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Adolescent mental health services in Nevada: assessing the perspectives of families

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Adolescent Mental Health Services in Nevada: Assessing the Perspectives of Families
by
Brittney Cunningham

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

August 2021

© Copyright by Brittney Cunningham 2021
All Rights Reserved

The Committee for Brittney Cunningham certifies the approval of this Dissertation

Patricia Burch
Sourena Haj-Mohamadi
Patricia Tobey, Committee Chair

Rossier School of Education
University of Southern California
2021
iv
Abstract
Mental health services for adolescents in Nevada have been ranked poorly in national ratings in
per capita spending and access to treatment. The purpose of this study was to assess families’
perspectives and explore their experiences in accessing mental health services on behalf of an
adolescent. Using Bronfenbrenner’s ecological systems theory, this study examined systemic
effects of mental health and interdependence of systems. The study utilized quantitative content
analysis to code themes from the narrative portions of the consumer satisfaction surveys given to
families upon discharge from fiscal years 2017–2019. There were 392 survey respondents. The
findings of this study suggest that although families were grateful to have accessed services,
there were still areas for improvement. Implications of the study include the need for an increase
in funding, improvements in communication, specialized treatment, increases in therapy, and
enhanced safety measures to improve satisfaction with mental health services for adolescents.

v
Dedication
To my Lord and Savior Jesus Christ, my loving husband Jamal and beautiful baby girl Zoe.
Husband, you prayed with me, encouraged me to keep going, and supported my thoughts of
going back to school after giving birth to our beautiful, vibrant, and sassy baby girl. I am not sure
what we were thinking going to school at the same time with young ones, but we did it. Lending
an ear to hear me vent my frustrations or even reminding me that it was okay to be tired when I
would be hard on myself. Thank you. To my beautiful baby girl Zoe who would try to unplug the
computer on Saturdays and say hello to all my classmates, thank you for your patience and for
being my biggest cheerleader.

To Summer and Gavin, my children in love, thank you for your constant prayers for me to pass
all my exams and do well. I wanted to be an example of pushing forward and seeking education
to break barriers and be a living example for you to push forward in whatever you do.

To my nephews who encouraged me to apply to USC and shared in my excitement about my
acceptance, keep pushing forward and soon you’ll be applying as to colleges as well.

To my parents: thank you for being living examples of God’s mercy, resilience, and strength.

vi
Acknowledgements
I am grateful to Dr. Wade, thank you for cheering me on throughout the years. To
Division of Child and Family Services, Dr. Freeman, and Dr. Guevara, thank you for your
assistance and support. To my supportive family and friends, thank you for the kind words and
fellowship throughout this process. To Dr. Tobey, Dr. Burch, Dr. Haj-Mohamadi, Dr. Murphy,
Dr. Grant, Dr. Jenkins, Mrs., Griffin, and every professor who took the time to read, edit,
encourage, and support me during this journey, please know words cannot express my gratitude.
I will continue to strive to be as great as an example as you all have been and will continue to
pay it forward.

vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ........................................................................................................................................v
Acknowledgements ........................................................................................................................ vi
List of Tables ................................................................................................................................. ix
List of Figures ..................................................................................................................................x
Organizational Context and Mission ...................................................................................3
Importance of Addressing the Problem ...............................................................................4
Organizational Performance Goals ......................................................................................6
Stakeholder Group of Focus and Stakeholder Goal .............................................................7
Purpose of the Study and Research Questions .....................................................................7
Overview of Theoretical Framework and Methodology .....................................................8
Definitions............................................................................................................................8
Review of the Literature ......................................................................................................9
Overview of Methodology .................................................................................................25
Findings and Results ..........................................................................................................29
Discussion and Recommendations ....................................................................................36
Conclusion .........................................................................................................................39
References ......................................................................................................................................40
Appendix A: Division of Health Care Financing and Policy Exclusionary Criteria .....................49
Appendix B: Division of Child and Family Services Consumer Satisfaction Survey ...................51
Appendix C: A Priori Codes ..........................................................................................................57
Appendix D: Implementation and Evaluation Plan .......................................................................59
Appendix E: Ethics and Role of Researcher ..................................................................................63
Appendix F: Limitations and Delimitations ..................................................................................64
viii
Appendix G: Division of Child and Family Services Consumer Satisfaction Policy ...................65
Appendix H: Theoretical Framework Alignment Communications ..............................................69
Appendix I: Communications ........................................................................................................72
Appendix J: Information Sheet ......................................................................................................73

ix
List of Tables
Table 1: Southern Regional Behavioral Health Policy Survey Findings (Question 1) n = 53 11
Table 2: Southern Regional Behavioral Health Policy Survey Findings (Question 6) n = 45 15
Table 3: Different Social Choices and Decisions in Mental Health 21
Table 4: Demographics of Families 29
Table 5: Distribution of Participant Responses to Consumer Satisfaction Survey Items 31
Table 6: Responses on Improving Safety 34
Appendix C: A Priori Codes 57
Table D1: Implementation and Evaluation Plan Using CIPP Model 62

x
List of Figures
Figure 1: Nevada Population Growth 2
Figure 2: State of Nevada Government 4
Figure 3: Policy Triangle Model and Interplay 6
Figure 4: Bronfenbrenner Ecological Systems Theory 23
Figure 5: Conceptual Framework 24
Figure 6: Most Helpful Areas of Treatment for Child and Family 32

1

Adolescent Mental Health Services in Nevada: Assessing the Perspectives of Families
Mental health, as defined by the World Health Organization (2021), “is a state of well-
being in which an individual realizes his or her own abilities, can cope with the normal stresses
of life, can work productively, and is able to make a contribution to his or her community” (para.
1) Despite the prevalence of mental health in Nevada, it is currently ranked 51st behind the
District of Columbia in mental health services (America’s Health Rankings, 2019). The
perspectives of the consumers, specifically the families of adolescents, are limited in the
literature, although the lack of access impacts them most. Nevada has only 8.5 psychiatrists per
capita compared to the national average of 16.1, and according to Mental Health America’s 2018
report, Nevada ranks 47th in access to mental health treatment. This study examined the problem
of the lack of access to mental health treatment for adolescents in Nevada. There is a need to
explore potential barriers as mental health has systemic implications and has been identified as
contributing to homelessness, domestic violence, incarceration, and substance abuse, impacting
individual’s ability to work productively and contribute to their communities (Folsom et al.,
2005; Houghton et al., 2017).
Nevada’s per capita behavioral health expenditures ranked 42nd in the nation (America’s
Health Rankings, 2019, and Nevada’s general mental health budget was reduced by
approximately 60 million from 2009 to 2013 (Department of Health and Human Services, 2014).
According to Wang et al. (2005), funding was noted as the primary barrier to service
development, and interventions such as outreach, changing mental health priority, financing
mental health services, expanding treatment resources to underserved areas, and financing
mental health services could improve the quality of care and well-being (Saraceno et al., 2007;
Wang et al., 2005). Nevada offers the opportunity for improvements in policy and expenditures
2

for mental health services to increase access to treatment for adolescents and families (America’s
Health Rankings, 2019). According to the US Census Bureau, Nevada is listed in the top 10 for
population growth in the last decade. With the increase in the need for mental health services as
well as the population growth (Figure 1), access and treatment may become scarce.

Figure 1
Nevada Population Growth

Note. Population growth for Nevada is shown in Figure 1. Nevada has an overall 14.1%
population growth over the last decade. Adapted from “2019 Annual Services Report,” by
Department of Health and Human Services Division of Child and Family Services, 2019, p. 6
http://dcfs.nv.gov/uploadedFiles/dcfsnvgov/content/Tips/Reports/NV_APSR_2019_FINAL.PDF

3

Organizational Context and Mission
The mission of Nevada’s Division of Child and Family Services (DCFS) under the
Department of Health and Human Services (DHHS), as publicly reported on their website, is
Together in genuine partnership with families, communities and other governmental
agencies, provides support and services to assist Nevada’s children and families in
reaching their full human potential. DCFS recognizes that Nevada’s families are our
future and children, youth and families thrive when they: live in safe, permanent settings,
experience a sense of sustainable emotional and physical well-being, receive support to
consistently make positive choices for family and the common good. The current vision
is safe, healthy, and thriving kids in every Nevada community. (DCFS, 2019, para. 2)
Since DCFS is a subsidiary of the DHHS and state-operated, it is important to understand the
Nevada state government. Figure 2 depicts Nevada’s government hierarchy.

4

Figure 2
State of Nevada Government

Note. Figure 2 outlines the government within Nevada. Adapted from “2019 Legislative
Manual,” by Research Division Legislative Counsel Bureau, 2019, p. 11
https://www.leg.state.nv.us/Division/Research/Publications/LegManual/2019/Directory2019.pdf

Importance of Addressing the Problem
It is important to solve this problem for a variety of reasons. Nevada has a high
prevalence of mental illness but lacks appropriate treatment. Mental health is an essential factor
in the overall quality of life and well-being (Chisholm, 2015; Mann et al., 1994; Marcotte &
Wilcox-Gok 2001; Sunkel, 2012; Wang et al., 2005). According to Olivier (2017), citizens are
increasingly demanding improvements in service delivery for the public sector. Additionally,
Keyes (2007) argued that even those considered moderately mentally healthy had significant
Voters of Nevada
Judicial Branch Executive Branch
Constitutional
Entities/Officers
Executive Agencies -
Department of Health and
Human Services
Division of Child and Family
Services
Legislative
Branch
5

impairments, lower productivity, poor physical health, and limitations in daily living. Barry
(2009) discussed the importance of mental health promotion related to achieving positive mental
health, well-being, and prevention in the general population. The author also contended that
government departments have a responsibility to encompass a concern with policies that impact
social values, well-being, and quality of life. According to Saraceno et al. (2007), many barriers
to progress can be overcome by accessibility, political will, and human health care. Specifically,
this study focused on access to mental health treatment for adolescents from the families’
perspectives. Markedly, Chisholm (2015) stated government, in partnership with relevant
stakeholders, has a lead role in addressing current barriers, reshaping the debate, and responding
to mental health. Moreover, the author also contended that information, awareness and
education, improved health, as well as social and financial protections are key actions to promote
mental health. Furthermore, with the increase in mass shootings, suicides, and overpopulation in
emergency rooms, jails, and shelters, Nevada has the moral responsibility to address mental
health access and funding or continue risking the lives of many. Figure 3 depicts the intersection
of policy, process, and context when seeking to implement policy changes. Through the DHHS,
it is important to understand the policy triangle model as adopted by Walt and Gilson (1994).
This model has been used to analyze various health issues, including mental health (Mokitimi et
al., 2018). Figure 3 depicts this interplay.

