Services for adolescents with psychiatric disorders: 12-month data from the National Comorbidity Survey-Adolescent

Universal Mental Health Screening Practices in Midwestern Schools: A Window of Opportunity for School Psychologist Leadership and Role Expansion?

The conducting of universal mental health screening is one widely endorsed practice suitable for use within P-12 school settings to more proactively identify children and young people experiencing or displaying characteristics of a mental health disorder. Absent routine screening, many school-age youth with mental health concerns, especially those of an internalizing nature, may go unidentified and left without timely treatment, support, and services. The current study, which employed survey methodology with principal respondents from four Midwestern states, primarily sought to contribute to and update the literature on the universal mental health screening practice habits of P-12 schools. Most principal respondents reported that their school does not currently conduct universal mental health screening and cited barriers (e.g., money, time, lack of support system in place) to screening commonly documented in prior studies. Many principals reported at least a moderate degree of interest in their school beginning to conduct universal screening in their buildings; however, a similar majority reported little to no knowledge about this important practice. Fortunately, principal respondents were generally interested in and receptive to support from their school psychologist in exploring and eventually implementing the conducting of universal mental health screening in their building. Implications for practice and future research, along with the potential for school psychologist leadership and role expansion, are discussed.

A DSM-5 AMPD and ICD-11 compatible measure for an early identification of personality disorders in adolescence–LoPF-Q 12–18 latent structure and short form

The LoPF-Q 12–18 (Levels of Personality Functioning Questionnaire) was designed for clinical use and to promote early detection of personality disorder (PD). It is a self-report measure with 97 items to assess personality functioning in adolescents from 12 years up. It operationalizes the dimensional concept of personality disorder (PD) severity used in the Alternative DSM-5 Model for Personality Disorders and the ICD-11. In this study, we investigated the factorial structure of the LoPF-Q 12–18. Additionally, a short version was developed to meet the need of efficient screening for PD in clinical and research applications. To investigate the factorial structure, several confirmatory factor analysis models were compared. A bifactor model with a strong general factor and four specific factors showed the best nominal fit (CFI = .91, RMSEA = .04, SRMR = .07). The short version was derived using the ant colony optimization algorithm. This procedure resulted in a 20-item version with excellent fit for a hierarchical model with four first order factors to represent the domains and a secondary higher order factor to represent personality functioning (CFI = .98, RMSEA = .05, SRMR = .04). Clinical validity (effect size d = 3.1 between PD patients and controls) and clinical utility (cutoff ≥ 36 providing 87.5% specificity and 80.2% sensitivity) for detecting patients with PD were high for the short version. Both, the long and short LoPF-Q 12–18 version are ready to be used for research and diagnostic purposes.

When is Psychotherapy Brief? Considering Sociodemographic Factors, Problem Complexity, and Problem Type in U.S. Adolescents

Objective: When psychotherapy is brief (1-2 sessions), "early dropout" - defined as premature treatment discontinuation due to financial or structural barriers - is a commonly assumed cause. However, there are several possible reasons why treatment may be brief, including youth-level factors such as psychopathology complexity or problem type. Better characterizing whether factors beyond financial and structural barriers predict adolescents' receipt of briefer (versus longer-term) treatment may guide efforts to retain specific youth in longer-term services - and disseminate intentionally brief interventions to youth potentially positioned to benefit.Method: Using data from the 2017 SAMHSA National Survey on Drug Use and Health, we examined whether sociodemographic disadvantage (minority race, low-income, government assistance), perceived problem type, and psychopathology complexity (1 versus multiple problem types) related to psychotherapy length (1-2 versus 3-24+ sessions) among adolescents receiving outpatient psychotherapy (N = 1,601; ages 12-17; 60.59% white; 64.50% female).Results: Among adolescents beginning outpatient psychotherapy, 23.36% ended treatment after 1-2 sessions. Psychopathology complexity predicted greater likelihood of receiving >2 sessions, after adjusting for specific problem type (χ2 = 75.14, p < .001, OR = 1.80). Further, although certain problem types (e.g., depression, anxiety, and anger control) were associated with increased likelihood of greater treatment length, these findings did not hold after accounting for psychopathology complexity. No sociodemographic factors significantly predicted treatment length.Conclusions: Structural and financial barriers alone may not explain when and why youth psychotherapy is brief. Additional factors, such as psychopathology complexity, may be important and potentially primary contributors to treatment duration among youth who access outpatient services. Future research may examine whether youth with less comorbidity differentially benefit from intentionally brief interventions, along with strategies for retaining youth who might benefit from longer-term care - such as those with multiple co-occurring problems - in treatment.

A longitudinal study of headspace youth oriented mental health service satisfaction, service utilization and clinical characteristics

AIM

This study examined satisfaction with accessibility, staff attitudes, personal outcomes service components of youth-oriented mental health service, Headspace, and those components' associations with psychological distress and functional status at intake, service utilization patterns and demographic characteristics at middle and end of treatment.

METHODS

Data were collected between March 2016 and June 2018 from 112 participants (12-25 years) who consented and completed at least seven sessions at the Headspace youth integrated-care centre in Israel using the centre's registries and the Youth Service Satisfaction Scale.

RESULTS

Headspace participants attended an average of 12 sessions (SD = 3.12), they waited up to 2 weeks for their first intake (n = 57; 73%), after which most were offered a psychotherapy session (n = 80, 71%) within 2 months. Participants' satisfaction with Headspace was above the mid-point for all service aspects. The overall effect for time was not significant, F(1) = 1.14, p > .05. However, a significant increase in satisfaction with personal outcomes was found between the middle and the end of treatment, F(2,4) = 3.11, p < .05 compared to all other aspects. The length of waiting time, level of distress, number of sessions attended by parents and age were correlated with satisfaction. Correlations were found with waiting time, distress level, number of sessions attended by parents and age.

CONCLUSIONS

High levels of satisfaction with Headspace service aspects strengthens the evidence for areas of importance in designing youth mental health services: youth-friendly staff, general environment, accessibility and outcomes achievement.

Predictors of adolescent engagement and outcomes - A cross-sectional study using the togetherall (formerly Big White Wall) digital mental health platform

BACKGROUND

Online mental health platforms can improve access to, and use of, mental health support for young people who may find it difficult to engage with face-to-face delivery.

OBJECTIVE

We modelled predictors of engagement and symptom change in adolescent users of the Togetherall (formerly "Big White Wall") anonymous digital mental health peer-support platform.

METHODS

We report a retrospective analysis of longitudinal user data from UK 16-18 year Togetherall users, referred from mental health services (N = 606). Baseline demographics were reported for participants who logged anxiety and depression measures. Number of log-ins, mean session duration, total usage time, number of guided support courses and self-help materials accessed were our usage metrics. Participant characteristics and symptoms were used to predict engagement. For n = 245 users with symptom measures at >1 timepoint we modelled the effect of predictors on symptom scores.

RESULTS

Mean logins was 5.11 and mean usage time was 64.22 mins. Participants with one log-in represented 33.5% of the sample. Total time accessing Togetherall predicated greater usage of self-help materials and courses. Females made greater use of materials and courses than males. In a subsample, higher baseline depression and anxiety, longer total usage time and mean session duration predicted final depression scores, whereas higher baseline depression and anxiety and greater accessed self-help materials predicted lower final anxiety scores.

LIMITATIONS

A naturalistic design was used and symptom modelling should be interpreted with caution.

CONCLUSIONS

Findings suggest adolescents can engage with the Togetherall platform. Baseline symptoms and characteristics can inform user engagement with digital platforms.

Do "Real World" Childhood Mental Health Services Reduce Risk for Adult Psychiatric Disorders?

OBJECTIVE

This study tested the "intervention as prevention" hypothesis: that treatment of childhood psychopathology in the community might reduce risk for adult psychopathology.

METHOD

Analyses were based on a prospective, population-based study of 1,420 children followed up to 8 times during childhood (ages 9-16 years; 6,674 observations) about psychiatric status and specialty mental health services use. Participants were followed up 4 times in adulthood (ages 19, 21, 25, and 30 years; 4,556 observations of 1,336 participants) to assess adult psychopathology.

