The children's services interview: validity and reliability

ADHD in adults with recurrent depression

BACKGROUND

Depression is highly heterogeneous in its clinical presentation. Those with attention deficit/hyperactivity disorder (ADHD) may be at risk of a more chronic and impairing depression compared to those with depression alone according to studies of young people. However, no studies to date have examined ADHD in recurrently depressed adults in mid-life.

METHOD

In a sample of women in mid-life (n=148) taken from a UK based prospective cohort of adults with a history of recurrent depression, we investigated the prevalence of ADHD and the association of ADHD with clinical features of depression.

RESULTS

12.8% of the recurrently depressed women had elevated ADHD symptoms and 3.4% met DSM-5 diagnostic criteria for ADHD. None of the women reported having a diagnosis of ADHD from a medical professional. ADHD symptoms were associated with earlier age of depression onset, higher depression associated impairment, a greater recurrence of depressive episodes and increased persistence of subthreshold depression symptoms over the study period, higher levels of irritability and increased risk of self-harm or suicide attempt. ADHD symptoms were associated with increased risk of hospitalisation and receiving non-first-line antidepressant medication.

LIMITATIONS

ADHD was measured using a questionnaire measure. We focussed on mothers in a longitudinal study of recurrent depression, so the findings may not apply to males or other groups.

CONCLUSIONS

Higher ADHD symptoms appear to index a worse clinical presentation for depression. Clinical implications include that in women with early onset, impairing and recurrent depression, the possibility of underlying ADHD masked by depression needs to be considered.

Parent-perceived barriers to accessing services for their child's mental health problems

BACKGROUND

Many children and adolescents with impairing mental health disorders are not in contact with specialized child and adolescent mental health services (CAMHS). In order to close the service gap, it is important to increase our knowledge of barriers to access. The aim of this study was to investigate parent perceived barriers to accessing services for their child's mental health problems to identify potential areas for improvement of access to CAMHS.

METHOD

In this cross-sectional observational study 244 parents of children and adolescents referred to outpatient psychiatric assessment were interviewed using the Children's services interview regarding barriers to accessing child mental health services across healthcare, educational services and social services. Parent reported barriers were analyzed in relation to the child's age, referral reason, symptom duration and impairment of the child.

RESULTS

The most commonly reported barriers were lack of information about were to seek help (60.3%), the perception that professionals did not listen (59.8%) and professionals refusing to initiate interventions or provide referral to services (53.7%). Lack of knowledge, stigmatization and unavailability of services were common themes across barriers to help-seeking. Long symptom duration and parent rated impairment was associated with increased risk of reporting several barriers to help-seeking.

CONCLUSION

Parents seeking help for their child's mental health encounter numerous barriers that could explain part of the treatment gap and long duration of mental health problems in children prior to referral to CAMHS.

Barriers to help-seeking in Israeli Arab minority adolescents with mental health problems: results from the Galilee study

BACKGROUND

The Galilee Study assessed mental health service needs among Israeli Muslim and Druze adolescents and their mothers. Studies show that mothers of adolescents belonging to the Arab minority have much lower help-seeking rates than Jewish mothers. This paper examines mothers' structural and cultural barriers to help-seeking.

METHODS

All 9th grade students living in 5 towns representative of Muslim and Druze localities in northern Israel, were eligible for the study and 1639 (69.3%) obtained parental agreement and participated. Emotional or behavioral problem were assessed in the classroom using the Strengths and Difficulties Questionnaire. A total of 704 adolescent-mother dyads participated in the follow-up, and were interviewed at home, using the Development and Well Being Assessment inventory, the Composite Barriers to Help-Seeking Questionnaire, the General Health Questionnaire - 12, the Subjective Feelings of Discrimination Index and socio-demographic questions. Pearson χ2 test and multivariate binary logistic regressions were performed to analyze mothers' consultation rates by risk factors. Exploratory factor analysis was performed to identify underlying factors and assess construct validity of the Composite Barriers to Help-Seeking Questionnaire, and also mean scores and standard deviations for the distinct scales were calculated.

RESULTS

More mothers of adolescents with a mental disorder than those without a mental disorder consulted a professional or school source (39.7% vs. 20.5%; χ2 = 45.636; p = < 0.001). The most important barriers to help-seeking were those related to "Accessibility", followed by barriers related to the belief that "Treatment is detrimental" and to the possibility of "Reprisal by authorities". Barriers related to "Stigma" and "Distrust of professionals" had the lowest means scores. Differences by ethnicity/religion were found.

CONCLUSIONS

Structural barriers related to lack of access, were considered the main obstacle to help-seeking in this Israeli Arab minority population. Cultural barriers such as stigma were considered of secondary importance. Structural barriers could be reduced by increasing the number of accessible public mental health clinics in the minority localities, a responsibility of the Ministry of Health and the HMOs. Information campaigns and psychoeducation for parents would help reduce other barriers to mental health treatment.

Family Factors and Repeat Pediatric Emergency Department Visits for Mental Health: A Retrospective Cohort Study

OBJECTIVES

Approximately 45% of youth presenting to the emergency department (ED) for mental health (MH) concerns will have a repeat ED visit. Since youth greatly depend on their caregivers to access MH services, the objective of this study was to determine if family characteristics were associated with repeat ED visits.

