Examining the Structure of a New Pediatric Measure of Functional Independence Using the interRAI Child and Youth Mental Health Assessment System

Identifying Factors Associated with Bullying Roles Using the interRAI Child and Youth Mental Health (ChYMH) Suite of Instruments

Bullying is a common problem amongst school-aged children and youth and is a significant concern for caregivers and teachers. interRAI is an international not-for-profit network of roughly 150 researchers and clinicians from over 35 countries. The main goal of interRAI is to develop and support standardized assessment systems for vulnerable individuals to support care planning, evidence-based clinical decision making, outcome measurement and quality assurance. This study aimed to examine factors associated with bullying roles in a large clinical sample (n = 26,069) using interRAI Child and Youth Mental Health assessments. Findings revealed children who both bullied peers and were victims of bullying (compared to those who were solely bullies, victims, or neither) were more likely to experience interpersonal traumas including witnessing domestic violence, physical and sexual assault; increased risk of self-harm and suicide, depression; more behavioural/externalizing problems; conflict within the school and home contexts; and higher levels of financial, familial, and living instability. The potential causes and implications of these distinctions are discussed. Findings can aid professionals in tailoring preventive measures that could more effectively minimize the incidence and effect of bullying.

Examining the Biopsychosocial Factors Related to Lifetime History of Concussion in Children and Youth

This study investigated the prevalence of lifetime concussions, related psychosocial problems, and post-concussion recovery rates in a clinical sample of children and youth. Participants were 24,186 children and youth (M = 11.9 years, SD = 3.5) who completed an interRAI Child and Youth Mental Health Assessment at mental health agencies across Ontario, Canada. In addition to the expected physiological correlates, results found concussions to be more prevalent in children and youth with attention deficit hyperactivity disorders, anxiety disorders, disruptive behaviour disorders, mood disorders, and those involved in self-harm, harm to others, destructive aggression, and internalizing and externalizing symptoms. The results of this study add to our understanding of children and youth's experiences with concussions. Clinical implications and recommendations are discussed to maximize the effectiveness of evidence-based interventions related to concussion recovery.

A cross-sectional examination of service complexity in youths with co-occurring autism spectrum disorder and psychiatric or medical diagnoses across service sectors

Introduction

Autism spectrum disorder (ASD) is a heterogeneous, life-long, and complex condition. Youth diagnosed with ASD require several supports addressing core symptoms associated with the disorder, but also those resulting from co-occurring mental and physical health conditions. As a result, their care is overseen by numerous professionals spanning various service sectors, but communication between sectors is hindered due to the absence of a standardized assessment system to identify and triage youth to services. A paucity of information surrounding this population's service use lingers and a siloed delivery system persists.

Methods

Using archival data collected from 1,020 youth between 12 and 18 years of age, this study explored service complexity among autistic youth with and without psychiatric and medical co-occurring conditions in Ontario, Canada. In doing so, a negative binomial regression was utilized to investigate which predisposing, enabling, and need variables were associated with service complexity.

Results

Results revealed that experiencing financial difficulties was not associated with service complexity. However, age, sex, caregiver distress, comorbidity, intellectual disability, and evaluated health status were significant predictors. More specifically, female youth and youth with distressed caregivers had greater mental health service complexity scores. Additionally, youth diagnosed with two or more conditions in addition to ASD who required longer durations of programming, controlling for other predictors, had greater mental health service complexity scores. Yet, youth with an intellectual disability had lower service complexity scores.

Discussion

Clinical implications of this study are discussed to inform future investments into mental health efforts for autistic youth.

Age, Sex and Relationship Strengths: Internalizing Symptom Differences in Children and Youth Within a Clinical Sample

BACKGROUND

Internalizing problems such as depression, anxiety and anhedonia are particularly problematic due to their covert nature. Due to their deleterious effects on psychological well-being, social connection and education, it is important to understand the development of internalizing problems and their unique contributors.