RESULTS

Participants with a childhood psychiatric disorder who used childhood specialty mental health services were at similar risk for adult emotional (odds ratio [OR] = 0.7; 95% CI = 0.3-1.4, p = .29) disorders and at higher risk for adult substance disorders (OR = 2.1; 95% CI = 1.1-4.2, p = .03) as compared those with a childhood disorder who did not use services. The risk for substance disorders was driven by children with behavioral disorders (OR = 3.6; 95% CI = 1.6-8.1, p = .002). Sensitivity analyses suggest that an unmeasured confounder would have to have an E value of 3.26 or risk ratio of 1.92 to alter this finding. Higher "dose" of services use (defined at 6+ visits) was not associated with improved outcomes.

CONCLUSION

Community services use may reduce psychopathology within childhood, but they do not necessarily prevent adult psychiatric problems. These findings are consistent with the notion of mental health problems as chronic conditions that often begin in childhood but that may recur in different forms across the lifespan even when treated.

Adolescent, parent, and provider perspectives on school-related influences of mental health in adolescents with suicide-related thoughts and behaviors

Previous research supports a link between school-related factors, such as bullying and school connectedness, and suicidal thoughts and behaviors. To deepen understanding of how school experiences may function as both protective and risk factors for youth struggling with suicidal thoughts and behaviors, this qualitative study explored multiple perspectives. Specifically, in-depth interviews were conducted with adolescents previously hospitalized for a suicidal crisis (n = 19), their parents (n = 19), and the professionals they may interact with in schools and hospitals (i.e., school professionals [n = 19] and hospital providers [n = 7]). Data were analyzed using applied thematic analysis revealing three main themes related to perceptions of how school experiences can positively or negatively impact mental health, including (a) school activities, (b) school social experiences, and (c) school interventions. An emergent theme related to the complexity of suicide-related risk identified the ways in which school experiences may intersect with other environmental, biological, and psychological factors. Findings underscore the need for school-based approaches to address the unique academic, social, and emotional needs of students with suicide-related risk that complement the supports and services provided in their home and community.

Five-Year Trends in Pediatric Mental Health Emergency Department Visits in Massachusetts: A Population-Based Cohort Study

OBJECTIVES

To evaluate temporal changes in pediatric emergency department (ED) visits for mental health problems in Massachusetts based on diagnoses and patient characteristics and to assess trends in all-cause pediatric ED visits.

STUDY DESIGN

This statewide population-based retrospective cohort study used the Massachusetts All-Payer Claims Database, which includes almost all Massachusetts residents. The study sample consisted of residents aged <21 years who were enrolled in a health plan between 2013 and 2017. Using multivariate regression, we examined temporal trends in mental health-related and all-cause ED visits in 2013-2017, with person-quarter as the unit of analysis; we also estimated differential trends by sociodemographic and diagnostic subgroups. The outcomes were number of mental health-related (any diagnosis, plus 14 individual diagnoses) and all-cause ED visits/1000 patients/quarter.

RESULTS

Of the 967 590 Massachusetts residents in our study (representing 14.8 million person-quarters), the mean age was 8.1 years, 48% were female, and 57% had Medicaid coverage. For this population, mental health-related (any) and all-cause ED visits decreased from 2013 to 2017 (P < .001). Persons aged 18-21 years experienced the largest declines in mental health-related (63.0% decrease) and all-cause (60.9% decrease) ED visits. Although mental health-related ED visits declined across most diagnostic subgroups, ED visits related to autism spectrum disorder-related and suicide-related diagnoses increased by 108% and 44%, respectively.

CONCLUSIONS

Overall rates of pediatric ED visits with mental health diagnoses in Massachusetts declined from 2013 to 2017, although ED visits with autism- and suicide-related diagnoses increased. Massachusetts' policies and care delivery models aimed at pediatric mental health may hold promise, although there are important opportunities for improvement.

Risk and Resilience Factors Associated With Frequency of School-Based Health Center Use

BACKGROUND

School-based health centers (SBHCs) provide health care to vulnerable youth. The purpose of the study was to identify characteristics of youth who use SBHCs with the highest frequency to understand their health needs and receipt of health services.

METHODS

This study examined cross-sectional survey data from adolescents in 3 urban school districts (n = 2641) to identify the characteristics of youth who use SBHCs with high frequency (10+ visits). Analyses included calculations of simple frequencies and percentages, chi-square tests of significance and multivariate regression.

RESULTS

High-frequency SBHC users were more likely to have seriously considered attempting suicide (adjusted odds ratio [AOR]: 3.2), be sexually active (AOR: 6.8), and have been victimized at school (AOR: 2.2) compared to their peers who did not use the SBHC. High-frequency SBHC users were also significantly more likely than their peers to report "always" getting mental health (AOR: 7.0) and sexual health (AOR: 6.6) care when needed, and having talked with a health care provider about their moods/feelings (AOR: 3.1) and how school is going (AOR: 3.2) in the past year.

CONCLUSIONS

These findings hold important relevance to demonstrating the value of SBHCs in increasing vulnerable youth's access to health care, particularly in urban settings.

Racial/Ethnic Disparity Trends in Children's Mental Health Care Access and Expenditures From 2010-2017: Disparities Remain Despite Sweeping Policy Reform

OBJECTIVE

To examine trends in mental health care use for Black and Latinx children and adolescents.

METHOD

Data from the Medical Expenditure Panel Survey for 2010-2017 were analyzed to assess trends among youth ages 5-17 in use and expenditures for any mental health care, outpatient mental health care, and psychotropic medication prescription fills. Unadjusted trends for all youth and the subpopulation of youth reporting need for mental health care and disparities adjusting for need were examined.

RESULTS

Between 2010 and 2017, Black youth rates of any past year mental health care use decreased (from 9% to 8%), while White (from 13% to 15%) and Latinx (from 6% to 8%) youth rates increased. Among the subpopulation with need and in regression analysis adjusting for need, we identified significant Black-White and Latinx-White disparities in any mental health care use and any outpatient mental health care use in 2010-2011 and 2016-2017, with significant worsening of Black-White disparities over time. White youth were more than twice as likely as Latinx youth to use psychotropic medications, and Latinx-White and Black-White disparities in psychotropic medication prescription fills persisted over time. Black-White disparities existed in overall mental health expenditures (2016-2017) and outpatient mental health expenditures (2010-2011 and 2016-2017).

CONCLUSION

Affordable, ubiquitous access to mental health care for Black and Latinx youth remains an elusive target. Significant disparities exist in receiving mental health care despite reforms and policies designed to increase mental health care access in the general population. Additional outreach and treatment strategies tailored to the cultural, linguistic, and structural needs of youth of color are required.

Characterizing mental health related service contacts in children and youth: a linkage study of health survey and administrative data

BACKGROUND

To inform the provision and organization of care, and to improve equitable access to mental health services for children and youth, we must first characterize the children and youth being served, taking into consideration factors related to mental health need. Our objective was to use a population-based survey linked with health administrative data to estimate mental health related contacts and determine socio-demographic correlates, after adjusting for factors related to mental health need.

METHODS

Data from the 2014 Ontario Child Health Study (OCHS) were linked at the individual level to health administrative databases from Ontario's Ministry of Health and Long-Term Care (MOHLTC). Mental health related service contacts were identified in the 6-months prior to the OCHS survey date. Service contacts with physicians were obtained from health administrative data, and non-physician service contacts from survey data (parent-report).

RESULTS

21.7% of Ontarian children (4-11 years) and youth (12-17 years) had at least one mental health related contact in the 6-months prior to their OCHS survey date (18.8% non-physician, 8.0% physician, 5.2% both). Children and youth contacting both physician and non-physician services (ref. contact with physician or non-physician services alone) had higher mean symptom ratings of mental disorders across all classes of disorder. After adjusting for total symptom ratings, children and youth with immigrant parent(s) (ref. non-immigrant) (Prevalence Ratio: 0.65, 95% CI 0.55, 0.75) were less likely to have any mental health related service contact.

CONCLUSIONS

Results indicate that children and youth with the highest mental health symptom ratings are more likely to have contact with multiple providers across sectors. As such, the coordination of care across and within sectors are critical components of mental health related services for children and youth. Our results indicate that the greatest disparities in mental health related service contacts may exist for children and youth with immigrant parent(s) and that targeted outreach efforts are required to reduce barriers to care and improve equitable access to mental health related services for children and youth in Ontario.

