The evolution of systems of care for children's mental health: forty years of community child and adolescent psychiatry

The interRAI Child and Youth Suite of Mental Health Assessment Instruments: An Integrated Approach to Mental Health Service Delivery

Various biological, social, psychological, and environmental factors impact children and youth living with mental health problems across their lifespan. To meet the wide-ranging challenges of mental illness, service system integration is needed to improve efficiencies and reduce fragmentation. Unfortunately, the mental health system has been plagued by the lack of coordination across services. There is a general consensus that mental health service delivery must ensure a child or youth's needs are addressed in a collaborative, coordinated, and seamless manner. A key element to successful integration is the development of a comprehensive standardized screening and assessment system. Numerous assessments have been developed to assess child mental health and functioning, but they typically have a very narrow focus with limited use and utility. Not only does this reduce the ability to take a life course perspective to mental health, but this uncoordinated approach also results in redundancies in information collected, additional resources, and increased assessor burden for children, youth, and their families. The interRAI child and youth mental health assessment suite was developed in response to the need for an integrated mental health system for young persons. This suite includes screening and assessment instruments for in-patient and community settings, emergency departments, educational settings, and youth justice custodial facilities. The instruments form a mental health information system intentionally designed to work in an integrated fashion beginning in infancy, and incorporate key applications such as care planning, outcome measurement, resource allocation, and quality improvement. The design of these assessment tools and their psychometric properties are reviewed. Data is then presented using examples related to interpersonal trauma, illustrating the use and utility of the integrated suite, along with the various applications of these assessment systems.

Developing a Structure of Essential Services for a Child and Adolescent Mental Health System

Policy Points That child and adolescent mental health services needs are frequently unmet has been known for many decades, yet few systemic solutions have been sought and fewer have been implemented at scale. Key among the barriers to improving child and adolescent mental health services has been the lack of well-organized primary mental health care. Such care is a mutual but uncoordinated responsibility of multiple disciplines and agencies. Achieving consensus on the essential structures and processes of mental health services is a feasible first step toward creating an organized system.

Pediatric Community Mental Health

The emotional health and wellbeing of children and adolescents and their families is of utmost importance. Pediatricians are at the front line in identifying mental illness in children and adolescents and either linking them to resources in the community or providing treatment options themselves. Collaboration and integrative health care models is the cornerstone of effective strategies to provide access and quality mental health care to children and families in communities across the country.

Doing more with what we know: introduction to the special issue

This article introduces a special issue that provides an overarching conceptual model for advancing the impact of science on service delivery and includes some illustrations of these concepts in action from a variety of research teams in a diversity of contexts. Themes of the special issue include balancing considerations of efficacy, effectiveness, and extensiveness--for example, ensuring that treatments are not only reliable but also robust and widely relevant. It is argued that such a balance might be achieved through an increased focus on improving coordination of system resources (e.g., clients, providers, treatments, training programs) and through dynamic and developmental designs. The special issue is intended to raise the broader question of whether our current paradigms are satisfactory in moving us toward our shared vision, or whether we could do more with what we already know.

Beyond context to the skyline: thinking in 3D

Sweeping and profound structural, regulatory, and fiscal changes are rapidly reshaping the contours of health and mental health practice. The community-based practice contexts described in the excellent review by Garland and colleagues are being fundamentally altered with different business models, regional networks, accountability standards, and incentive structures. If community-based mental health services are to remain viable, the two-dimensional and flat research and practice paradigm has to be replaced with three-dimensional thinking. Failure to take seriously the changes that are happening to the larger healthcare context and respond actively through significant system redesign will lead to the demise of specialty mental health services.

The characteristics and activities of child and adolescent mental health services in Italy: a regional survey

BACKGROUND

To date, no studies have assessed in detail the characteristics, organisation, and functioning of Child and Adolescent Mental Health Services (CAMHS). This information gap represents a major limitation for researchers and clinicians because most mental disorders have their onset in childhood or adolescence, and effective interventions can therefore represent a major factor in avoiding chronicity. Interventions and mental health care are delivered by and through services, and not by individual, private clinicians, and drawbacks or limitations of services generally translate in inappropriateness and ineffectiveness of treatments and interventions: therefore information about services is essential to improve the quality of care and ultimately the course and outcome of mental disorders in childhood and adolescence.The present paper reports the results of the first study aimed at providing detailed, updated and comprehensive data on CAMHS of a densely populated Italian region (over 4 million inhabitants) with a target population of 633,725 subjects aged 0-17 years.

