Neighborhood Sociodemographic Predictors of Serious Emotional Disturbance (SED) in Schools: Demonstrating a Small Area Estimation Method in the National Comorbidity Survey (NCS-A) Adolescent Supplement

  • Jennifer Greif GreenEmail author
  • Margarita Alegría
  • Ronald C. Kessler
  • Katie A. McLaughlin
  • Michael J. Gruber
  • Nancy A. Sampson
  • Alan M. Zaslavsky
Original Article


We evaluate the precision of a model estimating school prevalence of SED using a small area estimation method based on readily-available predictors from area-level census block data and school principal questionnaires. Adolescents at 314 schools participated in the National Comorbidity Supplement, a national survey of DSM-IV disorders among adolescents. A multilevel model indicated that predictors accounted for under half of the variance in school-level SED and even less when considering block-group predictors or principal report alone. While Census measures and principal questionnaires are significant predictors of individual-level SED, associations are too weak to generate precise school-level predictions of SED prevalence.


Small area estimation Assessment Serious emotional disturbance National comorbidity survey adolescent supplement 



Preparation of this paper was supported by NIMH K01-MH085710 (Green) and NIMH K01-MH092526 (McLaughlin). This work is also supported by the National Institutes of Health/National Institute on Minority Health and Health Disparities (NIH/NIMHD) Recovery Act Project, which funded Challenge Grant 5RC1MD004588. The National Comorbidity Survey Replication Adolescent Supplement (NCS-A) is supported by the National Institute of Mental Health (NIMH; U01-MH60220 and R01-MH66627) with supplemental support from the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Robert Wood Johnson Foundation (RWJF; Grant 044780), and the John W. Alden Trust. The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or U.S. Government. A complete list of NCS-A publications can be found at Send correspondence to The NCS-A is carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative. We thank the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis. The WMH Data Coordination Centres have received support from NIMH (R01-MH070884, R13-MH066849, R01-MH069864, R01-MH077883), NIDA (R01-DA016558), the Fogarty International Center of the National Institutes of Health (FIRCA R03-TW006481), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, and the Pan American Health Organization. The WMH Data Coordination Centres have also received unrestricted educational grants from Astra Zeneca, BristolMyersSquibb, Eli Lilly and Company, GlaxoSmithKline, Ortho-McNeil, Pfizer, Sanofi-Aventis, and Wyeth. A complete list of WMH publications can be found at

Conflict of interest

Dr. Alegría has served as an expert presenter for Shire US, Inc. Dr. Kessler has been a consultant for AstraZeneca, Analysis Group, Bristol-Myers Squibb, Cerner-Galt Associates, Eli Lilly & Company, GlaxoSmithKline Inc., HealthCore Inc., Health Dialog, Hoffman-LaRoche, Inc., Integrated Benefits Institute, John Snow Inc., Kaiser Permanente, Matria Inc., Mensante, Merck & Co, Inc., Ortho-McNeil Janssen Scientific Affairs, Pfizer Inc., Primary Care Network, Research Triangle Institute, Sanofi-Aventis Groupe, Shire US Inc., SRA International, Inc., Takeda Global Research & Development, Transcept Pharmaceuticals Inc., and Wyeth-Ayerst. Dr. Kessler has served on advisory boards for Appliance Computing II, Eli Lilly & Company, Mindsite, Ortho-McNeil Janssen Scientific Affairs, Johnson & Johnson, Plus One Health Management and Wyeth-Ayerst. Dr. Kessler has had research support for his epidemiological studies from Analysis Group Inc., Bristol-Myers Squibb, Eli Lilly & Company, EPI-Q, GlaxoSmithKline, Johnson & Johnson Pharmaceuticals, Ortho-McNeil Janssen Scientific Affairs., Pfizer Inc., Sanofi-Aventis Groupe, Shire US, Inc., and Walgreens Co. Dr. Kessler owns 25 % share in DataStat, Inc. The remaining authors report no conflict of interest.