6

Figure 3
Policy Triangle Model and Interplay

Note. Adapted from “Child and Adolescent Mental Health Policy in South Africa: History,
Current Policy Development and Implementation, and Policy Analysis,” by S. Mokitimi, S.
Schneider, and de Vries, P.J., 2018, International Journal of Mental Health Systems, 12, 36, p. 5
https://doi.org/10.1186/s13033-018-0213-3

Organizational Performance Goals
The Child Mental Health Services Performance Quality Improvement Plan identifies
DCFS performance goals in compliance with the Council of Accreditation (COA), an
internationally recognized child and family behavioral healthcare accrediting organization. The
COA describes four key areas: service compliance, service efficiency, service effectiveness, and
service quality (DCFS, 2012). At the time of this study, the overall goal within the DCFS was to
7

continue to provide services within the seven outcomes and seven system factors as identified in
the performance improvement plan submitted to the Children’s Bureau from 2018 to the present
(DHHS, 2019). The Children’s Bureau is a part of the DHHS that administers the Child and
Family Services Review. The review consists of seven outcome domains and seven system
factors. Nevada was found to be substantially out of conformity with all seven outcomes and six
systemic factors. For the purpose of this study, the emphasis was on the seventh outcome:
receiving adequate services to meeting physical and mental health needs. DCFS is governed by
the Nevada Revised Statutes and Nevada Administrative Code.
Stakeholder Group of Focus and Stakeholder Goal
Families who have accessed mental health services on behalf of an adolescent in Nevada
were the primary stakeholders for this study. This study sought to better understand the
perspectives of the families and youth in obtaining services. This study aimed to identify
potential gaps in services and offer solutions. Participants in this study were at least 18 years old
and identified as a parent, guardian, family member, or temporary guardian of adolescents ages
12 to 17 for whom they were seeking mental health treatment or had sought treatment in the last
three years. This is inclusive of residential treatment. Participants in this study were asked to
share their experiences with accessing mental health treatment post-discharge from residential
treatment.
Purpose of the Study and Research Questions
The purpose of this study was to explore the families’ perspectives and experiences in
accessing or attempting to access mental health treatment for adolescents in Nevada. This study
entailed quantitative content analysis and coding themes from the narrative portions of the
consumer satisfaction surveys given to families upon discharge. For practical purposes, this
8

study specifically assessed if the public data represented by the DCFS aligns with families’ true
experiences. As such, two research questions guided this project:
1. What are the families’ perspectives of Nevada’s role in the access to quality mental
health treatment for adolescents?
2. How do the proposed solutions offered by families compare to those offered by
legislators concerning access to mental health treatment for adolescents in Nevada?
Overview of Theoretical Framework and Methodology
For this specific problem of practice, I examined Bronfenbrenner’s ecological systems
theory. The theory is used to explain how children interact in multiple environments, also known
as ecological systems, with a specific focus on human development and complex layers
(Paquette & Ryan, 2001). According to Eriksson et al. (2018), systems theory has been used to
guide interventions, mental health policy, and practice and is useful for conceptualization. The
theory was used herein to examine this problem of practice because it emphasizes the
interdependence of systems that have all been impacted by mental health. These systems are
microsystems, mesosystems, exosystems, macrosystems, and chronosystems (Bronfenbrenner,
1994). In recognizing the complexities of mental health, it is important to understand how
changes are needed throughout various systems to address barriers to access to treatment and
how this has impacted various ecological systems.
Definitions
• Mental Health is defined by the World Health Organization as mental and psychological
well-being.
• Treatment, as defined by Collins Dictionary, is defined as services devoted to the
treatment of mental illness and the improvement of mental disorders.
9

• Access, as defined by Andersen et al. (2014), is getting the right services at the right time
to improve health outcomes.
• Families are parents, guardians, temporary custodians, relatives of an adolescent for
whom they have inquired or sought mental health services and/or resources. Does not
include friends who are not a primary caregiver or temporary custodian.
• Adolescents are defined as male, female, cisgender, or transgender teens between ages 12
and 17.
Review of the Literature
This review covers literature under three topic areas that emerged from the review
process. These topic areas are deinstitutionalization, barriers to access, and treatment. Although
the literature presented here has been applied to a variety of problems, this review focuses
primarily on the literature’s application to the perspectives of families accessing adolescent
mental health services in Nevada. In a 2018 Southern Nevada Behavioral Health Annual Report,
the top three problems in the region were identified as a lack of quality specialized providers and
programs (89.79%), insurance issues like coverage and reimbursement (60.37%), and difficulty
in accessing due to health insurance (30.82%). The top policy changes or promising areas of
practice were increased hiring, funding, training or community education (52.17%), and juvenile
services (47.48%). Notably, there were also challenges with navigating the system (31.11%),
overcoming insurance barriers (21.11%), difficulty finding/locating providers (20.55%), and
long waitlists (20.51%). Moreover, the authors noted mental-health-related disorders were the
underlying cause of 94,703 emergency room visits and 77,073 inpatient admissions among
Southern Nevada residents in 2017. As a supplement to previous studies and surveys completed
in Nevada, this study sought to collect data that addressed these research questions:
10

1. What are the families’ perspectives of Nevada’s role in the access to quality mental
health treatment for adolescents?
2. How do the proposed solutions offered by families compare to those offered by
legislators concerning access to mental health treatment for adolescents in Nevada?
To answer the research questions, relevant literature regarding access, treatment, and
funding was reviewed. The literature will be presented alongside an explanation of how it shaped
my understanding of the families’ perceptions of accessing quality mental health services.
Furthermore, the review will conclude by offering a conceptual framework that guided my study
design, data collection, and analysis. Table 1 summarizes the information presented in this
section regarding the findings from the Southern Nevada Behavioral Health Policy, specifically
for the top three issues in behavioral health. Table 1 addresses the top three problems or issues
related to behavioral health in Southern Nevada.

11

Table 1
Southern Regional Behavioral Health Policy Survey Findings (Question 1) n = 53
Code Name/Category Total

%
Lack of quality specialized providers and programs 89.8
Insurance issues (Coverage & provider reimbursement) 60.4
Access difficult due to health insurance 30.8
Lack of quality providers (general) 29.3
Awareness about services (by provider and consumer) 18.9
Funding for and costs of program care 18.9
Long wait time 18.9
Received inadequate services 11.3
Resources 11.3
Confused or frightened by the system and procedures to
find appropriate care
9.4
Housing issues and homelessness 9.4
Inpatient Care 9.4
Poor training 9.4
Substance abuse related issues 5.7
Provider licensing difficulties 5.7
Affordability 3.8

Note. The top 3 problems or issues related to behavioral health in Southern Nevada were
identified in Table 1. Adapted from “Southern Nevada Behavioral Annual Report,” by Division
of Public and Behavioral Health, 2018, p. 101
http://dpbh.nv.gov/uploadedFiles/dpbhnvgov/content/Boards/CBH/Meetings/2019/SNBHPolicy
BoardAnnualReport2018FINAL.pdf

The Role of Deinstitutionalization in Accessing Mental Health Services
To understand the increase in community placements in mental health, it is important to
recognize the interplay and history of deinstitutionalization. According to Lamb and Bachrach
(2001), deinstitutionalization can be described as replacing long-stay hospitals, asylums, and
12

residential settings with community-based alternatives for mentally ill people. According to
Diamond et al. (2001), deinstitutionalization of the mentally ill, which began in the 1960s,
contributed to overcrowding in jails and prisons. As a result, the United States is now more than
three times more likely to have a mentally ill person in jail or prison than in hospital (Torrey et
al., 2010). Nevada has approximately 10 times more mentally ill persons in prison than in a
hospital (Torrey et al., 2010).
Although Nevada has a mental health court as a result of deinstitutionalization, this
initiative’s success has been argued throughout the years. According to White and Whiteford (as
cited by Primeau et al., 2013), correctional facilities are becoming the psychiatric institutions of
the 21st century. Arguably, 64% of those incarcerated in jails, 56% of state inmates, and 45% of
federal prisoners exhibit symptoms of severe psychopathology (Peternelj-Taylor, 2008, as cited
by Primeau et al., 2013). It appears that barriers inherent to incarceration also prevent mentally
ill offenders from receiving sufficient treatment during their incarceration (Gottfried &
Christopher, 2017). Moreover, Belcher (1988) concluded that a combination of mental illness
amongst the homeless population, decompensation in a non-structured environment, and poor
follow-through with aftercare planning contributed to involvement with criminal justice systems.
Consequently, one of the unforeseen negative consequences of deinstitutionalization is
transinstitutionalization, which is the process of moving a mental health client from one
institution to the next, resulting in over 80 million dollars by each state yearly (Mowbray et al.,
2002, as cited by Primeau et al., 2013). Deinstitutionalization, although originally viewed as a
success, contributed to the lack of access and funding for mental health services. Overall, the
influx of persons with mental health needs in the criminal justice system due to
deinstitutionalization also contributed to barriers to treatment. As of Fiscal Year 2019 (July 1,
13