METHODS

A retrospective cohort study of youth aged 6-18 years (62% female) treated at a tertiary pediatric ED for a discharge diagnosis related to MH was conducted. Data were gathered from medical records, telephone interviews, and questionnaires. Family factor contribution was analyzed using a multivariable logistic regression model controlling for demographic, clinical and service utilization factors. Variables associated with earlier and more frequent visits were determined using cox regression and negative binomial regression.

RESULTS

Of 266 participants, 70 (26%) had a repeat visit. While caregiver history of MH treatment decreased the odds of having a repeat ED visit, family functioning and perceived family burden were not associated with repeat visits. Post-visit MH services, prior psychiatric hospitalization, higher severity of symptoms, and living closer to the hospital increased the odds of repeat visits.

CONCLUSIONS

This study examined the contribution of multiple family factors in predicting repeat MH visits to the ED. Results suggest caregiver characteristics may impact the decision to return. Healthcare providers should therefore consider caregiver and youth service utilization factors to inform patient management and discharge planning.

How do child and adolescent mental health problems influence public sector costs? Interindividual variations in a nationally representative British sample

BACKGROUND

Policy and practice guidelines emphasize that responses to children and young people with poor mental health should be tailored to needs, but little is known about the impact on costs. We investigated variations in service-related public sector costs for a nationally representative sample of children in Britain, focusing on the impact of mental health problems.

METHODS

Analysis of service uses data and associated costs for 2461 children aged 5-15 from the British Child and Adolescent Mental Health Surveys. Multivariate statistical analyses, including two-part models, examined factors potentially associated with interindividual differences in service use related to emotional or behavioural problems and cost. We categorized service use into primary care, specialist mental health services, frontline education, special education and social care.

RESULTS

Marked interindividual variations in utilization and costs were observed. Impairment, reading attainment, child age, gender and ethnicity, maternal age, parental anxiety and depression, social class, family size and functioning were significantly associated with utilization and/or costs.

CONCLUSIONS

Unexplained variation in costs could indicate poor targeting, inequality and inefficiency in the way that mental health, education and social care systems respond to emotional and behavioural problems.

Predictors of and barriers to service use for children at risk of ADHD: longitudinal study

Many children with, or at risk of, ADHD do not receive healthcare services for their difficulties. This longitudinal study investigates barriers to and predictors of specialist health service use. This is a 5-year follow-up study of children who participated in a cluster randomised controlled trial, which investigated school-level interventions (provision of books with evidence-based information and/or feedback of names of children) for children at risk of ADHD. 162 children who had high levels of ADHD symptoms at age 5 (baseline) were followed up at age 10 years. Using baseline data and follow-up information collected from parents and teachers, children who had and had not used specialist health services over the follow-up period were compared and predictors (symptom severity, comorbid problems, parental perception of burden, parental mental health, and socio-demographic factors) of specialist service use investigated. The most common parent-reported barrier reflected lack of information about who could help. Amongst children using specialist health services who met criteria for ADHD at follow-up, 36% had been prescribed stimulant medication. Specialist health service use was associated with each one-point increase in teacher-rated symptoms at baseline [inattention symptoms (adjusted OR = 1.40; 95% CI 1.12-1.76) and hyperactivity/impulsivity symptoms (adjusted OR = 1.23; 95% CI 1.05-1.44)]. Parental mental health problems were also independently associated with service use (for each one-point increase in symptoms, adjusted OR = 1.41; 95% CI 1.04-1.91). Severity of teacher-rated ADHD symptoms in early school years is a determinant of subsequent service use. Clinicians and teachers should be aware that parental mental health problems are independently associated with service use for children at risk of ADHD.

Youth services: meeting the mental health needs of adolescents

Objectives

Youth mental health services are poised for a paradigm shift. Recent epidemiological evidence confirms the seriousness of adolescence as a risk period for mental ill-health - 50% of all adult mental disorders begin before the age of 16% and 75% before the age of 25. Here, we identify issues with transition of care between CAMHS-AMHS service, and effectiveness of early intervention services.

Methods

We provide a selective review providing evidence of adolescence as a risk period, discuss CAMHS-AMHS service transition problems, and discuss avenues for change to implement the early intervention model across youth mental health.

Results

Traditional service structures,with paediatric -adult split at 16–18 years increasingly appear not fit for purpose. A radical redesign of youth mental health services is not only necessary, it is also feasible and achievable, as illustrated by a pilot Birmingham youth service – Youthspace.

Conclusions

Pilot youth mental projects currently underway can help radically redesign the existing child and adolescent services. This will in turn lead to an improvement in the young people's experience of engagement with the services so that they too have a positive future.

Economic impact of childhood psychiatric disorder on public sector services in Britain: estimates from national survey data

BACKGROUND

Approximately one in ten children aged 5-15 in Britain has a conduct, hyperactivity or emotional disorder.

METHODS

The British Child and Adolescent Mental Health Surveys (BCAMHS) identified children aged 5-15 with a psychiatric disorder, and their use of health, education and social care services. Service costs were estimated for each child and weighted to estimate the overall economic impact at national level.