  1. Achenbach, T. M. (1991). Manual for the child behavior checklist/4-18 and 1991 profile. Burlington: University of Vermont: Department of Psychiatry.Google Scholar
  2. Braaten, E. B., Biederman, J., DiMauro, A., Mick, E., Monuteaux, M. C., Muehl, K., et al. (2001). Methodological complexities in the diagnosis of major depression in youth: An analysis of mother and youth self-reports. Journal of Child and Adolescent Psychopharmacology, 11(4), 395–407.PubMedCrossRefGoogle Scholar
  3. Chorpita, B. F., Reise, S., Weisz, J. R., Grubbs, K., Becker, K. D., Krull, J. L., et al. (2010). Evaluation of the brief problem checklist: Child and caregiver interviews to measure clinical progress. Journal of Consulting and Clinical Psychology, 78(4), 526–536.PubMedCrossRefGoogle Scholar
  4. Doll, B., & Cummings, J. A. (2008). Population-based approaches to promoting the competency and wellness of children. Thousand Oaks, CA: National Association of School Psychologists.Google Scholar
  5. Dowdy, E., Ritchey, K., & Kamphaus, R. W. (2010). School-based screening: A population-based approach to inform and monitor children’s mental health needs. School Mental Health, 2(4), 166–176.PubMedCentralPubMedCrossRefGoogle Scholar
  6. Dowdy, E., Twyford, J. M., Chin, J. K., DiStefano, C. A., Kamphaus, R. W., & Mays, K. L. (2011). Factor structure of the BASC–2 behavioral and emotional screening system student form. Psychological Assessment, 23(2), 379–387.PubMedCrossRefGoogle Scholar
  7. Dupéré, V., Leventhal, T., & Lacourse, E. (2009). Neighborhood poverty and suicidal thoughts and attempts in late adolescence. Psychological Medicine, 39, 1295–1306.PubMedCrossRefGoogle Scholar
  8. Garrison, C. Z., Addy, C. L., Jackson, K. L., McKeown, R. E., & Waller, J. L. (1991). The CES-D as a screen for depression and other psychiatric disorders in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 30(4), 636–641.PubMedCrossRefGoogle Scholar
  9. Goldsmith, H. F., Holzer, C. E., & Manderscheid, R. W. (1998). Neighborhood characteristics and mental illness. Evaluation and Program Planning, 21(2), 211–225.CrossRefGoogle Scholar
  10. Goodman, R. (2001). Psychometric properties of the strengths and difficulties questionnaire. Journal of the American Academy of Child and Adolescent Psychiatry, 40(11), 1337–1345.PubMedCrossRefGoogle Scholar
  11. Green, J. G., Avenevoli, S., Finkelman, M., Gruber, M. J., Kessler, R. C., Merikangas, K. R., et al. (2010a). Attention deficit hyperactivity disorder: Concordance of the adolescent version of the composite international diagnostic interview version 3.0 (GDI) with the K-SADS in the US national comorbidity survey replication adolescent (NCS-A) supplement. International Journal of Methods in Psychiatric Research, 19(1), 34–49.PubMedCentralPubMedCrossRefGoogle Scholar
  12. Green, J. G., Gruber, M. J., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2010b). Improving the K6 short scale to predict serious emotional disturbance in adolescents in the USA. International Journal of Methods in Psychiatric Research, 19, 23–35.PubMedCentralPubMedCrossRefGoogle Scholar
  13. Grills, A. E., & Ollendick, T. H. (2002). Issues in parent-child agreement: The case of structured diagnostic interviews. Clinical Child and Family Psychology Review, 5(1), 57–83.PubMedCrossRefGoogle Scholar
  14. Holzer, C. E., Jackson, D. J., & Tweed, D. (1981). Horizontal synthetic estimation: A strategy for estimating small area health related characteristics. Evaluation and Program Planning, 4, 29–34.PubMedCrossRefGoogle Scholar
  15. Horner, R. H., Sugai, G., Smolkowski, K., Eber, L., Nakasato, J., Todd, A. W., et al. (2009). A randomized, wait-list controlled effectiveness trial assessing school-wide positive behavior support in elementary schools. Journal of Positive Behavior Interventions, 11(3), 133–144.CrossRefGoogle Scholar
  16. Hudson, C. G. (2009). Validation of a model for estimating state and local prevalence of serious mental illness. International Journal of Methods in Psychiatric Research, 18(4), 251–264.PubMedGoogle Scholar
  17. Hudson, G. G., & Abbott, M. W. (2013). Modeling the geographic distribution of serious mental illness in New Zealand. Social Psychiatry and Psychiatric Epidemiology, 48, 25–36.PubMedCrossRefGoogle Scholar
  18. Hull, P., Kilbourne, B., Reece, M., & Husaini, B. (2008). Community involvement and adolescent mental health: Moderating effects of race/ethnicity and neighborhood disadvantage. Journal of Community Psychology, 36(4), 534–551.CrossRefGoogle Scholar