School-based screening for childhood anxiety problems and intervention delivery: a codesign approach

OBJECTIVES

A very small proportion of children with anxiety problems receive evidence-based treatment. Barriers to access include difficulties with problem identification, concerns about stigma and a lack of clarity about how to access specialist services and their limited availability. A school-based programme that integrates screening to identify those children who are most likely to be experiencing anxiety problems with the offer of intervention has the potential to overcome many of these barriers. This article is a process-based account of how we used codesign to develop a primary school-based screening and intervention programme for child anxiety problems.

DESIGN

Codesign.

SETTING

UK primary schools.

PARTICIPANTS

Data were collected from year 4 children (aged 8-9 years), parents, school staff and mental health practitioners.

RESULTS

We report how the developed programme was experienced and perceived by a range of users, including parents, children, school staff and mental health practitioners, as well as how the programme was adapted following user feedback.

CONCLUSIONS

We reflect on the mitigation techniques we employed, the lessons learnt from the codesign process and give recommendations that may inform the development and implementation of future school-based screening and intervention programmes.

Meta-analysis: Are Psychotherapies Less Effective for Black Youth in Communities With Higher Levels of Anti-Black Racism?

OBJECTIVE

To examine whether anti-Black cultural racism moderates the efficacy of psychotherapy interventions among youth.

METHOD

A subset of studies from a previous meta-analysis of 5 decades of youth psychotherapy randomized controlled trials was analyzed. Studies were published in English between 1963 and 2017 and identified through a systematic search. The 194 studies (N = 14,081 participants; age range, 2-19) across 34 states comprised 2,678 effect sizes (ESs) measuring mental health problems (eg, depression) targeted by interventions. Anti-Black cultural racism was operationalized using a composite index of 31 items measuring explicit racial attitudes (obtained from publicly available sources, eg, General Social Survey) aggregated to the state level and linked to the meta-analytic database. Analyses were conducted with samples of majority-Black (ie, ≥50% Black) (n = 36 studies) and majority-White (n = 158 studies) youth.

RESULTS

Two-level random-effects meta-regression analyses indicated that higher anti-Black cultural racism was associated with lower ESs for studies with majority-Black youth (β = -0.2, 95% CI [-0.35, -0.04], p = .02) but was unrelated to ESs for studies with majority-White youth (β = 0.0004, 95% CI [-0.03, 0.03], p = .98), controlling for relevant area-level covariates. In studies with majority-Black youth, mean ESs were significantly lower in states with the highest anti-Black cultural racism (>1 SD above the mean; Hedges' g = 0.19) compared with states with the lowest racism (<1 SD below the mean; Hedges' g = 0.60).

CONCLUSION

Psychotherapies tested with samples of majority-Black youth were significantly less effective in states with higher (vs lower) levels of anti-Black cultural racism, suggesting that anti-Black cultural racism may be one contextual moderator of treatment effect heterogeneity.

Advancing Mental Health Screening in Schools: Innovative, Field-Tested Practices and Observed Trends During a 15-Month Learning Collaborative

Schools are well positioned to facilitate early identification and intervention for youth with emerging mental health needs through universal mental health screening. Early identification of mental health concerns via screening can improve long-term student development and success, but schools face logistical challenges and lack of pragmatic guidance to develop local screening policies and practices. This study summarizes mental health screening practices tested by six school districts participating in a 15-month learning collaborative. Qualitative analysis of 42 Plan-Do-Study-Act cycles revealed that districts tested quality improvement changes across seven screening practice areas, with all teams conducting at least one test to: 1) build a foundation; and 2) identify resources, logistics and administration processes. Quantitative data indicated that the average percentage of total students screened increased from 0% to 22% (range = 270 - 4,850 students screened at follow-up). Together, these results demonstrate how school districts not currently engaged in mental health screening can apply small, specific tests of change to develop a locally-tailored, practical and scalable process to screen for student mental health concerns. Lessons learned are provided to inform future directions for school-based teams.

Estimating prevalence of child and youth mental disorder and mental health-related service contacts: a comparison of survey data and linked administrative health data

AIMS

Prevalence estimates of child and youth mental disorder and mental health-related service contacts are needed for policy formulation, research, advocacy and resource allocation. Our aim is to compare prevalence estimates of child and youth mental disorder and mental health-related service contacts derived from general population survey data v. linked administrative health data.

METHODS

Provincially representative 2014 Ontario Child Health Study data were linked to administrative health records for 5563 children and youth aged 4-17 in Ontario. Emotional disorders (mood and anxiety) and attention-deficit/hyperactivity disorder were assessed using a standardised diagnostic interview in the survey and using diagnostic codes in administrative health data. Physician-based mental health-related service contacts were assessed using parent self-reports from the survey and administrative data related to mental health-related diagnostic codes. Prevalence estimates were calculated and compared based on one-sample z-tests and ratios of survey data to administrative data-based prevalence. Sensitivity, specificity and agreement between classifications were compared using κ. Prevalence estimates were calculated by age, sex and geography sub-groups and consistent group differences across data source were counted.

RESULTS

Disorder prevalence and service contact estimates were significantly higher in survey data in all cases, except for mood disorder. Ratios of survey data to administrative data-based prevalence varied, ranging from 0.80 (mood) to 11.01 (attention-deficit/hyperactivity disorder). Specificity was high (0.98-1.00), sensitivity was low (0.07-0.41) and agreement ranged from slight (κ = 0.13) to moderate (κ = 0.46). Out of 18 sub-group difference comparisons, half were non-significant in either data source. In the remaining nine comparisons, the only significant differences between groups that were consistent across data source were for sex-based differences (attention-deficit/hyperactivity disorder and service contacts). There were no consistent age- or geography-based differences in prevalence across data sources.

CONCLUSIONS

Our findings suggest that conclusions drawn about prevalence, service contacts and sub-group differences in these estimates are dependent on data source. Further research is needed to understand who and what is being captured by each source. Researchers should conduct data linkage where possible to access and compare multiple sources of information.

The roles of school in supporting LGBTQ+ youth: A systematic review and ecological framework for understanding risk for suicide-related thoughts and behaviors

The extant literature on suicide-related thoughts and behaviors (STB) has highlighted increased patterns of risk among specific minoritized populations, including lesbian, gay, bisexual, transgender, questioning, intersex, two spirit, and queer (LGBTQ+) youth. Compared to their heterosexual and cisgender peers, LGBTQ+ youth are at increased risk for having STB. Identity-specific stressors such as homonegativity and anti-queerness are among the unique factors posited to contribute to this risk and inhibit factors that protect against suicide. The school setting has been a focal point for suicide prevention and intervention and may also play a key role in linking students to care; however, schools also hold the potential to provide supports and experiences that may buffer against risk factors for STB in LGBTQ+ students. This systematic literature review presents findings from 44 studies examining school-related correlates of STB in LGBTQ+ students, informing an ecological approach to suicide prevention for school settings. Findings underscore the importance of school context for preventing STB in LGBTQ+ youth. Approaches that prioritize safety and acceptance of LGBTQ+ youth should span multiple layers of a student's ecology, including district and state level policies and school programs and interventions, such as Gender and Sexuality Alliances and universal bullying prevention programs. Beyond their role as a primary access point for behavioral health services, schools offer a unique opportunity to support suicide prevention by combating minority stressors through promoting positive social relationships and a safe community for LGBTQ+ students.

School Supports for Reintegration Following a Suicide-Related Crisis: A Mixed Methods Study Informing Hospital Recommendations for Schools During Discharge

The immediate period following psychiatric hospitalization is marked by increased risk for suicide behavior and rehospitalization. Because adolescents commonly return to school settings following hospital discharge, school-related stressors and supports are important considerations for psychiatric treatment and discharge planning. The current study aimed to inform recommendations provided by hospitals to schools to improve school reintegration practices by employing a concurrent, mixed-methods design. Specifically, we: (1) surveyed school professionals (n = 133) in schools varying in resource availability and populations in one southeastern state of the United States about supports and services provided to returning students; and (2) conducted in-depth interviews with a subset of these professionals (n = 19) regarding their perceptions of the hospital to school transition for youth recovering from suicide-related crises. Findings from survey responses indicated that, compared to schools located in urban and suburban areas, schools in rural areas were less likely to have school reintegration protocols for returning students. More generally, however, available interventions and modifications were relatively consistent across rural and urban/suburban schools, schools serving high and low poverty communities, and schools with predominantly white and predominantly ethnic and racial minoritized student bodies. Key themes across interviews signify the importance of communication between stakeholders, the type of information used to develop re-entry plans, available school-based services for returning youth, and the need to mitigate stigma associated with mental health crises. Findings inform recommendations that can be provided by hospitals to schools to support adolescent recovery as they return to school following psychiatric hospitalization.

