2014 Ontario Child Health Study Findings: Policy Implications for Canada

Comparing youth with vs without outpatient mental health services on subsequent acute mental health care visits

BACKGROUND

Use of acute care for mental health concerns has been increasing among youth in recent years. Improving access to outpatient mental health services may prevent downstream acute care visits.

PURPOSE

To examine differences in rates of acute mental health care visits among youth with- versus without prior outpatient mental health services.

METHODOLOGY

A total of 2,442 youth ages 14-17 years participated in a provincially representative cross-sectional epidemiological survey, the 2014 Ontario Child Health Study. This sample was individually linked to health administrative databases, with nearly universal coverage of all medically necessary physician and acute care visits. Our exposure was parent and youth reported outpatient mental health service use in the six-month period prior to completing the survey. Exposed youth (n=691) were matched with unexposed youth using a propensity score informed by a range of clinical and socio-demographic factors. Our outcome was acute mental health care visits in the 18-month period following completion of the survey, ascertained though the linked health administrative data.

RESULTS

In our propensity score matched sample, we found no difference in rates of subsequent acute mental health care visits (HR= 1.14, 95%CI 0.44, 2.98) between youth with- versus without prior outpatient mental health services.

CONCLUSIONS

There is a need to further understand the types of services youth are receiving in outpatient settings to determine if, and for whom, outpatient mental health services reduces the likelihood of future acute mental health care visits.

Age-specific determinants of psychiatric outcomes after the first COVID-19 wave: baseline findings from a Canadian online cohort study

BACKGROUND

Canadians endured unprecedented mental health (MH) and support access challenges during the first COVID-19 wave. Identifying groups of individuals who remain at risk beyond the acute pandemic phase is key to guiding systemic intervention efforts and policy. We hypothesized that determinants of three complementary, clinically actionable psychiatric outcomes would differ across Canadian age groups.

METHODS

The Personal Impacts of COVID-19 Survey (PICS) was iteratively developed with stakeholder feedback, incorporating validated, age-appropriate measures. Baseline, cross-sectional online data collected between November 2020-July 2021 was used in analyses. Age group-specific determinants were sought for three key baseline MH outcomes: (1) current probable depression, generalized anxiety disorder, obsessive-compulsive disorder and/or suicide attempt during COVID-19, (2) increased severity of any lifetime psychiatric diagnosis, and (3) inadequate MH support access during COVID-19. Multivariable logistic regression models were constructed for children, youth (self- and parent-report), young adults (19-29 years) and adults over 29 years, using survey type as a covariate. Statistical significance was defined by 95% confidence interval excluding an odds ratio of one.

RESULTS

Data from 3140 baseline surveys were analyzed. Late adolescence and early adulthood were identified as life phases with the worst MH outcomes. Poverty, limited education, home maker/caregiver roles, female and non-binary gender, LGBTQ2S + status and special educational, psychiatric and medical conditions were differentially identified as determinants across age groups.

INTERPRETATION

Negative psychiatric impacts of COVID-19 on Canadians that include poor access to MH support clearly persisted beyond the first wave, widening pre-existing inequity gaps. This should guide policy makers and clinicians in current and future prioritization efforts.

Accessing and re-accessing mental health walk-in clinics for children and families

Background

Many child and youth mental health (CYMH) agencies across Canada and in Ontario are using mental health walk-in clinics (MHWCs).

Objectives

(1) Explore how MHWCs are used by families (e.g. mean, mode, and median number of visits), and (2) document how often and how soon families returned for a second MHWC visit and identify correlates of time to a second MHWC visit.

Design

Administrative data from two CYMH agencies in Ontario were extracted, including demographics, visit data, and presenting concerns.

Methods

In this exploratory, descriptive study, analyses of administrative data were conducted to identify patterns and correlates of MHWC use before other agency services, compared to MHWC use exclusively.

Results

About a third of children and families using MHWCs had two or more visits. Child age, guardianship, and disposition at discharge emerged as correlates of time to a second MHWC visit.

Conclusion

MHWCs can save families' time, and both agencies' time and money by eliminating the need to complete a detailed assessment prior to treatment for cases that would go on to have a single visit within this service.

Health System-Level Evaluation of Tele-Mental Health Services Among Children and Adolescents in Ontario, Canada

OBJECTIVE

To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization.

METHOD

Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1-18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization.

RESULTS

In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P < 0.001)] or hospitalizations [10.2% pre vs. 8.7% post (test statistic 11.96, P < 0.001)] declined in the year following tele-mental health consultation, while local psychiatry visits increased [8.4% pre vs. 17.0% post (test statistic 298.69, P < 0.001)]. In the second cohort (n = 84,033), only 1.5% received tele-mental health services, 40.7% saw a psychiatrist in-person, and 32.5% received no MHA-related outpatient care in follow-up.

CONCLUSIONS

Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.

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).

Physical-mental multimorbidity in children and youth: a scoping review

OBJECTIVE

Efforts to describe the current state of research are needed to advance the field of physical-mental multimorbidity (ie, the co-occurrence of at least one physical illness and at least one mental disorder) among children and youth. Our objective was to systematically explore the breadth of physical-mental multimorbidity research in children and youth and to provide an overview of existing literature topics.

DESIGN

Scoping review.

METHODS

We conducted a systematic search of four key databases: PubMed, EMBASE, PsycINFO and Scopus as well as a thorough scan of relevant grey literature. We included studies of any research design, published in English, referring to physical-mental multimorbidity among children and youth aged ≤18 years. Studies were screened for eligibility and data were extracted, charted and summarised narratively by research focus. Critical appraisal was employed using the modified Quality Index (QI).