2018 – June 30, 2019), there were approximately 170 youth placed out of state from child
welfare or juvenile justice agencies due to waitlist or specialized needs (DCFS, 2019). It is
important to note how deinstitutionalization and poverty also impacted accessing mental health
services.
Barriers to Accessing Mental Health Services
Poverty
Studies have demonstrated disparities in accessing mental health treatment for those
living in poverty or of lower socioeconomic status. According to Miranda and Green (1999), the
poor are disproportionally women and children, making up 63% of households, and 55% are
women and ethnic minorities. According to Copeland (2005), ethnic minorities suffer disparities
in mortality, prevalence, and adverse health outcomes compared to white Americans.
Additionally, racial and ethnic health disparities are noted within populations and
subpopulations, demonstrating that this is a problem with access (Copeland, 2005).
Notably, understanding access is essential in addressing systemic healthcare challenges
(Kominski, 2013). According to Hodgkinson et al. (2017), mental health access is an ongoing
issue globally, and it is disproportionately harder for those who are poor to be connected with
high-quality mental health care. For those who are of higher socioeconomic status, there is more
access and options related to education and healthcare. Hodgkinson et al. (2017) found that
living in poverty or in low-income households was linked to health-related issues and increased
risk for mental health-related problems in both adults in children. Hodgkinson et al. (2017) noted
financial stress has been studied for years and is compounded when someone is emotionally
vulnerable or in a mental health crisis. Additionally, the authors asserted that despite the high
14

need for services, children and families living in poor neighborhoods or in poverty were least
likely to be connected with adequate quality mental health services.
Copeland (2005) emphasized disparities in job opportunities for both minority males and
females and the importance of reviewing healthcare coverage related to the quality of providers
within access. Furthermore, the author reported minorities are less likely to have private or
employment-based insurance. They are most likely to have public health insurance or Medicaid,
limiting the in-network or contracted providers available to them under these plans and may also
increase wait times and decrease quality of care (Copeland, 2005). According to Snowden
(2001), African Americans are more likely to live in deep poverty than White families, which
contributes to receiving inadequate mental health services. About 14% of African American
families reported income of less than 5,000 a year, while 3.5% of white families reported the
same, and their medium net worth is only one-tenth of that of White families. With disparities in
job opportunities for both African American males and females, it is important to look at
healthcare coverage related to the quality of providers within access. In addition, Belcher (1988)
noted fewer resources and higher homelessness rates among African Americans than Latinos and
Caucasians. Poverty and lower socioeconomic status are barriers to receiving adequate mental
health services. Furthermore, it is also important to highlight insurance and the vast literature on
the impact related to access and treatment. A study completed in 2018 identified some of the
barriers to seeking or receiving services for a patient’s family members (Table 2).

15

Table 2
Southern Regional Behavioral Health Policy Survey Findings (Question 6) n = 45
Code Name/Category Frequency Total

n = 45 %
Navigating the system 14 31.11
Insurance barriers, including insurance coverage issues 9.5 21.11
Difficulty finding/locating providers 9.25 20.55
Long wait lists 9.23 20.51
Negative emotions 9 20
Lack of access to different treatment levels (such as
specialists or emergency visits)
5.6 12.44
Lack of funding/money to pay for service 4 8.88
Difficulty accessing providers in general 2 4.44
Poor quality providers 2 4.44
Difficulty reaching providers via phone calls 1 2.22
Providers misrepresenting credentials and qualifications 1 2.22

Note. The experiences of families accessing and receiving treatment in Southern Nevada
identified in Table 2. Adapted from “Southern Nevada Behavioral Annual Report,” by Division
of Public and Behavioral Health, 2018, p. 106
http://dpbh.nv.gov/uploadedFiles/dpbhnvgov/content/Boards/CBH/Meetings/2019/SNBHPolicy
BoardAnnualReport2018FINAL.pdf

Insurance
Recent research revealed various barriers to quality, access, and treatment of mental
health services. In an empirical study, Cunningham (2009) recognized that primary care
providers (PCPs) became a gateway for mental health services and attempted to understand
barriers. This study followed the Mental Health Parity and Addiction Equity Act of 2008, which
addressed the lack of access by requiring group health plans to provide the same level of
coverage for mental health as physical health. Approximately 6,600 nonfederal primary care
16

physicians were surveyed from 2004-2005 from 60 communities selected randomly, with a
response rate of 52%. The sample also included a subsample of 2,900 PCPs in pediatrics, family
medicine, and general internal medicine. Ordinary least squares regression analysis was used to
examine the four regressions. The study found that two-thirds of the physicians could not obtain
mental health services for the patients they referred to a mental health specialist. The physicians
cited inadequate coverage, shortages of providers, and health plan barriers as contributing to
their patients’ lack of access.
Notably, Cunningham stated mental health services were twice as difficult to obtain
compared to other specialty referrals. According to Wang (2005), treatment of mental disorders
in the United States continues to be disturbingly low, with most not receiving treatment within
the last year. In fact, the author noted disparities among those who received treatment in the
effectiveness of prevention and treatment, clinical assessments, ongoing monitoring, and
delivery of treatments. Furthermore, only one-third of treatment met minimal standards or was
evidence-based. With the newly revised Nevada Medicaid Services Manual published through
the Division of Health Care Financing and Policy, there is an increase in exclusionary criteria
related to mental health and reimbursement, which was identified as another top barrier in the
2018 Southern Nevada Behavioral Annual Report. Notably, with an increase in exclusionary
criteria, it is important to note disparities in access (Appendix A).
Disparity in Access
Although many factors contribute to the limited access to appropriate mental health
services for marginalized populations, barriers to access have been a reoccurring theme
throughout the literature. According to Davis et al. (2008), barriers to treatment included
transportation disapproval, limited finances, and unfamiliarity with accessing services. In this
17

study, 220 participants were approached while waiting for appointments in a non-psychiatric
clinic and later given face-to-face interviews (Davis et al., 2008). Twenty-two percent met the
criteria for PTSD, and only 13% had received prior trauma-focused treatment. Moreover, the
authors concluded that ineligibility, intimidating procedures, and unfamiliarity with clinical
services were institutional barriers that affected compliance with treatment. It can be assumed
that with psychiatric treatment being a very personal and sensitive area, clients respond better to
those they can trust, and consumers noted mistrust of providers.
According to Alegria et al. (2002), Latinos and African Americans were less likely to
receive specialty health care. In this study, 8,098 English-speaking participants responded to a
National Comorbidity Survey completed from 1990 to 1992. There was a potential barrier of
mistrust identified by over 35% of the 987 African Americans surveyed. Those surveyed had
experienced racism and mistreatment by the health care system, which may have discouraged
their use of specialty care (Alegria et al., 2002). Some of the barriers identified were lack of
access to primary care, lack of insurance, lack of childcare and transportation, and inflexibility in
their jobs to attend these appointments. Furthermore, it was not uncommon for mental health
services to be outside of the neighborhoods they frequented the most and for the quality of care
when treated to be poor (McGuire & Miranda, 2008).
According to Paradies et al. (2015), limiting access to resources, capacities, unfair
inequalities in power, and opportunity across ethnic groups is a form of racism. Several barriers
contributed to the disparity in accessing mental health services for minoritized populations. From
a theoretical lens in examining disparities in access, there has been historical conflict over
limited resources, social order by power, and dominance. It is a federal mandate through the
Social Security Act of 1935, which established the Departments of Health and Human Services
18

to protect the health and well-being of all Americans, which does not exclude minoritized
populations. Additionally, stigma has had a significant impact on the treatment of mental health.
The Importance of Treatment in Mental Health Services
Stigma
There are many stigmas faced when seeking mental health services. Some are often
ostracized and face backlash from their families and community, which has a sociohistorical
context. Although stigma is associated with mental illness globally, Gary (2005) reported ethnic
minority groups suffer double stigma when facing mental illness. This double stigma was also
one of the reasons some ethnic minorities may not seek or participate in services, although it may
be beneficial (Gary, 2005). Families have also become stigmatized when a relative needs service.
Furthermore, membership in a minority group in conjunction with stigma affects well-being and
may contribute to mortalities and morbidities. Specifically, Gary (2005) highlighted disapproval
within the family and community for mental health treatment is often rooted in dependence on
faith and the church community to help cope with problems and mental health difficulties. In a
study conducted by Ward et al. (2009), minority participants endorsed prayer and counseling
through the church as coping strategies and were ambivalent about using medications. The
authors emphasized barriers to treatment as stigma, poor access to care, and lack of awareness of
mental illness.
Further, according to Lindsey et al. (2010), many minority youths were distrusting of
mental health professionals and their authenticity, which were often shared perceptions from
their families or taught to them. The authors used a survey with a mixed-methods design to
interview 69 participants from treatment and community-based programs in a Northeastern city.
The survey assessed mental health stigma, social support, and demographic characteristics. It
19

should be noted that some of the generational beliefs and experiences related to mental health
were shared. This influenced help-seeking behaviors within this community. According to
Queener et al. (2001), mental health professionals should consider collaborating with the church
to increase education and decrease barriers among the African American community. Moreover,
as identified extensively in the literature, funding has also played a vital role in access to
treatment for mental health services in Nevada.
Disparities in Funding
Disparities in funding have been identified as one of the top barriers to mental health
services, and Nevada has low expenditure compared to other states. From 2001 to 2003, 9,282
face-to-face interviews were conducted to assess diagnosis, service use, and treatment.
Approximately 41.1% of interviewees received some treatment in the previous 12 months, and
most (22.8%) were treated by a general medical provider. The study revealed mental health in
the United States was treated inadequately or untreated altogether and underfunded (Wang,
2005). General medical practitioners rather than psychiatrists provided treatment of mental
illness; furthermore, the author identified severe underfunding of mental health services for both
insured and uninsured (Wang, 2005). Other providers stressed the lack of funding, access,
insurance coverage, fragmented service delivery, and shortages of providers (Cunningham, 2009;
Saraceno et al., 2007; Wang et al., 2005).
In a qualitative study conducted by Saraceno et al. (2007), 60 senior experts were
questioned on barriers to mental health service development, which included public-health
priority agenda, funding, decentralization of mental health services, challenges to
implementation, and training. Funding was noted as the primary barrier to service development
(Saraceno et al., 2007). Thus, interventions such as outreach, changing mental health priority,
20

financing mental health services, expanding treatment resources to underserved areas, and
financing mental health services could improve the quality of care and well-being (Wang et al.,
2005; Saraceno et al., 2007). Due to the decrease in expenditures since 2016, budget cuts have
had a damaging effect on access to specialized treatment for adjudicated youth with sex offenses,
intellectual disabilities, autism spectrum disorders, extreme aggression, and victims of sex
trafficking. Specialized training is also needed to help professionals provide evidence-based
treatment to adolescents and families. Disregarding the importance of deinstitutionalization,
barriers to treatment, and disparity in funding has severe implications and increase the risk of
Nevada being out of compliance with federal and state mandates. Table 3 outlines different
values pertaining to social choices and decisions in mental health (World Health Organization,
2013).