The Impact of Community Mental Health Programs for Australian Youth: A Systematic Review

Australia has undergone significant youth mental health reform over the past 10 years, leading to numerous studies examining the effects of community-based mental health care programs for Australian youth. However, no synthesis of this literature currently exists. Therefore, this systematic review aimed to: (1) describe the types of community-based mental health programs that have been delivered to Australian youth in the past 10 years; and (2) examine their impact in improving young people’s mental health symptomology and psychosocial functioning. A systematic search of the peer-reviewed literature was conducted. Studies were included if they evaluated the extent to which such programs improved mental health symptomology (e.g., depression, anxiety, substance use) and/or psychosocial outcomes (e.g., social functioning, school engagement, employment) for Australian youth aged 10–25 years. Thirty-seven studies were included. Four types of community-based youth mental health care programs were identified: therapy (n = 16), case management (n = 9), integrated ‘one-stop-shop’ (n = 6) and lifestyle (n = 6) programs. The majority of therapeutic programs were effective in reducing mental health symptomology. Case management and integrated approaches consistently yielded significant improvements in both symptomology and psychosocial outcomes. Lifestyle programs were effective in alleviating depressive symptoms, but inconclusive for other outcomes. This review provides support for youth-friendly, systemic, multidisciplinary and integrated assertive outreach models of community mental health care to improve outcomes for young Australians experiencing mental health concerns. Several recommendations for future research are provided to strengthen the local evidence-base supporting community mental health programs to ultimately enhance young people’s life trajectory.

Predictive modeling of service discontinuation in transitional age youth with recent behavioral health service use

OBJECTIVE

To develop and test predictive models of discontinuation of behavioral health service use within 12 months in transitional age youth with recent behavioral health service use.

DATA SOURCES

Administrative claims for Medicaid beneficiaries aged 15-26 years in Connecticut.

STUDY DESIGN

We compared the performance of a decision tree, random forest, and gradient boosting machine learning algorithms to logistic regression in predicting service discontinuation within 12 months among beneficiaries using behavioral health services.

DATA EXTRACTION

We identified 33,532 transitional age youth with ≥1 claim for a primary behavioral health diagnosis in 2016 and Medicaid enrollment of ≥11 months in 2016 and ≥11 months in 2017.

PRINCIPAL FINDINGS

Classification accuracy for identifying youth who discontinued behavioral health service use was highest for gradient boosting (80%, AUC = 0.86), decision tree (79%, AUC = 0.84), and random forest (79%, AUC = 0.86), as compared with logistic regression (71%, AUC = 0.71).

CONCLUSIONS

Predictive models based on Medicaid claims can assist in identifying transitional age youth who are at risk of discontinuing from behavioral health care within 12 months, thus allowing for proactive assessment and outreach to promote continuity of care for younger persons who have behavioral health needs.

The mediating role of anxiety/depression symptoms between adverse childhood experiences (ACEs) and somatic symptoms in adolescents

INTRODUCTION

This study examines the relationships among recent adverse childhood experiences (ACEs), somatic symptoms, and anxiety/depression symptoms during adolescence and whether anxiety/depression symptoms mediate the relationship between ACEs and somatic symptoms.

METHODS

Longitudinal prospective data from the Longitudinal Studies of Child Abuse and Neglect study of 1354 children and their primary caregivers in the United States was used in this study. A longitudinal cross-lagged path analysis among recent ACEs, anxiety/depression symptoms, and somatic symptoms at three points during adolescence (ages 12, 14, and 16 years) was conducted.

RESULTS

The sample was 51% female and 53% African American. The results indicated significant concurrent associations between recent ACEs and increased anxiety/depression symptoms at ages 12, 14, and 16 (β = .27, p < .001; β = .15, p < .001; β = .07, p < .05) and between anxiety/depression symptoms and increased somatic symptoms at ages 12, 14, and 16 years (β = .44, p < .001; β = .39, p < .001; β = .49, p < .001). Moreover, anxiety/depression symptoms significantly mediated the relationship between recent ACEs and concurrent somatic symptoms at ages 12, 14, and 16 years (β = .12, p < .001; β = .06, p < .001; β = .04, p < .05). However, there was no significant relationship between recent ACEs and somatic symptoms.

CONCLUSION

The findings suggest that anxiety/depression symptoms mediate the concurrent relationships between recent ACEs and somatic symptoms at ages 12, 14, and 16. Clinicians should consider assessing anxiety/depression symptoms and possible concurrent exposure to ACEs when caring for adolescents who present with somatic symptoms.

Teacher and School Characteristics Associated with the Identification and Referral of Adolescent Depression and Oppositional Defiant Disorders by U.S. Teachers

Teachers contribute to the process of identifying and referring students for mental health services, however, relatively little is known about how they make those decisions and how decision-making differs across school contexts. This study used a vignette-based method to investigate individual and school contextual factors associated with the likelihood that teachers identify and refer students for mental health services. Teachers were recruited from public middle and high schools across the U.S. using a stratified random sampling strategy. Teachers (N = 462) responded to vignettes by indicating their concern for students, as well as their likelihood of providing mental health referrals. Vignettes varied by problem type (depression, oppositional defiant disorder), problem severity (moderate, severe), and student gender (male, female). Data on school characteristics were extracted from the U.S. Department of Education database. Regression models indicated several significant associations of teacher demographic characteristics and school characteristics with vignette ratings. For example, female teachers were more likely than males to rate vignettes as concerning, and middle school teachers were more likely than high school teachers to indicate they would refer students for mental health services. Teachers in schools with a higher proportion of Black students rated depression vignettes as less serious and indicated they were less likely to refer students for mental health services than teachers in majority white schools. Results suggest school characteristics may contribute to established disparities in mental health service access. Findings have implications for targeting mental health supports in schools.

Validation and Use of the Measure of Effective Attributes of Trainers in School-Based Implementation of Proactive Classroom Management Strategies

In-service training is a critical and frequently utilized implementation strategy to support the adoption and delivery of evidence-based practice (EBP) across service settings, but is characteristically ineffective in producing provider behavior changes, particularly when delivered in single exposure didactic events. EBP trainers are in a strategic position to leverage their trainee-perceived characteristics to influence trainees' attitudes, motivation, and intentions to implement, and ultimately increase the likelihood of successful uptake of skills. The purpose of this study was to extend research on the measure of effective attributes of trainers (MEAT) by examining its underlying factor structure and reliability in the context of in-service EBP training for teachers (i.e., structural validity). This study also examined the predictive validity of the MEAT by examining relationships with a measure of teacher intentions to implement EBPs following a standardized training experience (i.e., predictive validity). An exploratory factor analysis (EFA) was employed to determine the latent factors (i.e., subscales of characteristics) that underlie the data. Additionally, a forward selection, stepwise regression was conducted to determine the extent to which trainer attributes could explain variance in intentions to implement. Results indicated that the MEAT was a valid and reliable measure to examine trainer attributes in school settings. Moreover, findings suggested that trainer attributes, particularly those related to trainee perceptions of the trainers' welcoming disposition (i.e., related to trainers' warm, positive temperament and internal character traits), were significantly associated with trainees' intentions to implement the trained upon EBP.

Headache and mental disorders in a nationally representative sample of American youth

The objective of this study is to examine the association between headache and mental disorders in a nationally representative sample of American youth. We used the National Comorbidity Survey-Adolescent Supplement to assess sex-specific prevalence of lifetime migraine and non-migraine headache using modified International Headache Society criteria and examine associations between headache subtypes and DSM-IV mental disorders. Adolescent report (n = 10,123) was used to identify headache subtypes and anxiety, mood, eating, and substance use disorders. ADHD and behavior disorder were based on parent report (n = 6483). Multivariate logistic regression analyses controlling for key demographic characteristics were used to examine associations between headache and mental disorders. Headache was endorsed by 26.9% (SE = 0.7) of the total sample and was more prevalent among females. Youth with headache were more than twice as likely (OR 2.74, 95% CI 1.94-3.83) to meet criteria for a DSM-IV disorder. Migraine, particularly with aura, was associated with depression and anxiety (adjusted OR 1.90-2.90) and with multiple classes of disorders. Adolescent headache, particularly migraine, is associated with anxiety, mood, and behavior disorders in a nationally representative sample of US youth. Headache is highly prevalent among youth with mental disorders, and youth with headache should be assessed for comorbid depression and anxiety that may influence treatment, severity, and course of both headache and mental disorders.