RESULTS

We included 431 studies and 2 sources of grey literature. Existing research emphasises the co-occurrence of anxiety, mood and attention disorders among children with epilepsy, asthma and allergy. Evidence consists of mostly small, observational studies that use cross-sectional data. The average QI score across applicable studies was 9.1 (SD=1.8).

CONCLUSIONS

There is a pressing need for more robust research within the field of child physical-mental multimorbidity.

Transdiagnostic Associations Among Parental Causal Locus Attributions, Child Behavior and Psychosocial Treatment Outcomes: A Systematic Review

Parents' interpretations of the cause of their children's behavior, i.e., parental attributions, are linked to parenting behavior and child development. However, it is not yet known whether parental attributions are systematically associated with children's internalizing and externalizing symptoms and behavior or psychosocial treatment engagement and outcomes across diagnostic categories. This systematic review aimed to fill this knowledge gap using a transdiagnostic perspective to synthesize the literature on the associations between parent-causal and child-responsible attributions and children's internalizing and externalizing behavior, treatment engagement, and treatment outcomes for parents and children. A total of 67 studies were identified. Overall, biased child-responsible attributions were associated with elevated child internalizing and externalizing symptoms and behavior across diagnoses, while findings on the association between parent-causal attributions and child behavior were inconsistent. The link between parental attributions and treatment engagement was also mixed, varying across treatment type, child diagnosis, and focus of attributions. Regarding treatment outcomes, less biased parent-causal and child-responsible attributions were linked to post-treatment improvements in children's behaviors, while mixed findings were reported on post-treatment improvements in parental attributions. Findings are discussed with a focus on approaches to enhance the effectiveness of assessment and psychosocial treatment approaches across diagnostic categories with consideration of parental attributions.

The British Columbia Healthy Connections Project: findings on socioeconomic disadvantage in early pregnancy

Background

Maternal exposure to socioeconomic disadvantage increases the risk of child injuries and subsequent child developmental and mental health problems — particularly for young mothers. To inform early intervention planning, this research therefore aimed to describe the health and social adversities experienced by a cohort of girls and young women in early pregnancy in British Columbia (BC), Canada.

Methods

Participants were recruited for the BC Healthy Connections Project (BCHCP), a randomized controlled trial examining the effectiveness of Nurse-Family Partnership, a home visitation program, in improving child and maternal outcomes. Baseline data were collected from 739 participants on trial entry. Participants were selected on the basis of preparing to parent for the first time and experiencing socioeconomic disadvantage. Analyses involved descriptive statistics and age-group comparisons.

Results

Most participants reported having low income (84%), having limited education (52%) and being single (91%) at trial entry. Beyond these eligibility criteria, other health and social adversities included: housing instability (52%); severe anxiety or depression (47%); other diagnosed mental disorders (22%); prenatal nicotine and cannabis use (27 and 21%); physical health problems (20%); child maltreatment when younger (56%); and intimate partner violence recently (50%). As well, few (29%) had received income assistance entitlements. More than two thirds (70%) were experiencing four or more forms of adversity. Age-group differences were observed for cognitive functioning, being single, low income, limited education, psychological distress and service use (p-value ≤0.05).

Conclusions

This cohort was selected on the basis of socioeconomic disadvantage. Yet all participants were experiencing substantial added adversities — at higher rates than other Canadians. Furthermore, despite Canada’s public programs, these pregnant girls and young women were not being adequately reached by social services. Our study adds new data to inform early intervention planning, suggesting that unacceptably high levels of socioeconomic disadvantage exist for some young British Columbians. Therefore greater health and social supports and services are warranted for these young mothers and their children.

Trial registration

Registered August 24, 2012 with ClinicalTrials.gov Identifier: NCT01672060. Active not recruiting.

Six decades of preventing and treating childhood anxiety disorders: a systematic review and meta-analysis to inform policy and practice

Question

Anxiety disorders are the most prevalent childhood mental disorders. They also start early and persist, causing high individual and collective costs. To inform policy and practice, we therefore asked: What is the best available research evidence on preventing and treating these disorders?

Methods

We sought randomised controlled trials (RCTs) evaluating interventions addressing anxiety problems in young people. We identified RCTs by searching CINAHL, ERIC, MEDLINE, PsycINFO and Web of Science. Thirty-three RCTs met inclusion criteria—evaluating 8 prevention programmes, 12 psychosocial treatments and 7 pharmacological treatments. We then conducted meta-analyses by intervention type.

Findings

For prevention, the cognitive-behavioural therapy (CBT) programme Coping and Promoting Strength stood out for reducing anxiety diagnoses. For psychosocial treatment, 9 CBT interventions also reduced diagnoses: Cool Kids; Cool Little Kids Plus Social Skills; Coping Cat; Coping Koala; One-Session Treatment; Parent Education Program; Skills for Academic and Social Success; Strongest Families and Timid to Tiger. Successful CBT interventions were used with children ranging from pre-schoolers to teens in homes, communities/schools and clinics. For pharmacological treatment, selective-serotonergic-reuptake-inhibitors (SSRIs) significantly improved symptoms. Fluoxetine stood out for also reducing post-test diagnoses, but caused adverse events. Meta-analyses indicated strongest effects for CBT (Log OR=0.95; 95% CI, 0.69 to 1.21) and SSRI treatments (1.57; 1.09 to 2.06).

Conclusions

CBT is effective for preventing and treating childhood anxiety—across a range of ages and formats. Fluoxetine is also an effective treatment but side effects must be managed. CBT prevention and treatment interventions should be made widely available, adding fluoxetine in severe cases.