, insurance, and usual source of care) as follows: Income is operationalized as the family's poverty status, which was collapsed into 3 categories representing <100% of the federal poverty level (FPL), 100% to 185% FPL, and >185% FPL. Following the scheme used by Honberg et al,41 we classified children as having private insurance coverage (composed of private plans or military coverage), public coverage (Medicaid, State Children's Health Insurance Program, Title V coverage, or other public coverage), both private and public, or uninsured at the time of interview. We exclude children with "other" or unknown coverage (n = 146). A child's actual source of care was obtained for those children reporting having a usual source of care. The categories were doctor's office, clinic, and other (which included sources such as a school or hospital emergency department). Children who did not have a usual source of care were identified as such.

Need factors (condition severity, condition stability, and the presence of EDB conditions) are operationalized as follows: Severity was originally measured in the survey on a 0 to 10 Likert scale, which we collapsed into 4 categories following the classification system used by Mayer et al31 in their analysis of unmet needs for routine and specialty care. Stability was recorded in the survey as "needs change all the time; needs change only once in a while; needs are usually stable; none of the above." We exclude "none of the above" (n = 89) from our analyses. We also include a variable capturing the presence of an EDB condition for the child in the needs factor. Predisposing factors (age, maternal education, and race/ethnicity) are operationalized as follows: Child's age was categorized to reflect 5 developmental stages: 1 to 4, 5 to 9, 10 to 12, and 13 to 18 years of age; we dropped children <1 year old from our analyses (n = 486). Maternal education was collapsed into 3 categories representing less than high school, high school (completed), or more than high school education. Race and ethnicity were considered as separate variables, with race being represented by 3 categories (white, black, and other) and ethnicity being coded as Hispanic (vs non-Hispanic). As mentioned above, we include family unmet need in the child regressions and child unmet need in the family regressions in an effort to tap the family health dimension of the Andersen framework.36

To capture environmental and health systems factors, we include an indicator for residence in a metropolitan area, and we also merged per-capita rates of general pediatricians, pediatric specialists, and pediatric psychiatrists from the area resource file on the basis of state and metropolitan statistical area (MSA) status.42 The area resource file is a county-specific health resources information system containing data on health facilities, health professions, measures of resource scarcity, health status, economic activity, health training programs, and socioeconomic and environmental characteristics. Per the method used by Mayer et al,31 we created 3 variables to capture local availability of relevant health care resources (the number of pediatricians per 10000 children <18 years old, the number of pediatric specialists per 10000 children <18 years old, and the number of pediatric psychiatrists per 10000 children <18 years old) that are matched to the NS-CSHCN respondents on state and MSA/non-MSA status.

Variables in this data set were missing data at varying rates, ranging from 0% for insurance to 3.4% for maternal education and 9.4% for family income. Almost 16% of the cases were missing some data. To preserve as many cases as possible and minimize potential internal validity bias resulting from deleting cases with missing data (eg, those children missing income were more likely to have public versus private insurance and lower maternal education and less likely to rank in intermediate condition severity),43–46 we imputed multiple values for all missing data by using the sequential regression approach developed by Raghunathan et al47 as implemented by the IVEware macro for SAS statistical software.48, 49 Because the variables in the NS-CSHCN are categorical and there are logical restrictions for some variables (eg, the question about having a usual source of care must be first affirmatively endorsed to report the source of care), the sequential regression approach is more appropriate than the more common multivariate normal approach.46, 50 This approach is also appropriate for use with the NS-CSHCN data because the variables do not follow the multivariate normal distribution. Conventional analyses (computing descriptive statistics and estimating logistic-regression models) were conducted using the multiple imputed data sets, and standard procedures for combining descriptive statistics, regression coefficients, and SE estimates from the multiple imputed data were then used.43, 44 Descriptive statistics and logistic-regression models were estimated, adjusting for the complex sampling design of the NS-CSHCN by using both Stata 8.251 and SAS 949 software, and unless noted otherwise, all estimates were weighted to be nationally representative.

