Identifying the interactional processes in the first assessments in child mental health

Factors within the clinical encounter that impact upon risk assessment within child and adolescent mental health services: a rapid realist synthesis

Background

Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway.

Aims

To map research relating to risk assessment for child and adolescent mental health and to identify features that relate to a successful risk assessment.

Objectives

To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: i. to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context ii. to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK.

Data sources

Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites.

Review methods

A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines.

Results

From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan.

Limitations

Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment.

Conclusions

No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement.

Study registration

This study is registered as PROSPERO CRD42021276671.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135079) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

Revisiting the intake policy at the mental child and adolescent clinics

BACKGROUND

The psychiatric intake interview is crucial for the delivery of quality care. Currently, the interview in most public clinics varies in nature. It often consists of a clinical face-to-face interview (structured/unstructured) with or without self-report questionnaires (systematic/non-systematic). By integrating structured computerized self-report questionnaires into the intake, the assessment process could be shortened, and diagnostic accuracy increased.

OBJECTIVES

The study aims to assess whether adding structured computerized questionnaires will increase the efficacy of the intake process, as indicates by shortened intakes and a higher level of diagnostic accuracy, for children and adolescents in mental health clinics in Israel.

METHODOLOGY

Patients (M_age = 8.62, SD_age = 1.86; 33.8% females) referred to the youth mental health clinic of Maccabi HaSharon district, were included in either the CIA group (Comprehensive Intake Assessment - with questionnaires) or IAU group (Intake as Usual - without questionnaires).

RESULTS

In terms of accuracy and time measurements, the CIA group had higher diagnostic accuracy and a shorter intake duration of 6.63 min, almost 15% of an intake meeting, compared to the IAU group. No differences were found in satisfaction and therapeutic alliance between the groups.

CONCLUSIONS AND IMPLICATIONS

More accurate diagnosis is essential to tailor the appropriate treatment for the child's needs. Moreover, reducing intake time by a few minutes contributes significantly to the ongoing activities of mental health clinics. With this reduction, more intakes can be scheduled at a given time, optimizing the intake process, and reducing long wait times, which are increasing due to the growing demand for psychotherapeutic and psychiatric care.

Promoting the Value of Discursive Psychology for the Field of Human Resource Development: A Pedagogical Guide for Qualitative Researchers

To date, the study of how health and wellbeing are actualized in organizations and how an organization’s interactional practices shape an environment that is potentially harmful to health is understudied. Much of the research around this topic has centered on personality and individual differences, as well as health and safety or ergonomics. Little understanding exists of how interactional practices might serve to prioritize health and wellbeing. In this paper, we introduce discursive psychology (DP) – a qualitative approach to studying talk and text that focuses on examining what is accomplished through people’s interactional practices. We provide an overview of DP and discuss its underlying assumptions, analytic process, and quality measures. To illustrate the application of DP to HRD, we include data extracts that highlight the impact of question design. To conclude, we point to how DP might afford HRD scholars opportunities to generate new theoretical understandings about organizational practices.

Adolescent mothers: A qualitative study on barriers and facilitators to mental health in a low-resource setting in Cape Town, South Africa

BACKGROUND

Pregnant and postnatal adolescent women are a high-risk group for common mental disorders (CMDs); however, they have low levels of engagement and retention with mental health services. Negative consequences of CMDs have been documented for both mother and child.

AIM

The study aimed to explore the barriers and facilitators to service access for adolescents in low-resource settings.

SETTING

We interviewed 12 adolescents, aged 15-19 years, from low-resource settings in Cape Town, South Africa. Participants had previously engaged with a mental health service, integrated into maternity care.

METHODS

Twelve semi-structured, individual interviews were used for this qualitative study. Interviews were recorded, transcribed and coded. A framework analysis was employed for data analysis.

RESULTS

Adolescents perceived considerable stigma around both teenage pregnancy and mental illness, which inhibited use of mental health services. Other barriers included fearing a lack of confidentiality as well as logistical and environmental obstacles. Service uptake was facilitated by support from other adults and flexible appointment times. Face-to-face individual counselling was their preferred format for a mental health intervention.

CONCLUSION

Several key components for adolescent-friendly mental health services emerged from our findings: integrate routine mental health screening into existing obstetric services to de-stigmatise mental health problems and optimise screening coverage; coordinate obstetric and counselling appointment times to rationalise the use of limited resources; and sensitise care providers to the needs of adolescents to reduce stigma around adolescent sexual activity and mental illness. A non-judgemental, caring and confidential relationship between counsellors and clients is crucial for successful interactions.

The Child-Centered EMDR Approach: A Case Study Investigating a Young Girl’s Treatment for Sexual Abuse

This article seeks to address the underrepresented area of eye movement desensitization and reprocessing (EMDR) treatment for sexually abused children. It presents the child-centered EMDR approach–a new protocol derived from Klaff (2016). This approach is built on Shapiro’s Adaptive Information Processing model and assumes that a successful outcome can be achieved without directly processing memories of the abuse since children have the ability to open channels of association to uncover, process, and resolve emotional trauma relating to the abuse. Instead of focusing on traumatic memories, the treatment targets whatever current concerns the child presents, as it is thought that these concerns may provide a pathway to covert and possibly unconscious issues. This approach is tested with a case study, which explores its use with a 9-year-old girl who presented with emotional triggers originating from sexual abuse by her biological father. She received six sessions addressing memories of being taunted by other children and of her father using drugs, but her memories of the sexual abuse were not directly addressed. Following treatment, her scores on the Child Report of Post-Traumatic Symptoms (CROPS) and Parent Report of Post-Traumatic Symptoms (PROPS) decreased to nonclinical levels, with results maintained 2 months later at follow-up. The promising results suggest the value of future research to further test this approach.

