Care use and its intensity in children with complex problems are related to varying child and family factors: A follow-up study

Noortje M Pannebakker; Paul L Kocken; Paula van Dommelen; Krista van Mourik; Ria Reis; Sijmen A Reijneveld; Mattijs E Numans

doi:10.1371/journal.pone.0231620

. 2020 May 6;15(5):e0231620. doi: 10.1371/journal.pone.0231620

Care use and its intensity in children with complex problems are related to varying child and family factors: A follow-up study

Noortje M Pannebakker ^1,^2,^*, Paul L Kocken ^1,², Paula van Dommelen ¹, Krista van Mourik ², Ria Reis ², Sijmen A Reijneveld ³, Mattijs E Numans ⁴

Editor: Luca Cerniglia⁵

PMCID: PMC7202640 PMID: 32374786

Abstract

Background

There is little evidence on the child and family factors that affect the intensity of care use by children with complex problems. We therefore wished to identify changes in these factors associated with changes in care service use and its intensity, for care use in general and psychosocial care in particular.

Methods

Parents of 272 children with problems in several life domains completed questionnaires at baseline (response 69.1%) and after 12 months. Negative binominal Hurdle analyses enabled us to distinguish between using care services (yes/ no) and its intensity, i.e. number of contacts when using care.

Results

Change in care use was more likely if the burden of adverse life events (ALE) decreased (odds ratio, OR = 0.94, 95% confidence interval, CI = 0.90–0.99) and if parenting concerns increased (OR = 1.29, CI = 1.11–1.51). Psychosocial care use became more likely for school-age children (vs. pre-school) (OR = 1.99, CI = 1.09–3.63) if ALE decreased (OR = 0.93, CI = 0.89–0.97) and if parenting concerns increased (OR = 1.26, CI = 1.10–1.45). Intensity of use (>0 contacts) of any care decreased when ALE decreased (relative risk, RR = 0.95, CI = 0.92–0.98) and when psychosocial problems became less severe (RR = 0.38, CI = 0.20–0.73). Intensity of psychosocial care also decreased when severe psychosocial problems became less severe (RR = 0.39, CI = 0.18–0.84).

Conclusions

Changes in care-service use (vs. no use) and its intensity (>0 contacts) are explained by background characteristics and changes in a child’s problems. Care use is related to factors other than changes in its intensity, indicating that care use and its intensity have different drivers. ALE in particular contribute to intensity of any care use.

Introduction

Little research has been conducted on factors affecting the intensity of care use by children with complex problems (CP). The need of these children for health and social services, especially psychosocial care, is typically greater than would be expected based on their chronic physical, developmental, behavioral or emotional conditions; this is the case because their problems interact and enhance vulnerabilities [1–4]. These children are also referred to as members of troubled families or hotspotters [5–7]. Children with complex problems form the top 5% of children with the most challenging problems, amounting in the Netherlands to 170,000 children. Western countries struggle to organize effective and efficient care pathways for these children [8]. As a result, a major part of the budgets of psychosocial services is spent on children with CP [9,10].

The determinants of care use as such have been studied in depth, revealing several factors that impact access [11–16]. Less attention was paid to understanding the intensity of care use, i.e. the number of contacts with care providers. The scarce literature shows that higher intensity of care-service use by children with CP is related to two main groups of factors: child factors (age and impact of psychosocial problems); and parental factors (educational level, healthcare use, social support, and parental psychosocial problems) [17–20]. Research shows that the determinants affecting care use (yes/no) and the intensity with which it is used differ when studied simultaneously [17–19]. This suggests that intensity of care use may be a unique component of the help-seeking behavior of families with a child with complex problems. A better understanding of the intensity of care use will help us to organize more efficient care paths for these children.

Research on determinants of care use is often guided by Andersen and Newman’s behavioral-health model [21]. This model was developed to explain the use of care by an individual or population and has shown its value as comprehensive model for this purpose in health care research during the past decades [22,23]. The model describes care use on the basis of three factors: 1. predisposing factors, i.e., a child’s characteristics or abilities to use a specific service (such as age); 2. enabling factors, i.e., means whereby a family accesses care (such as social support); and 3. healthcare needs (such as a child’s psychosocial problems). This broad framework is a good fit with the wide-ranging problems experienced by children with CP. Our study is the first to apply this framework to the intensity of care use by these children.

We previously reported that overall care use was associated with social support and psychosocial problems and that the use of psychosocial care was associated with a child’s age and parenting concerns, based on a cross-sectional study in families with severe complex problems [16]. In the current study with a follow-up design, we additionally examined changes in intensity of care use in children with and at risk on developing CP, ensuring a wide range of intensity of care use. Accordingly, the aim of this study is to identify the changes in the predisposing, enabling and need factors that are associated 1. with a higher likelihood of changes in use of care services and 2. with changes in the intensity of use. The care services use studied comprised a broad spectrum of general care services including health and psychosocial care, and also the subset psychosocial care, including child mental healthcare and child and family services. We selected several predisposing characteristics of the child (such as age and gender, and also including predetermined factors such as parental education level and adverse life events), as well as enabling (social support and parental care use) and need factors (chronical condition, psychosocial problems, satisfaction with the parent-child relationship, and parenting concerns). This selection was based on the literature regarding determinants impacting the intensity of use of psychosocial care by children, as well as on our former study [4–6; 11–16].

Method

Sample and procedure

For this longitudinal study, we followed a cohort of children with CP and their parents, living in an urban setting in the Netherlands. The study was conducted according to the Helsinki regulation. The Medical Ethics Committee at Leiden University decided that approval was not required under Dutch Law (C12.041).

We aimed to include parents of children with CP or at risk of developing them with a wide range in intensity of care use living in the community. We recruited these parents in the general population, using inclusion criteria that concurred with the framework for identifying families with CP [24,25]. We included parents when they met the following inclusion criteria: 1. they had a child between 18 months and 12 years and 2. they experienced at least one of the following conditions: A. the child’s elevated total score on the parent-reported Strengths and Difficulties Questionnaire (SDQ) [26] or Brief Infant Toddler Social Emotional Assessment (BITSEA) [27]; B. persistent parenting concerns as judged by the preventive health care worker and/or parents; C. one or more major life event(s) during the past year as assessed using the standard screening questionnaire of the well child clinic [28] and D. care utilization of the child or parent in the past six months. Almost all respondents had three or more of these conditions (97%).

We identified the respondents during well-child visits, which are provided in the Netherlands by the preventive youth healthcare services. Attendance rates at these visits are high: 95% of all children [29]. To ensure the inclusion of children who used care with a high intensity, we additionally included children enrolled in specialist child and family services i.e. services that are only accessible after referral from primary care. Together this study group is expected to represent the whole group of children with CP or at risk of developing them.

We used the following inclusion procedure. First, a nurse, doctor or social worker identified parents based on our inclusion criteria, which were embedded in their routine intake questionnaire. Professional care givers then provided oral and written information about the study to the identified families and asked permission from parents to be called by a research assistant. Thereafter, the research assistant asked for informed consent regarding participation in this study.

Data were collected by trained research assistants at two time points, the first in 2013 (T1) and the second 12 months later (T2). Data were collected in a digital questionnaire, although parents could also opt to be interviewed by telephone in the language of their preference. Parents were reminded three times to fill in this questionnaire and received a gift certificate of 20 euros after doing so. Parents were informed that they could withdraw at any moment.

A total of 512 parents were approached, 354 of whom participated at T1 (response = 69.1%). Of these, 272 participated in the follow-up at 1 year (T1-T2 response = 76.8%), 239 from the well-child clinic group (T1 = 309), and 33 from the group of children using care in a high intensity (T1 = 45). Parents who dropped out at T2 had significantly more sons; more of them were of non-western origin and, on the basis of their home neighborhoods, and more of them had a lower socio-economic position [30].

Measures

We used validated questionnaires if available and assessed their reliability in the sample under study. The children’s service use and intensity of this use in the past six months were measured with the Questionnaire Intensive Care for Youth, a questionnaire measuring use of a pre-set list of types of Dutch services [31, 32]. This list has been adapted to the setting of care for youth from the valid and reliable Questionnaire for Costs Associated with Psychiatric Illnesses and Care Use (TiC-P) [33,34]. As allowed for by this standard questionnaire, we have added and omitted specific items of care services depending on their relevance for our target population. Moreover, respondents had the opportunity to add services we had not listed. Services are defined as any care provider or group of care providers. Dichotomized use at baseline and at follow-up led to four categories expressing change in use, i.e. “never used care”, “stopped using care”, “started using care” and “continued using care”. Intensity of care service use was measured as the number of contacts, defined as planned or unplanned contacts with a professional caregiver by telephone, email, or appointment or home visit; this did not include contacts to make an appointment. We made a distinction between 1. use of any services, which included the use of care delivered in the psychosocial or medical domain; and 2. use of psychosocial services, which included a subset of any care delivered by mental healthcare services, social care services, school care services or family services.

On the basis of Andersen and Newman’s behavioral-health model of access to care, we measured potential determinants of care use, i.e. predisposing, enabling and need factors [21]. We used six predisposing factors: child’s age; parents’ educational level; household composition; child’s ethnicity; parental mental health, and impact of any adverse life events the family had experienced (ALE). Parental mental health status was measured using the validated 12-item version of the General Health Questionnaire (Cronbach’s α = .86) [35]. To measure the burden of adverse life events in the previous 12 months, we used the life-events scale of the Brief Instrument Psychological and Pedagogical Problem Inventory (Cronbach’s α = .72) [36].

We measured three enabling factors: partner’s provision of social support, family provision of social support, and care use by a parent. To measure social support, we used two subscales of the validated Dutch Family Functioning Questionnaire [37]: “relationship with partner”(Cronbach’s α = .88), and “social functioning of the family” (Cronbach’s α = .91). Parental care use was measured using the TiC-P, similar to the way the child’s care use was measured (see above) [33].

We included four need factors in this study, i.e. a child’s chronic condition; a child’s emotional and behavioral problems; parenting concerns and a parent’s assessment of the quality of their relationship with their child. Questions measuring a child’s chronic health were the following. “Does your child have one or more chronic health condition—such as asthma, diabetes, ADHD or autism—for which treatment is or was needed? What is the impact of this condition on your child’s daily life?” [38]. We measured child behavioral and emotional problems using the BITSEA (for children aged between 18 months and 3 years) and the SDQ (for children aged between 3 and 12 years). We constructed the variable as a dichotomy, to be able combine the scores on the different instruments for the whole group. The Dutch versions of both were found to be reliable [26, 39–42]. Cronbach’s α’s as measured in this study of the SDQ subscales range from .39 to .74 and Cronbach’s α’s of the two BITSAE subscales on our data were .67 and .80. To measure parenting concerns we used the following question: “In the last 12 months, have you had concerns about your parenting?”[43] Finally, parents’ assessment of their relationship with their child was measured using the subscale of the validated Dutch Parenting Load Questionnaire (Cronbach’s α = .83) [44]. Answers were given in a five point Likert-scale. We dichotomized scale sum scores using their medians as cut off.

Analyses

First, we described the background characteristics; the scores of the predisposing, enabling and need factors; the use and intensity of any care; and the use and intensity of psychosocial care, all at baseline (T1). Next, on the basis of patterns of use and intensity, we described the changes between baseline and follow-up of predisposing, enabling and need factors for use of any care and use of psychosocial care. Next, we used negative binomial Hurdle modeling to assess the associations between the changes in factors and the changes in care use and its intensity. The score of the dependent variable at T1 was entered as covariate in the Hurdle analyses to be able to address ‘change’ in the outcomes.

Our use of Hurdle modeling was intended to overcome the statistical challenges inherent to data on care use, which typically follow a distribution with many zeroes (no use of care) [45, 46]. Hurdle models have the advantage of estimating two separate parameters in one model to accommodate many zero counts: one dichotomous outcome regarding using care services or not (>0 contacts versus no contacts), and one continuous outcome regarding the number of contacts within the group using care services (>0 contacts). First we assessed the univariate associations of the changes in the independent variables with any care and psychosocial care. On the basis of backward elimination in Hurdle models of all independent variables that were univariately significantly related at the p≤0.1 level, we then assessed which predisposing, enabling and need factors, and changes in these, were associated with changes in use and its intensity. The criterion for removing a factor out from the final models was set at p≤ 0.05. Analyses were performed using SPSS 22.0 [47], and the Hurdle analyses were performed in R, version 3.3.2 [48].

Results

Response and respondents’ background characteristics

The sample included more boys than girls, more school-aged children than pre-schoolers, more children of two-parent families than one-parent families, and more children of Dutch ethnicity than of non-Dutch ethnicity (see Table 1). About half of the parents with a high educational level experienced mental health problems and/or experienced burden of adverse life events in the previous year.

Table 1. Respondents’ baseline characteristics, and care use and intensity of use of any care and of psychosocial care.