Psychopathology in Children and Adolescents in Lebanon Study (PALS): a national household survey

INTRODUCTION

Psychiatric disorders are among the leading causes of disability in children and adolescents globally. In Lebanon, a country that has endured a prolonged history of conflict and economic and political uncertainty, mental health surveys in children and adolescents have been limited to specific disorders or specific settings or cities. PALS (Psychopathology in Children and Adolescents in Lebanon Study) is the first study to screen a nationally representative sample of children and adolescents for psychiatric disorders and estimate the national prevalence of children and adolescents at risk of having a psychiatric disorder.

METHODS

A nationally representative household sample of 1517 children and adolescents (aged 5 years 0 months to 17 years 11 months) was recruited through a multi-stage stratified proportionate sampling technique between February 2018 and November 2018. Parents and adolescents completed a battery of self-reported scales including the Strengths and Feelings Questionnaire (SDQ), Mood and Feelings Questionnaire (MFQ), Screen for Child Anxiety and Emotional Related Disorders (SCARED), the Peer Relations Questionnaire (PRQ), General Health Questionnaire (GHQ), and Conflict Behavior Questionnaire (CBQ), Child Revised Impact of Events Scale (CRIES), and a demographic/clinical information questionnaire. Logistic regression models were used to examine the correlates of screening positive for psychiatric disorders.

RESULTS

About a third of children and adolescents (32.7%, n = 497) screened positive for at least one psychiatric disorder, of whom only 5% (n = 25) reported ever seeking professional mental health help. Academic performance, having a chronic physical illness, higher parental GHQ scores, and involvement in bullying were associated with a higher odds of screening positive for a psychiatric disorder. Higher family income was negatively associated with screening positive for a psychiatric disorder.

CONCLUSION

This first national study shows a high prevalence of psychiatric symptoms in Lebanese children and adolescents and an alarming treatment gap. School-based primary prevention programs or screening in primary care settings are key for early detection and management of psychiatric symptoms, and prevention of psychiatric disorders.

Trajectories of medical service use among girls and boys with and without early-onset conduct problems

BACKGROUND

Children with conduct problems (CP) have been found to be heavy and costly medical service users in adulthood. However, there is little knowledge on how medical service use develops during childhood and adolescence among youth with and without childhood CP. Knowing whether differences in developmental trajectories of medical service use for specific types of problems (e.g., injuries) are predicted by childhood CP would help clinicians identify developmental periods during which they might intensify interventions for young people with CP in order to prevent later problems and associated increased service use.

METHODS

Participants were drawn from an ongoing longitudinal study of boys and girls with and without childhood CP as rated by parents and teachers. Medical service use was assessed using administrative data from a public single payer health plan. Latent growth modeling was used to estimate the mean trajectory of four types of medical visits (psychiatric, injury-related, preventative, total visits) across time and evaluate the effect of CP and other covariates.

RESULTS

Support the hypothesis that early CP predicts higher medical service use at nine years old, and that this difference persists in a chronic manner over time, even when controlling the effects of ADHD and family income. Girls had fewer medical visits for psychiatric reasons than boys at baseline, but this difference diminished over time.

CONCLUSIONS

Clinicians should be aware that childhood CP already predicts increased medical service use in elementary school. Issues specific to different contexts in which injuries might occur and sex differences are discussed.

Professional and informal help-seeking among low-income adolescents exposed to violence in the community and at school

BACKGROUND

Adolescents may seek help for many reasons beyond health needs, such as personal stress due to violence exposure.

OBJECTIVE

To investigate factors associated with receiving professional assistance and informal help due to violence exposure in the community and at school.

PARTICIPANTS AND SETTING

This study was conducted in Itaboraí, a low-income medium-size city in the State of Rio de Janeiro, Southeast Brazil, characterized by poverty, inequality and violence. It analyses data reported by 669 in-school adolescents (11-15-years, 51.7% girls).

METHODS

This is a cross-sectional study nested in a longitudinal study (Itaboraí Youth Study). The Itaboraí Youth Study involved a probabilistic community-based sample of 1409 6-to-15-year-olds based on a 3-stage probabilistic sampling plan that included a random selection of census units, eligible households and the target child.

RESULTS

Professional assistance was mainly received from psychologists (the Brazilian population has free access to health services). Family members were the main source of informal help. Correlates of professional assistance were having clinical emotional problems and not counting on an adult (if needing help) for community violence victims, and absent father for community and school violence victims. Correlates of informal help were female sex, maternal anxiety/depression and absent father for community violence victims, and younger age and higher maternal education for school violence victims.

CONCLUSIONS

The mental health needs of violence victims, and maternal difficulties to deal with the adolescent distress resulting from violence exposure (maternal increased burden due to father absence and/or having anxiety/depression) are important influences on the help-seeking process.

Care improves self-reported daily functioning of adolescents with emotional and behavioural problems

Emotional and behavioural problems (EBP) have a negative impact on various life domains of adolescents. Receiving care for EBP may improve the functioning of adolescents with EBP, but evidence on long-term outcomes in real-life settings is lacking. We, therefore, investigated self-reported functioning in different life domains of adolescents with various EBP, and the role of care during a three-year period. We used data from the TAKECARE study, which consist of a care and community cohort. We followed adolescents aged 12 and over (n = 733) during 3 years over five assessment rounds. Using the Strengths and Difficulties Questionnaire, self-reported functioning was measured in four life domains: home life, friendships, classroom learning and leisure activities. We categorized the respondents into four groups: (1) adolescents without emotional and behavioural problems (n = 298); (2) adolescents with emotional problems (n = 192); (3) adolescents with behavioural problems (n = 80); and (4) adolescents with both emotional and behavioural problems (n = 163). The development of functioning over time was analyzed using longitudinal ordinal (probit) regression analyses. Adolescents with both emotional and behavioural problems reported poorer functioning at baseline in all domains and adolescents who received care reported poorer functioning at baseline compared to adolescents who did not receive care. Regarding the change in functioning during the 3 years, adolescents who received care showed improved functioning in all domains. We found improved functioning after care, even if the problems may not have been solved. Psychosocial care can contribute to the functioning of adolescents with EBP, which can have major effects on their future life.

LovesCompany: evaluating the safety and feasibility of a mental health-focused online community for adolescents

Background: Adolescents are at risk for mental health (MH) disorders but are unlikely to seek services and may be reluctant to talk about their MH. An anonymous, online MH-focused community could help reduce suffering. However, online forums can also promote negative behaviours such as cyberbullying. This study aimed to evaluate the safety and feasibility of an online community - LovesCompany - to improve MH outcomes for adolescents.Methods: American adolescents (14-17 years) were recruited through social media. Eligible participants were randomised to LovesCompany or a placebo MH resource site. Outcomes were assessed every other week for six months, and at twelve months. Multilevel models assessed group differences in depression, anxiety, and suicidal ideation. A subgroup of participants participated in qualitative interviews.Results: Participants (N = 202) were mostly female (70%), White non-Hispanic (69%), and cisgender (80%). There were no instances of inappropriate behaviour such as bullying or posting explicit content. Symptoms for both groups improved over time. Participants appreciated hearing others' experiences and valued the opportunity to offer support.Conclusion: Although adolescents are often resistant to MH treatment, they appear to be interested in anonymous, online, MH-focused conversation, and can benefit from giving and seeking support. Finding a balance between an appealing user experience, ethical considerations, and resource needs is challenging.

Mechanisms of Change in Digital Health Interventions for Mental Disorders in Youth: Systematic Review

BACKGROUND

Digital health interventions (DHIs) are efficacious for several mental disorders in youth; however, integrated, evidence-based knowledge about the mechanisms of change in these interventions is lacking.

OBJECTIVE

This systematic review aims to comprehensively evaluate studies on mediators and mechanisms of change in different DHIs for common mental disorders in children and adolescents.