21

Table 3
Different Social Choices and Decisions in Mental Health
Perspective Primary Concerns/Core
Values
Issues related (mental) health
Public Health Promote, prevent, restore, and
maintain health
The attributable and avertable
burden of disease
Economic welfare Maximize individual and
social well-being
Health as a key component of
economic welfare
Economic growth and
productivity
Improve the standard of living
by increasing economic
output (via more efficient
production)
Effect of reduced health on
production (labour) and
consumption (health care)
Equity Promote fairness in equality
of opportunity
Health and access to health care as
a human right
Socialcultural Influence Influence of beliefs, customs,
and attitudes regarding the
way societies perceive and
organize themselves
Perceptions or beliefs about the
causes of illness (stigma)
Political Influence Formulate and implement
state policies, uphold the
law, and, where necessary,
intervene in private markets
Market failures in healthcare (e.g.,
incomplete information among
service users)

Note. Table 3 outlines social attitudes and perspectives on social choices and decisions. Adapted
from “Investing in Mental Health: Evidence for Action,” by World Health Organization, 2013, p.
12, https://apps.who.int/iris/bitstream/handle/10665/87232/9789241564618_eng.pdf

Theoretical Framework and Models: Ecological Systems Theory
Ecological systems theory (Bronfenbrenner, 1994) has been used throughout social
sciences to explain the interplay between a child’s development and interactions between
systems. Mental health is associated with affecting overall health and well-being individually
and has implications systemically. According to Jacob et al. (2007), most countries have
inadequate staffing and allocate scarce financial resources. Ecological systems theory implicitly
22

explains systems working interdependently (Bronfenbrenner, 1994). Mental health is very
complex and affects all frames in the Bronfenbrenner model. The five frames are the
microsystem, mesosystem, exosystem, macrosystem, and chronosystem (Bronfenbrenner, 1994).
Bronfenbrenner emphasized examining the entire ecological system to understand growth.
Ecological systems theory could help explain the complexities of mental health from an
individual struggling with shame and guilt to the chronosystem and past sociohistorical attitudes
of asylums, shock therapy, and segregation. As seen in Figure 4, ecological systems theory helps
explain mental health across systems and stakeholders.

23

Figure 4
Bronfenbrenner Ecological Systems Theory

Conceptual Framework
Mental health has systemic effects, and ecological factors have also contributed to human
development. In this study, families were asked to discuss their experiences with accessing or
attempting to access services for mental health. Some of the questions designed in the survey ask
about treatment, barriers, and open-ended general experiences. Throughout the ecological
systems theory, we noted the impact systems have on the individual within the microsystem and
24

on families within the macrosystem. Figure 5 identifies concepts related to families’ experiences
while attempting to access mental health services for an adolescent, as discussed in the literature
review.

Figure 5
Conceptual Framework

Note. Figure 5 depicts the multiple factors families may encounter while trying to obtain
treatment for their adolescent. Figure 5 also conceptualizes the themes identified in the literature
across the systems identified in Bronfenbrenner’s theory.

25

Summary
In reviewing the literature related to mental health services in Nevada, it is important to
recognize how the intersection of concepts like barriers, treatment, and funding impacts the
families’ experiences and recommendations. There are often misconceptions related to inpatient
beds per capita and limited discussions on disparities in access. Nevada’s consecutive rating of
51st for several years has damaging effects on the adolescents and families who have been
affected by the lack of oversight and attention to this issue. One of the reasons I chose to explore
ecological systems theory was to examine the effects of mental health systemically. Historically,
mental health has been discarded as an individual issue; however, with the increase in diagnosis
and funding allocated for studies, discussion related to this issue is increasing. This study sought
to capture family members’ experiences. The solutions offered by families and DCFS were
reviewed and compared.
Overview of Methodology
I conducted a quantitative content analysis using secondary data from consumer
satisfaction surveys completed from fiscal years 2017–2019. Families completed 392 surveys
during this time. Adolescents’ families complete these surveys upon the child’s discharge from a
residential setting after a stay typically lasting three to six months. The DCFS Planning and
Evaluation Unit (PEU) deidentified the secondary data before providing them to me. A summary
of the surveys is presented to administrators and becomes public record through the DHHS
annually. The survey asked 53 questions (4 open-ended) on demographics, treatment, and
experiences (Appendix B).
Prior to this study, the open-ended questions had not been coded using data analysis
software, which could increase the probability of operationalization or manipulation of variables
26

(Cramer, 2003). This study focused on the open-ended questions and used data analysis software
ATLAS.ti for coding themes. Data from 2017–2019 was the explicit focus with emphasis on
residential treatment in the state of Nevada. In all, 392 surveys were analyzed. The data were
first separated by year and then by question. Lastly, data across all years were compared.
Most prior research focused on the voices and barriers presented by the referring
providers instead of the family members seeking services for an adolescent. In Nevada, consent
for a minor to participate in a study must be given by their legal custodian, which is why this
study assessed the experiences of those accessing services on behalf of the adolescent. According
to Merriam and Tisdell (2016), these participants are collective experts who can name and study
the problem and offer solutions. This aligns with the paradigm of inquiry as I explored
critical/transformative to understand both general and marginalized populations and their access.
Although one could argue that the specific stories are only generalizable to the individual family,
the richness of the data collected over years provides insight to identify patterns to educate
legislators, increase awareness, and generate possible solutions.
Instrumentation
This research was descriptive and phenomenological. In a review of literature related to
this topic, there was a focus on the perspectives of referring providers and the barriers they faced.
There is a gap in the research related to the voices of the families and youth. Furthermore, due to
the requirement of parental consent for minors to receive mental health treatment, the families
were the primary voice in this research. For this study, I used phenomenology and sought the
lived experiences and perspectives of families who sought mental health services for an
adolescent. This involved getting perspectives of those facing the problem.

27

Data Collection
Consumer satisfaction surveys from 2017 to 2019 were submitted to PEU from Nevada’s
various residential mental health programs. Although data were also collected from community
mental health agencies, this study’s emphasis was on residential treatment, as the average length
of stay was 3 to 6 months. These surveys were given at discharge to youth, parents, and
stakeholders who received services. The surveys are not offered intermittently while receiving
services. Surveys from all programs were aggregated yearly and shared with the various
programs. The results were also presented as an executive summary and posted publicly.
According to Boslaugh (2010), secondary data is becoming popular in social sciences due to the
availability of large data sets.
Data Analysis
Data from completed surveys were deidentified prior to data analysis. The survey
questions were answered using a Likert scale. On this survey, there were approximately four
questions about improving services, improving safety, helpful aspects of services, and additional
comments. Respondents were asked the following open-ended questions: “What has been the
most helpful thing about the services your child and family received?” What would improve
services your child and the family received?” “Please indicate ways in which we could improve
client safety” “Any additional comments?” Respondents were also asked to elaborate on their
selection of “other” when their selection was not a predefined option.
Using ATLAS.ti, the raw narrative data from fiscal years 2017 to 2019were uploaded.
The survey data were uploaded on an Excel spreadsheet by question and separated by year. The
data were first separated by year and then by the question asked. There were approximately 176
codes grouped and summarized by responses such as “helpful, improvement, safety, additional
28

comments” (Appendix C). Data were coded, grouped, and put into themes. According to
Johnston (2017), using secondary data is becoming more prevalent as it offers flexibility and is a
viable method when systemic procedures are followed. As discussed by Heaton (2003),
secondary data are widely used by researchers of quantitative data and are also being applied to
qualitative data. The author also stressed the importance of savings of money, personnel, time,
and resources when using secondary data (Heaton, 2003). As with all data analysis, it has also
been argued that safeguards must be in place to preserve the data’s integrity, including
preparation and cleaning. Demographics such as ethnicity and age were summarized and
highlighted from previous reports.
Credibility and Trustworthiness
Per recommendations by Merriam and Tisdell (2016), to increase credibility, this study
included member checks. To increase dependability, the secondary data were previously
analyzed by a member of the PEU to ensure accurate recording and interpretation. The PEU gave
this information directly to ensure accuracy in recording raw data responses. It was provided as
line items. To increase confirmability, I used process notes and audit rails and searched for
themes through data reconstruction. To increase credibility, reports were reviewed by an outside
party. It was beneficial to have someone outside of the mental health field review the data to
decrease the use of mental health jargon and confusion for the reader. There were also benefits to
using someone in the mental health field to determine whether they would have drawn the same
conclusions from the data. To increase management of the narrative responses, systems were put
in place for organizing the data and their retrieval. According to Merriam and Tisdell (2016),
many researchers are overwhelmed by the amount of data in a qualitative study.

29

Findings and Results
The purpose of this project was to evaluate adolescent mental health services in Nevada
and present the perspectives of families by highlighting their written narratives from surveys
completed at discharge. This section presents data collected through 392 consumer satisfaction
surveys completed by families of adolescents with an average age of 12 to 17 discharging from
residential treatment for fiscal years 2017 to 2019. There were also 11 surveys submitted for
children between the ages of 9 and 11. Of the families defined, most respondents identified
themselves as birth parents (n = 294), adoptive parents (n = 31), and grandparents (n = 27). The
responses came from birth parents, adoptive parents, stepparents, grandparents, guardians, foster
parents, and others. Table 4 present a comprehensive summary.

Table 4
Demographics of Families
Characteristics FY 2017 FY 2018 FY 2019 Total of n % of N = 392
Birthparents 114 79 101 294 75%
Adoptive parent 10 10 11 31 7%
Foster parent 0 0 2 2 0.005%
Stepparent 1 1 6 8 .020%
Grandparent 8 9 10 27 6.8%
Legal guardian 0 1 3 4 .01%
Other 8 2 4 14 3.5%
No response 3 6 3 12 3.0%

Note. Listed Table 4 is a summary of how respondents identified their relationship to the
adolescent.

30

Helpful Areas of Treatment
Approximately 199 families (N = 392), roughly 50%, strongly agreed that overall they
were pleased with services their child or family received. Approximately 115 families agreed
with the statement, while 28 disagreed or strongly disagreed. In response to the question “the
services my child and family received were right for us,” 199 families strongly agreed, while 86
agreed. Twenty-nine families were undecided, while 17 disagreed or strongly disagreed. Some of
the items written in narratives that were deemed helpful were therapy, learning coping skills,
medication management, and caring staff. Especially, one respondent noted “the therapy of
talking about family issues” as helpful, while another stated, “the staff’s experience, helpfulness,
caring attitude to try to better our relationship.” Table 5 presents a breakdown of the participants’
responses by question. Figure 6 presents the top four categories that were the most helpful areas
of treatment.