OBJECTIVES

Examine whether internalizing symptoms vary by (i) age, and (ii) sex, and whether (iii) relationship strengths are associated with sex and internalizing symptoms.

METHOD

Using a polynomial model with Tweedie distribution with log link, this study examined relationships for 18,701 clinically referred children and adolescents between 4 and 18 years of age assessed using the interRAI Child and Youth Mental Health assessment.

RESULTS

Internalizing symptoms reported by children and adolescents varied by age and sex. Sex differences in internalizing symptoms became prominent after about six years of age with female adolescents reporting higher levels when compared to male peers. An increase in relationship strengths corresponded with a decrease in internalizing symptoms for both sexes. However, the pattern depended on sex. In our sample, females required a greater number of relationship strengths to observe a decrease in internalizing symptoms.

CONCLUSIONS

The current study illustrates a difference in internalizing symptoms between females and males with respect to age and relationship strengths. The results may have implications for prevention and intervention strategies geared towards internalizing symptoms for children and adolescents.

Mental Health Service Urgency in Children's Mental Health: Factors Impacting the Need for Expedited Services

Delayed access to mental health services for children and adolescents has been linked to an increased risk of harm and nonattendance to scheduled appointments. While studies suggest that the lack of standardized assessments for prioritizing individuals has contributed to long wait times, the inconsistent use of assessments across service sectors in Ontario continues to persist. This has contributed to a paucity of information surrounding which children and adolescents may require urgent mental health services. Using a large secondary data set, this study examined whether service sector (e.g., school), and other individual client characteristics (e.g., age, sex, legal guardianship, interpersonal and school conflict) predicted greater mental health service urgency in 61,448 children and adolescents assessed using the interRAI Child and Youth Mental Health Screener. Binary logistic regression revealed that all predictors, except for sector, showed a significant effect on service urgency. Findings are instrumental in prioritization, reducing the likelihood that children with acute needs remain on waitlists.

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.

School Disengagement and Mental Health Service Intensity Need Among Clinically Referred Students Utilizing the interRAI Child and Youth Mental Health Assessment Instrument

Although mental health challenges are widespread, impacting 1 in 5 children and youth, only 25% of these young people receive the required mental health supports. Unmet mental health needs are strongly associated with functional impairments including poor self-care, interpersonal challenges, and school difficulties among young people. School disengagement, or a student's lack of involvement in education through interest, curiosity, motivation, and active participation, is associated with a wide array of detrimental outcomes including chronic mental health difficulties, conduct and delinquent behaviors, criminal justice involvement, and unemployment in adolescence and adulthood. Disengagement observed within the school setting may be indicative of underlying mental health challenges and reflective of service intensity need. The current study extends the literature by examining the relationship between school disengagement and mental health service intensity need among 14,750 clinically referred students across elementary and secondary school utilizing the interRAI Child and Youth Mental Health instrument. Findings indicated that more than 25% of clinically referred students were at heighted risk for school disengagement and required high-intensity services. Further, mental health service intensity need was positively associated with risk of school disengagement among students, along with the specific reason for referral (i.e., psychiatric symptoms, harm to self, harm to others, or addiction or dependency), after controlling for sex and age. Implications of the findings are explored within the context of the school setting and future directions are suggested.

Examining the Mental Health Presentations of Treatment-Seeking Transgender and Gender Nonconforming (TGNC) Youth

Recent research suggests that transgender and/or gender nonconforming (TGNC) youth present with heightened levels of mental health problems compared to peers. This study seeks to examine the mental health needs of a large sample of treatment-seeking TGNC youth by comparing them to cisgender males and females. Participants were 94,804 children and youth ages 4-18 years (M = 12.1, SD = 3.72) who completed the interRAI Child and Youth Mental Health Instrument (ChYMH) or Screener (ChYMH-S) at participating mental health agencies in the Ontario, Canada. Overall, the mental health presentations of TGNC youth were similar to cisgender females but at higher acuity levels. TGNC youth showed significantly higher levels of anxiety, depression, social disengagement, positive symptoms, risk of suicide/self-harm, and were more likely to report experiencing emotional abuse, past suicide attempts, and a less strong, supportive family relationship than cisgender females and males. Clinical implications of these findings are discussed.