	Total	Any care services		Psychosocial care services
	N^##	any use	intensity when using mean (SD)^b	any use	intensity when using mean (SD)^b
	N^##	n (%)^a	intensity when using mean (SD)^b	n (%)^a	intensity when using mean (SD)^b
Total	272	203 (75)	21 (35)	121 (45)	25 (39)
Predisposing factors
Child’s gender
Boy	152	117 (77)	24 (41)	67 (55)	29 (46)
Girl	120	86 (72)	17 (25)	54 (45)	20 (29)
Child’s age
Pre-school	107	67 (63)	25 (41)	38 (36)	28 (44)
School-aged	165	111 (67)	15 (23)	87 (53)	15 (19)
Parental educational level
High	132	93 (71)	24 (39)	53 (40)	18 (26)
Low/ medium	138	109 (79)	16 (26)	67(49)	28 (43)
Household composition
2-parent family	133	109 (82)	19 (34)	55 (41)	27 (39)
1-parent family	112	73 (65)	22 (37)	49 (44)	24 (45)
Other	23	19 (83)	26 (30)	15 (65)	20 (18)
Ethnicity
Dutch	155	122 (79)	22 (38)	78 (50)	25 (48)
Western	24	16 (67)	17 (24)	11 (46)	17 (25)
Non-Western	91	64 (70)	20 (33)	31 (34)	28 (38)
Parent had mental health problems
Yes	150	91 (75)	23 (42)	67 (45)	30 (47)
No	122	112 (75)	18 (25)	54 (44)	19 (26)
Burden of adverse life events
High	133	100 (76)	26 (40)	64 (48)	30 (44)
Low	124	94 (75)	16 (31)	51 (41)	19 (35)
Enabling factors
Partner’s provision of social support
High	140	105 (75)	25 (40)	53 (38)	22 (36)
Low	130	97 (75)	17 (31)	67 (52)	28 (42)
Family provision of social support
High	139	110 (79)	19 (31)	70 (50)	18 (31)
Low	130	90 (69)	24 (40)	51 (39)	35 (47)
Care use by parent
Yes	110	88 (80)	26 (38)	54 (49)	30 (40)
No	162	115 (71)	17 (38)	67 (41)	21 (39)
Need factors
Burden due to chronic condition
Yes	53	44 (83)	41 (53)	32 (60)	44 (55)
No condition/ no burden	217	159 (73)	25 (26)	89 (41)	18 (29)
Psychosocial problems
Yes	124	100 (81)	26 (42)	64 (52)	32 (46)
No	138	95 (69)	14 (21)	53 (38)	13 (16)
Parenting concerns
High	120	90 (75)	30 (44)	60 (50)	35 (47)
Low	152	113 (74)	14 (24)	61 (40)	15 (28)
Parental satisfaction with parent-child relationship
High	144	115 (80)	33 (19)	61 (42)	22 (36)
Low	127	88 (69)	23 (39)	60 (47)	28 (43)

Open in a new tab

^## N is taken at T1 and n varies due to missing data.

^a Respondents using care and the within group percentage.

^b Mean and standard deviation of care contacts when a respondent was using care.

Care service use and its intensity, and scores on predisposing, enabling and need factors

At baseline, three-quarters of the children in our sample were using some sort of care, and 45% were using psychosocial care (Table 1). For any child using care services, the average intensity of care use was 21 contacts. The intensity of service use was higher if a child was using psychosocial care, with an average of 25 contacts in the previous six months. Predisposing and enabling factors followed a different pattern for ‘any’ and ‘psychosocial care’ use (yes/no) and their intensity (>0 contacts). However, need factors showed the same pattern both for any care use and for psychosocial care use: children whose parents reported a higher score on a need factor used care more often and with a higher intensity than those who reported a lower score.

Change in a child’s predisposing, enabling and need factors for care service use and its intensity

Table 2 shows changes in predisposing, enabling and need factors and in care use (yes/no) and its intensity (>0 contacts) over time during the use of care services. Regardless of their difference score on the independent variable, most children were in the “continued care use” category for any care services, and in the “never used care” category for psychosocial care services. More children with an increase in the level of need factors tended to be in the “started care” category than those whose needs were decreased or remained unchanged.

Table 2. Descriptives for the change in predisposing, enabling and need factors and any and psychosocial care use and its intensity by children with or at risk of developing CP.

		Care service use (yes/no)				Intensity/number of contacts when using care
	N^#	never used care	stopped using care	started using care	continued using care	stopped using care	started using care	continued using care
		never used care	stopped using care	started using care	continued using care	stopped using care	started using care	T1	T2
		n (%)^a	n (%)^a	n (%)^a	n (%)^a	mean (sd)^b	mean (sd)^b	mean (sd)^b	mean (sd) ^b
*Results for any care*
Predisposing factors
Δ Burden of adverse life events
No change	181	21 (12)	38 (21)	16 (9)	106 (59)	7 (8)	19 (32)	25 (44)	19 (35)
Decrease	57	10 (18)	7 (12)	10 (18)	30 (53)	38 (15)	9 (9)	26 (30)	27 (35)
Increase	9	2 (22)	2 (22)	0	5 (56)	8 (10)	-	8 (11)	16 (13)
Need factors
Δ Child’s psychosocial problems
No change	198	29 (15)	39 (20)	22 (11)	108 (55)	9 (12)	15 (28)	22 (34)	21 (30)
Decrease	39	9 (23)	7 (18)	3 (8)	20 (51)	48 (59)	4 (5)	29 (34)	10 (10)
Increase	21	1 (5)	2 (10)	3 (15)	15 (70)	10 (9)	15 (6)	21 (15)	35 (64)
ΔParenting concerns
No change	197	26 (13)	37 (18)	17(9)	117 (59)	10 (13)	17 (32)	26 (41)	19 (24)
No change	197	26 (13)	37 (18)	17(9)	117 (59)	(911)	17 (32)	26 (41)	19 (24)
Decrease	17	3 (18)	3 (18)	2 (12)	9 (53)	5(3)	10 (11)	20 (22)	58 (92)
Increase	57	11 (19)	13 (23)	10 (18)	23 (40)	14 (24)	8 (8)	20 (36)	16 (30)
*Results for psychosocial care*
Predisposing factors
Child’s age^d
Pre-school	107	54 (50)	15 (14)	21 (20)	17 (16)	14 (22)	8 (13)	17 (16)	19 (18)
School-aged	165	51 (31)	27 (16)	25 (15)	62 (38)	12 (11)	10 (12)	36 (51)	22 (30)
Δ Burden of adverse life events
No change	181	70 (39)	31 (17)	31 (17)	49 (27)	8 (8)	10 (14)	38 (54)	23 (32)
Decrease	57	19 (33)	4 (7)	12 (21)	22 (39)	36 (10)	7 (8)	25 (30)	19 (22)
Increase	9	4 (44)	2 (22)	0	3 (27)	7 (9)	-	14 (12)	13 (14)
Need factors
Δ Child’s psychosocial problems^c
No change	198	78 (39)	30 (15)	33 (17)	57 (29)	11 (12)	12 (14)	26 (36)	22 (30)
Decrease	39	16 (41)	6 (15)	7 (18)	10 (26)	8 (8)	3 (3)	44 (56)	13 (11)
Increase	21	7 (33)	3 (15)	4 (19)	7 (33)	30 (41)	8 (4)	15 (18)	28 (24)
Δ Parenting concerns^c
No change	197	75 (38)	28 (14)	28 (14)	66 (34)	13(13)	12 (15)	31 (48)	20 (22)
Decrease	17	6 (35)	3(18)	4 (23)	4 (23)	3 (2)	6 (3)	27 (29)	57 (82)
Increase	57	24 (42)	10 (18)	14 (24)	9 (16)	15 (12)	6 (8)	37(46)	13 (19)
Increase	57	24 (42)	10 (18)	14 (24)	9 (16)	15 (12)	6 (8)	37(46)	14 (87)

Open in a new tab

^## n varies due to missing data.

^a Respondents using care and the within group-percentage.

^b Mean and standard deviation of care contacts when a respondent who used care.

Regarding change in the intensity of care service use (>0 contacts), we found in the “continuing care” category that children whose need factors had decreased also showed a decrease in the intensity of care use. In line with this finding, children with an increase in need factors also showed an increase in the intensity of care in the “continuing care” category. However, we did not find the same relationship for parenting concerns.

Table 3 shows the final Hurdle models regarding the multivariate associations of change in independent variables with change in use of any and psychosocial care, and their intensity (see S1 Appendix for the results of the univariate regression models for all factors). First we discuss the zero part of the Hurdle models regarding care use (yes/no). The final model regarding use of any care consisted of burden of adverse life events (ALE) (a predisposing factor), and parenting concerns (a need factor). Whereas a decrease in ALE was associated with lower odds of change of care use, an increase in parenting concerns was associated with higher odds. Regarding psychosocial care use, the final model consisted of the same factors as use of any care, but with the addition of child’s age. School-aged children had higher odds on change of psychosocial care use than did pre-school children.

Table 3. Final Hurdle models for change in factors associated with change in care use and its intensity by children with CP using care: Multivariate odds ratios for changes in care use and rate ratios for changes in intensity of care use for any care and for psychosocial care services.

	Δ Care service use (yes/no)	Δ Intensity/number of contacts when using care
	adj. OR (95% CI)^a ^b	adj. RR (95% CI)^a ^c
*Final model for any care*^>>
Predisposing factors
Δ Burden of adverse life events^d	0.94 (0.90;0.99)^*	0.95 (0.92;0.98)^**
Need factors
Δ Child’s psychosocial problems^d
No change	Ref (1)	Ref (1)
Decrease	0.73 (0.32;1.68)	0.38 (0.20;0.73)^**
Increase	3.27 (0.69;15.48)	1.17 (0.54;2.56)
Δ Parenting concerns^c	1.29 (1.11;1.51) ^***	1.13 (0.99;1.29)
*Final model for psychosocial care*^>>
Predisposing factors
Child’s age^d
Pre-school	Ref (1)	Ref (1)
School-aged	1.99 (1.09;3.63)^*	1.32 (0.72;2.43)
Δ Burden of adverse life events^d	0.93 (0.89;0.97)^***	0.98 (0.95;1.01)
Need factors
Δ Child’s psychosocial problems^e
No change	Ref (1)	Ref (1)
Decrease	0.84 (0.36;1.97)	0.39 (0.18;0.84)^*
Increase	1.02 (0.36;2.92)	1.16 (0.46;2.90)
Δ Parenting concerns^c	1.26 (1.10;1.45)^**	1.08 (0.95;1.24)

Open in a new tab

^a Backward stepwise regression analyses were conducted with the difference score of the factor, if available, and care use at T1 as covariate. The factors entered were parental educational level, child’s age, burden of adverse life events, partner’s provision of social support, child’s chronic condition, child’s psychosocial problems, and parenting concerns. The criterion for removing a factor from the model was set at P-value>0.05

^b Predictors were removed in the following order: chronic condition, parental educational level, and partner’s provision of social support

^c Only one factor, chronic condition, was removed from the model.

^d These factors are constructed as difference-of-scale scores between T2-T1.

^e This factor is constructed as difference of dichotomized scores between T2-T1.

*p<0.05

**p<0.01

***p<0.001.

Next, we discuss the count part of the Hurdle analyses (>0 contacts). Regarding the intensity of any care use, the final model consisted of burden of adverse life events (a predisposing factor), and psychosocial problems (a need factor). A child’s decrease in ALE was associated with decreased intensity of use, and a child’s decrease in psychosocial problems was associated with decreased intensity of psychosocial care, in comparison with children with no changes in their level of problems. The final model for psychosocial care services consisted only of psychosocial problems (a need factor), with associations similar to those for any care.

Discussion

This study shows that changes in the predisposing and need factors of Andersen and Newman’s behavioral-health model of access to care were relevant to explaining changes in care use and its intensity by children with CP or at risk of developing it. However, enabling factors were not. We also found that care use was related to factors other than changes in its intensity. Relative to the situation at baseline, when children experienced a diminished burden of life events (ALE) or when more parenting concerns were reported at follow-up, children were less likely to use any care or psychosocial care. School-aged children were also more likely than pre-schoolers to use psychosocial care. The intensity of any care use and of psychosocial care use decreased when the degree of psychosocial problems decreased. The intensity of any care use also decreased when ALE decreased. Moreover, where ALE was associated both with care use and with its intensity, parenting problems uniquely impacted care use and psychosocial problems uniquely impacted its intensity.

We found that several changes in predisposing (i.e. burden of ALE and a child’s age) and need factors (i.e. parenting concerns and psychosocial problems) were associated with changes in care use and its intensity, both for overall care use and for the use of psychosocial services, but that changes in enabling factors were not. The determinants we found are in line with previous findings [49–55]. An explanation may be that enabling factors are harder to change than predisposing and need factors in the relative short time span of our study (one year). For example, it is more difficult for a child social worker to convince parents to make use of mental health care for their own mental problems than to address parenting concerns. This study shows the value of the Andersen and Newman model for studying the intensity of care use, especially in distinguishing enabling factors from other factors affecting families with a child at risk of CP or of developing them.