31

Table 5
Distribution of Participant Responses to Consumer Satisfaction Survey Items
Survey Item Response FY 17-19 total n % of N =
392

Q. 10 Overall I was pleased with the
services my child and the family
received

Strong Disagree
Disagree
Undecided
Agree
Strongly Agree
No response
Does not apply

13
15
25
115
199
10
14

3.3%
3.8%
6.3%
29%
50%
2.5%
3.5%
Q. 18 The services my child and
family received were right for us
Strong Disagree
Disagree
Undecided
Agree
Strongly Agree
No response
Does not apply
9
8
29
86
199
4
2
2.2%
2%
7%
21%
50%
0.10%
.005%
Q. 28 Services were provided in a
safe, comfortable environment that
was well cared for
Strong Disagree
Disagree
Undecided
Agree
Strongly Agree
No response
Does not apply
7
6
16
140
188
1
2
1.7%
1.5%
4.0%
35.7%
47.9%
.002%
.005%

Note. In Table 5, information was taken from previously analyzed secondary data, and the total
of all values of n does not equal 100%; however, the actual percentages were still calculated
using N value of 392.

32

Figure 6
Most Helpful Areas of Treatment for Child and Family

Note. In the survey given to families (Appendix B), the top four most helpful areas of treatment
are identified.

Improving Safety
Families were asked if “services were provided in a safe, comfortable environment that
was well cared for.” Results were that 188 families strongly agreed, and 140 agreed. Out of 392
responses, families offered two main recommendations to improve safety: communication and
separation of violent youth. Table 6 displays the open-ended questions asked in the narratives of
“please indicate ways in which we could improve client safety.” Eleven families discussed
improvements needed in communication, such as “explanation of procedures, policy and
Therapy
“She took the time to actually listen and
understand what was going on versus
dismissing everything I said”
Coping Skills
"We were able to identify trouble
spots/triggers and learn new strategies
to deal with them more effectively"
Safe Environment
"My child was in a safe and
comfortable environment that was
crucial for his health and for
improvement"
Medication Management/ Assessment
"Dr. helping with medication
adjustments and being willing to help
with other aspect of care (i.e. weight
gain, sleeplessness and RX side effects)”
33

services,” “better communication with other staff and parents.” Seven other families noted
concern with violent behaviors and recommended separating youth with violent behaviors,
specifically “keeping children that are aggressive around each other not in such closer quarters”
and “separate violent kids.” Although at least 81 families felt safe or would not make any
changes, stating it was a “very safe environment,” it is important to consider the themes that
came out of the narrative responses. Table 6 displays the questions and responses on improving
safety.

34

Table 6
Responses on Improving Safety
Survey Question Theme Respondent’s Comments
Q. 52 Please indicate
ways in which we
could improve client
safety
Communication “working on communication better”

“more communication”

“doctors refused to communicate with me”

“explanation of procedures, policy and
services”

“better communication with other staff and
parents”
Separation “separate violent kids”

“checking for violent kids”

“keeping children that are aggressive around
each other not in such closer quarters”

“kids who aren’t immediately involved in
altercations should be allowed to go to room
when fight breaks out”

“different areas for certain patients”

“having an area where patient that act out can
be instead of interrupting family visits”

“the staff does a great job; however if just
children with mental problems without any
violence were admitted”

Note. Listed in this Table 6 are responses related to safety. These comments resulted in
identifying the top two recommendations to increase communication between providers and
families and separation of youth with violent behaviors.

35

Improvement of Services
Families were asked, “What would improve services your child and the family received?”
Sixteen families identified a need for improvement in communication, such as “daily updates,”
“better communication amongst the nurses,” “communication from psychiatrist especially when
discussing the child’s future plans,” “rules should be set in stone and should not change from day
to swing.” Another theme was the desire for more therapy and specialized treatment. One family
stated they “would like more family session and maybe a drug/counseling program for teens,”
while another family wanted “maybe more counseling sessions for youth and parents” and “more
therapy.”
Additional Comments
Of the additional comments received, 42 families gave staff compliments like “staff was
great and helpful,” “staff is friendly and helpful, thank you,” “all staff was wonderful and very
helpful with any info needed.” These families identified helpful staff as an essential part in
adolescents’ treatment, as illustrated by one comment: “the complete staff was always very
helpful always courteous and nice. I cannot say anything that I could find wrong with any of the
staff. I am very pleased. Thank you all very much.” Approximately 121 families expressed
gratitude for receiving services in general with responses such as “I am very pleased with the
care and support both my child and myself received throughout the program,” and “Thank you
all for caring for my daughter. I pray she never need this.” One of the families especially noted
the changes in their adolescent, stating, “I just want to thank everyone who helped with the
service my child received. I have seen and heard the change in her. Thanks so much and God
bless.” Of the additional comments identified, families highlighted the importance of caring
staff. These are important considerations as the implementation and evaluation plan is explored
36

in Appendix D related to training and resources needed for staff to feel motivated, satisfied, and
efficacious in providing treatment to youth and families.
Discussion and Recommendations
Presented in this section are the proposed solutions and recommendations that could
assist in exploring systemic changes needed to increase consumers’ satisfaction with mental
health services for adolescents in Nevada. Implications will be explored using ecological systems
theory (Bronfenbrenner, 1994). According to Eriksson et al. (2018), this approach offers a broad
sense of looking at trends, environmental change, mental health practice, and policy.
Appendix D lists the implementation and evaluation plan. This study sought to answer the
following research questions:
1. What are the families’ perspectives of Nevada’s role in the access to quality mental
health treatment for adolescents?
2. How do the proposed solutions offered by families compare to those offered by
legislators concerning access to mental health treatment for adolescents in Nevada?
The findings revealed two main recommendations to improve services and safety. These
recommendations were access to specialized treatment for youth with violent behaviors and an
increase in provider-to-family and provider-to-provider communication.
Recommendation 1: Increase Access to Specialized Treatment
One of the themes was the importance of separation in proximity and programming for
youth with violent behaviors. Several families highlighted concerns with the needs of youth with
violent behaviors and the need for specialized treatment, as identified in Table 6. This was also
previously recommended and implemented by the Legislative Counsel Bureau. Specifically, in
juvenile justice facilities, Nevada implemented screenings for mental health disorders. Chino et
37

al. (2004) noted in their recommendations that the state needs to also provide intensive,
appropriate, quality mental health services in the facilities. While there are increasing numbers of
adolescents with mental health disorders in juvenile justice facilities, there are limitations to
removing them from facilities and putting them in generalized residential settings that may not
suit both their mental health and behavioral needs. In comparison to the general population, a
study completed by Rosenberg et al. (2014) found that 350 youth were screened and had eight
times the probability of PTSD and six times the likelihood of substance abuse in addition to other
factors such as depression. This demonstrates the need for an increase in specialized training to
meet their needs and the needs of other youth sent out of state to access services not offered in
Nevada. Perhaps policy changes, improvement in screening, and access to specialized treatment
within the facilities could improve outcomes. According to a DCFS 2019 report presented to the
80th legislative session, youth were sent out of state mainly due to their complex needs,
specialized treatment, and extensive waitlist in Nevada for residential treatment. This was also
highlighted in the surveys, as several families had concerns or asked for increased therapy, drug
programs, and screenings.
As such, it is recommended that agencies train, recruit, and collaborate with providers
with specialized training in areas such as substance abuse, trauma, autism, intellectual
disabilities, and adjudicated youth with conduct-related behaviors and offenses. This
recommendation may improve outcomes, increase access to local evidence-based treatment,
decrease the need to send youth out of state, and improve satisfaction with treatment for youth
and families.

38

Recommendation 2: Improving Communication
Communication and collaboration in healthcare are associated with positive patient and
provider outcomes and identified as core competencies to increasing collaborative practices
(Suter et al., 2009). Families identified provider-to-family and provider-to-provider
communication as areas that could improve safety and treatment. Specifically, some families
wanted “explanation of procedures, policy and services,” as well as “better communication with
other staff and parents.” According to Wong et al. (2019), respectful communication may
improve recovery for mental health, and respecting perspectives may improve the quality of care
and outcomes. A study by Hart et al. (2007) identified parent-provider communication as an
important factor in the quality of care and satisfaction. The authors also noted collaboration
when working with families with psychosocial concerns enhanced quality of care. In another
study, communication improved the transition of services and decreased the information gap
(Luu et al., 2016).
As such, it is recommended that organizations improve provider-to-family and provider-
to-provider communication. This may involve a communication system designated for families
to have questions answered, increased times outside of treatment teams for families to ask
specific questions and receive daily updates, and a system for families to leave messages for
providers. This program would include a HIPAA-compliant electronic communication system to
increase provider-to-provider and family-to-provider collaboration and efficiency in services.
This would increase communication with direct providers outside of standard treatment team and
child and family team meetings to properly aid in discharge planning and improve both treatment
and continuity of care.
39

It is recommended that future research assess the consumer satisfaction surveys
completed by youth to explore their perspectives and satisfaction with treatment. The narrative
portions of the surveys could be coded and themed as well. This information could be compared
to the surveys completed by caregivers as well as the opinions of community stakeholders.
Future research could also analyze the experiences of youth and families of color to explore
treatment effectiveness and practices related to diversity, equity, and inclusion.
Conclusion
Mental health services in Nevada have faced large cuts in expenditures throughout the
years despite advocates’ and providers’ beliefs that the conservative budget is inadequate in
meeting adolescents’ needs. This belief is also supported by consistently poor rankings in
national ratings. With an increase in youth being sent out of state to access specialized treatment
and decrease waiting time, it is argued that increased funding to address these concerns locally
may reduce the need to send youth out of state. With the evolving mental health needs of youth,
additional training is warranted. An important factor to consider is the effectiveness and quality
of treatment received, as it is a misleading assumption that access to services equates to
effectiveness and quality. Treatment can cause more harm if not driven by evidence and data to
support it. Considering the national ratings for mental health treatment in Nevada, it is evident
that systemically we need to do more to meet the mental health needs of adolescents and
families.