Following the Epidemic Waves: Child and Youth Mental Health Assessments in Ontario Through Multiple Pandemic Waves

Emerging studies across the globe are reporting the impact of COVID-19 and its related virus containment measures, such as school closures and social distancing, on the mental health presentations and service utilization of children and youth during the early stages of lockdowns in their respective countries. However, there remains a need for studies which examine the impact of COVID-19 on children and youth's mental health needs and service utilization across multiple waves of the pandemic. The present study used data from 35,162 interRAI Child and Youth Mental Health (ChYMH) assessments across 53 participating mental health agencies in Ontario, Canada, to assess the mental health presentations and referral trends of children and youth across the first two waves of the COVID-19 pandemic in the province. Wave 1 consisted of data from March to June 2020, with Wave 2 consisting of data from September 2020 to January 2021. Data from each wave were compared to each other and to the equivalent period one year prior. While assessment volumes declined during both pandemic waves, during the second wave, child and youth assessments in low-income neighborhoods declined more than those within high-income neighborhoods. There were changes in family stressors noted in both waves. Notably, the proportion of children exposed to domestic violence and recent parental stressors increased in both waves of the pandemic, whereas there were decreases noted in the proportion of parents expressing feelings of distress, anger, or depression and reporting recent family involvement with child protection services. When comparing the two waves, while depressive symptoms and recent self-injurious attempts were more prevalent in the second wave of the pandemic when compared to the first, a decrease was noted in the prevalence of disruptive/aggressive behaviors and risk of injury to others from Wave 1 to Wave 2. These findings highlight the multifaceted impact of multiple pandemic waves on children and youth's mental health needs and underscore the need for future research into factors impacting children and youth's access to mental health agencies during this time.

Interpersonal polyvictimization: Addressing the care planning needs of traumatized children and youth

BACKGROUND

Exposure to maltreatment has a detrimental impact on both physical and mental health. However, research on the relationship between polyvictimization and care planning needs is scarce.

OBJECTIVES

This study investigated the associations between interpersonal polyvictimization and care planning needs for children and youth, controlling for sex and age differences.

PARTICIPANTS AND SETTINGS

The sample included 18,701 children and youth (M_age = 12.33, SD_age = 3.53) between 4 and 18 years. Participants were recruited from over 58 mental health agencies, facilities, and schools in Ontario, Canada between November 2012 and February 2020.

METHODS

Multivariate binary logistic regression was used to investigate polyvictimization, sex and age groups, as predictors on care planning outcomes. Significant interaction effects were further examined using simple effects analyses.

RESULTS

Children and youth experiencing polyvictimization, compared to those who did not, were more likely to report attachment difficulties, lack of informal support, interpersonal conflict, substance use and harm to self or others. In addition, the relationship between polyvictimization and attachment and interpersonal conflict care planning was moderated by sex.

CONCLUSIONS

Findings emphasize the importance of focusing on interpersonal polyvictimization and sex differences when developing treatment plans for a variety of care planning needs. Mental health practitioners could utilize the study findings to guide their clinical practices and ensure effective services are provided to those seeking mental health care.