The results of this study added burden of ALE as a factor impacting change in intensity of care use. Research showed that ALE is an important determinant of care use in general [56, 57]. ALE will especially affect children with CP, interacting strongly with the other problems of these children, thereby leading to more intense problems. Unexpectedly, we found a slight negative relative risk between ALE and the intensity of any care use. We noted that the burden of ALE decreased in a relatively large group of children while they were using care. Children with CP may have been motivated to continue treatment even when the burden of ALE decreased, because trauma-based therapies are known to have a positive effect on other emotional conditions [58,59]. Furthermore, when the safety of a child is at risk, as in cases of domestic violence, care professionals will ideally continue treatment to monitor the situation. Our results indicate that change in ALE is relevant to the whole care process, i.e. not only care use itself, but also to its intensity.

Although improving social support is at the core of treatment of families with complex problems, in the final models of our study this factor was absent [60]. It can be hypothesized that social support works differently for families with complex problems than for the general population [16, 61–63]. The families’ social networks in case of CP are usually large and suitable for dealing with daily challenges of living with a child with complex problem[61–63]. However, regardless of their perceived social support, families will turn to professionals to bring about long-term improvements, surmising that they may not be able to achieve these improvements with their own network. Also, professionals may not yet have managed to bring about changes in the quality of support by the social environment because of the relatively short period of our study (one year). Although social support is a known determinant impacting a child’s care use, more research is needed to understand how to optimize its impact for families of a child with CP.

Finally, we found that changes that changes in intensity with which care is used (>0 contacts) were affected by factors other than changes in care use in itself (yes/no). This supports earlier findings in the scarce research available on intensity of care use [8–10]. For both any care and psychosocial care, our study shows that parents with parenting concerns were more likely to use care, and the intensity of care use increased when there were psychosocial problems. Both need factors are known drivers of help-seeking behavior [64]. Our study showed that parenting concerns impacted care use but not intensity, while a child’s psychosocial problems were relevant to intensity rather than to care use.

Strengths and limitations

A major strength of this study is its comprehensive use of the data, obtained by using the Hurdle model. This model overcomes the difficulties inherent to using a single model to assess factors that impact care use and its intensity, which cannot be assessed by mainstream generalized linear models. We therefore believe that the use of Hurdle models provides added value for researchers interested in care utilization. Another strength of the study is that the study group of children with or at risk of developing CP were living in the community, including children in treatment with different intensities of care use or not using care at all. In most other research the study groups are limited to children with CP who are using a specific treatment [8,25].

A limitation of this study concerned some small selective loss to follow-up. A relatively high number of children who were lost to follow-up were boys and had parents of non-western origin. Another limitation is that we used a self-report questionnaire to establish care use in the previous six months. This may have caused some recall bias, especially for intensity of care use and the determinants burden of ALE and impact of chronical conditions of the child. This may have added measurement error and thus a weakening of reported associations, probably without clear under- or overestimation.

Implications for practice

A new finding in this study is the effect that the burden of ALE has on the intensity of care use, a factor that is relevant to the whole care-seeking process, i.e. not only entering care, but also the intensity of its use. This shows the importance of providing interventions that focus on the effects of ALE, on the impact of these effects on intensity, and thus on the costs of care [58, 59]. For this reason, those who assess and treat children with CP should pay close attention to adverse life events and the way children and their families deal with them.

We also found that, while a decline in psychosocial problems was associated with a decrease in intensity of care use, care use in itself was not affected by changes in psychosocial problems. Conceivably, various barriers hinder the process of starting care. In their recent systematic review, in which they provide an overview of the barriers facing children with or at risk of developing CP, Reardon and colleagues show how insufficient knowledge and understanding of psychosocial problems and the help-seeking process on the part of parents is a core component that hinders care use [65]. Policymakers and professional care providers should make efforts to educate parents on recognizing their child’s psychosocial problems, and also on the local pathways to help.

Implications for further research

With regard to care use and its intensity in this group of children, our study shows the enabling factors defined by Andersen and Newman to be less relevant than the predisposing and need factors [8]. To understand the contribution and any possible indirect impact of enabling factors, further research is required. We therefore have two recommendations: 1. a larger respondent group (to accommodate mediation analysis); and 2. extension of the time-lapse in the longitudinal design.

Regarding the enabling factor social support, more research is needed on how to improve the quality of support provided by the network of families with a child with complex problems. We advise the development and evaluation of a treatment module for parents and key persons in their social network to improve support skills. These new skills can be thought by volunteers who are able to model healthy support.

In this group of children we also found that the intensity of use of care services is affected by factors different from those influencing the use of care in itself. Understanding the mechanism underlying the intensity of care use can help the development of more effective and efficient pathways to care for children with or at risk of developing CP. This will require further research into this mechanism behind care use and its intensity by children with CP.

Conclusion

With regard to the use of any care, or psychosocial care, and the intensity of this care by children who with or at risk of developing CP, our study shows that changes in predisposing factors (i.e., a child’s age and burden of life events) and need factors (i.e., a child’s psychosocial problems and parenting concerns) are associated with change in use or intensity of use, and enabling factors are not. The importance of effective treatment of ALE is emphasized by the fact that ALE are a factor that contributes to the intensity of care use. The level of a child’s psychosocial problems is also relevant to the intensity of care use (>0 contacts), but not to the use of care in itself (yes/no). To improve care use by children with these needs, policymakers should address parents’ knowledge with regard to identifying psychosocial problems and the help-seeking process. Finally, our findings demonstrate the added value of studying the intensity of care use, especially on the basis of Andersen and Newman’s model of care-seeking. Such study will improve our insight into the drivers of the intensity of care use by children with CP.

Supporting information

S1 Appendix. Results of the hurdle analyses.

(DOCX)

Click here for additional data file.^{(46.3KB, docx)}

S2 Appendix. Interview protocol for the project oké in Den Haag.

(DOCX)

Click here for additional data file.^{(22.3KB, docx)}

S1 File

(PDF)

Click here for additional data file.^{(295.9KB, pdf)}

S2 File

(DOCX)

Click here for additional data file.^{(17.9KB, docx)}

Acknowledgments

First and foremost we thank the parents who participated in this study. Thanks for recruiting them are due to the preventive healthcare workers at the Preventive Child Health Care services in The Hague and to the caseworkers at BKK, MEE and Bureau Jeugdzorg in the Hollands Midden region. We thank research assistants Ellen Westhoff, Jasper Boerrigter, Sophie Wins and Rosanne Schoorl for their work on this project, and Yvonne Schonbeck for her support with project organization. Finally, we thank Meinou Theunissen for data analysis and Mascha Kamphuis for management of the project.

Data Availability

We are not able to make all data underlying the findings described in our manuscript fully available without restriction, because the informed consents given by our participants do not give us the permission to do so. We are able to provide a detailed metadata description of our dataset and we have made all our methods and analysis scripts available within the DANS repository at DOI: 10.17026/dans-xnr-j7yj. Researchers interested in our dataset can contact us via our data access committee. The data access committee is responsible for reviewing applications and finding the appropriate solution for data access in agreement with the given informed consents. We are happy to supply the contact information of our data access committee: Name: Front Office TNO Child health Email: zelfstandig-tno-secretariaatCHLS@tno.nl Phone number: 0031+(0) 88 866 90 00 Address: Schipholweg 77 2316 ZL Leiden P.O. 3005, 2301 DA Leiden

Funding Statement

This study was funded by ZonMw, The Netherlands Organization for Health Research and Development (15901.0005). This funding body played no role in the design, conducting, analysis or write-up of the study.