Reflecting on what 'you said' as a way of reintroducing difficult topics in child mental health assessments

BACKGROUND

In child and adolescent mental health assessments, questions are integral to the process. There has been limited research focused on the assessment process, or on how questions are constructed within this clinical environment.

METHODS

We examined 28 naturally occurring initial assessments, with particular attention to how practitioners used questions in their communication with children and young people. We utilised conversation analysis to examine the data.

RESULTS

Analysis revealed a particular type of question preface used to reintroduce a prior topic. This was achieved through the use of 'you said x' as a foundation for asking a follow-up question and demonstrated active listening.

CONCLUSIONS

Arguably, this approach is a useful way of gathering assessment-relevant information in a child-centred way.

Agenda setting with children using the 'three wishes' technique

The National Health Service (UK) offers initial screening appointments for children referred to child and adolescent mental health services to determine clinical need and assess risk. Conversation analysis was utilized on 28 video recordings of these assessments, lasting approximately 90 minutes each with a multidisciplinary team. This article focuses on the agenda setting strategies used to establish relevant goals with children and adolescents; specifically, the technique of offering 'three wishes'. For example, ' if you had three wishes, what would you like to make happen?' In cases where children initially volunteered an assessment-relevant wish, they tended not to articulate further wishes. Non-assessment-relevant wishes (i.e. fantasy wishes, such as being 'rich') were treated as insufficient, with many approaches used to realign establishing assessment relevant goals. Where responses were not institutionally relevant, practitioners undertook considerable discursive work to realign the focus of the three wishes task to assessment relevance. In these cases, the wish responses were treated as irrelevant and tended to be dismissed, rather than explored for further detail. Such work with the children's contributions has implications for engaging children and child-centred practices.

The clinical use of Subjective Units of Distress scales (SUDs) in child mental health assessments: a thematic evaluation

Background: Despite the ubiquitous use of Subjective Units of Distress scales (SUDs) in mental health settings to establish levels of distressing emotion, there has been little empirical research in this area. SUDs are commonly used in therapy and assessments, and are a particularly useful tool for establishing current and previous levels of distress in children and young people.Aims: To explore the use of the SUD analogue rating scale in initial child mental health assessments to better understand its application in this context.Method: The data corpus consisted of 28 naturally-occurring video recordings of children and young people attending their first assessment appointment at Child and Adolescent Mental Health Services (CAMHS). A thematic analysis was utilised to explore the specific interactional use of SUDs.Results: Four themes were identified; recency, longevity, context and miscommunication. The first three themes were found to supplement the child's emotional score on the scale and were important in establishing the necessity for further therapeutic support. Miscommunication as a theme highlighted the need for clarity when using SUDs with children and young people.Conclusions: Recommendations were suggested for practitioners working with children and young people relating to the extended use of rating scales in clinical assessments.

"This is a question we have to ask everyone": asking young people about self-harm and suicide

WHAT IS KNOWN ON THE SUBJECT?: An essential part of the mental health assessment is to evaluate the risk of harm to self. Fundamentally this involves asking directly about self-harming behaviour and suicidal thoughts or urges, but practitioners often find it difficult to open up these conversations. This evaluation of risk is particularly important as self-harm and suicidal thoughts are frequently found in young people who attend mental health services. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Young people are not always routinely asked directly about self-harm or suicidal thoughts when they are assessed. There are two ways that mental health practitioners introduce this topic: first, by building up to it by initially asking about general feelings, and second by stating that it is a requirement to ask everyone. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These questions should not be avoided by mental health practitioners just because they are difficult. We offer suggestions as to how to ask questions about self-harm and suicide based on real-world practice.

ABSTRACT

Introduction Questions about self-harm and suicide are essential in risk assessments with children and young people, yet little is known about how mental health practitioners do this. Aim The core aim was to examine how questions about self-harm and suicidal ideation are asked in real-world practice. Method A qualitative design was employed to analyse 28 video-recorded naturally occurring mental health assessments in a child and adolescent mental health service. Data were analysed using conversation analysis (CA). Results In 13 cases young people were asked about self-harm and suicide, but 15 were not. Analysis revealed how practitioners asked these questions. Two main styles were revealed. First was an incremental approach, beginning with inquiries about emotions and behaviours, building to asking about self-harm and suicidal intent. Second was to externalize the question as being required by outside agencies. Discussion The study concluded that the design of risk questions to young people had implications for how open they were to engaging with the practitioner. Implications for practice The study has implications for training and practice for psychiatric nurses and other mental health practitioners in feeling more confident in communicating with young people about self-harm and suicidal ideation.

Question use in child mental health assessments and the challenges of listening to families

BACKGROUND

The mental health assessment is a fundamental aspect of clinical practice and central to this is the use of questions.

AIMS

To investigate the frequency and type of questions utilised within a child mental health assessment.

METHOD

The data consisted of 28 naturally occurring assessments from a UK child and adolescent mental health service. Data were analysed using quantitative and qualitative content analysis to determine frequencies and question type.

RESULTS

Results indicated a total of 9086 questions in 41 h across the 28 clinical encounters. This equated to a mean of 3.7 questions per minute. Four types of questions were identified; yes-no interrogatives, wh-prefaced questions, declarative questions and tag questions.

CONCLUSIONS

The current format of questioning may impede the opportunity for families to fully express their particular concerns and this has implications for service delivery and training.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.