METHODS

Unit Chiefs of all the CAMHS filled in a structured 'Facility Form', with activity data referring to 2008 (data for inpatient facilities referred to 2009), which were then analysed in detail.

RESULTS

Eleven CAMHS were operative, including 110 outpatient units, with a ratio of approximately 20 child psychiatrists and 23 psychologists per 100,000 inhabitants aged 0-17 years. All outpatient units were well equipped and organized and all granted free service access. In 2008, approximately 6% of the target population was in contact with outpatient CAMHS, showing substantial homogeneity across the eleven areas thereby. Most patients in contact in 2008 received a language disorder- or learning disability diagnosis (41%). First-ever contacts accounted for 30% of annual visits across all units. Hospital bed availability was 5 per 100,000 inhabitants aged 0-17 years.

CONCLUSION

The percentage of young people in contact with CAMHS for mental disorders is in line with those observed in previous epidemiological studies. The overall number of child psychiatrists per 100,000 inhabitants is one of the highest in Europe and it is comparable with the most well equipped areas in the US. This comparison should be interpreted with caution, however, because in Italy, child psychiatrists also treat neurological disorders. Critical areas requiring improvement are: the uneven utilisation of standardised assessment procedures and the limited availability of dedicated emergency services during non-office hours (e.g., nights and holidays).

Development of a measure to assess the implementation of children's systems of care: the Systems of Care Implementation Survey (SOCIS)

The children's system of care framework has been extensively implemented in the U.S. Since its inception in 1993, the Comprehensive Community Mental Health Services for Children and Their Families Program has invested in excess of $1 billion supporting the development of systems of care in 164 grantee sites across the country. Despite these efforts to implement children's systems of care nationally, little is known about the extent to which the principles and values actually have been put into practice outside of the funded grantee sites. This paper describes the development of the Systems of Care Implementation Survey, a measure designed specifically for the first ever study assessing the level of implementation of factors contributing to effective children's systems of care in a nationally representative sample of counties throughout the U.S.

The challenges in providing services to clients with mental illness: managed care, burnout and somatic symptoms among social workers

This study examined the relationship between social workers' experiences when interfacing with managed care organizations and burnout. A total of 591 social workers completed questionnaires that included several measures: Self-perceived competence in the context of managed care, professional involvement with clients with severe mental illness, and burnout. Results showed that self-perceived competence in the context of managed care had statistically significant correlations with burnout dimensions. The author discusses the role of social work schools in preparing students for the realistic aspects of mental health work, and recommends a partnership between managed care organizations and professionals for best care giving.

Organizational capacity to deliver effective treatments for children and adolescents

Treatment and services research in the general medical sector has emphasized the importance of addressing organizational capacity to improve interventions for patients with chronic conditions. Efficacious interventions for child and adolescent mental disorders without substantial enhancements in mental health organizational capacity will not result in improvements for children. This paper (a) lists some organizational enhancements that have resulted in improved medical care, (b) briefly underscores recent market trends such as state healthcare reform efforts, increased use of electronic records and contracting initiatives that push consolidation of agencies, and (c) describes one example of the organizational development of child behavioral services that will enhance treatment delivery.

Racial and ethnic disparities in pediatric mental health

Disparities remain in mental health status and care for racial and ethnic minority youth, despite national attention to disparity reduction. This article offers a comprehensive picture of the status of pediatric disparities, by addressing the major areas affecting minority youth mental health, including: prevention of problems, need for services, access to care, mental health treatment types, and treatment outcomes. The authors address relevant factors in the family, community and socioeconomic context, and describe various local and national programs that aim to tackle the obstacles and fill the gaps in high-quality care for racial/ethnic minority youth. The article concludes by offering recommendations for improvement that acknowledge the importance of understanding preferences and attitudes toward treatment, ensuring that screening and diagnosis is appropriate to minority youth, and ensuring that evidence-based programs are available at multiple levels to best service children and succeed in addressing their needs.