References

1.Denholm R, Power C, Li L, Thomas C. Child maltreatment and household dysfunction in a British Birth Cohort. Child Abuse Rev 2013;22(5):340–353. [Google Scholar]
2.Stith SM, Liu T, Davies LC, Boykin EL, Alder MC, Harris JM, et al. (2009). Risk factors in child maltreatment: A meta-analytic review of the literature. Aggression and Violent Behavior, 14(1), 13–29. 10.1016/j.avb.2006.03.006 [DOI] [Google Scholar]
3.Lucas PJ, McIntosh K, Petticrew M, Roberts HM, Shiell A. Financial benefits for child health and well-being in low income or socially disadvantaged families in developed world countries. Cochrane Database of Systematic Reviews 2008(2). [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. The Lancet 2017 4–10 March 2017; 389(10072):951–963. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Gawande A. The Hot Spotters, can we lower medical costs by giving the neediest patients better care? The New Yorker, Januari 17^th 2011: 40–51. [PubMed] [Google Scholar]
6.Hayden C, Jenkins C. Children taken into care and custody and the 'troubled families' agenda in England. Child Fam Soc Work 2015;20(4):459–469. [Google Scholar]
7.Hayden C, Jenkins C. ‘Troubled Families’ Programme in England: ‘wicked problems’ and policy-based evidence. Policy Stud 2014;35(6):631–649. [Google Scholar]
8.Tausendfreund T, Knot-Dickscheit J, Post WJ, Knorth EJ, Grietens H. Outcomes of a coaching program for families with multiple problems in the Netherlands: A prospective study. Children and Youth Services Review 2014. 11;46:203–212. [Google Scholar]
9.Goerge RM, Smithgall C, Seshadri R, Ballard P. llinois Families and Their Use of Multiple Service Systems. Chicago: Chapin Hall at the University of Chicago; 2010. [Google Scholar]
10.Sacco FC, Twemlow SW, Fonagy P. Secure attachment to family and community: a proposal for cost containment within high user populations of multiple problem families Smith College Studies in Social Work 2008. [Google Scholar]
11.Nanninga M, Jansen DEMC, Knorth EJ, Reijneveld SA. Enrolment of children and adolescents in psychosocial care: more likely with low family social support and poor parenting skills. Eur Child Adolesc Psychiatry 2015;24 (4):407–416. 10.1007/s00787-014-0590-3 [DOI] [PubMed] [Google Scholar]
12.Burns BJ, Phillips SD, Wagner HR, Barth RP, Kolko DJ, Campbell Y, et al. Mental health need and access to mental health services by youths involved with child welfare: A national survey. J Am Acad Child Adolesc Psychiatry 2004;43(8):960–970. 10.1097/01.chi.0000127590.95585.65 [DOI] [PubMed] [Google Scholar]
13.Verhulst FC, Van Der Ende J. Factors associated with child mental health service use in the community. J Am Acad Child Adolesc Psychiatry 1997;36(7):901–909. 10.1097/00004583-199707000-00011 [DOI] [PubMed] [Google Scholar]
14.Tick NT, Van Der Ende J, Verhulst FC. Ten-year increase in service use in the Dutch population. European Child and Adolescent Psychiatry 2008;17(6):373–380. 10.1007/s00787-008-0679-7 [DOI] [PubMed] [Google Scholar]
15.Tausendfreund T, Knot-Dickscheit J, Schulze GC, Knorth EJ, Grietens H. Families in multi-problem situations: Backgrounds, characteristics, and care services. Child Youth Serv 2016;37(1):4–22. [Google Scholar]
16.Pannebakker NM, Kocken PL, Theunissen MHC, van Mourik K, Crone MR, Numans ME, et al. Services use by children and parents in multiproblem families. Child Youth Serv Rev 2018;84:222–228. [Google Scholar]
17.Farmer EMZ, Stangl DK, Burns BJ, Costello EJ, Angold A. Use, persistence, and intensity: Patterns of care for children's mental health across one year. Community Ment Health J 1999;35(1):31–46. 10.1023/a:1018743908617 [DOI] [PubMed] [Google Scholar]
18.Hamilton HA, Paglia-Boak A, Wekerle C, Danielson AM, Mann RE. Psychological Distress, Service Utilization, and Prescribed Medications among Youth with and without Histories of Involvement with Child Protective Services. Int J Ment Health Addict 2011;9(4):398–409. [Google Scholar]
19.Saurina C, Vall-Llosera L, Saez M. Factors determining access to and use of primary health care services in the Girona Health Region (Spain). Eur J Health Econ 2012;13(4):419–427. 10.1007/s10198-011-0313-3 [DOI] [PubMed] [Google Scholar]
20.Palacio-Vieira J, Villalonga-Olives E, Valderas JM, Herdman M, Alonso J, Rajmil L. Predictors of the use of healthcare services in children and adolescents in Spain. International Journal of Public Health 2013;58(2):207–215 10.1007/s00038-012-0360-2 [DOI] [PubMed] [Google Scholar]
21.Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank mem fd quart 1973;51(1):95–124. [PubMed] [Google Scholar]
22.Phillips KA, Morrison KR, Andersen R, Aday LA. Understanding the context of healthcare utilization: Assessing environmental and provider-related variables in the behavioral model of utilization. Health Serv Res 1998;33(3 I):571–596 [PMC free article] [PubMed] [Google Scholar]
23.Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen's Behavioral Model of Health Services Use: a systematic review of studies from 1998–2011. Psychosoc Med. 2012;9. [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Bodden DHM, Dekovitch M. Multiprobleemgezinnen ontrafeld [multiproblem families discovered]. Tijdschrift voor Orthopedagogiek 2010;49:259–271. [Google Scholar]
25.Bodden DHM, Dekovic M. Multiproblem Families Referred to Youth Mental Health: What's in a Name? Fam Process 2016;55(1):31–47. 10.1111/famp.12144 [DOI] [PubMed] [Google Scholar]
26.Goodman R. The strengths and difficulties questionnaire: A research note. J Child Psychol Psychiatry Allied Disciplines 1997;38(5):581–586. [DOI] [PubMed] [Google Scholar]
27.Briggs-Gowan MJ, Carter AS, Irwin JR, Wachtel K, Cicchetti DV. The Brief Infant-Toddler Social and Emotional Assessment: Screening for Social-Emotional Problems and Delays in Competence. J Pediatr Psychol 2004;29(2):143–155. 10.1093/jpepsy/jsh017 [DOI] [PubMed] [Google Scholar]
28.Theunissen M., Pas van der S. & Harten van L. Achtergronddocument: Een uniform triageprotocol voor het signaleren van ontwikkelings- of gezondheidsrisico’s bij basisschoolkinderen door de Jeugdgezondheidszorg [Background information: a uniform protocol for discovering a triage of risks on developmental and health problems by child preventive health care]. 2019; 06016673. [Google Scholar]
29.CBS Statistics Netherlands. Ouders geven consultatiebureau gemiddeld een ruime 7 [Parents appreciatie well visit clinics]. 2014; Available at: www.cbs.nl/nl-nl/nieuws/2014/44/ouders-geven-consultatiebureau-gemiddeld-een-ruime-7.
30.Sociaal Cultureel Planbureau. social economic status. 2015 August 18th.
31.Bouwmans CAM, Schawo SJ, Jansen DEMC, Vermeulen KM, Reijneveld SA, Hakkaart-van Roijen L. Handleiding Vragenlijst Intensieve Jeugdzorg: Zorggebruik en productieverlies [Manual Questionnaire Intensive Care for Youth: health care utilization and productivity loss]. Rotterdam: Erasmus MC; 2012. [Google Scholar]
32.Jansen DE, Vermeulen KM, Schuurman-Luinge AH, Knorth EJ, Buskens E, Reijneveld SA. Cost-effectiveness of Multisystemic Therapy for adolescents with antisocial behavior: Study protocol of a randomized controlled trial. BMC Public Health 2013;13(1). [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Hakkaart-Van Roijen L, Van Straten A, Donker M, Tiemens B. Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness (TiC-P). Rotterdam; 2002. [Google Scholar]
34.Bouwmans C, De Jong K, Timman R, Zijlstra-Vlasveld M, Van Der Feltz-Cornelis C, Tan SS, et al. Feasibility, reliability and validity of a questionnaire on healthcare consumption and productivity loss in patients with a psychiatric disorder (TiC-P). BMC Health Serv Res 2013;13(1). [DOI] [PMC free article] [PubMed] [Google Scholar]
35.Koeter MWJ, Ormel J. General health questionnaire, manual [Nederlandse bewerking, Handleiding]. Lisse: Swets & Zeitlinger; 1991. [Google Scholar]
36.De Wolff MS, Theunissen MHC, Vogels AGC, Reijneveld SA. Three questionnaires to detect psychosocial problems in toddlers: A comparison of the BITSEA, ASQ:SE, and KIPPPI. Academic Pediatrics 2013;13(6):587–592. 10.1016/j.acap.2013.07.007 [DOI] [PubMed] [Google Scholar]
37.Van der Ploeg JD, Scholte EM. Handleiding Vragenlijst Gezinsfunctioneren (GVL) [Manual Family Functioning Questionnaire]. Houten: Bohn Stafleu Van Loghum; 2008. [Google Scholar]
38.Wingerd M. Gezondheidsenquete-2013 [Dutch Health care questionnaire]. 12-02-2020; Available at: www.cbs.nl/nl-nl/achtergrond/2015/15/gezondheidsvragenlijst-gezondheidsenquete-2015
39.Kruizinga I, Jansen W, de Haan CL, van der Ende J, Carter AS, Raat H. Reliability and validity of the Dutch version of the brief infant-toddler social and emotional assessment (BITSEA). PLoS ONE 2012;7(6). [DOI] [PMC free article] [PubMed] [Google Scholar]
40.Theunissen MHC, Vogels AGC, De Wolff MS, Reijneveld SA. Characteristics of the strengths and difficulties questionnaire in preschool children. Pediatrics 2013; 131(2):e446–e454. 10.1542/peds.2012-0089 [DOI] [PubMed] [Google Scholar]
41.Vogels AG, Crone MR, Hoekstra F, Reijneveld SA. Comparing three short questionnaires to detect psychosocial dysfunction among primary school children: A randomized method. BMC Public Health 2009;9. [DOI] [PMC free article] [PubMed] [Google Scholar]
42.Mieloo C, Raat H, van Oort F, Bevaart F, Vogel I, Donker M., et al. (2012). Validity and reliability of the strengths and difficulties questionnaire in 5–6 year olds: Differences by gender or by parental education? PLoS ONE, 7:5. [DOI] [PMC free article] [PubMed] [Google Scholar]
43.Reijneveld S. A., De Meer G., Wiefferink C. H., & Crone M. R. (2008). Parents' concerns about children are highly prevalent but often not confirmed by child doctors and nurses. BMC Public Health, 8 10.1186/1471-2458-8-124 [DOI] [PMC free article] [PubMed] [Google Scholar]
44.Vermulst A, Kroes G, De Meyer RE, Nguyen RE, Veerman JW. Opvoedingsbelastingvragenlijst (OBVL) Handleiding [The Parenting Load Questionnaire, instruction manual]. Nijmegen: Radboud Universiteit Nijmegen / Praktikon; 2012. [Google Scholar]
45.Hofstetter H, Dusseldorp E, Zeileis A, Schuller AA. Modeling Caries Experience: Advantages of the use of the hurdle model. Caries Res 2016;50(6):517–526. 10.1159/000448197 [DOI] [PubMed] [Google Scholar]
46.Lee AH, Wang K, Scott JA, Yau KKW, McLachlan GJ. Multi-level zero-inflated poisson regression modelling of correlated count data with excess zeros. Stat Methods Med Res 2006;15(1):47–61. 10.1191/0962280206sm429oa [DOI] [PubMed] [Google Scholar]
47.IBM corp. IBM SPSS Statistics for Windows. 2013.
48.R Core Team. R: A language and environment for statistical computing. 2013. [Google Scholar]
49.Wu P, Hoven CW, Bird HR, Moore RE, Cohen P, Alegria M, et al. Depressive and disruptive disorders and mental health service utilization in children and adolescents. J Am Acad Child Adolesc Psychiatry 1999;38(9):1081–1090. 10.1097/00004583-199909000-00010 [DOI] [PubMed] [Google Scholar]
50.Janicke DM, Finney JW. Determinants of children's primary health care use. Journal of Clinical Psychology in Medical Settings 2000;7(1):29–39. [Google Scholar]
51.Riley AW, Finney JW, Mellits ED, Starfield B, Kidwell S, Quaskey S, et al. Determinants of children’s health care use: An investigation of psychosocial factors. Med Care 1993;31(9):767–783. 10.1097/00005650-199309000-00002 [DOI] [PubMed] [Google Scholar]
52.Stahmer AC, Leslie LK, Hurlburt M, Barth RP, Webb MB, Landsverk J, et al. Developmental and behavioral needs and service use for young children in child welfare. Pediatrics 2005;116(4):891–900. 10.1542/peds.2004-2135 [DOI] [PMC free article] [PubMed] [Google Scholar]
53.Welkom JS, Hilliard ME, Rand CS, Eakin MN, Riekert KA. Caregiver depression and perceptions of primary care predict clinic attendance in head start children with asthma. Journal of Asthma 2015;52(2):176–182. 10.3109/02770903.2014.956891 [DOI] [PMC free article] [PubMed] [Google Scholar]
54.Fernandez E. Supporting children and responding to their families: Capturing the evidence on family support. Child Youth Serv Rev 2007;29(10):1368–1394. [Google Scholar]
55.Martinez JI, Lau AS. Do Social Networks Push Families Toward or Away From Youth Mental Health Services?: A National Study of Families in Child Welfare. J Emot Behav Disord 2011;19(3):169–181. 10.1177/1063426610377898 [DOI] [PMC free article] [PubMed] [Google Scholar]
56.Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis. PLoS Med 2012;9(11). [DOI] [PMC free article] [PubMed] [Google Scholar]
57.Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health 2017;2(8):e356–e366. 10.1016/S2468-2667(17)30118-4 [DOI] [PubMed] [Google Scholar]
58.Schneider SJ, Grilli SF, Schneider JR. Evidence-based treatments for traumatized children and adolescents. Curr Psychiatry Rep 2013;15(1).-012-0332-5 [DOI] [PubMed] [Google Scholar]
59.Connor DF, Ford JD, Arnsten AFT, Greene CA. An update on posttraumatic stress disorder in children and adolescents. Clin Pediatr 2015;54(6):517–528. [DOI] [PubMed] [Google Scholar]
60.Stanhope V, Videka L, Thorning H, McKay M. Moving Toward Integrated Health: An Opportunity for Social Work. Soc Work Health Care 2015;54(5):383–407. 10.1080/00981389.2015.1025122 [DOI] [PubMed] [Google Scholar]
61.Matos AR, Sousa LM. How multiproblem families try to find support in social services. J Soc Work Pract 2004;18(1):65–80. [Google Scholar]
62.Sousa L. Building on personal networks when intervening with multi-problem poor families. J Soc Work Pract 2005;19(2):163–179. [Google Scholar]
63.Sousa L, Rodrigues S. Linking formal and informal support in multiproblem low-income families: The role of the family manager. J Community Psychol 2009;37(5):649–662. [Google Scholar]
64.Pohlmeier W, Ulrich V. An econometric model of the two-part decision making process in the demand for healthcare. J Hum Resour 1995;30(2):339–361. [Google Scholar]
65.Reardon T, Harvey K, Baranowska M, O’Brien D, Smith L, Creswell C. What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies. Eur Child Adolesc Psychiatry 2017;26(6):623–647. 10.1007/s00787-016-0930-6 [DOI] [PMC free article] [PubMed] [Google Scholar]

PLoS One. doi: 10.1371/journal.pone.0231620.r001

Decision Letter 0

Luca Cerniglia

19 Nov 2019

PONE-D-19-15380

Care use and its intensity in children with complex problems are related to varying child and family factors: a follow-up study

PLOS ONE

Dear Authors,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by 12/18/2019. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Luca Cerniglia, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

1. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

2. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Introduction:

How are “children with complex problems” defined? Is this your definition, or one that has been frequently used in the literature? This is an unfamiliar term to me, and without description, I am uncertain about why this population is of interest or how it differs from other “high-risk” subsets of youth.

I appreciate brevity, but previous literature and how it is insufficient and/or different from the current study, and how it drives the need for the current study, needs a bit more explanation. As does the Anderson and Newman behavioral health model – I appreciate the brief example of enabling factors, for example – but perhaps an additional sentence or two to introduce the model given its importance to the study?

The previously published paper’s findings and how they influenced this study need to be explained. And, what does “more variation in complex problems” mean?

Which types of predisposing, enabling, and need factors will be explored and why (on the basis of what literature?)

How are care services defined? This definition needs to be alluded to even in the intro

Method:

How do you define “specialist” services? In general, the paper contains jargon (“multiproblem” families?)

More information needed on how children were identified for the study. For example, “during well visits” doesn’t describe how they were identified as potential participants, or give info as to rates of declined participation etc. Also, what constituted major life events? What did “persistent parenting concerns” consist of and how were those identified?

Who collected the data; how were digital questionnaires offered?

Were OT and speech services included? (please define “services” more exactly)

Please explain reliability/validity information for selected scales

What is the TIC-P?

Was the parenting concerns question answered dichotomously?

The Method does not provide enough information to support replicability (nor contextualization of study results give the sample – for example, how does the sample studied compare to the population of children with CP? To children in the general population?)

Unless this is a journal specific variation, info about participants should go in Method section

Discussion:

A strength of the study is noted to be the “community-based” sample – please be more specific about how sample was obtained and how it differs from other samples utilized in similar research

In what way do you think recall bias influenced the data? For example, it seems that those who perceive their children’s needs as greater might be more likely to overestimate care use & contacts

Why is limiting care consumption a goal? Often, research on engagement in mental health/psychosocial services has the opposite goal (increase engagement to improve treatment benefit).

Summary:

Research on care use and intensity of use is of importance but results seem to highly differ per study given the sample and the type of care use in question. Thus, my rationale for asking for additional contextualization and information about the sample.

Reviewer #2: In the manuscript entitled “Care use and its intensity in children with complex problems are related to varying child and family factors: a follow-up study”, the authors aimed to investigate mainly the impact of child and family factors on the intensity of care use by children with complex problems (CP), with particular attention to psychological care.

The results of this study are interesting, the manuscript has several positive aspects, but I think that it needs some revisions in order to be clearer to the readers.

In a few cases the text is not clear and I would suggest some English editing.

The introduction, the density of results and the discussion are not always aligned.