40

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49

Appendix A: Division of Health Care Financing and Policy Exclusionary Criteria
Per the Division of Health Care Financing and Policy Medicaid (2021), one or more of
the following criteria must be met which prohibit the recipient from benefiting rehabilitatively
from RTC treatment or involve the RTC’s inability to provide a necessary specialized service or
program, clinical decisions will be made individually on a case-by-case basis:
a. Psychiatric symptoms requiring acute hospitalization;
b. The following conditions which limits the recipient’s ability to fully participate in RTC
services and cannot be reasonably accommodated by the RTC;
1. Physical Disability;
2. Learning Capacity;
3. Traumatic Brain Injury (TBI);
4. Organic brain syndrome;
c. Pregnancy, unless the RTC can appropriately meet the needs of the adolescent, including
obtaining prenatal care while in the facility. In the case of the birth of the infant while the
recipient is in the RTC, planning for the infant’s care is included in the discharge plan.
(In such an instance the infant would be covered individually by Medicaid for medically
necessary costs associated with medical care);
d. Chronic unmanageable violent behavior incompatible with RTC services which poses
unacceptable and unsafe risks to other clients or staff for any reason (i.e., a danger to self,
others or property);
e. Medical illness which limits the recipient’s ability to fully participate in RTC services
and is beyond the RTC’s capacity for medical care;
50

f. Drug and/or alcohol detoxification is required as a primary treatment modality before a
recipient can benefit rehabilitatively from RTC services; or
g. A diagnosis of Oppositional Defiant Disorder (ODD) and/or Conduct Disorder, alone and
apart from any other covered, current ICD diagnosis.

51

Appendix B: Division of Child and Family Services Consumer Satisfaction Survey
Please help our Agency improve by answering some questions about the services you and your child
received.
Your answers are confidential and anonymous.
PLEASE COMPLETE THIS SURVEY FOR ONE (1) CHILD ONLY
T oday’s Date: __________________

1. Have you heard of Nevada’s
System of Care philosophy, values
and principles?
 Yes
 No
2. Please define your relationship to
the child you are filling out this
survey for:
 Birth Parent  Sibling
 Adoptive Parent  Grandparent
 Foster Parent  Step Parent
 Other: __________________________________
3. How long did your child receive
services at the location above?
 Less than 3 months  6 months – 1
year
 3-5 months  More than 1 year
4. Where will your child live once
he/she is discharged?
 With One or More Parents
 With Another Family Member
 Foster Home
 Therapeutic Foster Home
 Another Group Home
 Other:
5. What is your child’s Age? _________
6. What is your child’s Gender?  Male  Transgender
 Female  Other
7. What is your child’s Race?
(Mark all that apply)

 African American
 Am. Indian/Alaskan Native
 Asian
 Native Hawaiian/Other Pacific Islander
 White (Caucasian)
 Other _________________
8. Are your child’s birth parents of
Spanish, Hispanic, Mexican or
Latino Origin?
 Yes
 No
9. Who in your child’s family is
currently serving on active duty in
or retired/separated from the
Armed Forces, the Reserves or the
National Guard? (Mark all that
apply)
 None  Grandparent
 Parent/Caregiver  Uncle/Aunt
 Sibling  Cousin

52

Please indicate if you Strongly Disagree, Disagree, are Undecided, Agree, or Strongly Agree with
each of the statements below. Put a mark (X) in the box that best describes your answer. If a statement
does not apply to you, you may mark the Does Not Apply box.

Strongly
Disagree
Disagree Undecided Agree
Strongly
Agree
Does
Not
Apply
10 Overall, I was pleased with
the services my child and
the family received.

11 My child’s educational
needs were met during
his/her stay in the
residential services.

12 I helped identify my child’s
treatment goals.

13 I attended treatment team
meetings or child and
family team (CFT)
meetings.

14 A NV PEP Family
Specialist helped me to
have a lead role in my
child’s treatment planning
or child and family team
meetings.

15 The staff helping my child
and family stuck with us no
matter what.

16 I felt my child and family
had someone to talk to
when troubled.

17 I participated in my child’s
treatment.

18 The services my child and
family received were right
for us.

19 Staff explained my child’s
diagnosis, medication and
treatment services and
options.

20 Staff explained my child’s
and family’s rights, safety
and confidentiality issues.

21 Services were scheduled at
times that were right for us.

53

Strongly
Disagree
Disagree Undecided Agree
Strongly
Agree
Does
Not
Apply
**If you Disagree/Strongly
Disagree, please explain
your answer below.
______________________
______________________
______________________
______________________
____________________
22 My family got the help we
wanted for my child.

23 We got as much as help as
we needed for my child.

24 Staff treated me and my
family with respect.

25 Staff respected my family’s
religious/spiritual beliefs.

26 Staff spoke with me in a
way that I understood.

27 Staff was sensitive to my
cultural and ethnic
background.

28 Services were provided in a
safe, comfortable
environment that was well
cared for.

29 I received support and
advocacy from a NV PEP
Family Specialist.

30 Staff have referred us to
resources we can access in
the community after
discharge.

54

As a result of services:

Strongly
Disagree
Disagree Undecided Agree
Strongly
Agree
Does
Not
Apply
31 My child is better at
handling daily life.

32 My child gets along better
with family members.

33 My child gets along better
with friends and other
people.

34 My child is doing better in
school.

35 My child copes in difficult
situations much better.

36 I am satisfied with our
family life right now.

37 Our family is aware of
people and services in the
community that support
us.

38 I am better able to handle
our family issues.

39 I learned helpful parenting
skills while receiving
services.

40 I received information
about my child’s
developmental
expectations and needs.

41. Did a psychiatrist/doctor (MD) through
this agency prescribe medications for
your child?
 Yes
 No***

***If you answered NO to question 41, please skip to question 50.
If you answered YES, please continue with question 42.

55

Psychiatrist/MD:

Strongly
Disagree
Disagree Undecided Agree
Strongly
Agree
Does
Not
Apply
42 My child’s
Psychiatrist/MD was
respectful and helpful.

43 My child’s
Psychiatrist/MD answered
my questions.

44 My child’s
Psychiatrist/MD spent
enough time with him/her.

45 My child’s
Psychiatrist/MD provided
guidance and support to
his/her treatment.

46 My child’s
Psychiatrist/MD
understood his/her
problems and feelings.

47 My child’s meetings with
his/her Psychiatrist/MD
were helpful.

48 The medications that my
child’s Psychiatrist/MD
prescribed (if applicable)
were explained to him/her
(side effects, effectiveness,
and expectations of
outcomes).

49 Overall, I was pleased
with the services my child
received from his/her
Psychiatrist/MD.

50. What has been the most helpful thing about the services your child and the family received?

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

56

51. What would improve services your child and the family received?

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

52. Please indicate ways in which we could improve client safety.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Please provide any additional comments you would like to share with us.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Thank you for taking the time to answer the Survey.
We will be happy to share the results of this survey with you.
Please call the Division of Child and Family S er v i ce s’ Planning and Evaluation Unit
at 775-688-3744 if you have any questions or comments regarding this survey.

57

Appendix C: A Priori Codes
Codes Groups Definitions Example
Helpful Areas of services or areas of
treatment deemed helpful to
adolescent and families
Therapy, communication,
safe environment, family
relationships, medication
management
Safety Areas identified that could
improve safety, reduce risk,
create a sense of security
and comfort
Communication, separation
of youth, specialized
treatment, safe
environment, seclusion, and
restraint
Improve Areas of treatment, services
or safety that was needed to
improve services needed for
the adolescent and families
Communication, decrease
waiting list, explanation of
policies and procedures,
discharge planning,
transition of care, daily
updates
Additional comments Additional comments
families wanted to share
with the agency to improve,
highlight or acknowledge
Staff compliments, general
sentiments, safety concerns,
process improvements
Access Ability to receive services in
a timely manner as deemed
appropriate given the
family’s crisis or concerns,
services available to meet
the need of adolescent and
families
(Houghton et al., 2017).
Waiting list, limited
specialized treatment,
location and scheduling
conflicts, denial of services,
limited coverage through
insurance (Houghton et al.,
2017).
Therapy Therapy session or group
meetings used to problem
solve or discuss issues at
hand, meeting to discuss
progress
Individual, group and family
therapy, team meetings,
treatment teams, child and
family team meetings
Treatment Access to care to address
mental health concerns to
make (Wang, 2005).
Individual, group and family
therapy, medication
management, evaluation,
crisis intervention (Wang,
2005).

58

Codes Groups Definitions Example
Barriers Areas identified that may
have delayed access to care
or created an obstacle in
treatment (Saraceno et al.,
2007).
Waiting lists, limited
specialized care,
transportation, visiting
times intake process,
exclusionary criteria
through insurance, denials
(Saraceno et al., 2007).
Medication
Management/Assessment
Ongoing assessments with
medical provider
prescribing medication
Compliance, medication
evaluations, diagnosis,
treatment
Communication Direct contact with providers
regarding treatment
recommendations, progress,
and limitations
Phone calls, meetings,
treatment team, family
session

Note. The a priori codes listed are grouped based on common themes identified throughout the
176 codes analyzed. The top areas are listed and not the exhaustive list.