METHODS

A systematic literature search of the electronic databases Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PsycINFO was conducted, complemented by backward and forward searches. Two independent reviewers selected studies for inclusion, extracted the data, and rated the methodological quality of eligible studies (ie, risk of bias and 8 quality criteria for process research).

RESULTS

A total of 25 studies that have evaluated 39 potential mediators were included in this review. Cognitive mediators were the largest group of examined intervening variables, followed by a broad range of emotional and affective, interpersonal, parenting behavior, and other mediators. The mediator categories with the highest percentages of significant intervening variables were the groups of affective mediators (4/4, 100%) and combined cognitive mediators (13/19, 68%). Although more than three-quarters of the eligible studies met 5 or more quality criteria, causal conclusions have been widely precluded.

CONCLUSIONS

The findings of this review might guide the empirically informed advancement of DHIs, contributing to improved intervention outcomes, and the discussion of methodological recommendations for process research might facilitate mediation studies with more pertinent designs, allowing for conclusions with higher causal certainty in the future.

Development of a Brief Group CBT Intervention to Reduce COVID-19 Related Distress Among School-Age Youth

School-aged youth have been significantly impacted by the COVID-19 pandemic. The effects of the pandemic will likely have long-standing effects on the well-being of youth, and access to mental health care is even more critical during this time. For the past 5 years, TRAILS (Transforming Research into Action to Improve the Lives of Students) has been working throughout the state to increase utilization of evidence-based mental health practices among K-12 school mental health professionals (SMHPs). By leveraging SMHPs who are widely accessible to students, TRAILS seeks to improve youth access to effective mental health care and reduce current mental health inequities. In March 2020, TRAILS responded to the COVID-19 pandemic by developing a group manual designed to be delivered virtually by SMHPs to help students develop effective coping skills to mitigate the impact of COVID-19. TRAILS focuses on promoting use of CBT and mindfulness, as these skills are ideally suited for school-based delivery, and thus the new manual, Coping with COVID-19 (CC-19), was grounded in these modalities. This article will describe the design, development, and deployment of the CC-19 program to address the mental health needs of students in the context of the pandemic. Early acceptability and penetration data will also be discussed.

Engaging Parents and Health Care Stakeholders to Inform Development of a Behavioral Intervention Technology to Promote Pediatric Behavioral Health: Mixed Methods Study

BACKGROUND

Despite effective psychosocial interventions, gaps in access to care persist for youth and families in need. Behavioral intervention technologies (BITs) that apply psychosocial intervention strategies using technological features represent a modality for targeted prevention that is promising for the transformation of primary care behavioral health by empowering parents to take charge of the behavioral health care of their children. To realize the potential of BITs for parents, research is needed to understand the status quo of parental self-help and parent-provider collaboration to address behavioral health challenges and unmet parental needs that could be addressed by BITs.

OBJECTIVE

The aim of this study is to conduct foundational research with parents and health care stakeholders (HCS) to discover current practices and unmet needs related to common behavioral health challenges to inform the design, build, and testing of BITs to address these care gaps within a predominantly rural health system.

METHODS

We conducted a convergent mixed-parallel study within a large, predominantly rural health system in which the BITs will be developed and implemented. We analyzed data from parent surveys (N=385) on current practices and preferences related to behavioral health topics to be addressed in BITs along with focus group data of 48 HCS in 9 clinics regarding internal and external contextual factors contributing to unmet parental needs and current practices. By comparing and relating the findings, we formed interpretations that will inform subsequent BIT development activities.

RESULTS

Parents frequently endorsed several behavioral health topics, and several topics were relatively more or less frequently endorsed based on the child's age. The HCS suggested that BITs may connect families with evidence-based guidance sooner and indicated that a web-based platform aligns with how parents already seek behavioral health guidance. Areas of divergence between parents and HCS were related to internalizing problems and cross-cutting issues such as parenting stress, which may be more difficult for health care HCS to detect or address because of the time constraints of routine medical visits.

CONCLUSIONS

These findings provide a rich understanding of the complexity involved in meeting parents' needs for behavioral health guidance in a primary care setting using BITs. User testing studies for BIT prototypes are needed to successfully design, build, and test effective BITs to empower parents to take charge of promoting the behavioral health of their children.

Service providers endorse integrated services model for youth with mental health and substance use challenges: findings from a discrete choice experiment

BACKGROUND

Given high rates of mental health and substance challenges among youth and substantial system access barriers, system innovation is required. Integrated youth services (IYS) models aim to transform youth mental health and substance use services by creating integrative, collaborative models of care in youth-friendly settings. This study examines service provider perspectives on the key service components to include in IYS models.

METHOD

A discrete choice experiment modeled service provider preferences for the service components of IYSs. The sample includes 388 service provider/agency leader participants (age 18+) from youth-serving organizations in Ontario. Importance scores and utility values were calculated for 12 attributes represented by four levels each. Latent class analysis identified subgroups of participants with different preferences.

RESULTS

The majority of participants were direct service providers working in larger organizations in the mental health and/or substance use sectors in large urban centers. Participants strongly endorsed service models that provide rapid access to the widest variety of culturally sensitive service options, with supplementary e-health services, in youth-focused community settings with evening and weekend hours. They prefer caregiver involvement in youth services and treatment decisions and support youth and family engagement. Latent class analyses reveal three segments of service providers: a Youth-Focused Service Accessibility segment representing 62.1% (241/388) of participants, a Service Options segment representing 27.6% (107/388) of participants, and a Caregiver Integration segment representing 10.3% (40/388) of participants. Within these segments, the degree of prioritization of the various service components differ; however, the overall endorsement of the service components remains largely consistent across classes for most attributes. The segments did not differ based on demographic or agency characteristics.

CONCLUSIONS

The core characteristics of IYS settings for youth with mental health and substance use challenges, i.e., rapid access to a wide range of youth-oriented services, are strong priorities of service providers and youth-serving agency leaders. These findings confirm that youth-oriented service providers endorse the importance and relevance of IYS models as a whole; strong service provider buy-in to the model is expected to facilitate development, implementation and scaling of IYS models. Hearing stakeholder perspectives, including those of service providers, youth, and caregivers, is essential to developing, effectively implementing, and scaling effective youth services.

Youth Mental Health First Aid: Examining the Influence of Pre-Existing Attitudes and Knowledge on Training Effectiveness

Youth Mental Health First Aid (YMHFA) is a gatekeeper training designed to assist professionals in their identification and response to youth mental illness. Despite widespread implementation, few studies have examined how individual-level trainee characteristics may impact the effectiveness of this training. In this study, we examined how pre-existing knowledge and attitudes about youth mental illness (measured prior to participation in the program) influenced training outcomes. We used a sample of 987 child-serving professionals who completed the YMHFA training program to identify demographic and work-related factors that predicted pre-existing attitudes and knowledge. The sample was then divided into two groups based on pre-existing attitudes and knowledge. We examined training effectiveness across four constructs: knowledge, confidence, intentions to intervene, and stigma. Findings indicate that gender and work-related characteristics were associated with pre-existing knowledge and attitudes about youth mental illness. The magnitude of training effectiveness varied across pre-existing attitudes and knowledge. Those participants with above average attitudes and knowledge benefited little from the program, suggesting that universal implementation of YMHFA may not be an efficient use of resources. Suggestions for a tiered implementation plan that prioritizes professionals most in need of the training are discussed.

Prevalence of childhood mental disorders in high-income countries: a systematic review and meta-analysis to inform policymaking

QUESTION

Mental disorders typically start in childhood and persist, causing high individual and collective burdens. To inform policymaking to address children's mental health in high-income countries we aimed to identify updated data on disorder prevalence.

METHODS

We identified epidemiological studies reporting mental disorder prevalence in representative samples of children aged 18 years or younger-including a range of disorders and ages and assessing impairment (searching January 1990 through February 2021). We extracted associated service-use data where studies assessed this. We conducted meta-analyses using a random effects logistic model (using R metafor package).

FINDINGS

Fourteen studies in 11 countries met inclusion criteria, published from 2003 to 2020 with a pooled sample of 61 545 children aged 4-18 years, including eight reporting service use. (All data were collected pre-COVID-19.) Overall prevalence of any childhood mental disorder was 12.7% (95% CI 10.1% to 15.9%; I²=99.1%). Significant heterogeneity pertained to diagnostic measurement and study location. Anxiety (5.2%), attention-deficit/hyperactivity (3.7%), oppositional defiant (3.3%), substance use (2.3%), conduct (1.3%) and depressive (1.3%) disorders were the most common. Among children with mental disorders, only 44.2% (95% CI 37.6% to 50.9%) received any services for these conditions.