The following are suggestions to make the manuscript clearer:

- The Introduction suffers from some weaknesses.

In my opinion, the first part of the Introduction should be made clearer. I think that the main focus of the article would benefit from a more logical structure in which to insert a deeper literature review even if in this field the articles are not many.

For example the authors state “The few studies on this topic show that factors predicting the intensity of use differ from those predicting whether care is used at all”. How does this happen?

In addition at the end of the introduction we find a sentence that is not clear: when they write: “in a study group of children with more variation in complex problems” what do they mean by “more variation in complex problems”?

Finally, the motivation for the study could be explained better, providing explanations to why this particular study is needed and what exact problems it will solve.

- In the Measures section (p. 5), the authors use the acronym TIC-P without ever describing what it corresponds to.

- In the description of the sample, they refer to two groups (the community sample and the sample of care use for complex problems); in the description of the results they mention the number of parents on the two groups at follow-up at 1 year, but they don’t mention the number of persons at the beginning of the study.

One more aspect about the sample requires clarification. It seems that in the subsequent analyses of the predisposing, enabling and need factors the sample is considered a single group… Is this so?

- In the Results section (p.6), describing the sample, the authors state: “Similar percentages had

experienced mental health problems and/or some burden of adverse life events in the previous year”. What do they refer to with “similar percentages”? To “About half of the parents”? This needs to be explained.

- In the Discussion, the authors describe the results of the study, but, in my opinion, they should also interpret them more. Authors should provide a possible explanation of the results.

- Finally, two minor errors to amend:

1. The references should be reviewed because the numbers in the text do not correspond to the final list.

2. In the Discussion section, please, remove the reference to the table “see Table 2” (p. 12). It is not necessary.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Erin Hambrick

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 May 6;15(5):e0231620. doi: 10.1371/journal.pone.0231620.r002

Author response to Decision Letter 0

23 Mar 2020

Review Comments to the Author

Reviewer #1:

Introduction:

[COMMENT 1.1]

[RESPONSE]

We thank the reviewer for the request for more information about the definition of the target group of our study. Children with complex problems are increasingly being studied because of their acute needs and the challenges facing Western countries in organizing their care.

We have added the following text (Introduction; new text italicized):

“Little research has been conducted on factors affecting the intensity of care use by children with complex problems (CP). The need of these children for health and social services, especially psychosocial care, is typically greater than would be expected based on their chronic physical, developmental, behavioral or emotional condition; this is the case because their problems interact and enhance vulnerabilities [1-3, Mendenhall et al., 2017]. These children are also referred to as members of troubled families or hotspotters [Hayden & Jenkins, 20145; Hayden & Jenkins, 2015; Gawande 2011]. Children with complex problems form the top 5% of children with the most challenging problems, amounting in the Netherlands to 170,000 children. Western countries struggle to organize effective and efficient care pathways for these children [Tausendfreud et al., 2014]. As a result, a major part of the budgets of psychosocial services is spent on children with CP [Goerge et al., 2010; Sacco et al., 2008].”

Added references:

1. Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. The Lancet 2017 4–10 March 2017; 389(10072):951-963.

2. Hayden C, Jenkins C. Children taken into care and custody and the 'troubled families' agenda in England. Child Fam Soc Work 2015;20(4):459-469.

3. Hayden C, Jenkins C. ‘Troubled Families’ Programme in England: ‘wicked problems’ and policy-based evidence. Policy Stud 2014;35(6):631-649.

4. Tausendfreund T, Knot-Dickscheit J, Schulze GC, Knorth EJ, Grietens H. Families in multi-problem situations: Backgrounds, characteristics, and care services. Child Youth Serv 2016;37(1):4-22.

5. Gawande A. The Hot Spotters, can we lower medical costs by giving the neediest patients better care? The New Yorker, January 17th 2011: 40-51.

6. Goerge, RM, Smithgall, C, Seshadri, R, Ballard, P. llinois Families and Their Use of Multiple Service Systems. Chicago: Chapin Hall at the University of Chicago; 2010.

7. Sacco FC, Twemlow SW, Fonagy P. Secure attachment to family and community: a proposal for cost containment within high user populations of multiple problem families Smith College Studies in Social Work 2008

[COMMENT 1.2a]

I appreciate brevity, but previous literature and how it is insufficient and/or different from the current study, and how it drives the need for the current study, needs a bit more explanation.

[RESPONSE]

We thank the reviewer for the request for more information about the relevance of our study. We have added the following text (Introduction; new text italicized):

“The determinants of care use as such have been studied in depth, revealing several factors that impact access [Nanninga et al., 2015; Burns et al., 2004; Verhulst et al., 1997; Tick ea, 2008; Tausendfreud et al., 2016; Pannebakker et al., 2018]. Less attention was paid to understanding the intensity of care use, i.e. the number of contacts with care providers. The scarce literature shows that higher intensity of care-service use by children with CP is related to two main groups of factors: child factors (age and impact of psychosocial problems); and parental factors (educational level, healthcare use, social support, and parental psychosocial problems) [4-6]. Research shows that the determinants affecting care use (yes/no) and the intensity with which it is used differ when studied simultaneously [7-10]. This suggests that intensity of care use may be a unique component of the help-seeking behavior of children with complex problems and their parents. A better understanding of the intensity of care use will help us to organize more efficient care paths for these children.”

Added references:

1. Nanninga M, Jansen DEMC, Knorth EJ, Reijneveld SA. Enrolment of children and adolescents in psychosocial care: more likely with low family social support and poor parenting skills. Eur Child Adolesc Psychiatry 2015;24 (4):407-416.

2. Burns BJ, Phillips SD, Wagner HR, Barth RP, Kolko DJ, Campbell Y, et al. Mental health need and access to mental health services by youths involved with child welfare: A national survey. J Am Acad Child Adolesc Psychiatry 2004;43(8):960-970.

3. Verhulst FC, Van Der Ende J. Factors associated with child mental health service use in the community. J Am Acad Child Adolesc Psychiatry 1997;36(7):901-909.

4. Tick NT, Van Der Ende J, Verhulst FC. Ten-year increase in service use in the Dutch population. European Child and Adolescent Psychiatry 2008;17(6):373-380.

5. Tausendfreund T, Knot-Dickscheit J, Schulze GC, Knorth EJ, Grietens H. Families in multi-problem situations: Backgrounds, characteristics, and care services. Child Youth Serv 2016;37(1):4-22.

6. Pannebakker NM, Kocken PL, Theunissen MHC, van Mourik K, Crone MR, Numans ME, et al. Services use by children and parents in multiproblem families. Child Youth Serv Rev 2018;84:222-228.

[COMMENT 1.2b]

As does the Anderson and Newman behavioral health model – I appreciate the brief example of enabling factors, for example – but perhaps an additional sentence or two to introduce the model given its importance to the study?

[RESPONSE]

We thank the reviewer for the request for a more elaborate introduction of the Andersen framework. We have added the following text (Introduction; new text italicized):

“Research on determinants of care use is often guided by Andersen and Newman’s behavioral-health model [21]. This model was developed to explain the use of care by an individual or population, and has shown its value as comprehensive model for this purpose in health care research during the past decades [Phillips et al., 1998; Babitsch et al., 2012). The model describes care use on the basis of three factors: 1. predisposing factors, i.e., a child’s characteristics or abilities to use a specific service (such as age); 2. enabling factors, i.e., means whereby a family accesses care (such as social support); and 3. healthcare needs (such as a child’s psychosocial problems). This broad framework is a good fit with the wide-ranging problems experienced by children with CP and accommodates a systematic approach to assessing determinants of care intensity. Our study is the first to apply this framework to the intensity of care use by children with CP.”

Added references

1. Phillips KA, Morrison KR, Andersen R, Aday LA. Understanding the context of healthcare utilization: Assessing environmental and provider-related variables in the behavioral model of utilization. Health Serv Res 1998;33(3 I):571-596.

2. Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen's Behavioral Model of Health Services Use: a systematic review of studies from 1998-2011. Psychosoc Med. 2012;9.

[COMMENT 1.3]

The previously published paper’s findings and how they influenced this study need to be explained. And, what does “more variation in complex problems” mean?

[RESPONSE]

We thank the reviewer for her request for additional information about our other article. We have changed the following text (Introduction; new text italicized):

“We previously reported that overall care use was associated with social support and psychosocial problems, and that the use of psychosocial care was also associated with a child’s age and parenting concerns, based on a cross-sectional study in families with severe complex problems [16]. In the current study with a follow-up design, we additionally examined changes in intensity of care use in children with and at risk on developing CP, ensuring a wide range of intensity of care use.”

[COMMENT 1.4]

Which types of predisposing, enabling, and need factors will be explored and why (on the basis of what literature?)

[RESPONSE]

We have added the following text to clarify this (Introduction; new text italicized):

“We selected several predisposing characteristics of the child (such as age and gender, and also including predetermined factors such as parental education level and adverse life events), as well as enabling (social support and parental care use) and need factors (chronical condition, psychosocial problems, satisfaction with the parent-child relationship, and parenting concerns). This selection was based on the literature regarding determinants impacting the intensity of use of psychosocial care by children, as well as on our former study [4-6; Nanninga et al., 2015; Burns ea 2004; Verhulst et al., 1997; Tick et al., 2008; Tausendfreud et al., 2016; Pannebakker et al., 2018].”

We have added the following text (Introduction; new text italicized):

“The determinants of care use as such have been studied in depth, revealing several factors that impact access (refs). Less attention was focused on understanding the intensity of care use, i.e. the number of contacts with care providers. The scarce literature shows that higher intensity of care-service use by children with CP is related to two main groups of factors: child factors (age and impact of psychosocial problems); and parental factors (educational level, healthcare use, social support, and parental psychosocial problems) [17-20]. Research shows that the determinants affecting care use (yes/no) and the intensity with which it is used differ when studied simultaneously [17-19]. This suggests that intensity of care use may be a unique component of the help-seeking behavior of children with complex problems. A better understanding of intensity of care use will help us to organize more efficient care paths for these children.”

Added references:

3. Verhulst FC, Van Der Ende J. Factors associated with child mental health service use in the community. J Am Acad Child Adolesc Psychiatry 1997;36(7):901-909.

4. Tick NT, Van Der Ende J, Verhulst FC. Ten-year increase in service use in the Dutch population. European Child and Adolescent Psychiatry 2008;17(6):373-380.

5. Tausendfreund T, Knot-Dickscheit J, Schulze GC, Knorth EJ, Grietens H. Families in multi-problem situations: Backgrounds, characteristics, and care services. Child Youth Serv 2016;37(1):4-22.

6. Pannebakker NM, Kocken PL, Theunissen MHC, van Mourik K, Crone MR, Numans ME, et al. Services use by children and parents in multiproblem families. Child Youth Serv Rev 2018;84:222-228.

[COMMENT 1.5]

How are care services defined? This definition needs to be alluded to even in the intro.

[RESPONSE]

We have added the following text as definition of services (Introduction; new text italicized):

“The aim of this study is to identify the changes in the predisposing, enabling and need factors that are associated 1. with a higher likelihood of changes in use of care services and 2. with changes in the intensity of use. The care services use studied comprised a broad spectrum of general care services, including health and psychosocial care, and also a subset psychosocial care, including child mental healthcare and child and family services.”

Method:

[COMMENT 1.6]

How do you define “specialist” services? In general, the paper contains jargon (“multiproblem” families?)

[RESPONSE]

We thank the reviewer for noting our use of jargon. We have replaced multiproblem and defined specialist care (Introduction; new text italicized):

“in families with severe complex problems [16]”

And

“The second sample was a sample of care-using children with complex problems. It consisted of families enrolled in specialist child and family services, i.e. services accessible only after referral from primary care.”

[COMMENT 1.7]

[RESPONSE]

We thank the reviewer for her request for more information about the sample and procedure. We have made the following changes (Method section, sample and procedure; new text italicized):

“We used the following inclusion procedure. First, a nurse, doctor or social worker identified parents based on our inclusion criteria, which were embedded in their routine intake questionnaire. Professional care givers then provided oral and written information about the study to the identified families and asked permission from parents to be called by a research assistant. Thereafter, the research assistant asked for informed consent regarding participation in this study.”

And

“We included parents when they met the following inclusion criteria: 1. they had a child between 18 months and 12 years and 2. they experienced at least one of the following conditions: A. the child’s elevated total score on the parent-reported Strengths and Difficulties Questionnaire (SDQ) [27] or Brief Infant Toddler Social Emotional Assessment (BITSEA) [28]; B. persistent parenting concerns as judged by the preventive health care worker and/or parents; C. one or more major life event(s) during the past year as assessed using the standard screening questionnaire of the well child clinic [Theunissen, 2019] and D. care utilization of the child or parent in the past six months. Almost all respondents had three or more of these conditions (97%).”