  19. Husky, M. M., Sheridan, M., McGuire, L., & Olfson, M. (2011). Mental health screening and follow-up care in public high schools. Journal of the American Academy of Child and Adolescent Psychiatry, 50(9), 881–891.PubMedCrossRefGoogle Scholar
  20. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., et al. (1997). Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36(7), 980–988.PubMedCrossRefGoogle Scholar
  21. Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. T., et al. (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 32(6), 959–976.CrossRefGoogle Scholar
  22. Kessler, R. C., Avenevoli, S., Costello, E. J., Green, J. G., Gruber, M. J., Heeringa, S., et al. (2009a). Design and field procedures in the US national comorbidity survey replication adolescent supplement (NCS-A). International Journal of Methods in Psychiatric Research, 18(2), 69–83.PubMedCentralPubMedCrossRefGoogle Scholar
  23. Kessler, R. C., Avenevoli, S., Costello, E. J., Green, J. G., Gruber, M. J., Heeringa, S., et al. (2009b). National comorbidity survey replication adolescent supplement (NCS-A): II. overview and design. Journal of the American Academy of Child and Adolescent Psychiatry, 48(4), 380–385.PubMedCentralPubMedCrossRefGoogle Scholar
  24. Kessler, R. C., Avenevoli, S., Costello, E. J., Green, J. G., Gruber, M. J., McLaughlin, K. A., et al. (2012). Severity of 12-month DSM-IV disorders in the NCS-R adolescent supplement (NCS-A). Archives General Psychiatry, 69, 381–389.CrossRefGoogle Scholar
  25. Kessler, R. C., Avenevoli, S., Green, J., Gruber, M. J., Guyer, M., He, Y., et al. (2009c). National comorbidity survey replication adolescent supplement (NCS-A): III. concordance of DSM-IV/CIDI diagnoses with clinical reassessments. Journal of the American Academy of Child and Adolescent Psychiatry, 48(4), 386–399.PubMedCentralPubMedCrossRefGoogle Scholar
  26. Kessler, R. C., Barker, P. R., Colpe, L. J., Epstein, J. F., Gfroerer, J. C., Hiripi, E., et al. (2003). Screening for serious mental illness in the general population. Archives of General Psychiatry, 60(2), 184–189.PubMedCrossRefGoogle Scholar
  27. Kessler, R. C., Berglund, P. A., Walters, E. E., Leaf, P. J., Kouzis, A. C., Bruce, M. L., et al. (1999). A methodology for estimating the 12-month prevalence of serious mental illness. In R. W. Manderscheid & M. J. Henderson (Eds.), Mental health, United States 1998 (pp. 99–109). Washington DC: U.S. Government Printing Office.Google Scholar
  28. Kirkbridge, J. B., Jackson, D., Perez, J., Fowler, D., Winton, F., Coid, J. W., et al. (2013). A population-level prediction tool for the incidence of first-episode psychosis: Translational epidemiology based on cross-sectional data. BMJ Open,. doi: 10.1136/bmjopen-2012-001998.Google Scholar
  29. Konrad, T. R., Ellis, A. R., Thomas, K. C., Holzer, C. E., & Morrissey, J. P. (2009). County-level estimates of need for mental health professionals in the United States. Psychiatric Services, 60(10), 1307–1314.PubMedCrossRefGoogle Scholar
  30. Krieger, N., Chen, J., Waterman, P., Soobader, M., Subramanian, S., & Carson, R. (2002). Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: Does the choice of area-based measure and geographic level matter? American Journal of Epidemiology, 156, 471–482.PubMedCrossRefGoogle Scholar
  31. Kuo, E., Vander Stoep, A., McCauley, E., & Kernic, M. A. (2009). Cost-effectiveness of a school-based emotional health screening program. Journal of School Health, 79, 277–285.PubMedCentralPubMedCrossRefGoogle Scholar
  32. Lantz, P. M., & Pritchard, A. (2010). Socioeconomic indicators that matter for population health. Preventing Chronic Disease, 7(4), A74.PubMedCentralPubMedGoogle Scholar
  33. Leon, A. C., Olfson, M., Portera, L., Farber, L., & Sheehan, D. V. (1997). Assessing psychiatric impairment in primary care with the sheehan disability scale. International Journal of Psychiatry in Medicine, 27(2), 93–105.PubMedCrossRefGoogle Scholar
  34. Levitt, J. M., Saka, N., Romanelli, L. H., & Hoagwood, K. (2007). Early identification of mental health problems in schools: The status of instrumentation. Journal of School Psychology, 45(2), 163–191.CrossRefGoogle Scholar
  35. Li, F., Green, J. G., Kessler, R. C., & Zaslavsky, A. M. (2010). Estimating prevalence of serious emotional disturbance in schools using a brief screening scale. International Journal of Methods in Psychiatric Research, 19, 88–98.PubMedCentralPubMedCrossRefGoogle Scholar