CONCLUSIONS

An estimated one in eight children have mental disorders at any given time, causing symptoms and impairment, therefore requiring treatment. Yet even in high-income countries, most children with mental disorders are not receiving services for these conditions. We discuss the implications, particularly the need to substantially increase public investments in effective interventions. We also discuss the policy urgency, given the emerging increases in childhood mental health problems since the onset of the COVID-19 pandemic (PROSPERO CRD42020157262).

Youth and Provider Perspectives on Behavior-Tracking Mobile Apps: Qualitative Analysis

BACKGROUND

Mobile health apps stand as one possible means of improving evidence-based mental health interventions for youth. However, a better understanding of youth and provider perspectives is necessary to support widespread implementation.

OBJECTIVE

The objective of this research was to explore both youth and provider perspectives on using mobile apps to enhance evidence-based clinical care, with an emphasis on gathering perspectives on behavior-tracking apps.

METHODS

Inductive qualitative analysis was conducted on data obtained from semistructured interviews held with 10 youths who received psychotherapy and 12 mental health care providers who conducted therapy with youths aged 13-26 years. Interviews were independently coded by multiple coders and consensus meetings were held to establish reliability.

RESULTS

During the interviews, the youths and providers broadly agreed on the benefits of behavior tracking and believed that tracking via app could be more enjoyable and accessible. Providers and youths also shared similar concerns that negative emotions and user burden could limit app usage. Participants also suggested potential app features that, if implemented, would help meet the clinical needs of providers and support long-term use among youth. Such features included having a pleasant user interface, reminders for clients, and graphical output of data to clients and providers.

CONCLUSIONS

Youths and providers explained that the integration of mobile health into psychotherapy has the potential to make treatment, particularly behavior tracking, easy and more accessible. However, both groups had concerns about the increased burden that could be placed on the clients and providers.

Harnessing Home-School Partnerships and School Consultation to Support Youth With Anxiety

Youth with anxiety often experience significant impairment in the school setting. Despite the relevance and promise of addressing anxiety in schools, traditional treatment approaches to school-based anxiety often do not adequately address generalization to the school setting, or they require removing the student from the classroom to deliver time- and staff-intensive programs. Such programs often leave teachers and caregivers feeling ill-equipped to support the student with anxiety throughout the natural course of the school day. Given the heavy demands placed on teachers and documented burnout among school professionals, providing effective school supports requires collaborative partnerships among outpatient therapists/specialists, school personnel, and caregivers. Drawing from literature on collaborative models for externalizing problems, we offer recommendations for outpatient therapists and specialists working to implement evidence-based supports in school settings and promote home-school partnerships to benefit youth with anxiety in the school setting. Our recommendations touch upon several components of such school consultation, including (a) identification of key parties involved, (b) conducting a needs assessment, (c) collaborative goal setting and development of a fear hierarchy, (d) plan development and implementation (e.g., facilitating a school-based exposure mindset, promoting home-school communication, enhancing school relationships), and (e) progress monitoring and ongoing support. We conclude with a case example to bring these recommendations to life.

Predictors of Prolonged Length of Stay in Suicidal Children Transferred to Psychiatric Facilities

OBJECTIVES

To determine if sociodemographic factors or underlying mental health conditions serve as predictors for prolonged length of stay (pLOS) in children hospitalized for suicidal ideation (SI) or suicide attempt (SA) requiring transfer to psychiatric facilities. We hypothesized an association between certain patient and hospital characteristics and pLOS.

METHODS

For this retrospective cross-sectional study, we used the National Inpatient Sample. We included children <18 years old hospitalized with a primary or secondary International Classification of Diseases, 10th Edition, Clinical Modification diagnosis of SI or SA who were dispositioned to psychiatric facilities from 2016 to 2017. Exposures were patient sociodemographics, underlying mental health diagnoses, and hospital characteristics. Our outcome was pLOS. Adjusted prevalence ratios with 95% confidence intervals (CIs) were generated with log binomial regression.

RESULTS

Of 12 715 hospitalizations meeting inclusion criteria, 5475 had pLOS. After adjusting for sociodemographics and hospital characteristics, predictive factors for pLOS were public insurance use (prevalence ratio: 1.40; CI: 1.12-1.78), urban nonteaching hospital location (prevalence ratio: 4.61; CI: 2.33-9.12), urban teaching hospital location (prevalence ratio: 3.26; CI: 1.84-5.76), and underlying diagnosis of mood disorder (prevalence ratio: 1.98; CI: 1.63-3.42). Hispanic patients had decreased probability of pLOS (prevalence ratio: 0.69; CI: 0.52-0.93). Otherwise, age, zip income, sex, and hospital region were not predictive of pLOS.

CONCLUSIONS

Among children hospitalized for SI or SA requiring transfer to psychiatric facilities, public insurance, urban hospital location, and diagnoses of mood disorder, depression, and bipolar disorder were predictive of pLOS. Further research is needed on how to decrease disparities in length of stay among this vulnerable population.

Facilitating factors and barriers in help-seeking behaviour in adolescents and young adults with depressive symptoms: A qualitative study

OBJECTIVE

Despite the availability of mental health care, only a minority of depressed adolescents and young adults receive treatment. This study aimed to investigate facilitating factors and barriers in help-seeking behaviour of adolescents and young adults with depressive symptoms, using qualitative research methods.

METHODS

In-depth, semi-structured interviews with 32 participants with current or previous depressive symptoms aged 16 to 24 years using thematic content analysis.

FINDINGS

Our sample consisted mainly of adolescents who eventually found their way to professional help. Five main themes in help-seeking by adolescents and young adults were identified: (I) Individual functioning and well-being, (II) Health literacy, (III) Attitudinal aspects, (IV) Surroundings, and (V) Accessibility. Prompts to seek treatment were disease burden and poor academic performance. Health illiteracy negatively influenced treatment-seeking behaviour. Attitudinal aspects either hampered (shame, wanting to handle the problem oneself, negative attitudes towards treatment) or facilitated (positive attitudes towards treatment) help-seeking. Furthermore, adolescents' surroundings (school, family, and peers) appeared to play a critical role in the recognition of depressive symptoms and encouragement to seek help. Barriers regarding accessibility of mental health care were found, whereas direct and easy access to treatment greatly improved mental health care use.

CONCLUSION

Facilitating factors can play a critical role in the help-seeking process of depressed adolescents and young adults, and may guide efforts to increase access to mental health care of this vulnerable age group. In particular, recognition and encouragement from school personnel and peers and easy access to care providers positively influenced help-seeking in our sample. Health illiteracy and attitudinal aspects appeared to be important barriers to seeking treatment and public/school campaigns aimed at reducing health illiteracy and stigma might be necessary to improve treatment-seeking and health care utilization in this age group.

Receipt of Behavioral Health Services Among US Children and Youth With Adverse Childhood Experiences or Mental Health Symptoms

Importance

Epidemiological literature on children's mental health and children's adverse childhood experiences (ACEs) have consistently pointed to widespread, unaddressed, and treatable high-risk conditions among children.

Objective

To estimate the proportion of children with either high levels of ACEs and/or high levels of mental health symptoms who were not receiving services from behavioral health professionals.

Design, Setting, and Participants

This cross-sectional study included 11 896 children who participated in 3 National Surveys of Children's Exposure to Violence (NatSCEV), which were nationally representative surveys conducted in 2008, 2011, and 2014. The surveys entailed telephone interviews with youth aged 10 to 17 years and caregivers of children aged 2 to 9 years. Data were analyzed from February to August 2020.

Main Outcomes and Measures

Nationally representative samples were obtained from a mix of random digit dial and address-based sampling methods. The primary outcome was the proportion of children with high ACEs, high distress symptoms, and both who were receiving clinical contact, broken down by demographic characteristics.