We moved the following text from results Section to the Methods section:

A total of 512 parents were approached, 354 of whom participated at T1 (response=69.1%). Of these, 272 participated in the follow-up at 1 year (T1-T2 response =76.8%), 239 from the well-child clinic group (T1=309), and 33 from the group of children using care with high intensity (T1=45). Parents who dropped out at T2 had significantly more sons; more of them were of non-western origin and, on the basis of their home neighborhoods, more of them had a lower socio-economic position [30].”

Added References:

Theunissen, M., Pas van der, S. & Harten van, L. Background information: a uniform protocol for discovering a triage of risks on developmental and health problems by child preventive health care. 2019; 060.16673.

[COMMENT 1.8]

Who collected the data; how were digital questionnaires offered?

[RESPONSE]

We have added the following information about the data collection (Method section, sample and procedure; new text italicized):

“Data were collected by trained research assistants at two time points, the first in 2013 (T1) and the second 12 months later (T2). Data were collected in a digital questionnaire, although parents could also opt to be interviewed by telephone in the language of their preference. Parents were reminded three times to fill in this questionnaire and received a gift certificate of 20 euros after doing so. Parents were informed that they could withdraw at any moment.”

[COMMENT 1.9]

Were OT and speech services included? (please define “services” more exactly)

[RESPONSE]

Services are defined as any provider or groups of providers. We measured service use with a preset list of often used services. OT and speech services as such were not in this list; however respondents could endlessly add services to the list.

We have added to the measurements (Method section; new text italicized):

“Respondents also had the opportunity to add services that we had not listed.”

And

“Services are defined as any provider or group of providers.”

[COMMENT 1.10]

Please explain reliability/validity information for selected scales

[RESPONSE]

We have added the requested information about the reliability/validity of the questionnaires or scales used in the measures: (Method section, new text italicized):

“The children’s service use and intensity of this use in the past six months were measured with the Questionnaire Intensive Care for Youth, a questionnaire measuring use of a pre-set list of types of Dutch services [Bouwmans et al., 2013, Jansen et al., 2015]. This list has been adapted to the setting of care for youth from the valid and reliable Questionnaire for Costs Associated with Psychiatric Illnesses and care use (TIC-P) [Bouwmans et al., 2012; Hakkaart et al., 2002]. As allowed for by this standard questionnaire, we have added and omitted specific items of care services depending on their relevance for our target population. Moreover, respondents had the opportunity to add services we had not listed. Services are defined as any care provider or group of care providers.”

And

“We used validated questionnaires where available, and assessed their reliability in the sample under study.”

And

“Parental mental health status was measured using the validated 12-item version of the General Health Questionnaire (Cronbach’s α = .86).”

And

“To measure social support, we used two subscales of the validated Dutch Family questionnaire”

And

“Does your child have one or more chronic health condition—such as asthma, diabetes, ADHD or autism—for which treatment is or was needed? What is the impact of this condition on your child’s daily life?” [Wingerd et al., 2020].”

And

“Finally, parents’ assessment of their relationship with their child was measured using the subscale of the validated Dutch Parenting Load Questionnaire (Cronbach’s α= .83) [44].”

Added references:

1. Bouwmans, CAM, Schawo, SJ, Jansen, DEMC, Vermeulen, KM, Reijneveld, SA, Hakkaart-van Roijen, L. Handleiding Vragenlijst Intensieve Jeugdzorg: Zorggebruik en productieverlies. [Manual Questionnaire Intensive Care for Youth: health care utilization and productivity loss]. Rotterdam: Erasmus MC; 2012.

2. Jansen DE, Vermeulen KM, Schuurman-Luinge AH, Knorth EJ, Buskens E, Reijneveld SA. Cost-effectiveness of Multisystemic Therapy for adolescents with antisocial behavior: Study protocol of a randomized controlled trial. BMC Public Health 2013;13(1).

3. Hakkaart-Van Roijen, L, Van Straten, A, Donker, M, Tiemens, B. Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness (TiC-P). Rotterdam; 2002.

4. Bouwmans C, De Jong K, Timman R, Zijlstra-Vlasveld M, Van Der Feltz-Cornelis C, Tan SS, et al. Feasibility, reliability and validity of a questionnaire on healthcare consumption and productivity loss in patients with a psychiatric disorder (TiC-P). BMC Health Serv Res 2013;13(1).

5. Wingerd M. Gezondheidsenquete-2013 [Dutch Health care questionnaire]. 12-02-2020; Available at: www.cbs.nl/nl-nl/achtergrond/2015/15/gezondheidsvragenlijst-gezondheidsenquete-2015

[COMMENT 1.11]

What is the TIC-P?

[RESPONSE]

We have added the explanation of the abbreviation TIC-P (Methods section, Measures paragraph, new text italicized):

“This list has been adapted to the setting of care for youth from the valid and reliable Questionnaire for Costs Associated with Psychiatric Illnesses and care use (TIC-P) [33, 34].”

[COMMENT 1.12]

Was the parenting concerns question answered dichotomously?

[RESPONSE]

Thank you, we have clarified this. We have added the following text (Methods, new text italicized)

“Finally, parents’ assessment of their relationship with their child was measured using the subscale of the Parenting Load Questionnaire (Cronbach’s α= .83) [24]. Answers were given using a five-point Likert-scale. We dichotomized scale sum scores using their medians as cut off.”

[COMMENT 1.13]

[RESPONSE]

We thank the reviewer for her request for additional information about the sample. To our knowledge, no other available study used a Dutch population similar to ours so that we could compare our community based sample. We have added the following text (Methods section, sample and procedure; new text italicized):

And

“We identified the respondents during well-child visits, which are provided in the Netherlands by the preventive youth healthcare services. Attendance rates at these visits are high: 95% of all children [13]. To ensure the inclusion of children who used care with a high intensity, we additionally included children enrolled in specialist child and family services. Together this study group is expected to represent the whole group of children with CP or at risk of developing CP.”

We also changed (Discussion Section, strengths and limitations; new text italicized)

“Another strength of the study is that the study group of children with or at risk of developing CP were living in the community, including children in treatment with different intensities of care use or not using care at all. In most other research the study groups are limited to children with CP who are using a specific treatment [Bodden & Dekovic, 2015; Tausendfreud et al., 2014].”

Added references:

1. Bodden DHM, Dekovic M. Multiproblem Families Referred to Youth Mental Health: What's in a Name? Fam Process 2016;55(1):31-47.

2. Tausendfreund T, Knot-Dickscheit J, Schulze GC, Knorth EJ, Grietens H. Families in multi-problem situations: Backgrounds, characteristics, and care services. Child Youth Serv 2016;37(1):4-22.

[COMMENT 1.14]

Unless this is a journal specific variation, info about participants should go in Method section

[RESPONSE]

We moved the following text from the Results section to the Methods section:

“A total of 512 parents were approached, 354 of whom participated at T1 (response=69.1%). Of these, 272 participated in the follow-up at 1 year (T1-T2 response =76.8%), 239 in the community sample, and 33 in the sample of care use for complex problems. Parents who dropped out at T2 had significantly more sons; more of them were also of non-western origin and, on the basis of their home neighborhoods, more of them had a lower socio-economic position [30].”

Discussion:

[COMMENT 1.15]

A strength of the study is noted to be the “community-based” sample – please be more specific about how sample was obtained and how it differs from other samples utilized in similar research.

[RESPONSE]

Thank you; we have clarified this in our response to your COMMENT 1.13, second part.

[COMMENT 1.16]

In what way do you think recall bias influenced the data? For example, it seems that those who perceive their children’s needs as greater might be more likely to overestimate care use & contacts

[RESPONSE]

We thank the reviewer for challenging us about recall bias. We think intensity of care and its determinants: burden of adverse life events and impact of the chronical condition of the child, are sensitive to recall bias. We think this could lead to either overestimation or underestimation of care use intensity. To our knowledge, no research has been done on the bias in reporting intensity of care use.

We have added to our strengths and limitations (Discussion Section; new text italicized):

“Another limitation is that we used a self-report questionnaire to establish care use in the previous six months. This may have caused some recall bias, especially for intensity of care use and the determinants burden of ALE and impact of chronical conditions of the child. This may have added measurement error and thus a weakening of reported associations, probably without clear under- or overestimation.”

[COMMENT 1.17]

Why is limiting care consumption a goal? Often, research on engagement in mental health/psychosocial services has the opposite goal (increase engagement to improve treatment benefit).

[RESPONSE]

We thank the reviewer for this comment. Goals of our study regard improvement of access and cost-containment. We have clarified this by adding a rationale to the Introduction (Introduction; new text italicized):

“Western countries struggle to organize effective and efficient care pathways for children with CP [Tausendfreud et al., 2014]. As a result, a major part of the budgets of psychosocial services are spent on these children (Goerge et al. 2010; Sacco et al., 2008).”

We have further changed the following text (Discussion section, implications for further research; new text italicized):

“Understanding the mechanism underlying the intensity of care use can help the development of more effective and efficient pathways to care for children with or at risk of developing CP.”

Added references:

1. Tausendfreund T, Knot-Dickscheit J, Schulze GC, Knorth EJ, Grietens H. Families in multi-problem situations: Backgrounds, characteristics, and care services. Child Youth Serv 2016;37(1):4-22.

2. Goerge, RM, Smithgall, C, Seshadri, R, Ballard, P. llinois Families and Their Use of Multiple Service Systems. Chicago: Chapin Hall at the University of Chicago; 2010.

3. Sacco FC, Twemlow SW, Fonagy P. Secure attachment to family and community: a proposal for cost containment within high user populations of multiple problem families Smith College Studies in Social Work 2008.

Summary:

[COMMENT 1.18]

[RESPONSE]

We thank the reviewer for her constructive comments. We hope that our responses have adequately provided the requested information and clarifications.

Reviewer #2 (anonymous): In the manuscript entitled “Care use and its intensity in children with complex problems are related to varying child and family factors: a follow-up study”, the authors aimed to investigate mainly the impact of child and family factors on the intensity of care use by children with complex problems (CP), with particular attention to psychological care.

The results of this study are interesting, the manuscript has several positive aspects, but I think that it needs some revisions in order to be clearer to the readers. In a few cases the text is not clear and I would suggest some English editing. The introduction, the density of results and the discussion are not always aligned.

The following are suggestions to make the manuscript clearer:

[COMMENT 2.0]

I would suggest some English editing

[Response]

The manuscript had already been assessed by a native speaker. A native speaker again checked the full text.

[COMMENT 2.1]

The Introduction suffers from some weaknesses.

For example the authors state “The few studies on this topic show that factors predicting the intensity of use differ from those predicting whether care is used at all”. How does this happen?

[RESPONSE]

We thank the reviewer for requesting clarification of the structure of the introduction and more information about the literature review underlying our study. We have added the following text (Introduction; new text italicized):

Added references:

3. Verhulst FC, Van Der Ende J. Factors associated with child mental health service use in the community. J Am Acad Child Adolesc Psychiatry 1997;36(7):901-909.

4. Tick NT, Van Der Ende J, Verhulst FC. Ten-year increase in service use in the Dutch population. European Child and Adolescent Psychiatry 2008;17(6):373-380.

5. Tausendfreund T, Knot-Dickscheit J, Schulze GC, Knorth EJ, Grietens H. Families in multi-problem situations: Backgrounds, characteristics, and care services. Child Youth Serv 2016;37(1):4-22.

6. Pannebakker NM, Kocken PL, Theunissen MHC, van Mourik K, Crone MR, Numans ME, et al. Services use by children and parents in multiproblem families. Child Youth Serv Rev 2018;84:222-228.

[COMMENT 2.2]

[RESPONSE]

We thank the reviewer for her request for additional information about this previous study. We have changed the following text (Introduction; new text italicized):

“We previously reported that overall care use was associated with social support and psychosocial problems, and that the use of psychosocial care was also associated with a child’s age and parenting concerns, based on a cross-sectional study in families with severe complex problems [16]. In the current study, using a follow-up design, we examined changes in intensity of care use, as well as changes in the use of care itself, both for children with and at risk of developing CP, to ensure covering a wide range of intensity of care use.”

[COMMENT 2.3]

Finally, the motivation for the study could be explained better, providing explanations to why this particular study is needed and what exact problems it will solve.

[RESPONSE]

We thank the reviewer for requesting more information about the knowledge gap we hope to fill with our study. We have added the following text (Introduction; new text italicized):

“Little research has been conducted on factors affecting the intensity of care use by children with complex problems (CP). The need of these children for health and social services, especially psychosocial care, is typically greater than would be expected based on their chronic physical, developmental, behavioral or emotional condition; this is the case because their problems interact and enhance vulnerabilities [1-3, Mendenhall et al., 2017]. These children are also referred to as members of troubled families or hotspotters [Hayden & Jenkins, 20145; Hayden & Jenkins, 2015; Gawande 2011; Stanhope et al., 2015]. Children with complex problems form the top 5% of children with the most challenging problems, amounting in the Netherlands to 170,000 children. Western countries struggle to organize effective and efficient care pathways for these children [Tausendfreud et al., 2014]. As a result, a major part of the budgets of psychosocial services is spent on children with CP [Goerge et al., 2010; Sacco et al., 2008].”