Because of the strong correlation between the health and health care experiences of all family members, we need to be concerned about 2 sources of clustering or correlation that may affect our estimates: family composition and the impact of unobservable factors on both child and family unmet needs. To address the first concern we added variables capturing the presence and/or the number of children with and without SHCN in the family to the basic regression models. We also limited the analyses to those families with only 1 child (which is the target CSHCN) and to those families with only 1 CSHCN (but with potentially other children without SHCN). To address the second concern we estimated variants of the basic regression equations using seemingly unrelated probit equations.51, 52 This method accounts for the correlation between child unmet needs and other family unmet needs that result from common unobservable factors. Our main regression results are robust to these 2 types of sensitivity analyses.

After excluding children <1 year old, those with equivocal condition stability, and those with other or unknown insurance coverage, the final sample size is 36512 (93.9% of the original sample [N = 38866]).


   RESULTS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Approximately 30% of CSHCN have some type of EDB condition, representing ~2.6 million children in the United States. Table 1 displays the distribution of reported needs for mental health care services. Overall, 25.7% of CSHCN in the United States and 13.3% of their other family members had some need for mental health care (column 1). CSHCN with EDB conditions were more likely to have a need for mental health care than those CSHCN without EDB conditions (row 1, columns 2 and 3). Other family members of CSHCN with EDB conditions were also more likely to have some need for mental health care than other family members of CSHCN without EBD conditions (row 2, columns 2 and 3). Of those with reported needs for mental health care, 18.4% of the CSHCN and 21.3% of their other family members reported that their needs were not met (data not shown). Overall (when considering those with and without a reported need for mental health care services, as defined in "Methods"), 4.7% of CSHCN and 2.8% of other family members reported unmet mental health care needs, representing ~416000 CSHCN and 249000 families.


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  		TABLE 1 The Distribution of Reported Needs for Mental Health Care Services for CSHCN and their Families in the United States: 2000-2002

 
Table 2 reports the population estimates of the characteristics of the CSHCN meeting our sample selection criteria along with estimates of the proportion of unmet needs for mental health care services by those demographic characteristics. Family income is inversely related to unmet needs for mental health care services for CSHCN. Children living in families with household incomes <100% FPL are >3 times more likely to have unmet needs than those CSHCN living in families with household incomes >185% FPL. Uninsured CSHCN are more likely to have reported that their needs were not met than insured children, and CSHCN lacking a usual source of care are also more likely to report unmet mental health care needs than those with an identified doctor's office. CSHCN whose usual source of care is a clinic report similar rates of unmet mental health care needs as those without a usual source of care. The severity of a child's condition is directly related to the probability of reporting unmet mental health care needs for CSHCN, and those CSHCN with unstable conditions are also more likely to have unmet needs than those with stable conditions. CSHCN with EDB conditions are more likely to report unmet need than for those CSHCN without EDB conditions. Older CSHCN experience higher rates of unmet needs than do younger children, and CSHCN of more educated mothers experience lower rates of unmet need than CSHCN of less-educated mothers. Black CSHCN experience the highest rates of unmet need of all racial/ethnic groups. There is a strong correlation between child and other family members' unmet needs: 3.4% of children had unmet needs if other family members did not have unmet needs, yet 51.0% of children had unmet needs if other family members did have unmet needs. Except for the racial categories, the patterns of unmet need for mental health care services among other family members are similar to the patterns for CSHCN.


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  		TABLE 2 Population Characteristics of CSHCN in the United States and the Distribution of Unmet Needs for Mental Health Care Services for CSHCN and Other Family Members: 2000–2002

 
Table 3 displays the results of the 2 logistic-regression models for CSHCN unmet mental health care needs and for other family member's unmet mental health care needs. After simultaneously adjusting for child health and demographic factors, we find that access to higher levels of resources (enabling factors) and higher levels of need factors are associated with less unmet need for mental health care services for CSHCN, which largely reflect the unadjusted findings presented in Table 2. Even after simultaneously adjusting for income, insurance, and usual source of care, each of these factors are independently and statistically significantly associated with access to mental health care services for CSHCN. Compared to the highest income group, to those with private insurance coverage, and to those with a doctor's office at their usual source of care, CSHCN living in the poorest homes, those who are uninsured, and those with no usual source of care are more likely to report unmet needs for mental health care services. More severely affected children are more likely to report unmet needs than less severely affected children, as are children with EDB conditions (condition stability is not independently associated with unmet needs in this model). Maternal education is not independently associated with unmet needs in this model. Relative to white CSHCN, black children are more likely to experience unmet needs, Hispanic children are less likely to experience unmet needs than non-Hispanic children, and CSHCN living in metropolitan areas are more likely to experience unmet needs than those in nonmetropolitan areas. CSHCN living in families in which other family members experience unmet needs are very likely to experience unmet needs for mental health care services.


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  		TABLE 3 Survey Logistic–Regression Models for Unmet Mental Health Care Services for CSHCN and Their Families in the United States: 2000–2002

 
Many of the child factors, to some degree, are shared family factors (eg, income, metropolitan status, insurance coverage, and race/ethnicity), but as stated above, some of the other child factors may not be theoretically applicable to other family members. We find, after simultaneously adjusting for all of the same factors, that some differences emerge. Enabling factors (family income, the target child's insurance coverage, and the child's usual source of care) are not associated with unmet needs for other family members. On the other hand, all of the target child's need factors are associated with unmet needs for other family members: family members of more severely affected children and family members of CSHCN with EDB conditions tend to have higher unmet needs for mental health care services, with the odds ratios (ORs) for the most severely affected children (OR: 4.5) almost twice that for CSHCN unmet needs (OR: 2.6). However, relative to usually stable conditions, family members of CSHCN with unstable conditions (changing all of the time) are less likely to experience unmet needs for mental health care services. Family members of CSHCN who experienced unmet needs are also much more likely to experience unmet needs for mental health care services.


   DISCUSSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
This study presents the first set of estimates of the prevalence of reported need and unmet need for mental health care services for both CSHCN and their families using the nationally representative NS-CSHCN. Approximately 26% of CSHCN and ~13% of their other family members reported a need for mental health care services. Overall, 4.7% of children and 2.8% of their other family members reported that their needs for mental health care services were not met, representing ~416000 children and at least 249000 members of their families in the United States. Given the American Academy of Pediatrics statements on the use of medical homes for CSHCN,28–30 it is disconcerting that such significant proportions of CSHCN and their families continue to report not receiving needed care. Our estimated rates of need and unmet need for the children in the NS-CSHCN are approximately equivalent to rates reported by others.12, 32–34

In multiple logistic-regression models we found that the factors that are most strongly related to unmet need for CSHCN are poverty, lack of insurance coverage, lack of a usual source of medical care, condition severity, having an EDB condition, and family mental health care unmet needs. Older children and black children are also more likely to experience unmet needs, but Hispanic children are less likely to report experiencing unmet needs. Many of these factors tend to be associated with lower socioeconomic status, and using the same data, others have found that these factors are also related to unmet need for routine and specialty medical care,31 therapy services, eyeglasses or vision care, hearing aids and communication devices or hearing care, and mobility devices,53 as well as being related to delayed or forgone care.54 In addition to examining the prevalence and correlates of unmet mental health care needs for CSHCN, we also investigated unmet mental health care needs for other family members. As reviewed above, the literature reports that health and health care experiences of family members tend to be correlated.23, 25 In addition, the stresses of caring for a child with special needs (which may or may not include EDB conditions) may be related to mental health care needs for caregivers and siblings. In multiple logistic-regression models we found that if the target child's condition was more severe or if the child had an EDB condition or had unmet mental health care needs, then other family members were likely to have unmet needs.

The consistent evidence that child and other family members' unmet needs are highly intercorrelated suggests either reciprocal causal feedbacks (children's special health care needs status affects the mental health of other family members, which in turn can further impact children's health) or common related factors, including genetic factors, or both. However, as reported above, our results are robust to a number of different analytic approaches that accounted for such family clustering and correlations. These findings are also consistent with other work that has shown that stressful family environments, including parental illness, are negatively related to parents' self-reported efforts to obtain care for their children.55 Regardless of the underlying causal mechanism, it is clear that families caring for CSHCN with more severe problems or with unmet mental health care needs themselves tend to have high rates of unmet mental health care needs.

Although these results are important, there are limitations to our analyses. They are based on self-reported cross-sectional data, which makes it difficult to clearly assess the causal relationships between the enabling, need, predisposing, and environmental factors and unmet mental health care needs. Assessing the impact of the effects of other family members is also not straightforward, because the decisions to enroll children in mental health care services are dynamically linked to parent's mental health and well-being.56 In addition, parentally reported need (and therefore unmet need) may reflect parentally perceived needs versus medically evaluated needs, which, because of various mechanisms such as culturally and socioeconomically related values and perceived stigma, may bias our results in unknown directions. For example, in some studies, black parents report higher levels of negative expectations about the need for and the efficacy of mental health care for their children than white parents57, 58 (although minority children are often more likely to be identified as requiring mental health care services59), thus possibly downwardly biasing either the numerator (use of services) or the denominator (need for services), or both.

Although we attempted to control for the environmental/health care system characteristics by adding measures of availability of pediatricians and pediatric specialists, these measures may not capture all of the complexity of this factor. In particular, aspects of insufficient supply of mental health care services to children may be related to health system policies, such as low reimbursement rates (especially for children covered by public insurance programs), that constrain physician and even family behavior.60

Despite these limitations, using this rather large and nationally representative sample of CSHCN, we present the first set of estimates of these associations that show that both CSHCN and their families do experience mental health care needs and that some level of these needs go unmet. Given that even after controlling for need and predisposing factors, demographic and enabling factors such as poverty, insurance, source of care, and race are statistically significantly associated with unmet needs, indicating some degree of inequity in access to needed mental health care service for CSHCN and their families. These factors are strongly related to socioeconomic status, indicating that some families of lower socioeconomic status are disproportionately reporting unmet needs and that broader policies to identify and connect these families with needed services is warranted. Each of the enabling factors (income, insurance, usual source of care) in our analyses actually provide starting points for possible policy interventions to increase access to care such as antipoverty and insurance-expansion efforts.

Primary care physicians who provide care to CSHCN may have difficulty referring children and their families to mental health care services. In a sample of Boston-area primary care physicians caring for CSHCN, only 18% of physicians reported satisfaction with their ability to access outpatient mental health services for their patients, and only 12% were satisfied with their ability to access outpatient mental health care services for their patients' families.61 Furthermore, only ~30% reported being satisfied with their ability to address their patients' psychological and emotional needs, and 77% reported that they needed more access to psychological consultants. Expanded access to and better implementation of medical homes may also help to address the problem of unmet mental health care needs for CSHCN and their families.27


   CONCLUSIONS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
These results imply that still more can be done to improve access to needed mental health care services for CSHCN and their families. The correlations between child and other family members' unmet need further imply that broader policies to identify and connect these children and their families with needed services are warranted but that child- and family-centered approaches are not likely, alone, to be sufficient to meet the needs of CSHCN and their families. Other interventions such as antipoverty, insurance-expansion, and medical home–implementation efforts may be needed as well. Disadvantaged families and children may especially benefit from these changes.


   ACKNOWLEDGMENTS
 
This work was supported in part by funding from Maternal and Child Health Bureau grant 5T76 MC 00001 (formerly MCJ201).


   FOOTNOTES
 
Accepted Nov 15, 2005.

Address correspondence to Michael L. Ganz, MS, PhD, Harvard School of Public Health, Department of Society, Human Development, and Health, 677 Huntington Ave, Boston, MA 02115. E-mail: mganz{at}hsph.harvard.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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