A psychometric evaluation of the interRAI Child and Youth Mental Health instruments (ChYMH) anxiety scale in children with and without developmental disabilities

The Coronavirus Pandemic and Mental Health Presentations of Young Children

Children under the age of four are emotionally vulnerable to global disasters, such as the COVID-19 pandemic given the lack of socialization opportunities and coping mechanisms, and susceptibility to heightened caregiver stress. Currently, the extent to which the pandemic impacted the mental health of clinically referred young children is unknown. To evaluate how children's mental health outcomes were impacted during the pandemic, interRAI Early Years assessments (N = 1343) were obtained from 11 agencies across the Province of Ontario, during pre-pandemic and pandemic timepoints. Findings demonstrated that the number of completed assessments declined during the pandemic. Further, children's emotional concerns differed before and during the pandemic, whereby children exhibited greater emotional dysregulation during the pandemic. However, there were no significant differences when examining caregiver distress, parenting strengths, child distractibility/inattention or behavioural issues. Implications for young children and their families, clinicians, and policy makers are discussed.

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.

Family dynamics, trauma, and child-related characteristics: examining factors associated with co-occurring mental health problems in clinically-referred children with and without an intellectual (and developmental) disability

Psychiatric disorders are common in youth with intellectual and developmental disabilities. This is a vulnerable group of children whose behavioural problems often have more complicated care needs than other children, which can place a great deal of stress on their families. However, the association of family mental health issues, level of intellectual ability, and diagnostic co-morbidity in children is relatively under-studied. In the present study, we investigated the relationship among child diagnoses, family mental health problems, risk for self-injury, and disruption in care among children with (N = 517) and without (N = 517) intellectual and developmental disabilities. A negative binomial regression showed that mental health problems in multiple family members, self-injurious behaviour, and self-reported abuse/trauma was related to greater likelihood of provisional diagnoses of co-occurring psychiatric disorders in both a clinically referred sample and a sample with IDD. Implications for care-planning are discussed.

Treatment Seeking Children and Youth who have Experienced Warzone Trauma: Examining the Mental Health Care Planning Needs

This study compares mental health treatment-seeking children and youth who have experienced warzone-related trauma to other treatment-seeking children and youth to determine similarities and differences and aid in care planning. Data from 53 agencies across Ontario from 2015-2022 were analysed, resulting in a sample of 25,843 individuals, 188 of which met the warzone and immigration criteria. Individuals who experienced warzone-related trauma were less likely to: (a) have a psychiatric diagnosis; (b) speak English, and; (c) have close friends. Collaborative Action Plans (CAPS) related to traumatic life events, parenting, and informal support were triggered at a higher rate for those who experienced warzone-related trauma compared to those who did not. This study highlights areas where children and youth who have experienced warzone-related trauma require improved access to services. Findings also highlight issues related to a needs-based approach to service delivery to facilitate improved outcomes for these vulnerable children and their families.

The impact of child maltreatment on mental health outcome improvements among children and youth accessing community mental health care

BACKGROUND

Although children with histories of maltreatment are more likely to engage with mental healthcare than non-maltreated children, few studies have examined the impact of maltreatment on children's mental health outcome improvement over time.

OBJECTIVE

The current study addresses this gap in the present literature by exploring the ways that histories of physical, sexual, and emotional abuse and exposure to domestic violence can influence children's improvement on mental health outcomes commonly associated with trauma.

PARTICIPANTS AND SETTING

De-identified routine care data from 58 community mental health agencies across Ontario, Canada, representing 16,517 children was obtained. This data represented assessments that occurred between February 2015 and December 2021.

METHODS

General linear models were used to illustrate the effect of each trauma type on change scores computed between baseline and follow-up assessments of externalizing behaviours, risk of harm to others, depressive symptoms, risk of suicide and self-harm, and anxiety, while adjusting for baseline scores, inpatient status, time between assessments, and select demographic variables.

RESULTS

When the effects of each trauma type was considered separately, children without histories of trauma consistently showed greater improvement than those with that trauma across all mental health outcomes (0.07-0.44, p < 0.01). When all trauma types were considered together, sexual abuse was associated with some of the most significant negative impacts on children's mental health improvements.

CONCLUSIONS

Our findings highlight an urgent need for the implementation of standardized, evidence-based assessments that screen trauma histories of children accessing mental health supports and research examining the impact of trauma on children's treatment responsiveness.

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.