Trends in characteristics of children served by the Children's Mental Health Initiative: 1994-2007

Data from 14 years of the national evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program were used to understand the trends of the emotional and behavioral problems and demographic characteristics of children entering services. The data for this study were derived from information collected at intake into service in 90 sites who received their initial federal funding between 1993 and 2004. The findings from this study suggest children entering services later in a site's funding cycle had lower levels of behavioral problems and children served in sites funded later in the 14 year period had higher levels of behavioral problems. Females have consistently entered services with more severe problems and children referred from non-mental health sources, younger children, and those from non-white racial/ethnic backgrounds have entered system of care services with less severe problems. The policy and programming implications, as well as implications for local system of care program development and implementation are discussed.

Child and adolescent psychiatry for the future: challenges and opportunities

In this article, the authors focus on three particularly salient sets of issues that face the field of child and adolescent psychiatry as a sub-specialty of general psychiatry today-those related to workforce, public perception, and professional identity. In an article directed at the general psychiatrist, the authors present possibilities for refocusing the activities of the child and adolescent psychiatrist to emphasize consultative and collaborative roles. The authors embrace working in systems of care with communities and families as partners. Finally, they discuss the training implications of such shifts in professional identity, and the need to maintain the centrality of a scientifically-based developmental biopsychosocial formulation.

Violence in youth

Violence is an important public health issue. Because of a substantial variability in the intensity and frequency of violence worldwide a socio-cultural perspective is required for the better understanding of violent behaviours. This paper describes the current status of youth violence in Japan and the USA to elucidate critical points for mental health intervention. Although the profiles of youth violence in these two countries are quite different, violent behaviours in youths, including murder, are becoming more serious problems for both countries. From the experience in the USA a dual perspective, clinical and social/community, is proposed to understand youth violence. To prevent and treat youth violence, effective mental health service systems are needed and should be community-based and easily accessible for children and adolescents and their families as considered in the 'systems of care' philosophy.

Children and the Sphere standard on mental and social aspects of health

Most of the world's children live in resource-poor countries where people are at a relatively high risk of exposure to catastrophic situations arising from conflict and natural disasters.(6) Given the potential social, psychological and psychiatric consequences of exposure to disaster, mental health and psychosocial support programmes are increasingly part of humanitarian aid. A minimum standard on mental and social aspects of health is included in the recently revised Humanitarian Charter and Minimum Standards in Disaster Response (Sphere Handbook) (Sphere Project, 2004). Most recommendations for mental health and psychosocial interventions in guidance documents are based on expert opinion rather than research. Consequently, interventions are being implemented without full understanding of their potential benefit or harm. This paper offers a child-focused review of the evidence for each of the interventions described as indicators for the Sphere standard on mental and social aspects of health. It suggests some, but limited, support for each of them. However, the evidence base needs substantial strengthening.

Practice parameter on child and adolescent mental health care in community systems of care

This parameter presents overarching principles and practices for child and adolescent mental health care in community systems of care. Community systems of care are defined broadly as comprising the wide array of child-serving agencies, programs, and practitioners (both public and private), in addition to natural community supports such as religious and consumer organizations. Recommended principles and practices are derived from the system-of-care approach to service delivery. Based on the principles of the Child and Adolescent Service System Program, this approach has had a major influence on community systems of care through extensive federally funded projects and initiatives. The system-of-care model emphasizes that care should be tailored to the individual needs and strengths of the child and family and provided in the most community-based and least restrictive setting that meets their needs. Families are included as partners in the clinical process and are also involved in program development and evaluation. Services are coordinated and integrated into a comprehensive care plan. This model can be practiced even in the absence of formal systems of care or protocols, with the individual clinician promoting interagency coordination and child and family collaboration. This parameter is written for a broad audience of mental health professionals, with special emphasis on the roles of child and adolescent psychiatrists in community systems of care.

Community mental health in the People's Republic of China: a critical analysis

Community mental health has long been the crucial modality in service delivery of mental health services. This paper is an attempt to evaluate community mental health services in the People's Republic of China. The writer critically argues that community mental health services in the People's Republic of China still have faced a lot of difficulties such as huge demand but scarce resources, withdrawal of governmental funding in related services, inaccessibility of services to deprived and remote rural areas, political control, high mental health illiteracy and problems in formation of multidisciplinary team. An articulation of community mental health in the China context is also discussed.

Mental health of immigrants and refugees

The United States is a country of immigrants. With the exception of Native-Americans, every other American is, or descends from, an immigrant. First and second generation immigrant children are the most rapidly growing segment of the American population, with the great majority of this population being of non-European origin. This paper reviews the unique risk factors and mental health needs of our new immigrant populations, as well as treatment and services approaches to address their unique needs.