Results

Of the 11 896 children, 4045 (34.0%) participated in the 2008 NatSCEV; 4112 (34.6%) in the 2011 NatSCEV; and 3738 (31.4%) in the 2014 NatSCEV; 5532 (46.5%) were aged 2 to 9 years (2785 [50.4%] aged 2-5 years; 2693 [48.7%] girls; 3521 [63.7%] White children), and 6365 (53.5%) were aged 10 to 17 years (3612 [56.7%] aged 14-17 years; 3117 [49.0%] female participants; 4297 [67.5%] White individuals). Among participants aged 2 to 9 years, no clinical contact was reported for 57% (95% CI, 51%-62%) of the high ACE group, 53% (95% CI, 48%-58%) of the high distress symptom group, and 41% (95% CI, 32%-51%) of the group with high levels on both indicators. Among participants aged 10 to 17 years, the group with no clinical contact comprised 63% (95% CI, 56%-69%) of the high ACE group, 52% (95% CI, 46%-57%) of the high distress symptom group, and 62% (95% CI, 51%-71%) of youth scoring high on both indicators. Among racial groups, odds of contact were very low for Black children aged 2 to 9 years with high ACEs compared with non-Hispanic White children with the same age and exposure (odds ratio, 0.26; 95% CI, 0.14-0.49).

Conclusions and Relevance

In this cross-sectional study combining findings from 3 US national surveys, large portions of children at high risk because of adversity or mental health symptoms were not receiving clinical services. Better ways are needed to find these at-risk populations and help them obtain relevant intervention resources.

Experiences of pathways to mental health services for young people and their carers: a qualitative meta-synthesis review

Worldwide, growing concern with young people's mental health is spurring service reform efforts. Such reform requires a full understanding of the experiences of young people and their carers when seeking mental health help. To generate such an understanding, we conducted a meta-synthesis of qualitative literature on the perspectives of youths and their carers on navigating mental health systems. Five electronic databases were searched (Medline, PsycINFO, EMBASE, CINAHL, HealthSTAR). Studies were included if they explored the experiences of pathways to mental health services of persons aged 11-30 years and/or their carers; were published in English or French; and used qualitative methodology. Quality appraisal was conducted using the CASP tool. The synthesis of 31 included studies yielded three themes-initiating contact with mental health services; characteristics of services' response; and youths' and carers' appraisal of services. Themes about initiating contact included mental health literacy, structural barriers, and social support. Service response-related themes included complex pathways, waitlists, eligibility, and fragmented care. In terms of service appraisal, positive encounters featured providers who were accessible and perceived as caring. Negative appraisals resulted from feeling misunderstood and excluded and being ill-informed about treatment. Across diagnoses and settings, youths and carers had difficult experiences accessing mental healthcare. While individual, social, and healthcare factors shaping pathways to care varied, systemic complexities were a common inhibitor. This synthesis informs recommendations for improving mental health services and youths' pathways to them. It underlines the need for grounding reform in youths' and carers' perspectives and needs.

Effectiveness of Transdiagnostic Cognitive-Behavioral Psychotherapy Compared With Management as Usual for Youth With Common Mental Health Problems: A Randomized Clinical Trial

IMPORTANCE

Behavioral therapy and cognitive-behavioral therapy (CBT) programs targeting a single class of problems have not been widely implemented. The population of youths with common mental health problems is markedly undertreated.

OBJECTIVE

To determine the effectiveness of a new transdiagnostic CBT program (Mind My Mind [MMM]) compared with management as usual (MAU) in youths with emotional and behavioral problems below the threshold for referral to mental health care.

DESIGN, SETTING, AND PARTICIPANTS

This pragmatic, multisite, randomized clinical trial of MMM vs MAU was conducted from September 7, 2017, to August 28, 2019, including 8 weeks of postintervention follow-up, in 4 municipalities in Denmark. Consecutive help-seeking youths were randomized (1:1) to the MMM or the MAU group. Main inclusion criteria were age 6 to 16 years and anxiety, depressive symptoms, and/or behavioral disturbances as a primary problem. Data were analyzed from August 12 to October 25, 2019.

INTERVENTIONS

The MMM intervention consisted of 9 to 13 weekly, individually adapted sessions of manualized CBT delivered by local psychologists. The MAU group received 2 care coordination visits to enhance usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in mental health problems reported by parents at week 18, using the Strengths and Difficulties Questionnaire (SDQ) Impact scale (range, 0-10 points, with higher scores indicating greater severity of distress and impairment). Primary and secondary outcomes were assessed in the intention-to-treat population at week 18. Maintenance effects were assessed at week 26.

RESULTS

A total of 396 youths (mean [SD] age, 10.3 [2.4] years; 206 [52.0%] boys) were randomized to MMM (n = 197) or MAU (n = 199), with primary outcome data available in 177 (89.8%) and 167 (83.9%), respectively, at 18 weeks. The SDQ Impact score decreased by 2.34 points with MMM and 1.23 with MAU, from initial scores of 4.12 and 4.21, respectively (between-group difference, 1.10 [95% CI, 0.75-1.45]; P < .001; Cohen d = 0.60). Number of responders (≥1-point reduction in SDQ Impact score) was greater with MMM than with MAU (144 of 197 [73.1%] vs 93 of 199 [46.7%]; number needed to treat, 4 [95% CI, 3-6]). Secondary outcomes indicated statistically significant benefits in parent-reported changes of anxiety, depressive symptoms, daily functioning, school attendance, and the principal problem. All benefits were maintained at week 26 except for school attendance.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, the scalable transdiagnostic cognitive-behavioral intervention MMM outperformed MAU in a community setting on multiple, clinically relevant domains in youth with emotional and behavioral problems.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03535805.

Public Health Coverage and Access to Mental Health Care for Youth with Complex Behavioral Healthcare Needs

Drawing upon the National Survey of Children with Special Healthcare Needs (2009/2010), multilevel logistic regression analysis assessed the relationship between parent report of a youth having an emotional, behavioral, or developmental problem (EBDP), their level of reported functional limitations, and parents' report of unmet mental health care needs and experience with cost-barriers to accessing needed healthcare services. Results indicate that, compared to all privately insured youth with special health care needs, parents of privately insured youth with EBDP are much more likely to report their child having unmet mental health care needs (OR 12.16; p < 0.001) and experiencing cost barriers to care (OR 2.37; p < 0.001). Parents of privately insured youth with EBDP with functional limitations are even more likely to report these concerns (Unmet Mental Health Needs: OR 17.09; p < 0.001; Cost Barriers: OR 5.77; p < 0.001). However, findings suggest that having public insurance is associated with reductions in the odds of having unmet needs for youth with SED by 50%. Public insurance and dual coverage is associated with reductions in the odds of encountering cost barriers to care by almost 50% for children with EBDP, and by more 50% for youth with EBDP and functional impairments.

Police and mental health in elementary and secondary schools: A systematic review of the literature and implications for nursing

WHAT IS KNOWN ON THIS SUBJECT?: Police are often called on to respond to student mental health needs in schools. School nurses, who are part of interdisciplinary mental health teams, may collaborate with responding police officers. Currently, there are no reviews of the literature describing the use of police to respond to mental health crises in schools. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This systematic review found six articles addressing police response to student mental health needs in elementary and secondary schools. Articles primarily focused on the School Resource Officer programme; however, there was a lack of research on the effectiveness of this and other programmes in addressing the mental health needs of students. This paper highlights a significant gap in knowledge about how police are involved in responding to student mental health crises within schools. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Understanding how police respond to mental health crises on school campuses will help nurses serve in collaborative roles with responding officers. This study highlights gaps in research that need to be addressed for researchers and policymakers to best support students in crisis.

ABSTRACT

INTRODUCTION: Response to student mental health crises involves interdisciplinary school-community teams, which can include police officers. This paper presents the first systematic review of literature on how police address mental health in school settings. Results have implications for school nurses interacting with responding police.

QUESTION/AIM

How are police involved in responding to student mental health needs in elementary and secondary schools?

METHOD

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework, six articles met criteria for inclusion in this review.

RESULTS

Two themes were identified: (1) descriptions of roles of police in schools and (2) studies presenting programmes or models of police engagement. The most common use of police in schools is through the School Resource Officer model.

DISCUSSION

There are very few studies examining police involvement in mental health response in schools and little data available on whether prevailing models are effective. We are therefore unable to ascertain what impact school police have in responding to mental health crises or the extent to which they interact with school nurses.

IMPLICATIONS FOR PRACTICE

Understanding mental health crisis responses in schools can inform policy, practice, research and education for police and school providers, including nurses.