RESULTS

Additional health, social care and education costs associated with child psychiatric disorders totalled £1.47bn in 2008. The lion's share of the costs falls to frontline education and special education services.

CONCLUSIONS

There are huge costs to the public sector associated with child psychiatric disorder, particularly the education system. There is a pressing need to explore ways to reduce these costs while improving health and well-being.

Estimating the costs of ongoing care for adolescents with attention-deficit hyperactivity disorder

PURPOSE

Attention-deficit hyperactivity disorder (ADHD) is associated with increased use of health, social and education services. There is a lack of data to quantify the economic burden of ADHD in the UK. The aim of this study was to estimate additional education, health and social care costs amongst adolescents in the UK diagnosed with ADHD.

METHODS

Participants were 143, 12- to 18-year-olds from the Cardiff longitudinal ADHD study. Service use relating to mental health over the previous year was measured using the children's service interview. Individual resource use was combined with unit cost data, from national sources, to calculate costs per patient and subsequently the mean cost per patient. Mean costs, 95% confidence intervals and median use were calculated using nonparametric bootstrapping methods.

RESULTS

The mean cost per adolescent for NHS, social care and education resources used in a 12-month period related to ADHD was £5,493 (£4,415.68, £6,678.61) in 2010 prices and the median was £2,327. Education and NHS resources accounted for approximately 76 and 24%, respectively. Estimated annual total UK costs are £670 million.

CONCLUSIONS

The additional costs to the NHS and education system of treating adolescents remain substantial for several years after the initial ADHD diagnosis. There exists a need to develop and evaluate early interventions which have the potential to reduce the longer-term burden, particularly on education resource use.

Adolescent clinical outcomes for young people with attention-deficit hyperactivity disorder

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is recognised as a common, disabling condition. Little information is available regarding the long-term outcomes for individuals with ADHD in the UK.

AIMS

To examine the 5-year outcome for a UK cohort of children with diagnosed, treated ADHD and identify whether maternal and social factors predict key outcomes.

METHOD

One hundred and twenty-six school-aged children (mean age 9.4 years, s.d. = 1.7) diagnosed with ADHD were reassessed 5 years later during adolescence (mean age 14.5 years, s.d. = 1.7) for ADHD, conduct disorder and other antisocial behaviours.

RESULTS

Most adolescents (69.8%) continued to meet full criteria for ADHD, were known to specialist services and exhibited high levels of antisocial behaviour, criminal activity and substance use problems. Maternal childhood conduct disorder predicted offspring ADHD continuity; maternal childhood conduct disorder, lower child IQ and social class predicted offspring conduct disorder symptoms.

CONCLUSIONS

The treatment and monitoring of ADHD need to be intensified as outcomes are poor especially in offspring of mothers with childhood conduct disorder symptoms.

Five Years On: Public Sector Service Use Related to Mental Health in Young People with ADHD or Hyperkinetic Disorder Five Years After Diagnosis

BACKGROUND

  Little is known about ongoing service use among young people with ADHD, but this information is important to the development of services to support these young people.

METHODS

  A cohort of young people with ADHD or hyperkinetic disorder (n = 115) was followed up five to seven years after diagnosis. Details are presented of their use of public sector services over the 12 months preceding reassessment, compared to young people with ADHD from a large epidemiological study.

RESULTS

  Most children remained in contact with CAMHS, with high rates of contact with schools, educational professionals and the criminal justice system. Nearly all had taken medication at some point, while many still were using it. There were low reported rates of psychological and group interventions within the last twelve months, but this does not rule out earlier access to such treatments.

CONCLUSIONS

  Children with ADHD utilise long-term support from public sector services, and cross agency strategies or clinics may help to optimise functioning.

What is a mental health clinic? How to ask parents about help-seeking contacts within the mental health system

We compared parents' endorsement of having contacted a "mental health clinic or agency" when seeking help for their child, with parents' recognition of having contacted specific, named mental health agencies in their geographic region. Data were from two studies involving parents of children and adolescents seeking mental health services. Across the two studies, only 28 and 41% of parents reported having contacted a "mental health agency," but 100% reported contact when asked about specific agencies by name. Incorporating this simple modification in future studies could provide more accurate documentation of help-seeking for, and utilization of, children's mental health services.

Predictors of Service Use for Mental Health Problems Among British Schoolchildren

BACKGROUND

  Most previous studies of service use in relation to mental health have examined services in the USA. We wanted to provide up-to-date findings from a general population sample of British schoolchildren.

METHOD

  A total of 2461 children aged 5-15 from the 1999 British Child and Adolescent Mental Health Survey were followed up for 3 years. We examine the relationship between a wide variety of potential predictors gathered in 1999 and the use of services over the following 3 years.

RESULTS

  Contact with most services was predicted by three factors: the impact of psychopathology; contact with teachers or primary health care; and parents' and teachers' perceptions that the child had significant difficulties. Other predictors were specific to each service.

CONCLUSIONS

  Education of parents, teachers and other important adults might increase the proportion of children with impairing psychiatric disorders reaching services.