Parental Postnatal Depression in the Time of the COVID-19 Pandemic: A Systematic Review of Its Effects on the Parent-Child Relationship and the Child's Developmental Outcomes

The international literature has shown that maternal and paternal postnatal depression (PND) is one of the most common mental illnesses in the perinatal period, with significant consequences for parent-infant relationships and infant development. The COVID-19 pandemic has increased the rates of prevalence of PND, exacerbating the mental health risk for new families. This systematic review aims to examine the effect of maternal and paternal PND on parent-infant relationships and children's development in the first 36 months after childbirth during the COVID-19 outbreak. Eligible studies were identified using the following databases: Medline, CINAHL, SCOPUS, PsycINFO, PsycARTICLES, ScienceDirect, and Web of Science. Of the 1252 studies considered, 10 studies met the inclusion criteria. Results showed that maternal PND significantly affected the quality of the early mother-infant relationship and the infant's motor, self-regulation, and socio-emotional development. In addition, the detrimental impact of maternal PND on the quality of early mother-infant relationships seems to become stronger as COVID-19 concerns increase. No studies included fathers. These findings strengthened the importance of planning targeted prevention and treatment strategies to prevent PND and its short- and long-term consequences, especially in the case of stressful and traumatic events. They also suggested the urgent need for further exploration of fathers.

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.

Mood Disturbances Across the Continuum of Care Based on Self-Report and Clinician Rated Measures in the interRAI Suite of Assessment Instruments

BACKGROUND

Mood disturbance is a pervasive problem affecting persons of all ages in the general population and the subset of those receiving services from different health care providers. interRAI assessment instruments comprise an integrated health information system providing a common approach to comprehensive assessment of the strengths, preferences and needs of persons with complex needs across the continuum of care.

OBJECTIVE

Our objective was to create new mood scales for use with the full suite of interRAI assessments including a composite version with both clinician-rated and self-reported items as well as a self-report only version.

METHODS

We completed a cross-sectional analysis of 511,641 interRAI assessments of Canadian adults aged 18+ in community mental health, home care, community support services, nursing homes, palliative care, acute hospital, and general population surveys to develop, test, and refine new measures of mood disturbance that combined clinician and self-rated items. We examined validity and internal consistency across diverse care settings and populations.

RESULTS

The composite scale combining both clinician and self-report ratings and the self-report only variant showed different distributions across populations and settings with most severe signs of disturbed mood in community mental health settings and lowest severity in the general population prior to the COVID-19 pandemic. The self-report and composite measures were strongly correlated with each other but differed most in populations with high rates of missing values for self-report due to cognitive impairment (e.g., nursing homes). Evidence of reliability was strong across care settings, as was convergent validity with respect to depression/mood disorder diagnoses, sleep disturbance, and self-harm indicators. In a general population survey, the correlation of the self-reported mood scale with Kessler-10 was 0.73.

CONCLUSIONS

The new interRAI mood scales provide reliable and valid mental health measures that can be applied across diverse populations and care settings. Incorporating a person-centered approach to assessment, the composite scale considers the person's perspective and clinician views to provide a sensitive and robust measure that considers mood disturbances related to dysphoria, anxiety, and anhedonia.

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.

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.

Traumatic life events, polyvictimization, and externalizing symptoms in children with IDD and mental health problems

BACKGROUND AND AIMS

This study aims to examine the rates of potentially traumatic events (PTEs) and polyvictimization, as well as interrelationships among PTE types in children and youth with intellectual developmental disorder (IDD) and co-occurring mental health issues. It also examines the association between polyvictimization (experiencing three or more PTEs) and externalizing symptoms, controlling for IDD severity, sex and age.

METHOD

The study utilized archival data collected from 2012 to 2020 by trained assessors (e.g., nurses, social workers, psychologists) at intake into clinical mental health services in the Province of Ontario, Canada. The sample included 502 children and youth (age range: 4-18 years) who were assessed using the interRAI Child and Youth Mental Health and Developmental Disability (ChYMH-DD) instrument. Using this standardized assessment, trained clinicians reported on children's demographics, traumatic life events, and externalizing symptoms (proactive and reactive aggression) among other physical and mental health indicators.

RESULTS

64.74 % of the children had experienced at least one type of PTE, whereas 33.06 % experienced lifetime polyvictimization. Most of the PTE types were positively correlated, with the strongest associations between physical, emotional abuse, witnessing domestic violence, and parental addiction. In a multivariate model, experiences of three or more PTEs (vs. none), mild or moderate IDD (vs. severe/profound), male sex (vs. female) were associated with greater externalizing symptoms. There was a quadratic relationship between age and externalizing symptoms.

CONCLUSION

The project advances knowledge on trauma and polyvictimization patterns and their association with IDD severity and externalizing symptoms in this population. Trauma-informed services should be tailored to the specific needs of these children.

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.