An Examination of Correlates of Quality of Life in Children and Youth With Mental Health Issues

Quality of life (QoL) is significantly lower in children with mental health issues compared to those who are typically developing or have physical health problems. However, little research has examined factors associated with QoL in this particularly vulnerable population. To address this limitation, 347 clinically referred children and adolescents were assessed using the interRAI Child and Youth Mental Health (ChYMH) Assessment and Self-reported Quality of Life- Child and Youth Mental Health (QoL-ChYMH). Hierarchical multiple linear regression analyses were conducted to examine QoL at the domain-specific level. Children and adolescents who experienced heightened anhedonia and depressive symptoms reported lower social QoL (e.g., family, friends and activities; p = 0.024, 0.046, respectively). Additionally, children and youth who experienced heightened depressive symptoms reported lower QoL at the individual level (e.g., autonomy, health; p = 0.000), and level of basic needs (e.g., food, safety; p = 0.013). In contrast, no mental state indicators were associated with QoL related to services (e.g., school, treatment). Due to the paucity of research examining predictors of QoL in children and youth with mental health challenges, this study contributes to the field in assisting service providers with care planning and further providing implications for practice.

Autism Spectrum Screening Checklist (ASSC): The Development of a Scale to Identify High-Risk Individuals Within the Children's Mental Health System

Autism Spectrum Disorder (ASD) is a complex childhood onset neurodevelopmental disorder that has become the fastest growing developmental disability. Due to the increased demand for diagnostic assessments and subsequent increased wait times, standardized screening as part of regular clinical practice is needed. More specifically, there is an important need for the development of a more streamlined screening tool within an existing assessment system to identify those at greatest risk of having ASD. The current study utilized data from ~17,000 assessments obtained within the province of Ontario, based on the interRAI Child and Youth Mental Health (ChYMH) and Child and Youth Mental Health and Developmental Disability (ChYMH-DD), to develop a scale to identify children who have a higher likelihood of having autism. The scale was then tested on a trial population with data from the interRAI Early Years instrument. Further analyses examined the predictive validity of the scale. The Autism Spectrum Screening Checklist (ASSC) was found to be a good predictor of ASD with a sensitivity of 0.73 and specificity of 0.62, at the recommended cut-point of 2+. The results were consistent across several age ranges, specifically from 2 to 21 years of age. The ASSC scale provides an initial screen to help identify children and youth at heightened risk for autism within larger populations being assessed as part of routine practice. The main goal for the development and implementation of the ASSC scale is to harness the power of the existing interRAI assessment system to provide a more efficient, effective screening and referral process. This will ultimately help improve patient outcomes through needs-based care.

iCCareD: The Development of an Algorithm to Identify Factors Associated With Distress Among Caregivers of Children and Youth Referred for Mental Health Services

Caregiver well-being plays an important role in children's development and a number of factors have been found to impact distress levels among caregivers of children and youth referred for mental health services. Further, caregiver distress impacts youth psychopathology, its acuity as well as related mental health interventions. The purpose of this study was to develop and validate an algorithm for identifying caregivers who are at greatest risk of experiencing caregiver distress. This algorithm was derived from, and will be embedded in, existing comprehensive interRAI child and youth instruments. Ontario data based on the interRAI Child and Youth Mental Health assessment instruments (ChYMH and ChYMH-DD) were analyzed to identify predictors of distress among caregivers of children and youth ages 4-18 years. Starting with proactive aggression, the algorithm uses 40 assessment items to assign one of 30 nodes that are grouped into five levels of risk. The interRAI ChYMH Caregiver Distress (iCCareD) algorithm was validated using longitudinal data from mental health agencies across Ontario and was found to be a good predictor among this sample with a c-statistic of 0.71 for predicting new or ongoing caregiver distress and 65% for both sensitivity and specificity using algorithm values of 3 or greater. This algorithm provides an evidence-based decision-support tool embedded within a comprehensive assessment tool that may be used by clinicians to inform their selection of supports and services for families.