59

Appendix D: Implementation and Evaluation Plan
The implementation and evaluation plan used for this study is the Context, Input, Process,
and Product Model (CIPP) by Stufflebeam (2000). This model was designed to collect and
identify the strengths and limitations of a program and improve effectiveness. The model
consists of four areas: context, input, process, and product. According to Stufflebeam (2007),
each area focuses on elements such as: What needs to be done? How should it be done? Is it
being done, or did it succeed? This study evaluated and recommended solutions based on
surveys completed by families of youth discharging from residential treatment in Nevada, as
such a specific agency was not evaluated. This implementation and evaluation plan focused on
solutions for agencies providing residential treatment, personnel, administrators within DCFS,
and community stakeholders. Although there were several recommendations as given by the
families, this study will focus on the implementation of specialized treatment offered to youth in
these facilities to increase access, improve communication, increase collaboration, and increase
effectiveness of treatment provided to youth with complex needs.
Context
Based on the summary of recommendations from the responses of families in the
consumer satisfaction surveys completed in 2017 through 2019, several families suggested
specialized treatment offered locally in Nevada, such as “maybe a drug/counseling program for
teens.” In compliance with Assembly Bill 298, a report was compiled by DCFS for FY 2019 and
represented in the 80th legislative session. In this, it was reported that over 160 youth were sent
out of state for treatment. One of the reasons identified was the access to specialized treatment in
Nevada. Some of these treatment areas included youth with substance use, development
disability/intellectual disability and autism, fetal alcohol syndrome, trauma-informed care,
60

conduct related behaviors, sexually exploited youth, and adjudicated youth with sexual offenses.
This model was used to implement a plan to offer specialized treatment in the residential
treatment facilities here locally in Nevada. According to Zhang et al. (2011), the planning
implementation and assessment can be complex when it involves multiple constituencies. This
model is aimed to meet the needs of community partners and service providers.
Input
One of the ways this could be implemented is by training current personnel. This could
be done by retaining the providers that are currently in positions by mandating training in areas
listed above to provide the opportunity to continue to meet the needs of youth and families
without lapse. Examples are completion of certifications in trauma-informed cognitive behavior
therapy training, substance abuse treatment training as well as skills training for mental health
technicians. This could include paying for certifications or offering more opportunities division-
wide to receive certifications or mentorship in these areas. This would increase collaboration as
recommended by the Systems of Care principles and possibly improve outcomes (Dowd, 2005).
Another recommendation is to offer credentialing and privileges to outside providers with
specialized treatment to come into the facility as paid for by the facility versus Medicaid.
According to the Medicaid Manual Chapter 403.9B section 9, it is the responsibility of the
facility to fund services if it does not have them available. This would cause an increase in
independent contracts or the use of personnel with specializations to cross-train and provide
services across departments. Another recommendation is to modify recruitment to add
specializations to preferences or even required. Some of the current recruitment for providers
require the basic requirements and education wanted but does not include the knowledge, skills,
and abilities needed to be successful in the position and meet the needs of the youth with
61

complex needs. The skills training can also be provided to mental health technicians prior to
interact with youth, increasing training days per year and increasing options of courses as offered
by College of Southern Nevada. According to Bandura (2005), an increase in knowledge and
performance improves self-efficacy, which affects motivation.
Process
Annually, program managers in residential treatment, human resources, and planning and
evaluation units can submit data to DCFS administrators to ensure compliance and effectiveness
with the administration surveys. This will also provide the opportunity to review challenges,
successes, and process improvement. This will be reviewed with administrators and supervisors
and later shared with the staff of each program. This will continue to provide an opportunity to
continue data-driven decision making, as it seeks to collect, analyze, examine, and interpret data
to inform practice and policy (Mandinach, 2012).
Product
There are several ways to measure this implementation’ success. Some ways that would
be effective are providing formative and summative evaluations through consumer satisfaction
surveys offered every 90 days for youth and families to explore their satisfaction or services
received. A biannual employee satisfaction survey can also be given with specific questions
related to training, efficacy, and effectiveness of training and treatment provided. According to
Clark and Estes (2008), training will give an opportunity to implement checklist and review
policies and procedures. Ways to measure the effectiveness of treatment would be annual reports
from paying sources such as Medicaid with recidivism rates for youth in Nevada. Human
resources, as well as departments, could conduct annual comparisons to analyze agency retention
rates as well as compare results from exit interviews to assess if personnel felt they had the
62

supports and training necessary to do their job effectively. This will also explore their feelings
related to the environment as this can affect motivation and performance (Oliver, 2017). This
will help build collaboration and may possibly improve outcomes (Dowd, 2005). Listed in Table
D1 is a summary of recommendations using the CIPP model.

Table D1
Implementation and Evaluation Plan Using CIPP Model
CIPP Model Stufflebeam
Context
What needs to be
done?
Input
How should it be done?
Process
Is it being done?
Product
Did it succeed?
Increase
specialized
trainings to
treatment
providers

Increase awareness
to community
stakeholders
regarding mental
health services in
Nevada.
Increase specialized training,
certification, and
collaboration of providers in
current positions

Credentialing and
collaboration of outside
providers to provide
specialized treatment

Increase in independent
contracts

Job/ recruiting announcements
to include Knowledge, Skills
and Abilities and preferences
of specialized treatment
commensurate with
environment

Review of courses currently
required for promotion of
direct line staff
Annual summary
of data given to
DCFS
Administrators
by programs,
human
resources and
PEU

Data reviewed
with
Administrators,
supervisors, and
staff

Discussions on
challenges,
successes, and
process
improvements
Evaluation of 90-
day surveys
given to families
and youth
regarding
treatment
received

Biannual
employee
satisfaction
surveys
completed

Data compiled
from employee
exit interviews

Note. Table D1 summarizes the implementation and evaluation plan for increasing specialized
training using the CIPP model
63

Appendix E: Ethics and Role of Researcher
In this study, the participants may have been harmed by being interviewed, as it might
have evoked emotions and frustrations as they recalled experiences in seeking services for a
family member. They might also have been harmed by assuming that my interviewing them
directly might get them faster access to treatment. My positionality as a clinical program
manager for an inpatient hospital and licensed clinical social worker who has contact with
families seeking services may have influenced how some of the questions were answered. This is
one of the reasons I used secondary data from the surveys. I have been a provider of mental
health services and a supervisor of providers. As one of the administrators, I am responsible for
admissions on the residential unit, and some of the respondents may have felt that participating
in the study may decrease the waiting period for their adolescent or increase likelihood of being
clinically accepted. According to England (1994), it is important to look at positionality, power
and otherness when researching.

64

Appendix F: Limitations and Delimitations
There were three limitations of this study. The surveys for residential treatment were only
completed at discharge, which may be a limitation, as the families’ final experience may
influence their answers. It is possible if the surveys were also given at specific intervals in their
treatment, the data may be more reflective of their overall experiences throughout. A family’s
disagreement with discharge may have resulted in negative survey responses. The second
limitation was generalizability. It can be argued the opinions of the families pertain to residential
treatment and not community-based treatment. These may not include the opinions of families
who were still trying to access residential services for their adolescent.
There were several delimitations to limit the scope of this study. The first was the use of
secondary data from 2017 to 2019. It can be contended the opinions of families during those
years are not representative of the experiences in 2020. Additionally, external circumstances
during those years were not the same as the current ones, given COVID-19, so the
generalizability may be questioned. The questions asked in the survey were edited in 2020, and it
may be assumed that the previous surveys may not have asked the correct questions since it is
now separate surveys for both parents and stakeholders. Another delimitation was that I am a
novice researcher. I was becoming more familiar with software and how to best capture the
families’ experiences. It may also be assumed my opinions, given the years of experience, may
have influenced the presentation of the results.

65

Appendix G: Division of Child and Family Services Consumer Satisfaction Policy
DIVISION OF CHILD & FAMILY SERVICES
Children’s Mental Health Services
SUBJECT: Children’s Mental Health Services Satisfaction Survey
POLICY NUMBER: 4.10
NUMBER OF PAGES: 4
EFFECTIVE DATE: April 22, 2011
ISSUED DATE: April 15, 2011
REVIEWED BY::
DATE:
Children’s Mental Health Management Team
March 2, 2009
APPROVED BY:
DATE:
Deputy Administrator
March 3, 2011
SUPERCEDES:
PAGES:
4.10 10-01-07
All
APPROVED BY:
DATE:
Commission on Mental Health and Developmental Services
March 17, 2011
REFERENCES: N/A
ATTACHMENTS: N/A

POLICY:

It is the policy of the Division of Child and Family Services (DCFS) that all children, youth and
families/caregivers who receive DCFS mental health services have an opportunity to give
feedback and information concerning those services. As service recipients voluntarily participate
in regularly administered service surveys while in program and again at the time of discharge,
their input can produce valuable feedback for program managers, consumers, and DCFS
administrators regarding the quality of the mental health services DCFS provides.

PURPOSE:

This policy establishes the opportunity for continuous quality assurance feedback from the
children, youth, families and caregivers who are recipients of mental health services under
DCFS. By identifying from the consumer perspective the strengths and needs of its mental health
service delivery process, DCFS can strive to adhere more faithfully to a System of Care service
delivery model while continually working to enhance children’s mental health service
effectiveness.

DEFINITIONS:

DCFS Community Based Services Parent/Caregiver Survey: This hardcopy survey is
administered to parents and caregivers while participating in Outpatient, Early Childhood and/or
Wraparound in Nevada Services provided for their children and youth.

DCFS Community Based Services Youth Survey: This hardcopy survey is administered to youth
11 years and older who are receiving Outpatient and Wraparound in Nevada Services.
66

DCFS Residential and Psychiatric Inpatient Services Parent/Caregiver Discharge Survey: This
hardcopy survey is administered to parents and caregivers who participated in the treatment of
their children or youth who have received services in a residential or psychiatric inpatient
facility.

DCFS Residential and Psychiatric Inpatient Services Youth Discharge Survey: This hardcopy
survey is administered to youth 12 years and older who have received residential or psychiatric
inpatient services.

DCFS Residential and Psychiatric Inpatient Services Stakeholder Survey: This hardcopy survey
is administered periodically to community medical, legal, correctional, educational, religious,
psychotherapy, child welfare, and other professionals who have occasion to work in various
capacities with DCFS residential and psychiatric inpatient facilities and their staff.

Peace Treatment Center Children’s Consumer Service Evaluation: This hardcopy survey is
administered to children 6 through 10 years of age who are receiving psychiatric inpatient
services in the acute unit of Peace Treatment Center.

PROCEDURES:

A. Administration of DCFS Community Based Services Parent/Caregiver and Youth Surveys:

1. Community-based surveys will be conducted statewide once a calendar year during
the month of April with active clients and may be administered individually to clients
and their parents/caregivers at time of discharge from services.

2. A Survey Monitor will be appointed by the program manager of each community-
based service center for statewide survey implementation. Each Survey Monitor will
serve as their center’s contact with DCFS Planning and Evaluation Unit (PEU) staff
for purposes of preparing their service center for the survey, conducting the survey,
relaying information and securing support as needed, insuring the continued
availability of needed survey materials and collecting and forwarding the surveys to
PEU staff for processing.

3. PEU staff will send to each Survey Monitor a survey protocol that addresses survey
materials, provides instructions on how and when to conduct the surveys, and
identifies procedures for forwarding completed surveys to the PEU.

4. Surveys for office-based service recipients will be disseminated to caregivers and
youth by the receptionist in the lobby of each service center.