  36. Li, F., & Zaslavsky, A. M. (2010). Using a short screening scale for small-area estimation of mental illness prevalence for schools. Journal of the American Statistical Association, 105(492), 1323–1332.PubMedCentralPubMedCrossRefGoogle Scholar
  37. Mair, C., Diex Roux, A. V., & Galea, S. (2008). Are neighborhood characteristics associated with depressive symptoms? A review of evidence. Journal of Epidemiology and Community Health, 62, 940–946.PubMedGoogle Scholar
  38. Merikangas, K. R., Avenevoli, S., Costello, E. J., Koretz, D., & Kessler, R. C. (2009). National comorbidity survey replication adolescent supplement (NCS-A): I. background and measures. Journal of the American Academy of Child and Adolescent Psychiatry, 48(4), 367–379.PubMedCentralPubMedCrossRefGoogle Scholar
  39. Morenoff, J. D., House, J. S., Hansen, B. B., Williams, D. R., Kaplan, G. A., & Hunte, H. E. (2007). Understanding social disparities in hypertension prevalence, awareness, treatment, and control: The role of neighborhood context. Social Science and Medicine, 65(9), 1853–1866.PubMedCentralPubMedCrossRefGoogle Scholar
  40. Pickett, K. E., & Pearl, M. (2001). Multilevel analyses of neighborhood socioeconomic context and health outcomes: A critical review. Journal of Epidemiology and Community Health, 55(2), 111–122.PubMedCentralPubMedCrossRefGoogle Scholar
  41. Romer, D., & McIntosh, M. (2005). The roles and perspectives of school mental health professionals in promoting adolescent mental health. In T. Walsh (Ed.), Treating and preventing adolescent mental health disorders: What we know and what we don’t know: A research agenda for improving the mental health of our youth (pp. 597–615). New York: Oxford University Press.Google Scholar
  42. Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., et al. (1983). A children’s global assessment scale (CGAS). Archives of General Psychiatry, 40(11), 1228–1231.PubMedCrossRefGoogle Scholar
  43. Stiffman, A. R., Stelk, W., Horwitz, S. M., Evans, M. E., Outlaw, F. H., & Atkins, M. (2010). A public health approach to children’s mental health services: Possible solutions to current service inadequacies. Administration and Policy in Mental Health and Mental Health Services Research, 37, 120–124.PubMedCentralPubMedCrossRefGoogle Scholar
  44. Substance Abuse and Mental Health Services Administration. (1993). Final notice establishing definitions for (1) children with a serious emotional disturbance, and (2) adults with a serious mental illness. Federal Register, 58, 29422–29425.Google Scholar
  45. Tranmer, M., Pickles, A., Fieldhouse, E., Elliot, M., Dale, A., Brown, M., et al. (2005). The case for small area microdata. Journal of the Royal Statistical Society: Series A (Statistics in Society), 168, 29–49.CrossRefGoogle Scholar
  46. U.S. Department of Education (2004). Twenty-fourth annual report to congress on implementation of the Individuals with Disabilities Education Act. Washington, DC.Google Scholar
  47. Wagner, M., Friend, M., Bursuck, W. D., Kutash, K., Duchnowski, A. J., Sumi, W. C., et al. (2006). Educating students with emotional disturbances: A national perspective on programs and services. Journal of Emotional and Behavioral Disorders, 14, 12–30.CrossRefGoogle Scholar
  48. Wagner, M., Kutash, K., Duchnowski, A. J., Epstein, M. H., & Sumi, W. C. (2005). The children and youth we serve: A national picture of the characteristics of students with emotional disturbances receiving special education. Journal of Emotional and Behavioral Disorders, 13, 79–96.CrossRefGoogle Scholar
  49. Xue, Y., Leventhal, T., Brooks-Gunn, J., & Earls, F. J. (2005). Neighborhood residence and mental health problems of 5- to 11-year-olds. Archives of General Psychiatry, 62(5), 554–563.PubMedCrossRefGoogle Scholar
  50. Zhang, X., Onufrak, S., Holt, J. B., & Croft, J. B. (2013). A multilevel approach to estimating small area childhood obesity prevalence at the census block-group level. Preventing Chronic Disease, 10, 120252.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Jennifer Greif Green
    • 1
    Email author
  • Margarita Alegría
    • 2
    • 3
  • Ronald C. Kessler
    • 4
  • Katie A. McLaughlin
    • 5
  • Michael J. Gruber
    • 4
  • Nancy A. Sampson
    • 4
  • Alan M. Zaslavsky
    • 4
  1. 1.School of EducationBoston UniversityBostonUSA
  2. 2.Center for Multicultural Mental Health ResearchCambridge Health AllianceSomervilleUSA
  3. 3.Department of PsychiatryHarvard Medical SchoolBostonUSA
  4. 4.Department of Health Care PolicyHarvard Medical SchoolBostonUSA
  5. 5.Department of PsychologyUniversity of WashingtonSeattleUSA

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