A Case-Mix System for Children and Youth With Developmental Disabilities

Limited funding across health and social service programs presents a challenge regarding how to best match resources to the needs of the population. There is increasing consensus that differences in individual characteristics and care needs should be reflected in variations in service costs, which has led to the development of case-mix systems. The present study sought to develop a new approach to allocate resources among children and youth with intellectual and developmental disabilities (IDD) as part of a system-wide Medicaid payment reform initiative in Arkansas. To develop the system, assessment data collected using the interRAI Child and Youth Mental Health-Developmental Disability instrument was matched to paid service claims. The sample consisted of 346 children and youth with developmental disabilities in the home setting. Using automatic interactions detection, individuals were sorted into unique, clinically relevant groups (ie, based on similar resource use) and a standardized relative measure of the cost of services provided to each group was calculated. The resulting case-mix system has 8 distinct, final groups and explains 30% of the variance in per diem costs. Our analyses indicate that this case-mix classification system could provide the foundation for a future prospective payment system that is centered around stability and equitability in the allocation of limited resources within this vulnerable population.

InterRAI Child and Youth Mental Health-Screener (ChYMH-S): A Psychometric Evaluation and Validation Study

Mental health concerns among children are pervasive, with one in five in North America experiencing a mental health issue. Unfortunately, only about a quarter will receive the support they need. interRAI is an organization of expert researchers and clinicians who develop integrated assessment systems to improve evaluation for vulnerable populations. The interRAI Child and Youth Mental Health Screener (ChYMH-S) is a brief screener that provides an initial assessment for early identification, triaging, and prioritization of services. This study assesses the psychometric properties of the ChYMH-S. Data from children aged 4-18 years across Ontario mental health agencies were obtained. The screener demonstrated strong inter-item reliability on all measured scales and good convergent validity with the Behaviour Assessment System for Children, with all hypothesized comparisons demonstrating positive, significant correlations. Overall, results provide initial support for the reliability and convergent validity of the ChYMH-S in detecting mental health concerns in child populations.

Exposure to childhood interpersonal trauma and mental health service urgency

BACKGROUND

Children and youth with a history of maltreatment experience different developmental, psychiatric and health problems. Ensuring there is streamlined access to services is imperative to recovery. Yet, few reports of standardized methods for directing and prioritizing risk for children seeking services exist.

OBJECTIVE

The current study aims to address this gap and explore how mental health personnel triage highly vulnerable cases. Specifically, the goal of the current study is to examine whether experiencing childhood interpersonal trauma predicts service urgency.

PARTICIPANTS AND SETTING

Participants were 19,645 children and youth, ages 4-18 years (M = 11.1 SD = 3.4) who completed the interRAI Child and Youth Mental Health Screener (ChYMH-S) at various community-based and residential children's mental health facilities across Ontario.

METHODS

Retrospective data collected from the ChYMH-S was used to explore differences in maltreatment history, gender, and legal guardianship and their impact on service prioritization.

RESULTS

Children and youth who were exposed to some form of interpersonal trauma were more likely to have mental health issues requiring urgent follow-up service compared to those who were not exposed. Findings also suggested that gender and legal guardianship impact service urgency.

CONCLUSIONS

Children and youth who have experienced maltreatment are significantly more likely to score high on mental health service urgency than those who did not. This provides valuable insight that can support the development of appropriate system-level changes to policy and practice when servicing children and youth with mental health needs in Canada.

Risk of Suicide and Self-harm in Kids: The Development of an Algorithm to Identify High-Risk Individuals Within the Children's Mental Health System

Suicide is the second leading cause of death in adolescents within Canada. While several risk factors have been found to be associated with increased risk, appropriate decision-support tools are needed to identify children who are at highest risk for suicide and self-harm. The aim of the present study was to develop and validate a methodology for identifying children at heightened risk for self-harm and suicide. Ontario data based on the interRAI Child and Youth Mental Health Screener (ChYMH-S) were analyzed to develop a decision-support algorithm to identify young persons at risk for suicide or self-harm. The algorithm was validated with additional data from 59 agencies and found to be a strong predictor of suicidal ideation and self-harm. The RiSsK algorithm provides a psychometrically sound decision-support tool that may be used to identify children and youth who exhibit signs and symptoms noted to increase the likelihood of suicide and self-harm.