5. Family and youth survey participants ordinarily will place their completed surveys in
a drop box/other container located in the lobby of their respective service center.
Survey participants will also be given the option of returning their surveys by mail via
a stamped and self addressed envelope provided by the center.

67

6. Families and youth in home based services who choose to complete surveys will be
given the option of returning them by mail in stamped and self addressed envelopes
provided by their caseworker.

7. Community-based surveys will be available in both English and Spanish.

B. Administration of DCFS Residential and Psychiatric Inpatient Services Parent/Caregiver
and Youth Discharge Surveys:

1. Residential and Psychiatric Inpatient surveys will be conducted statewide by program
staff with all clients and their parents/caregivers at the time of discharge from services.

2. The program manager of each service facility will appoint a Survey Monitor to help
facilitate discharge survey implementation. The Survey Monitor will serve as the
facility’s contact with PEU staff for purposes of preparing facility staff for the discharge
survey process, conducting the surveys, relaying information and securing support as
needed, insuring the continued availability of needed survey materials and collecting and
forwarding the surveys to PEU staff for processing.

3. PEU staff will send to each Survey Monitor a survey protocol that addresses survey
materials, provides instructions on how and when to conduct the surveys, and identifies
procedures for forwarding completed surveys to the PEU.

4. Family and youth survey participants ordinarily will place their completed discharge
surveys in a drop box/other container provided by their treatment facility. Survey
participants will also be given the option of returning their surveys by mail via a stamped
and self addressed envelope provided by facility staff.

5. Residential and psychiatric inpatient surveys will be available in both English and
Spanish.

C. Administration of DCFS Peace Treatment Center (PTC) Children’s Consumer Service
Evaluation:

1. PTC Children’s Acute Program staff will ensure the administration of the Children’s
Consumer Services Evaluation upon discharge from the children’s acute unit.

2. All discharge surveys will be administered to parent/caregivers and youth by each unit’s
charge nurse.

3. PTC will update and/or revise their internal discharge survey on an as-needed basis per
Joint Commission updated standards.

D. Administration of DCFS Residential and Psychiatric Inpatient Services Stakeholder
Surveys:

68

1. Residential and Psychiatric Inpatient Stakeholder Surveys may be solicited from
community professionals/other individuals having a relationship with the treatment
facility by way of client referrals, participation in client treatment planning, agency
interaction or cooperation at a program level, other relationship having an interest in how
the facility performs its mission. Stakeholder surveys can be solicited annually from a
standard list of identified community consumers and/or on an as-occur basis when such
consumers function as members of a client’s treatment team.

2. Stakeholder survey participants ordinarily will place their completed surveys in a drop
box/other container provided by the treatment facility. Survey participants will also be
given the option of returning their surveys by mail via a stamped and self addressed
envelope provided by the center.

Data Entry and Reporting Process

1. The PEU will design the databases necessary for capturing respective survey data.

2. Peace Treatment Center discharge surveys will be maintained in a database at Peace and
the Quality Assurance Unit will be responsible in ensuring monthly reporting of findings
in accordance with the Joint Commission requirements for the facility. Peace Treatment
Center Quality Assurance Specialist will forward satisfaction survey results to the
Planning and Evaluation Unit.

3. All statewide implemented mental health services discharge surveys will be entered into
their respective databases by PEU staff.

4. PEU staff will be responsible for reporting survey results to appropriate entities.

69

Appendix H: Theoretical Framework Alignment Communications
Theoretical Framework Alignment Matrix – Secondary Data

Approximately 392 consumer satisfaction surveys were assessed from 2017-2019. The closed-
ended questions that supplement the narratives or answer the research questions were highlighted
in the analysis. The closed-ended portions were analyzed by PEU, and the narratives from the
open-ended questions were not. The narratives were coded and themed to answer the research
questions.

Research Question Theoretical/Conceptual
Framework
Data Instrument Questions
1. What are the families’
perspectives of Nevada’s
role in the access to quality
mental health treatment for
adolescents?

Individual and Microsystem
(adolescent and families)

50. What has been the most
helpful thing about the
services your child and the
family received?

54. Please provide any
additional comments you
would like to share with us.

2. How do the proposed
solutions offered by families
compare to those offered by
legislators concerning access
to mental health treatment
for adolescents in Nevada?

Microsystem (family
experiences, may change
depending on response)

All applicable systems (i.e.
increase in providers with
specialized training could
have various systemic
implications)
(Bronfenbrenner, 1994)
51. What would improve
services your child and the
family received?

52. Please indicate ways in
which we could improve
client safety

70

Quantitative (closed-ended) questions listed below were previously coded and summarized
by PEU and will be highlighted through my analysis.

Research Question Theoretical / Conceptual
Framework
Data Instrument Questions
1. What are the families’
perspectives of Nevada’s
role in the access to quality
mental health treatment for
adolescents?
Individual and microsystems
(adolescent and families,
consumer satisfaction with
services)

Microsystem and
Mesosystem (families and
community collaboration)

Microsystem and
Mesosystem (Families and
community services
effectiveness)

Microsystem (families and
assessing potential barriers)

Microsystem (families and
quality of services received)

Mesosystem and Exosystem
(community resources,
assessing access, quality, and
barriers)

Mesosystem and Exosystem
(mental health community
resources, DCFS, assessing
access of treatment)

Individual and Microsystems
(adolescents and families,
assessing effectiveness and
quality of treatment)
10. Overall, I was pleased
with the services my child
and the family received.

15. The staff helping my
child and family stuck with
us no matter what.

18. The services my child
and family received were
right for us.

21. Services were scheduled at
times that were right for us.

22. My family got the help
we wanted for my child.

28. Services were provided
in a safe, comfortable
environment that was well
cared for.

30. Staff have referred us to
resources we can access in
the community after
discharge.

23. We got as much as help
as we needed for my child

71

2. How do the proposed
solutions offered by families
compare to those offered by
legislators concerning access
to mental health treatment
for adolescents in Nevada?
Microsystem and
Mesosystem (families and
community, assessing
access)

Mesosystem (community
resources, neighborhood,
environment, assessing
quality of care)

Mesosystem and Exosystem
(mental health community
resources, DCFS, assessing
access of treatment)

Individual and Microsystems
(adolescents and families,
assessing effectiveness and
quality of treatment)
37. Our family is aware of
people and services in the
community that support us.

28. Services were provided
in a safe, comfortable
environment that was well
cared for.

30. Staff have referred us to
resources we can access in
the community after
discharge.

23. We got as much as help
as we needed for my child.

72

Appendix I: Communications
To: State of Nevada Planning and Evaluation Unit (PEU)
From: Brittney Cunningham
Subject: Consumer Satisfaction Survey Research
Through the use of secondary data primarily collected by PEU from consumer
satisfaction surveys given on behalf of adolescents, this study seeks to better understand the
perspectives of families and youth. This study will also analyze potential themes and solutions
offered by families versus legislators in Nevada. Participants in this study must be at least 21
years old and identify as a parent, guardian, family member or temporary guardian of an
adolescent ages 12-17 that they are seeking mental health treatment or have sought treatment for
in the last three years in Nevada. Participants in this study will be asked to share their
experiences with accessing mental health treatment in Nevada post-discharge from residential
treatment. The quantitative portions are presented yearly by PEU to DCFS; however, content
under comments or additional comments are typed verbatim and are not coded. This study will
specifically analyze and focus on this raw data.
You can learn more about the research, confidentiality, and other rights as a research
subject in this USC Information Sheet for Exempt Research.

Regards,
Brittney Cunningham
Doctoral Candidate, University of Southern California

73

Appendix J: Information Sheet
INFORMATION SHEET FOR EXEMPT RESEARCH

STUDY TITLE: Mental Health Services in Nevada: Assessing the Perspectives of
Families and Youth

PRINCIPAL INVESTIGATOR: Brittney Cunningham

FACULTY ADVISOR: Patricia Tobey, PhD

You are invited to participate in a research study. Your participation is voluntary. This
document explains information about this study. You should ask questions about
anything that is unclear to you.

PURPOSE
The purpose of this study is to understand the perspectives of families and adolescents
who have assessed mental health services in Nevada. You are invited as a possible
participant because you are a family member who have accessed mental health
services for an adolescent within the last three years.

PARTICIPANT INVOLVEMENT
Participants involved in this study are families of adolescents who has received mental
health services and discharge from a residential program in the last three years and
completed a Consumer Satisfaction Survey through the Department of Child and Family
Services. The answers to the survey will be used as secondary date and analyzed.
There is no direct contact between the researcher and family members who have
completed this survey.

CONFIDENTIALITY
The members of the research team, and the University of Southern California
Institutional Review Board (IRB) may access the data. The IRB reviews and monitors
research studies to protect the rights and welfare of research subjects.

When the results of the research are published or discussed in conferences, no
identifiable information will be used. When data is received from PEU it will be
deidentified to reduce risk. For any data containing the name of the agency a
pseudonym will be used. Data will be stored on a password protected computer using a
cloud-based system such as iCloud or Google drive.

Summarized information may be presented to State of Nevada Legislators or
Administrators to verbalize findings for potential program improvement, if applicable.
Although the secondary data used is public record and presented annually to DCFS, the
contents of the narrative portions will be highlighted to identify any themes.
74

INVESTIGATOR CONTACT INFORMATION
If you have any questions about this study, please contact Brittney Cunningham
(blcunnin@usc.edu) or Patricia Tobey, PhD (tobey@usc.edu).

IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the
University of Southern California Institutional Review Board at (323) 442-0114 or email
irb@usc.edu.

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Asset Metadata

Creator Cunningham, Brittney LaDell (author)

Core Title Adolescent mental health services in Nevada: assessing the perspectives of families

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2021-08

Publication Date 06/05/2023

Defense Date 05/26/2021

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag access,Adolescent,Families,mental health

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Tobey, Patricia (committee chair), Burch, Patricia (committee member), Haj-Mohamadi, Sourena (committee member)

Creator Email blcunnin@usc.edu,brea_allen@hotmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC13012501

Unique identifier UC13012501

Identifier etd-Cunningham-9645.pdf (filename)

Legacy Identifier etd-Cunningham-9645

Document Type Dissertation

Format theses (aat)

Rights Cunningham, Brittney LaDell

Internet Media Type application/pdf

Type texts

Source 20210611-usctheses-batch-839 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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