Added references

2. Hayden C, Jenkins C. Children taken into care and custody and the 'troubled families' agenda in England. Child Fam Soc Work 2015;20(4):459-469.

3. Hayden C, Jenkins C. ‘Troubled Families’ Programme in England: ‘wicked problems’ and policy-based evidence. Policy Stud 2014;35(6):631-649.

4. Tausendfreund T, Knot-Dickscheit J, Schulze GC, Knorth EJ, Grietens H. Families in multi-problem situations: Backgrounds, characteristics, and care services. Child Youth Serv 2016;37(1):4-22.

5. Gawande A. The Hot Spotters, can we lower medical costs by giving the neediest patients better care? The New Yorker, January 17th 2011: 40-51.

Measures section

[COMMENT 2.4]

- In the (p. 5), the authors use the acronym TIC-P without ever describing what it corresponds to.

[RESPONSE]

We have explained the abbreviation TIC-P (Methods section, Measures paragraph, new text italicized):

“Questionnaire for Costs Associated with Psychiatric Illnesses and Care Use (TiC-P) [33, 34].”

[COMMENT 2.5]

[RESPONSE]

We have added the number of parents at the beginning of the study per subgroup (Methods, new text italicized):

“A total of 512 parents were approached, 354 of whom participated at T1 (response=69.1%). Of these, 272 participated in the follow-up at 1 year (T1-T2 response =76.8%), 239 from the well-child clinic group (T1=309) and 33 from the group of children using care with a high intensity (T1=45).”

[COMMENT 2.6]

One more aspect about the sample requires clarification. It seems that in the subsequent analyses of the predisposing, enabling and need factors the sample is considered a single group… Is this so?

[RESPONSE]

Yes, the sample is considered as one group of children coming from the same community. We hope to have clarified this by our modifications in the Methods section (Methods section, sample and procedure; new text italicized):

“We aimed to include parents of children with or at risk of developing CP, with a wide range in intensity of care use, and living in the community. We recruited these parents from the general population, using inclusion criteria that concurred with the framework for identifying families with complex problems [Bodden & Dekovic, 2010; Bodden & Dekovic, 2015]. We identified the respondents during well-child visits, which are provided in the Netherlands by the preventive youth healthcare services. Attendance rates at these visits are high: 95% of all children [29]. To ensure the inclusion of children who used care with a high intensity, we additionally included children enrolled in specialist child and family services. Together this study group is expected to represent the whole group of children with CP or at risk of developing CP.”

We also changed (Discussion Section, strengths and limitations; new text italicized)

“Another strength of the study is that the study group of children with or at risk of developing CP were living in the community, including children in treatment with different intensity of care use or not using care at all. In most other research the study groups are limited to children with CP who are using a specific treatment [Bodden & Dekovitch, 2015; Tausendfreud et al., 2014].“

Added references:

1. Bodden DHM, Dekovic M. Multiproblem Families Referred to Youth Mental Health: What's in a Name? Fam Process 2016;55(1):31-47.

2. Tausendfreund T, Knot-Dickscheit J, Schulze GC, Knorth EJ, Grietens H. Families in multi-problem situations: Backgrounds, characteristics, and care services. Child Youth Serv 2016;37(1):4-22.

RESULTS

[COMMENT 2.7]

In the Results section (p.6), describing the sample, the authors state: “Similar percentages had

[RESPONSE]

“Similar percentages” indeed refers to the earlier mentioned “about half of the parents”.

We have changed this to (Results section, background characteristics; new text italicized):

“About half of the parents with a high educational level experienced mental health problems and/or experienced burden of adverse life events in the previous year.”

DISCUSSION

[COMMENT 2.8]

In the Discussion, the authors describe the results of the study, but, in my opinion, they should also interpret them more. Authors should provide a possible explanation of the results.

[RESPONSE]

We thank the reviewer for challenging us to more fully interpret and explain our results. We have tried to be more specific in our interpretations. We have also divided the second paragraph of the Discussion into two separate ones. The modified text is (Discussion; new text italicized):

“We found that several changes in predisposing (i.e. burden of ALE and a child’s age) and need factors (i.e. parenting concerns and psychosocial problems) were associated with changes in care use and its intensity, both for overall care use and for the use of psychosocial services, but that changes in enabling factors were not. The determinants found are in line with previous findings [10, 12, 33-36]. An explanation may be that enabling factors are harder to change than predisposing and need factors in the relative short time span of our study (one year). For example, it is more difficult for a child social worker to convince parents to make use of mental health care for their own mental problems than to address parenting concerns. This study shows the value of the Andersen and Newman model in studying the intensity of care use, especially in distinguishing enabling factors from other factors that affect families with a child at risk of CP or at risk of developing CP.

The results of this study added the burden of ALE as a factor impacting change in intensity of care use. Research has showed that ALE is an important determinant of care use in general [56,67]. ALE will especially affect children with CP, interacting strongly with the other problems of these children, thereby leading to more intense problems. Unexpectedly, we found a slight negative relative risk between ALE and the intensity of any care use. We noted that the burden of ALE decreased in a relatively large group of children while they were using care. Children with CP may have been motivated to continue treatment even when the burden of ALE decreased, because trauma-based therapies are known to have a positive effect on other emotional conditions [Schneider et al., 2012; Connor et al., 2015]. Furthermore, when the safety of a child is at risk, as in cases of domestic violence, care professionals will ideally continue treatment to monitor the situation. Our results indicate that changes in ALE are relevant to the whole care process, i.e. not only to care use itself, but also its intensity.

Although improving social support is at the core of treatment of families with complex problems, in the final models of our study this factor was absent [Stanhope et al.,2015]. It can be hypothesized that social support works differently for families with complex problems than for the general population [Matos et al., 2004; Sousa et al., 2005; Sousa et al., 2009, Pannebakker et al., 2018]. Usually in cases of children with CP, the families’ social networks are large and suitable for dealing with the challenges of daily living [Matos et al., 2004; Sousa et al., 2005; Sousa et al., 2009]. However, regardless of their perceived social support, families will turn to professionals to bring about long-term improvements, surmising that they may not be able to achieve these improvements with their own network. Also, professionals may not yet have managed to bring about changes in the quality of support by the social environment because of the relatively short period of our study (one year). Although social support is a known determinant of a child’s care use, more research is needed to understand how to optimize its impact for families with a child with CP.”

Finally, we have added the following text to the implications (Discussion section, implications for practice; new text italicized):

“Regarding the enabling factor social support, more research is needed on how to improve the quality of support provided by the network of families with a child with complex problems. We advise the development of a treatment module to improve support skills for parents and the key persons of their social network. These new skills can be taught by volunteers who are able to model healthy support.”

Added references

1. Schneider SJ, Grilli SF, Schneider JR. Evidence-based treatments for traumatized children and adolescents. Curr Psychiatry Rep 2013;15(1).-012-0332-5.

2. Connor DF, Ford JD, Arnsten AFT, Greene CA. An update on posttraumatic stress disorder in children and adolescents. Clin Pediatr 2015;54(6):517-528.

3. Stanhope V, Videka L, Thorning H, McKay M. Moving Toward Integrated Health: An Opportunity for Social Work. Soc Work Health Care 2015;54(5):383-407.

4. Matos AR, Sousa LM. How multiproblem families try to find support in social services. J Soc Work Pract 2004;18(1):65-80.

5. Sousa L. Building on personal networks when intervening with multi-problem poor families. J Soc Work Pract 2005;19(2):163-179.

6. Sousa L, Rodrigues S. Linking formal and informal support in multiproblem low-income families: The role of the family manager. J Community Psychol 2009;37(5):649-662.

7. Pannebakker NM, Kocken PL, Theunissen MHC, van Mourik K, Crone MR, Numans ME, et al. Services use by children and parents in multiproblem families. Child Youth Serv Rev 2018;84:222-228.

[COMMENT 2.9]

Finally, two minor errors to amend:

1. The references should be reviewed because the numbers in the text do not correspond to the final list.

2. In the Discussion section, please, remove the reference to the table “see Table 2” (p. 12). It is not necessary.

[RESPONSE]

Thank you for noticing these minor errors. We reviewed the references and removed the reference “see Table 2” from the Discussion section.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(66.2KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0231620.r003

Decision Letter 1

Luca Cerniglia

30 Mar 2020

Care use and its intensity in children with complex problems are related to varying child and family factors: a follow-up study

PONE-D-19-15380R1

Dear Authors,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

With kind regards,

Luca Cerniglia, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The Authors were responsive to all comemnts and I think the paper can be accepted in the present version.

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0231620.r004

Acceptance letter

Luca Cerniglia

9 Apr 2020

PONE-D-19-15380R1

Care use and its intensity in children with complex problems are related to varying child and family factors: a follow-up study

Dear Dr. Pannebakker:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Luca Cerniglia

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Appendix. Results of the hurdle analyses.

(DOCX)

Click here for additional data file.^{(46.3KB, docx)}

S2 Appendix. Interview protocol for the project oké in Den Haag.

(DOCX)

Click here for additional data file.^{(22.3KB, docx)}

S1 File

(PDF)

Click here for additional data file.^{(295.9KB, pdf)}

S2 File

(DOCX)

Click here for additional data file.^{(17.9KB, docx)}

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(66.2KB, docx)}

Data Availability Statement

[pone.0231620.ref001] 1.Denholm R, Power C, Li L, Thomas C. Child maltreatment and household dysfunction in a British Birth Cohort. Child Abuse Rev 2013;22(5):340–353. [Google Scholar]

[pone.0231620.ref002] 2.Stith SM, Liu T, Davies LC, Boykin EL, Alder MC, Harris JM, et al. (2009). Risk factors in child maltreatment: A meta-analytic review of the literature. Aggression and Violent Behavior, 14(1), 13–29. 10.1016/j.avb.2006.03.006 [DOI] [Google Scholar]

[pone.0231620.ref003] 3.Lucas PJ, McIntosh K, Petticrew M, Roberts HM, Shiell A. Financial benefits for child health and well-being in low income or socially disadvantaged families in developed world countries. Cochrane Database of Systematic Reviews 2008(2). [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref004] 4.Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. The Lancet 2017 4–10 March 2017; 389(10072):951–963. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref005] 5.Gawande A. The Hot Spotters, can we lower medical costs by giving the neediest patients better care? The New Yorker, Januari 17^th 2011: 40–51. [PubMed] [Google Scholar]

[pone.0231620.ref006] 6.Hayden C, Jenkins C. Children taken into care and custody and the 'troubled families' agenda in England. Child Fam Soc Work 2015;20(4):459–469. [Google Scholar]

[pone.0231620.ref007] 7.Hayden C, Jenkins C. ‘Troubled Families’ Programme in England: ‘wicked problems’ and policy-based evidence. Policy Stud 2014;35(6):631–649. [Google Scholar]

[pone.0231620.ref008] 8.Tausendfreund T, Knot-Dickscheit J, Post WJ, Knorth EJ, Grietens H. Outcomes of a coaching program for families with multiple problems in the Netherlands: A prospective study. Children and Youth Services Review 2014. 11;46:203–212. [Google Scholar]

[pone.0231620.ref009] 9.Goerge RM, Smithgall C, Seshadri R, Ballard P. llinois Families and Their Use of Multiple Service Systems. Chicago: Chapin Hall at the University of Chicago; 2010. [Google Scholar]

[pone.0231620.ref010] 10.Sacco FC, Twemlow SW, Fonagy P. Secure attachment to family and community: a proposal for cost containment within high user populations of multiple problem families Smith College Studies in Social Work 2008. [Google Scholar]

[pone.0231620.ref011] 11.Nanninga M, Jansen DEMC, Knorth EJ, Reijneveld SA. Enrolment of children and adolescents in psychosocial care: more likely with low family social support and poor parenting skills. Eur Child Adolesc Psychiatry 2015;24 (4):407–416. 10.1007/s00787-014-0590-3 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref012] 12.Burns BJ, Phillips SD, Wagner HR, Barth RP, Kolko DJ, Campbell Y, et al. Mental health need and access to mental health services by youths involved with child welfare: A national survey. J Am Acad Child Adolesc Psychiatry 2004;43(8):960–970. 10.1097/01.chi.0000127590.95585.65 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref013] 13.Verhulst FC, Van Der Ende J. Factors associated with child mental health service use in the community. J Am Acad Child Adolesc Psychiatry 1997;36(7):901–909. 10.1097/00004583-199707000-00011 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref014] 14.Tick NT, Van Der Ende J, Verhulst FC. Ten-year increase in service use in the Dutch population. European Child and Adolescent Psychiatry 2008;17(6):373–380. 10.1007/s00787-008-0679-7 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref015] 15.Tausendfreund T, Knot-Dickscheit J, Schulze GC, Knorth EJ, Grietens H. Families in multi-problem situations: Backgrounds, characteristics, and care services. Child Youth Serv 2016;37(1):4–22. [Google Scholar]

[pone.0231620.ref016] 16.Pannebakker NM, Kocken PL, Theunissen MHC, van Mourik K, Crone MR, Numans ME, et al. Services use by children and parents in multiproblem families. Child Youth Serv Rev 2018;84:222–228. [Google Scholar]

[pone.0231620.ref017] 17.Farmer EMZ, Stangl DK, Burns BJ, Costello EJ, Angold A. Use, persistence, and intensity: Patterns of care for children's mental health across one year. Community Ment Health J 1999;35(1):31–46. 10.1023/a:1018743908617 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref018] 18.Hamilton HA, Paglia-Boak A, Wekerle C, Danielson AM, Mann RE. Psychological Distress, Service Utilization, and Prescribed Medications among Youth with and without Histories of Involvement with Child Protective Services. Int J Ment Health Addict 2011;9(4):398–409. [Google Scholar]

[pone.0231620.ref019] 19.Saurina C, Vall-Llosera L, Saez M. Factors determining access to and use of primary health care services in the Girona Health Region (Spain). Eur J Health Econ 2012;13(4):419–427. 10.1007/s10198-011-0313-3 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref020] 20.Palacio-Vieira J, Villalonga-Olives E, Valderas JM, Herdman M, Alonso J, Rajmil L. Predictors of the use of healthcare services in children and adolescents in Spain. International Journal of Public Health 2013;58(2):207–215 10.1007/s00038-012-0360-2 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref021] 21.Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank mem fd quart 1973;51(1):95–124. [PubMed] [Google Scholar]

[pone.0231620.ref022] 22.Phillips KA, Morrison KR, Andersen R, Aday LA. Understanding the context of healthcare utilization: Assessing environmental and provider-related variables in the behavioral model of utilization. Health Serv Res 1998;33(3 I):571–596 [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref023] 23.Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen's Behavioral Model of Health Services Use: a systematic review of studies from 1998–2011. Psychosoc Med. 2012;9. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref024] 24.Bodden DHM, Dekovitch M. Multiprobleemgezinnen ontrafeld [multiproblem families discovered]. Tijdschrift voor Orthopedagogiek 2010;49:259–271. [Google Scholar]

[pone.0231620.ref025] 25.Bodden DHM, Dekovic M. Multiproblem Families Referred to Youth Mental Health: What's in a Name? Fam Process 2016;55(1):31–47. 10.1111/famp.12144 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref026] 26.Goodman R. The strengths and difficulties questionnaire: A research note. J Child Psychol Psychiatry Allied Disciplines 1997;38(5):581–586. [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref027] 27.Briggs-Gowan MJ, Carter AS, Irwin JR, Wachtel K, Cicchetti DV. The Brief Infant-Toddler Social and Emotional Assessment: Screening for Social-Emotional Problems and Delays in Competence. J Pediatr Psychol 2004;29(2):143–155. 10.1093/jpepsy/jsh017 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref028] 28.Theunissen M., Pas van der S. & Harten van L. Achtergronddocument: Een uniform triageprotocol voor het signaleren van ontwikkelings- of gezondheidsrisico’s bij basisschoolkinderen door de Jeugdgezondheidszorg [Background information: a uniform protocol for discovering a triage of risks on developmental and health problems by child preventive health care]. 2019; 06016673. [Google Scholar]

[pone.0231620.ref029] 29.CBS Statistics Netherlands. Ouders geven consultatiebureau gemiddeld een ruime 7 [Parents appreciatie well visit clinics]. 2014; Available at: www.cbs.nl/nl-nl/nieuws/2014/44/ouders-geven-consultatiebureau-gemiddeld-een-ruime-7.

[pone.0231620.ref030] 30.Sociaal Cultureel Planbureau. social economic status. 2015 August 18th.

[pone.0231620.ref031] 31.Bouwmans CAM, Schawo SJ, Jansen DEMC, Vermeulen KM, Reijneveld SA, Hakkaart-van Roijen L. Handleiding Vragenlijst Intensieve Jeugdzorg: Zorggebruik en productieverlies [Manual Questionnaire Intensive Care for Youth: health care utilization and productivity loss]. Rotterdam: Erasmus MC; 2012. [Google Scholar]

[pone.0231620.ref032] 32.Jansen DE, Vermeulen KM, Schuurman-Luinge AH, Knorth EJ, Buskens E, Reijneveld SA. Cost-effectiveness of Multisystemic Therapy for adolescents with antisocial behavior: Study protocol of a randomized controlled trial. BMC Public Health 2013;13(1). [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref033] 33.Hakkaart-Van Roijen L, Van Straten A, Donker M, Tiemens B. Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness (TiC-P). Rotterdam; 2002. [Google Scholar]

[pone.0231620.ref034] 34.Bouwmans C, De Jong K, Timman R, Zijlstra-Vlasveld M, Van Der Feltz-Cornelis C, Tan SS, et al. Feasibility, reliability and validity of a questionnaire on healthcare consumption and productivity loss in patients with a psychiatric disorder (TiC-P). BMC Health Serv Res 2013;13(1). [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref035] 35.Koeter MWJ, Ormel J. General health questionnaire, manual [Nederlandse bewerking, Handleiding]. Lisse: Swets & Zeitlinger; 1991. [Google Scholar]

[pone.0231620.ref036] 36.De Wolff MS, Theunissen MHC, Vogels AGC, Reijneveld SA. Three questionnaires to detect psychosocial problems in toddlers: A comparison of the BITSEA, ASQ:SE, and KIPPPI. Academic Pediatrics 2013;13(6):587–592. 10.1016/j.acap.2013.07.007 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref037] 37.Van der Ploeg JD, Scholte EM. Handleiding Vragenlijst Gezinsfunctioneren (GVL) [Manual Family Functioning Questionnaire]. Houten: Bohn Stafleu Van Loghum; 2008. [Google Scholar]

[pone.0231620.ref038] 38.Wingerd M. Gezondheidsenquete-2013 [Dutch Health care questionnaire]. 12-02-2020; Available at: www.cbs.nl/nl-nl/achtergrond/2015/15/gezondheidsvragenlijst-gezondheidsenquete-2015

[pone.0231620.ref039] 39.Kruizinga I, Jansen W, de Haan CL, van der Ende J, Carter AS, Raat H. Reliability and validity of the Dutch version of the brief infant-toddler social and emotional assessment (BITSEA). PLoS ONE 2012;7(6). [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref040] 40.Theunissen MHC, Vogels AGC, De Wolff MS, Reijneveld SA. Characteristics of the strengths and difficulties questionnaire in preschool children. Pediatrics 2013; 131(2):e446–e454. 10.1542/peds.2012-0089 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref041] 41.Vogels AG, Crone MR, Hoekstra F, Reijneveld SA. Comparing three short questionnaires to detect psychosocial dysfunction among primary school children: A randomized method. BMC Public Health 2009;9. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref042] 42.Mieloo C, Raat H, van Oort F, Bevaart F, Vogel I, Donker M., et al. (2012). Validity and reliability of the strengths and difficulties questionnaire in 5–6 year olds: Differences by gender or by parental education? PLoS ONE, 7:5. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref043] 43.Reijneveld S. A., De Meer G., Wiefferink C. H., & Crone M. R. (2008). Parents' concerns about children are highly prevalent but often not confirmed by child doctors and nurses. BMC Public Health, 8 10.1186/1471-2458-8-124 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref044] 44.Vermulst A, Kroes G, De Meyer RE, Nguyen RE, Veerman JW. Opvoedingsbelastingvragenlijst (OBVL) Handleiding [The Parenting Load Questionnaire, instruction manual]. Nijmegen: Radboud Universiteit Nijmegen / Praktikon; 2012. [Google Scholar]

[pone.0231620.ref045] 45.Hofstetter H, Dusseldorp E, Zeileis A, Schuller AA. Modeling Caries Experience: Advantages of the use of the hurdle model. Caries Res 2016;50(6):517–526. 10.1159/000448197 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref046] 46.Lee AH, Wang K, Scott JA, Yau KKW, McLachlan GJ. Multi-level zero-inflated poisson regression modelling of correlated count data with excess zeros. Stat Methods Med Res 2006;15(1):47–61. 10.1191/0962280206sm429oa [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref047] 47.IBM corp. IBM SPSS Statistics for Windows. 2013.

[pone.0231620.ref048] 48.R Core Team. R: A language and environment for statistical computing. 2013. [Google Scholar]

[pone.0231620.ref049] 49.Wu P, Hoven CW, Bird HR, Moore RE, Cohen P, Alegria M, et al. Depressive and disruptive disorders and mental health service utilization in children and adolescents. J Am Acad Child Adolesc Psychiatry 1999;38(9):1081–1090. 10.1097/00004583-199909000-00010 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref050] 50.Janicke DM, Finney JW. Determinants of children's primary health care use. Journal of Clinical Psychology in Medical Settings 2000;7(1):29–39. [Google Scholar]

[pone.0231620.ref051] 51.Riley AW, Finney JW, Mellits ED, Starfield B, Kidwell S, Quaskey S, et al. Determinants of children’s health care use: An investigation of psychosocial factors. Med Care 1993;31(9):767–783. 10.1097/00005650-199309000-00002 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref052] 52.Stahmer AC, Leslie LK, Hurlburt M, Barth RP, Webb MB, Landsverk J, et al. Developmental and behavioral needs and service use for young children in child welfare. Pediatrics 2005;116(4):891–900. 10.1542/peds.2004-2135 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref053] 53.Welkom JS, Hilliard ME, Rand CS, Eakin MN, Riekert KA. Caregiver depression and perceptions of primary care predict clinic attendance in head start children with asthma. Journal of Asthma 2015;52(2):176–182. 10.3109/02770903.2014.956891 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref054] 54.Fernandez E. Supporting children and responding to their families: Capturing the evidence on family support. Child Youth Serv Rev 2007;29(10):1368–1394. [Google Scholar]

[pone.0231620.ref055] 55.Martinez JI, Lau AS. Do Social Networks Push Families Toward or Away From Youth Mental Health Services?: A National Study of Families in Child Welfare. J Emot Behav Disord 2011;19(3):169–181. 10.1177/1063426610377898 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref056] 56.Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis. PLoS Med 2012;9(11). [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0231620.ref057] 57.Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health 2017;2(8):e356–e366. 10.1016/S2468-2667(17)30118-4 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref058] 58.Schneider SJ, Grilli SF, Schneider JR. Evidence-based treatments for traumatized children and adolescents. Curr Psychiatry Rep 2013;15(1).-012-0332-5 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref059] 59.Connor DF, Ford JD, Arnsten AFT, Greene CA. An update on posttraumatic stress disorder in children and adolescents. Clin Pediatr 2015;54(6):517–528. [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref060] 60.Stanhope V, Videka L, Thorning H, McKay M. Moving Toward Integrated Health: An Opportunity for Social Work. Soc Work Health Care 2015;54(5):383–407. 10.1080/00981389.2015.1025122 [DOI] [PubMed] [Google Scholar]

[pone.0231620.ref061] 61.Matos AR, Sousa LM. How multiproblem families try to find support in social services. J Soc Work Pract 2004;18(1):65–80. [Google Scholar]

[pone.0231620.ref062] 62.Sousa L. Building on personal networks when intervening with multi-problem poor families. J Soc Work Pract 2005;19(2):163–179. [Google Scholar]

[pone.0231620.ref063] 63.Sousa L, Rodrigues S. Linking formal and informal support in multiproblem low-income families: The role of the family manager. J Community Psychol 2009;37(5):649–662. [Google Scholar]

[pone.0231620.ref064] 64.Pohlmeier W, Ulrich V. An econometric model of the two-part decision making process in the demand for healthcare. J Hum Resour 1995;30(2):339–361. [Google Scholar]

[pone.0231620.ref065] 65.Reardon T, Harvey K, Baranowska M, O’Brien D, Smith L, Creswell C. What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies. Eur Child Adolesc Psychiatry 2017;26(6):623–647. 10.1007/s00787-016-0930-6 [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Care use and its intensity in children with complex problems are related to varying child and family factors: A follow-up study

Noortje M Pannebakker

Paul L Kocken

Paula van Dommelen

Krista van Mourik

Ria Reis

Sijmen A Reijneveld

Mattijs E Numans

Roles

Abstract

Background

Methods

Results

Conclusions

Introduction

Method

Sample and procedure

Measures

Analyses

Results

Response and respondents’ background characteristics

Table 1. Respondents’ baseline characteristics, and care use and intensity of use of any care and of psychosocial care.

Care service use and its intensity, and scores on predisposing, enabling and need factors

Change in a child’s predisposing, enabling and need factors for care service use and its intensity

Table 2. Descriptives for the change in predisposing, enabling and need factors and any and psychosocial care use and its intensity by children with or at risk of developing CP.

Table 3. Final Hurdle models for change in factors associated with change in care use and its intensity by children with CP using care: Multivariate odds ratios for changes in care use and rate ratios for changes in intensity of care use for any care and for psychosocial care services.

Discussion

Strengths and limitations

Implications for practice

Implications for further research

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Luca Cerniglia

Roles

Author response to Decision Letter 0

Decision Letter 1

Luca Cerniglia

Roles

Acceptance letter

Luca Cerniglia

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases