Barriers to managing child and adolescent mental health problems: a systematic review of primary care practitioners' perceptions

Motivational Interviewing in Pediatric Mental Health

Although many pediatric clinicians have familiarity with motivational interviewing (MI), they may have limited awareness of how it can benefit mental and behavioral health assessment and management. This article describes the spirit, tasks, and skills of MI. Cases illustrate the application of MI to common presentations of mental health concerns in pediatric primary care. These examples provide concrete guidance on how to navigate barriers to applying MI and underscore how MI aligns with the unique opportunities and values of primary care, including longitudinal relationships, opportunities to partner with families in shared decision-making, and valuing culturally-responsive, patient-centered care.

Psychiatry Consultation in Primary Care: Examining Treatment Access for Adolescent Depression

PURPOSE

Youth in the United States are experiencing mental health concerns at an unprecedented level. Child Psychiatry Access Programs offer an innovative approach to close the gap between the need for care and insufficient mental health workforce. This study examined whether primary care provider consultation with a Child Psychiatry Access Program, Michigan Clinical Consultation & Care (MC3), was associated with greater access to treatment for adolescents with moderate to severe depression symptoms.

METHODS

A retrospective chart review was conducted of primary care visits between 2017 and 2021 for adolescent patients with first-time positive scores on the Patient Health Questionnaire-9. Descriptive statistics and logistic regression were used to examine if patients whose primary care provider used MC3 psychiatric consultations had improved access to depression treatment compared to those who did not.

RESULTS

Four hundred seventy nine patients reported Patient Health Questionnaire-9 scores indicating moderate to severe depression symptoms. Compared to non-MC3 consult patients (n = 409), MC3 consult patients (n = 70) had higher odds of being prescribed antidepressant medications (odds ratio [OR], 2.16; 95% confidence interval [CI] [1.11-4.22], p = .05), 4 times higher odds of having a primary care follow-up visit to monitor depression symptoms (OR, 4.56, 95% CI [2.56-8.14], p < .001), and higher odds of accessing mental health therapy (OR, 2.14; 95% CI [1.13-4.05], p = .05).

DISCUSSION

Use of MC3 consultations was associated with increased utilization of evidence-based depression treatments including medication, therapy, and follow-up care. Greater adoption of models such as MC3 may increase the capacity for addressing mental health needs in children.

Implementing Foundry: A cohort study describing the regional and virtual expansion of a youth integrated service in British Columbia, Canada

AIM

Integrated youth services (IYS) have been identified as a national priority in response to the youth mental health and substance use (MHSU) crisis in Canada. In British Columbia (BC), an IYS initiative called Foundry expanded to 11 physical centres and launched a virtual service. The aim of the study was to describe the demographics of Foundry clients and patterns of service utilization during this expansion, along with the impact of the COVID-19 pandemic.

METHODS

Data were analysed for all youth (ages 12-24) accessing both in-person (April 27th, 2018-March 31st, 2021) and virtual (May 1st, 2020-March 31st, 2021) services. Cohorts containing all clients from before (April 27th, 2018-March 16th, 2020) and during (March 17th, 2020-March 31st, 2021) the COVID-19 pandemic were also examined.

RESULTS

A total of 23 749 unique youth accessed Foundry during the study period, with 110 145 services provided. Mean client age was 19.54 years (SD = 3.45) and 62% identified as female. Over 60% of youth scored 'high' or 'very high' for distress and 29% had a self-rated mental health of 'poor', with similar percentages seen for all services and virtual services. These ratings stayed consistent before and during the COVID-19 pandemic.

CONCLUSIONS

Foundry has continued to reach the target age group, with a 65% increase in number of clients during the study period compared with the pilot stage. This study highlights lessons learned and next steps to promote youth-centred data capture practices over time within an integrated youth services context.

Barriers to Mental Health care in Canada Identified by Healthcare Providers: A Scoping Review

The mental health treatment gap remains wide across the world despite mental illness being a significant cause of disability globally. Both end-user and healthcare provider perspectives are critical to understanding barriers to mental healthcare and developing interventions. However, the views of providers are relatively understudied. In this review, we synthesized findings from current literature regarding providers' perspectives on barriers to mental healthcare in Canada. We searched Medline, PsycINFO, Embase, and CINAHL for eligible Canadian studies published since 2000. Analysis and quality assessment were conducted on the included studies. Of 4,773 reports screened, 29 moderate-high quality studies were reviewed. Five themes of barriers emerged: health systems availability and complexity (reported in 72% of the studies), work conditions (55%), training/education (52%), patient accessibility (41%), and identity-based sensitivity (17%). Common barriers included lack of resources, fragmented services, and gaps in continuing education. Interestingly, clinicians often cited confusion in determining the ideal service for patients due to an overwhelming number of potential services without clear descriptions. These five domains of barriers present a synthesized review of areas of improvement for mental healthcare spanning both patients and clinicians. Canadian mental health systems face a need to improve capacity, clinician training, and in particular service navigability and collaboration.

Pre-implementation determinants for digital mental health integration in Chicago pediatric primary care

OBJECTIVE

Pediatric primary care (PPC) is a common treatment site for pediatric mental health, but it is currently unable to meet the needs of all teen patients, particularly those with minoritized identities and/or marginalized experiences. Digital mental health (DMH) low-intensity treatments (LITs) can increase mental health screening and care capacity in PPC, but how this is done successfully without burdening providers, patients, or families is unclear. This paper presents a pre-implementation study aimed at understanding the implementation context (PPCs in Chicago, IL) for a specific DMH LIT.

METHOD

Using a mixed-methods design, quantitative data from an online survey of providers assessed current DMH practices in PPC, and qualitative interviews with Pediatricians and Pediatric Psychologists examined implementation determinants for a specific DMH LIT. Quantitative data were analyzed using descriptive statistics, and interviews were analyzed using rapid qualitative assessment.

RESULTS

Survey reports (n = 105) and interviews (n = 6) indicated low current use of DMH. Providers in PPC clinics voiced multiple reasons for low usage and low perceived feasibility, including: Consolidated Framework for Implementation Research (CFIR) Inner Setting Domain (PPC clinic workflow, responsibility and ethical considerations, patient privacy and confidentiality), CFIR Outer Setting Domain (hospital and healthcare system factors), CFIR Innovation Domain (DMH design), and a cross-cutting theme of safety.

CONCLUSIONS

Provider-reported low feasibility for integrating DMH in PPC is a call to action to partner with interdisciplinary colleagues and identify how such settings can ethically and seamlessly deliver digital evidence-based and accessible screening and care prior to implementation.

The Capacity-to-Serve Model as a Data-Driven Process for Provider Capacity Management in Outpatient Community Mental Health

Despite increasing mental health provider supply shortages, research on capacity planning and management in the field of outpatient community mental healthcare is limited. There is an immediate need for strategies to plan and manage the capacity of existing mental healthcare providers to ensure a balance between demand and resources. To address this need, research on capacity planning and management in healthcare and mental healthcare settings is reviewed. Next, the Capacity-to-Serve Model is introduced and defined as a data-driven process for quantifying and reporting real-time standardized estimates of mental health provider availability based on qualifications, monitoring of outcome targets, and use of the Capacity-to-Serve Ratio and Realizing Capacity Measure. Finally, implications for using the model as an innovative solution for capacity management to meet demand in mental health are addressed. A case example is provided to demonstrate the application of the model. Ultimately, the Capacity-to-Serve Model can standardize capacity reporting of existing provider organizations and networks, both small and large, to support increased access to and supply of mental health services.

Psychosocial Competencies Among Clinic-Referred and Community-Based Children: Known-Groups Validity of the Psychosocial Strengths Inventory for Children and Adolescents (PSICA)

Child psychosocial competencies protect against the development of psychopathology, ameliorate existing psychosocial problems, and predict positive long-term developmental cascades. Assessment of these competencies can improve identification of children in need of psychosocial services, enrich treatment planning, and improve treatment progress and outcome monitoring. Yet, appropriate measures are limited. One promising option is the Psychosocial Strengths Inventory for Children and Adolescents (PSICA), although its discriminative properties were formerly unknown. The present study evaluated the PSICA's sensitivity, specificity, and optimal cutoff scores with 228 youth (38 clinic-referred and 190 community-based youth with case-control matching) ages 2-10 years (Mage = 5.8, 71% boys, 77% White). Results indicated large, significant discrepancies, with clinic-referred youth rated as having less overall psychosocial competence overall and across domains of compliance, prosociality, and attention. Caregivers also reported significantly less satisfaction with the psychosocial competence of clinic-referred versus community youth. Discriminative accuracy of the PSICA's Frequency and Satisfaction scales, and its subscales, were good-to-excellent. Such discriminative accuracy and empirically derived, if preliminary, cutoff scores further support the PSICA as a pragmatic, psychometrically strong tool to screen children for referral into services, and potentiate future investigations into the PSICA's use in treatment planning and evaluation.

Evaluation of practice nurses' management of paediatric psychosocial problems in general practice

BACKGROUND

Child mental health services are under major pressure worldwide. In the Netherlands, Youth Mental Health Practice Nurses (YMHPNs) have been introduced in general practice to improve access to care. In this study, we evaluated care delivered by YMHPNs.

METHODS

We used medical records of a population-based cohort (21 717 children, 0-17 years). Characteristics of children consulting a YMHPN, type of problem, care delivered by YMHPNs and referrals were assessed using quantitative content analysis.

RESULTS

Records of 375 children (mean age 12.9 years, 59.2% girl) were analysed. These children were often in their adolescence (57.3% was between 13 and 17 years), and more often female than male (59.2% vs 40.8%). YMHPNs had a median of four consultations (IQR 2-7) with the child. YMHPNs managed a variety of psychosocial problems. YMHPNs managed 22.4% of children without need of referral, 52.0% were eventually referred for additional care. 13.3% of children dropped out during the treatment trajectory. In the remaining 12.3% of children, the treatment trajectory was stopped because the child was already attending specialized services, the treatment trajectory was still ongoing or the medical record was inconclusive.

CONCLUSIONS

YMHPNs successfully managed one in four children with psychosocial problems without need for referral. Nevertheless, most children were eventually referred for additional care.

Psychological interventions for children with emotional and behavioral difficulties aged 5-12 years: An evidence review

In low- and middle-income countries (LMICs), children and families face a multitude of risk factors for mental health and well-being. These risks are even further exacerbated in humanitarian emergencies. However, access to effective mental health services in such settings is severely limited, leading to a large mental health treatment gap. Middle childhood (5-12 years) is a crucial period for human development during which symptoms of emotional distress often emerge, with one in three mental disorders developing prior to age 14. However, there is little evidence of effective psychological interventions for children in this developmental stage, and suitable for implementation within LMICs and humanitarian emergencies. We conducted this evidence review to inform the development of a new intervention package based on existing best practice for this age group, drawing insights from both global and LMIC resources. Our review synthesizes the findings of 52 intervention studies from LMICs and humanitarian settings; 53 existing systematic reviews and meta-analyses covering both LMICs and high-income countries, and 15 technical guidelines. Overall, there is limited high-quality evidence from which to draw recommendations for this age group; however, some promising intervention approaches were identified for children experiencing externalizing and internalizing symptoms, traumatic stress and a combination of difficulties. Several effective interventions utilize cognitive-behavioral techniques for children, in either group or individual format, and incorporate caregiver skills training into treatment, although the findings are mixed. Most evaluated interventions use specialists as delivery agents and are lengthy, which poses challenges for scale-up in settings where financial and human resources are scarce. These findings will inform the development of new psychological interventions for children in this age group with emotional and behavioral difficulties.

Adolescent behavioural risk screening in primary care: physician's point of view

BACKGROUND

Despite regular consultation between adolescents/young adults (AYA) and their physicians, they are not regularly screened for psychosocial risk behaviours. This study examines physicians' self-reported psychosocial risk behaviour screening in AYA. It aims to highlight which elements hinder or improve screening abilities.

METHODOLOGY

The design was a cross-sectional quantitative survey. Data were obtained through a self-reported questionnaire sent out to primary care physicians (PCP) in Switzerland in 2018. The target population consisted of 1,824 PCP (29% response rate). Participants were asked whether they screened youths from 3 age groups [10-14 y/o, 15-20 y/o, and 21-25y/o] for the HEEADSSS items during child well visits and routine checkups. Barriers to screening included primary consultation motive prioritization, insufficient time, patient compliance, reimbursement, lack of skills related to adolescent health, lack of referral options. Data were analysed first through a bivariate analysis using Chi-square tests then through a multinomial logistic regression.

RESULTS

The majority of physicians partook in preventive screening for 3-5 psychosocial risk elements. They reported the primary consultation motive as well as a lack of available time as having a high impact on their screening habits. Physician's experience and having discussed confidentiality were related to an increase in the number of topics addressed. Confidentiality remained a significant variable throughout all analyses.

CONCLUSION

Barriers such as lack of consultation time and prioritization issues were found by physicians to be critical but did not hinder screening habits. The main element impacting screening habits was assuring confidentiality and the second is self-efficacy.

Depression Screening in Pediatric Orthopedic Surgery Clinics and Identifying Patients At-Risk

BACKGROUND

Up to 25% of youth experience a depressive episode by 18 years of age, leading the US Preventive Services Task Force to recommend depression screening within this population. This study aimed to understand the prevalence of depression identified within pediatric orthopedic clinics compared with primary care clinics after the implementation of a screening program and present data on the prevalence of moderate-severe depression across specific pediatric orthopedic clinics, characterizing and identifying specific populations at higher risk.

METHODS

A retrospective review was performed to identify all patients screened using the 2-item and 9-item versions of the Patient Health Questionnaire (PHQ-2/PHQ-9) and the Columbia-Suicide Severity Rating Scale over a 2-year period (October 2018 to January 2021) within pediatric primary care and orthopaedic clinics. Demographic and clinical characteristics were collected. Statistical analysis was performed to compare scores between orthopedic and primary care clinics, as well as between the different pediatric orthopedic subspecialties and included χ 2 test, ANOVA, and logistic regression.

RESULTS

There were 32,787 unique adolescent patients screened in primary care clinics, with an additional 14,078 unique adolescent patients screened in orthopaedic clinics, leading to a 30% increase in the overall number of patients receiving depression screening. 5.2% of patients in primary care pediatric clinics screened positive for moderate-severe depression versus 2.0% in pediatric orthopaedic clinics ( P <0.001). 2.7% of primary care patients were at risk of self-harm compared with 0.8% of orthopedic patients ( P <0.001). Within orthopaedic subspecialty clinics, the spine patients were at the highest risk of moderate-severe depression (3.5%), significantly higher than both the sports (1.4%, P =0.006) and patients with acute fracture (1.3%, P <0.001).

CONCLUSIONS

This study demonstrates the high incidence of patients screening positive for depression in pediatric and adolescent orthopaedic clinics. By identifying high-risk clinics and patient groups, health care systems can apply a more practical approach and appropriately deploy behavioral health specialists for timely counseling and treatment discussions.

LEVEL OF EVIDENCE

Level-III.

Incorporating a Psychiatric Telehealth Simulation in a Family Nurse Practitioner Curriculum

The prevalence of mental health disorders in primary care is high and challenges related to the COVID pandemic warrant further training of the family nurse practitioner. A telehealth simulation learning experience that included common primary care diagnoses in mental health-general anxiety, depression, and substance use disorder-was incorporated into a non-clinical behavioral health course. Formative evaluation provided by licensed nurse practitioners confirmed the need for improving interviewing techniques, engaging clients, and promoting safety among this population. Students' confidence during the encounter was measured using the Simulation Effectiveness Tool. Findings suggest a simulation learning experience is an effective resource for training nurse practitioner students to treat mental health disorders.

Possible unintended consequences of pediatric clinician strategies for communicating about social-emotional and developmental concerns in diverse young children

INTRODUCTION

Screening to promote social-emotional well-being in toddlers has positive effects on long-term health and functioning. Communication about social-emotional well-being can be challenging for primary care clinicians for various reasons including lack of time, training and expertise, resource constraints, and cognitive burden. Therefore, we explored clinicians' perspectives on identifying and communicating with caregivers about social-emotional risk in toddlers.

METHOD

In 2021, semistructured interviews were conducted with pediatric clinicians (N = 20) practicing in Federally Qualified Health Centers in a single metropolitan area. Most participants identified as female (n = 15; 75%), white non-Hispanic/Latino (n = 14; 70%), and were Doctors of Medicine or Osteopathic Medicine (n = 14; 70%). Thematic analysis was conducted on audio-recorded interview transcripts.

RESULTS

Clinicians used various approaches to identify social-emotional concerns which were sometimes difficult to distinguish from other developmental concerns. The clinician-caregiver relationship guided identification and communication practices and cut-across themes. Themes include: starting with caregivers' concerns, communicating concerns with data and sensitivity, navigating labels, culture, and stigma, and limiting communication based on family capacity and interest.

DISCUSSION

Prioritizing the clinician-caregiver relationship is consistent with best practice and family-centered care. Yet, the dearth of standardized decision support may undermine clinician confidence and impede timely conversations about social-emotional concerns. An evidence-based approach with developmentally based culturally informed quantitative tools and standardized decision supports could help ensure equitable management and decision making about young children's social and emotional well-being and development. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Engaging primary care clinicians in the selection of implementation strategies for toddler social-emotional health promotion in community health centers

BACKGROUND

Social-emotional risk for subsequent behavioral health problems can be identified at toddler age, a period where prevention has a heightened impact. This study aimed to meaningfully engage pediatric clinicians, given the emphasis on health promotion and broad reach of primary care, to prepare an Implementation Research Logic Model to guide the implementation of a screening and referral process for toddlers with elevated social-emotional risk.

METHOD

Using an adaptation of a previously published community partner engagement method, six pediatricians from community health centers (CHCs) comprised a Clinical Partner Work Group. The group was engaged in identifying determinants (barriers/facilitators), selecting and specifying strategies, strategy-determinant matching, a modified Delphi approach for strategy prioritization, and user-centered design methods. The data gathered from individual interviews, two group sessions, and a follow-up survey resulted in a completed Implementation Research Logic Model.

RESULTS

The Clinical Partner Work Group identified 16 determinants, including barriers (e.g., patient access to electronic devices) and facilitators (e.g., clinician buy-in). They then selected and specified 14 strategies, which were prioritized based on ratings of feasibility, effectiveness, and priority. The highest-rated strategies (e.g., integration of the screener into the electronic health record) provided coverage of all identified barriers and comprised the primary implementation strategy "package" to be used and tested.

CONCLUSIONS

Clinical partners provided important context and insights for implementation strategy selection and specification to support the implementation of social-emotional risk screening and referral in pediatric primary care. The methodology described herein can improve partner engagement in implementation efforts and increase the likelihood of success. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Replicability and reproducibility of predictive models for diagnosis of depression among young adults using Electronic Health Records

BACKGROUND

Recent advances in machine learning combined with the growing availability of digitized health records offer new opportunities for improving early diagnosis of depression. An emerging body of research shows that Electronic Health Records can be used to accurately predict cases of depression on the basis of individual's primary care records. The successes of these studies are undeniable, but there is a growing concern that their results may not be replicable, which could cast doubt on their clinical usefulness.

METHODS

To address this issue in the present paper, we set out to reproduce and replicate the work by Nichols et al. (2018), who trained predictive models of depression among young adults using Electronic Healthcare Records. Our contribution consists of three parts. First, we attempt to replicate the methodology used by the original authors, acquiring a more up-to-date set of primary health care records to the same specification and reproducing their data processing and analysis. Second, we test models presented in the original paper on our own data, thus providing out-of-sample prediction of the predictive models. Third, we extend past work by considering several novel machine-learning approaches in an attempt to improve the predictive accuracy achieved in the original work.

RESULTS

In summary, our results demonstrate that the work of Nichols et al. is largely reproducible and replicable. This was the case both for the replication of the original model and the out-of-sample replication applying NRCBM coefficients to our new EHRs data. Although alternative predictive models did not improve model performance over standard logistic regression, our results indicate that stepwise variable selection is not stable even in the case of large data sets.

CONCLUSION

We discuss the challenges associated with the research on mental health and Electronic Health Records, including the need to produce interpretable and robust models. We demonstrated some potential issues associated with the reliance on EHRs, including changes in the regulations and guidelines (such as the QOF guidelines in the UK) and reliance on visits to GP as a predictor of specific disorders.

Efficacy of internet-based cognitive-behavioral therapy for depression in adolescents: A systematic review and meta-analysis

Objective

Internet-based cognitive behavior therapy (ICBT) may provide an accessible alternative to face-to-face treatment, but the evidence base in adolescents is limited. This systematic review and meta-analysis aims to comprehensively assess the efficacy of ICBT in addressing depression among adolescents.

Methods

Four electronic databases were searched on June 8, 2023. Randomized controlled trials (RCTs) evaluating the efficacy of ICBT for depression in adolescents were included. The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane Handbook. Furthermore, the GRADE approach was employed to gauge the certainty of the obtained evidence. Meta-analysis was conducted using RevMan 5.4, and Egger's test was implemented through Stata for assessment of potential publication bias.

Results

A total of 18 RCTs involving 1683 patients were included. In comparison to control groups like attention control, waiting list, and treatment as usual, our meta-analysis findings elucidate a significant reduction in depression scores (SMD = -0.42, 95 % CI: [-0.74, -0.11], p < .05) as well as anxiety scores (SMD = -0.34, 95 % CI: [-0.60, -0.08], p < .05) in adolescents following ICBT interventions. Furthermore, the analysis indicated no notable distinctions in patient's quality of life (QoL) scores. (SMD = 0.12, 95 % CI: [-0.10, 0.34], p > .05).

Conclusion

Results provide evidence of the efficacy of ICBT to reduce depressive and anxiety symptoms in adolescents. These research findings are of vital significance for the establishment of evidence-based treatment guidelines in the digital era.

Trial registration

PROSPERO registration: CRD42021277562.

A scoping review of the Choice and Partnership Approach in child and adolescent mental health services

Child and adolescent mental health (CAMH) problems are prevalent and inefficient mental health (MH) care systems can contribute to poor outcomes. The Choice and Partnership Approach (CAPA) is a MH care delivery model aiming to provide efficient, high-quality care. Although widely used, no CAPA research review exists. We conducted a scoping review to fill this gap. Medline, Embase, and PsycINFO databases were searched from inception to June 2021. Grey Matters and Google were used to search the grey literature. We identified 5322 records. Removal of duplicates left 4720 documents, which were successively screened and data extracted by pairs of co-authors. The final dataset comprised six published and three non-published studies, conducted primarily at CAMH sites in England, Scotland, Australia, or Canada. Each study had multiple research objectives, which we summarized into seven categories. Positive outcomes were reported for most objectives, but attributing causality to CAPA was hampered by research methodology. Observational designs were used in all studies and approaches to analyzing data varied considerably. Research gaps included the lack of healthcare economics studies of CAPA and no assessment of facilitators and barriers. Current research on CAPA provides intriguing findings meriting further investigation. We suggest strategies to improve future studies.

Estimates of Major Depressive Disorder and Treatment Among Adolescents by Race and Ethnicity

Importance

The COVID-19 pandemic has contributed to poorer mental health and a greater need for treatment. Nationally representative estimates of major depressive disorder (MDD) and mental health treatment among US adolescents during the pandemic are needed.

Objective

To estimate MDD prevalence among adolescents, evaluate mental health treatment use among adolescents with MDD, and assess differences by race and ethnicity.

Design, Setting, and Participants

This cross-sectional analysis of the nationally representative 2021 National Survey on Drug Use and Health included noninstitutionalized US adolescents between the ages of 12 and 17 years (n = 10 743). Analytic weights were applied to all rates and model estimates to be nationally representative and account for sample design and survey nonresponse. Data were collected from January 14 to December 20, 2021, and analyzed from February 11 to April 3, 2023.

Exposures

Self-reported race and ethnicity.

Main Outcomes and Measures

Dichotomous outcomes of MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), MDD-specific mental health treatment, any type of mental health treatment, telehealth visits, and delays in mental health treatment.

Results

The sample included 10 743 adolescents (51.1% male). Self-reported race and ethnicity included 5.1% Asian, 14.1% Black, 23.3% Latinx, 51.2% White, and 6.3% more than 1 race. Ages were evenly distributed: 34.0% aged 12 to 13 years; 33.3% aged 14 to 15 years; and 32.7% aged 16 to 17 years. Adolescents of more than 1 race or ethnicity had the highest MDD rate (26.5%). Compared with White adolescents, the lowest rates of any MDD treatment overall were found among Latinx adolescents (29.2% [95% CI, 22.2%-36.2%]) and those of more than 1 race or ethnicity (21.1% [95% CI, 11.6%-30.7%]). Similar results were found for treatment by any clinician (Latinx, 25.6% [95% CI, 18.8%-32.4%]; >1 race or ethnicity, 19.1% [95% CI, 9.7%-28.6%]), treatment by a mental health specialist (Latinx, 22.9% [95% CI, 16.9%-28.9%]; >1 race or ethnicity, 16.7% [95% CI, 7.1%-26.3%]), treatment by a nonspecialist clinician (Latinx, 7.3% [95% CI, 3.3%-11.3%]; >1 race or ethnicity, 4.8% [95% CI, 1.9%-7.7%]), and use of any psychotropic medication prescription (Latinx, 11.6% [95% CI, 7.3%-15.9%]; >1 race or ethnicity, 8.3% [95% CI, 2.8%-13.7]). Compared with White adolescents, Black adolescents had lower rates of MDD treatment by any clinician (31.7% [95% CI, 23.7%-39.8%]) and by nonspecialist clinicians (8.4% [95% CI, 3.8%-13.2%]) and experienced lower prescription rates for any psychotropic medication (12.6 [95% CI, 4.6%-20.6%]). Asian (16.0% [95% CI, 5.0%-27.2%]) and Latinx (17.8% [95% CI, 12.6%-23.0%]) adolescents had lower rates of virtual mental health treatment compared with White adolescents. Black (19.1% [95% CI, 14.1%-24.2%]) and Latinx (17.9% [95% CI, 15.0%-21.1%]) adolescents had lower rates of appointments transition to telehealth, while Black adolescents (14.1% [95% CI, 10.7%-17.4%]) experienced delays getting their prescriptions.

Conclusions and Relevance

During the first full calendar year of the pandemic, approximately 1 in 5 adolescents had MDD, and less than half of adolescents who needed treatment had any mental health treatment. Adolescents in racial and ethnic minority groups, particularly Latinx, experienced the lowest treatment rates. Federal policy should target adolescents as a whole, and minority populations in particular, to ensure equitable treatment access. Efforts should consider the social, racial, ethnic, and cultural determinants of health.

Community physician perceptions of managing complex child and adolescent psychiatric patients: a self-determination theory perspective

Children and adolescents with complex mental health needs often require a level of care that is unsustainable in tertiary settings. Yet, the psychological impact of this on community physicians, who are tasked with providing quality care to this population, is not well understood. Grounded in Self-Determination Theory (SDT), the present study explores how the challenges of caring for these patients is affecting community physicians' basic psychological needs (autonomy, competence, and relatedness) and intrinsic motivation. Participants from Calgary, Alberta, Canada, were invited to complete an anonymous online survey containing questions about managing complex child and adolescent psychiatric patients. We used SDT's needs-based framework and 22-item Intrinsic Motivation Inventory as a component of our pilot study, to explore and understand their ideas. Community physicians reported moderate-high interest/enjoyment and moderate perceived competence in managing complex child and adolescent patients, but little perceived choice and high tension/pressure in carrying out this task. Physician remarks provided meaningful insights into how these clinical experiences are impacting them, psychologically, and where opportunities may exist for interventions to support them and their patients. Findings from this study suggest that the participating community physicians feel interested and adequately skilled to manage complex child and adolescent psychiatric patients, but that systemic barriers are hindering their basic psychological needs and intrinsic motivation to do so. Potential explanations and implications for these findings are discussed.

Implementing Parenting Programs in Primary Care: A Framework and a Call for Action

Healthy parent-child relationships are clearly critical to healthy child development. Parenting programs develop caregivers' skills to support the health and well-being of children. Rigorous evidence has demonstrated the efficacy of these programs. Rising rates of child and youth depression, anxiety, grief, and suicide, both prior to and compounded by the COVID-19 pandemic, provide further reasons to implement parenting programs that support all parents in their essential roles. Parents can act as a buffer to stressors and support for children's well-being when they have the knowledge and skills to do so. Pediatric primary care practices are a natural setting for parenting programs, but challenges, including stigma, technology, workflow issues, and funding, have prevented their broad dissemination, implementation, and sustainability. In this article, we develop a framework for implementing parenting programs in primary care and present key considerations for selecting programs that fit the needs of parents, providers, patients, and the practice. We offer lessons from our experiences in overcoming these challenges, using the updated Consolidated Framework for Implementation Research to structure our discussion. We also provide an initial stepwise process which readers may use to plan their own parenting program implementation. Pediatric clinicians and practices can use this article and associated resources to plan, implement, and evaluate parenting programs in their practices as a strategy to help address the growing youth mental health crisis. Improving parenting behaviors can reduce the need for current or future mental health interventions by supporting optimal child development, emotional regulation, and parent-child relationships.

Longitudinal studies of child mental disorders in the general population: A systematic review of study characteristics

Introduction

Longitudinal studies of child mental disorders in the general population (herein study) investigate trends in prevalence, incidence, risk/protective factors, and sequelae for disorders. They are time and resource intensive but offer life-course perspectives and examination of causal mechanisms. Comprehensive syntheses of the methods of existing studies will provide an understanding of studies conducted to date, inventory studies, and inform the planning of new longitudinal studies.

Methods

A systematic review of the research literature in MEDLINE, EMBASE, and PsycINFO was conducted in December 2022 for longitudinal studies of child mental disorders in the general population. Records were grouped by study and assessed for eligibility. Data were extracted from one of four sources: a record reporting study methodology, a record documenting child mental disorder prevalence, study websites, or user guides. Narrative and tabular syntheses of the scope and design features of studies were generated.

Results

There were 18,133 unique records for 487 studies-159 of these were eligible for inclusion. Studies occurred from 1934 to 2019 worldwide, with data collection across 1 to 68 time points, with 70% of studies ongoing. Baseline sample sizes ranged from n = 151 to 64,136. Studies were most frequently conducted in the United States and at the city/town level. Internalizing disorders and disruptive, impulse control, and conduct disorders were the most frequently assessed mental disorders. Of studies reporting methods of disorder assessment, almost all used measurement scales. Individual, familial and environmental risk and protective factors and sequelae were examined.

Conclusions

These results summarize characteristics of existing longitudinal studies of child mental disorders in the general population, provide an understanding of studies conducted to date, encourage comprehensive and consistent reporting of study methodology to facilitate meta-analytic syntheses of longitudinal evidence, and offer recommendations and suggestions for the design of future studies. Registration DOI: 10.17605/OSF.IO/73HSW.

Norwegian health personnel's contacts and referrals for children of ill parents: an exploratory cross-sectional multi-centre study

BACKGROUND

In 2010, changes were made to the Norwegian Health Personnel Act. This led to all health personnel being obliged to support the patients' children and families. The aims of this study were to investigate whether health personnel contacted or referred the patients' children to family/friends or public services. We also investigated if there were factors in the family or the services that increased or decreased the degree of contacts and referrals. In addition the patients were asked whether the law had been a help or even a burden. This study was part of a larger multi-site study of children of ill parents conducted in five health trusts in Norway.

METHOD

We used cross-sectional data from 518 patients and 278 health personnel. The informants completed a questionnaire addressing the law. Data were analyzed by factor analysis and logistic regression.

RESULTS

The health personnel contacted/referred children to different services, but not to the degree desired by their parents. Only a few contacted family/friends, or the school and/or the public health nurse, those representing the helpers who live closest to the child, and thus well situated to participate in help and preventive efforts. The service most often referred to was the child welfare service.

CONCLUSION

The results indicate a change in contacts/referrals for children from their parents' health personnel but also reveal remaining needs for support/help for these children. Health personnel should strive to write more referrals and take more contacts than the current study suggests, to secure adequate support for children of ill parents in Norway, as intended in The Health Personnel Act.

Mental health services and resources for children with developmental disabilities and their families: scan of local practices, gaps, and opportunities created

Background

Mental health concerns in children with disabilities are common and have a significant and negative impact. Clinicians have reported high demand for this population to receive early, targeted, and family-centred mental health interventions.

Objective

We sought to map out and describe existing pediatric mental health services/resources for children with disabilities and their families across clinical sites and local and online communities.

Methods

Using a mixed-method triangulation study design, we outreached to clinical managers at the participating clinical sites and conducted a rapid online search of local in-person, telehealth, and web-based information. The nature, access method, admission criteria, target, focus, and other pertinent information were recorded and analyzed using descriptive statistics and a narrative synthesis approach.

Results

Eighty-one (n = 81) services/resources (in-person, n = 48; telehealth, n = 10; web-based information, n = 33) were identified. Few (n = 6, 13%) in-person services had a method of care access through an online booking portal. Nearly half of in-person resources (n = 23, 47%) had admission criteria specific for children with disabilities (e.g., diagnosis, age limit), and many (n = 32, 67%) required a formal referral. A small number of in-person and telehealth services targeted the mental health concerns of the entire family (n = 23, 47%; n = 2, 20%). Very few (n = 13, 16%) services incorporated follow-up support. Important gaps emerged for certain populations (e.g., children with cerebral palsy). Practitioners' inadequate training when intervening with co-existing mental health demands of children with disabilities was noted by clinical managers.

Conclusion

Findings could be used to create a user-friendly database to easily identify suitable services and to advocate for services/resources that are lacking.

Public health nurses experience of mental health encounters in the context of primary health care: a constructivist grounded theory study

BACKGROUND

In primary health care people with mental health needs are often overlooked or masked with physical complaints. It has been suggested that public health nurses lack sufficient knowledge when encountering people with mental health problems. Low levels of mental health literacy among professionals are associated with negative patient outcome. There is a need to understand public health nurses process and strategies used when encountering a person with mental health problems in order to promote mental health. This study aimed to construct a theory that explains the process of public health nurses experience when encountering people with mental health problems based on their knowledge, attitudes, and beliefs about mental health.

METHODS

A constructivist grounded theory design was used to meet the aim of the study. Interviews were conducted with 13 public health nurses working in primary health care between October 2019 and June 2021, and the data analysis was performed according to the principles of Charmaz.

RESULTS

The core category, "Public health nurses as a relationship builder - to initiate the dialogue" reflected the process while the main categories "Being on your own", "Being on top of things- knowing your limits", and "Professional comfort zone" reflected conditions that were decisive for initiating a dialogue.

CONCLUSION

Managing mental health encounters in primary health care was a personal and complex decision-making process that depends on the public health nurses' professional comfort zone and acquired mental health literacy. Narratives of the public health nurses helped to construct a theory and understand the conditions for recognizing, managing and promoting mental health in primary health care.

Identifying individuals at risk of developing psychosis: A systematic review of the literature in primary care services

AIM

Psychosis and related disorders are a major public health issue. Early identification and prevention for those at high risk (at-risk-mental-state, ARMS) is important. General practitioners (GPs) are often the first point of contact for health services. In this review we aim to identify (1) the most common methods for identifying individuals with an ARMS in primary care, (2) the methods for improving identification of individuals with an ARMS in primary care, and (3) the most common barriers that prevent GPs from screening for individuals with an ARMS.

METHODS

We conducted a systematic review (PROSPERO 42021245095) of quantitative and qualitative studies with no date restriction. Searches were performed in September 2021. Studies' quality was appraised using Mixed Methods Appraisal tool (MMAT).

RESULTS

We identified 16 eligible studies, and all but one provided quantitative data. Nearly two-thirds of studies were classified as 'medium' quality. Employing narrative synthesis, we identified three themes relating to (1) improving GP knowledge and confidence in identifying individuals with an ARMS, (2) balancing the over- and under-identification of individuals with an ARMS in primary care, and (3) supporting GPs as significant stakeholders in early diagnosis and treatment of individuals with an ARMS.

CONCLUSIONS

Improved identification of individuals with an ARMS is needed. We identified various strategies, including development and implementation of identification methods (e.g., screening measures), educational interventions for GPs (e.g., workshops), and systemic interventions (e.g., simplifying referrals to secondary care, developing integrated services). When implemented successfully, these interventions may help facilitate the access to appropriate care for individuals with an ARMS.

Anxiety and Depression Treatment in Primary Care Pediatrics

BACKGROUND AND OBJECTIVES

Primary care pediatricians (PCP) are often called on to manage child and adolescent anxiety and depression. The objective of this study was to describe PCP care practices around prescription of selective serotonin reuptake inhibitors (SSRI) for patients with anxiety and/or depression by using medical record review.

METHODS

We identified 1685 patients who had at least 1 visit with a diagnosis of anxiety and/or depression in a large primary care network and were prescribed an SSRI by a network PCP. We randomly selected 110 for chart review. We reviewed the visit when the SSRI was first prescribed (medication visit), immediately previous visit, and immediately subsequent visit. We abstracted rationale for prescribing medication, subspecialist involvement, referral for psychotherapy, and medication monitoring practices.

RESULTS

At the medication visit, in 82% (n = 90) of cases, PCPs documented reasons for starting an SSRI, most commonly clinical change (57%, n = 63). Thirty percent (n = 33) of patients had documented involvement of developmental-behavioral pediatrics or psychiatry subspecialists at 1 of the 3 visits reviewed. Thirty-three percent (n = 37) were referred to unspecified psychotherapy; 4% (n = 4) were referred specifically for cognitive behavioral therapy. Of 69 patients with a subsequent visit, 48% (n = 33) had documentation of monitoring for side effects.

CONCLUSIONS

When prescribing SSRIs for children with anxiety and/or depression, PCPs in this network documented appropriate indications for starting medication and prescribed without subspecialist involvement. Continuing medical education for PCPs who care for children with these conditions should include information about evidence-based psychotherapy and strategies for monitoring potential side effects.

Pediatrician and Child Adolescent Psychiatrist Perspectives of Coordinated Care for Emerging Adults

PURPOSE

To explore pediatrician and child/adolescent psychiatrists' perspectives of the role of coordinated care for emerging adults with serious mental health conditions, particularly as they transition to adult care.

METHODS

Semi-structured individual interviews of a purposive sample of 10 pediatricians and 11 child/adolescent psychiatrists in Massachusetts were used to explore coordinated care for emerging adults. Following verbatim transcription and double coding, we conducted a thematic analysis to identify key themes. Care coordination concepts explored included a case discussion, teamwork, communication methods, medication management, transition to adult care, the healthcare home, and youth and family role. Organizational and societal barriers were also discussed.

RESULTS

Providers described key barriers to continuous, coordinated care for youth with serious mental health conditions, including poor communication systems between providers, no organized process for the transition from pediatric to adult care, state licensing laws (particularly impacting college-age youth), inadequate connection to community supports, and poor reimbursement rates for psychiatric care. Termination of primary care in young adults and inadequate medication side effect monitoring were described as key gaps in care.

DISCUSSION

The current system of coordinated care for emerging adults with serious mental health conditions is a perfect storm of challenges that creates a vicious cycle of interconnected barriers which lead to fragmented, discontinuous, and sub-par care for this population.

Stemming the tide of mental health problems in young people: Challenges and potential solutions

One in five people experience clinically relevant mental health problems before the age of 25 years. Furthermore, in Australia, one in seven children are reported to experience a mental health disorder. Consequently, there has been a steady increase in demand for mental health services for children and young people, and this has been compounded by the COVID-19 pandemic. Unfortunately, currently many children and young people with mental health difficulties are not accessing appropriate and/or timely care, with individuals and families finding it increasingly difficult to access and navigate suitable services. In part, this is related to the fragmented and isolated manner in which child mental health services are operating. To address the current issues in access to appropriate child and adolescent mental health care in Australia, a novel Integrated Continuum of Connect and Care model is proposed to integrate relevant services along a tiered care pathway. The aim of this model is to facilitate timely access to mental health services that meet the specific needs of each child/young person and their family. This model will function within co-located service hubs that integrate health care through a comprehensive assessment followed by a link up to relevant services. The Integrated Continuum of Connect and Care has the potential to pave the way for unifying the fragmented child and youth mental health system in Australia.

The effect of the Development and Well-Being Assessment as an adjunct to standard referral letters on referral decisions by child and adolescent mental health services - a randomized feasibility trial

Background: High rejection rates for referrals to child and adolescent mental health services (CAMHS) are common. The most cited reasons for rejection are that the child does not have a clinical need for assessment and poor quality of the referrals. However, studies of interventions aimed at improving appropriateness of referrals are sparse. Methods: In this randomized feasibility trial, we tested if the Development and Well-Being Assessment (DAWBA) as an adjunct to referral letters could improve accuracy of referral decisions made by CAMHS. The primary outcome of the study was the proportion of "correct" referral decisions. Results: The study included 160 children referred to CAMHS. Almost all (95.6%) participants fulfilled criteria for a mental disorder and 82.1% also reported high impact of symptoms. Compared to the group who did not complete the DAWBA, referral decisions for the DAWBA group showed higher sensitivity (0.63 vs. 0.83), specificity (0.30 vs. 0.42), and negative predictive value (0.14 vs. 0.36) as well as slightly higher positive predictive value (0.81 vs. 0.86). Conclusions: The use of the DAWBA as an adjunct to standard referral letters could lead to more correct referral decisions and reduce the proportion of wrongful rejection referrals to CAMHS.

Parent-identified barriers to accessing exposure therapy: A qualitative study using process mapping

Background

Youth with anxiety and obsessive-compulsive disorder (OCD) rarely access exposure therapy, an evidence-based treatment. Known barriers include transportation, waitlists, and provider availability. Efforts to improve access to exposure require an understanding of the process that families take to find therapists, yet no prior studies have examined parents' perspectives of the steps involved.

Methods

Parents of children who have received exposure therapy for anxiety and/or OCD (N = 23) were recruited from a hospital-based specialty anxiety clinic where the majority of their children previously received exposure. Recruitment was ongoing until thematic saturation was reached. Parents completed questionnaires and attended an online focus group during which they were asked to describe each step they took-from recognizing their child needed treatment to beginning exposure. A process map was created and shown in real-time, edited for clarity, and emailed to parents for member checking. Authors analyzed process maps to identify common themes.

Results

Several themes emerged, as visually represented in a final process map. Participants identified a "search-outreach" loop, in which they repeated the cycle of looking for therapists, contacting them, and being unable to schedule an appointment due to factors such as cost, waitlists, and travel time. Parents often did not know about exposure and reported feeling guilty about their lack of knowledge and inability to find a suitable provider. Parents reported frustration that medical providers did not often know about exposure and sometimes dismissed parents' concerns. Participants emphasized the difficulty of navigating the mental health system; many reported that it took years to find an exposure therapist, and that the search was sometimes stalled due to fluctuating symptoms.

Conclusion

A common thread among identified barriers was the amount of burden placed on parents to find treatment with limited support, and the resultant feelings of isolation and guilt. Findings point to several directions for future research, such as the development of parent support groups for navigating the mental health system; enhancing coordination of care between medical and mental health providers; and streamlining referral processes.

Connecting and Attuning Mental Health Care for Adolescent Patients: The Role of Presence Practice

Introduction

The healthcare system over the years has witnessed evolvement and transformation in the care pattern, including in the mental healthcare system. This has seen a considerable and commendable improvement in patient care. This article aims to demonstrate the need for "presence practice" and practical implications thereof, in the care of adolescents with mental health illnesses and to further demonstrate the need for connecting and attuning mental health care for good care and positive nurse and patient outcomes. The developmental stage of adolescents is characterized by various psychosocial changes. At the same time, the emergence of numerous mental health conditions is prevalent at the adolescent stage, contributing to the disease burden among this age group. Understandably, the prevalence of mental health illnesses in adolescents could be associated with their vulnerability and the result of the interaction of numerous biopsychosocial factors in the lives of the individuals, asserting influences on their development and mental health such as family challenges, the stress associated with schooling, relationship issues, and abuse.

Method

This article follows a quality improvement method where the author took time to nonsystematically explain existing literature on presence practice and its practical implication and further practically demonstrated the need for and how to facilitate connecting and attuning mental health care for good care and positive nurse and patient outcomes.

Result

Presence practice should be adopted by mental health nurses to foster the establishment of relational care with mental health care users, such as adolescents with mental illness, and to help mitigate relapse. Being open-minded and preparing their minds to be receptive and present during care should be part of nurses effective presence practice.

Conclusion

The article concludes that mental health nurses, as frontline caregivers, should always endeavor to connect and attune care to the needs of the adolescents receiving mental health care to foster positive outcomes.

Referring Attention-Deficit/Hyperactivity Disorder: Gaining Perspective From Advanced Practice Providers in Primary Care

The objective of the current study is to identify provider, patient, and family characteristics associated with pediatric advanced practice provider (APP) decisions to refer to a subspecialist for diagnosis and management of attention-deficit/hyperactivity disorder (ADHD). We conducted a cross-sectional electronic survey of pediatric primary care APPs using member lists of professional organizations. T tests and chi-square analysis were conducted to identify group differences. Most respondents rated themselves as comfortable diagnosing and managing ADHD. We found no significant difference between groups based on comfort level or likelihood to refer. APPs working in suburban settings report significantly lower levels of comfort. Self-designation as the practice's primary provider for behavioral/mental health concerns had significantly higher levels of comfort and were less likely to refer. In a limited sample, most APPs reported comfort diagnosing and managing ADHD. Activities to identify and ameliorate gaps in ADHD knowledge and care need to consider this growing part of the workforce.

Parent, teacher, and nurse concerns and school doctor actions: an observational study of general health checks

OBJECTIVE

To evaluate the association between the concerns of parents, teachers, and nurses regarding each child's well-being and the school doctor actions conducted in routine general health checks.

DESIGN

A blinded, observational study. Prior to the health check parents, teachers, and nurses completed questionnaires assessing their concerns. Doctors, blinded to the responses, routinely examined all children accompanied by parents and reported their actions after each health check. Multilevel logistic regression was used to analyse the association of the concerns with the actions.

SETTING

21 primary schools in four municipalities in Finland.

PARTICIPANTS

Between August 2017 and August 2018, we randomly recruited 1341 children from grades 1 and 5, aged 7 and 11 years, respectively.

OUTCOME MEASURES

Outcome measures were the respondents' concerns and the school doctor actions. The extent of concerns was assessed on a five-point Likert scale. Concern refers to 'Quite a lot or a great deal of concern' by at least one respondent. The school doctor actions included instructions and/or significant discussions, prescriptions, laboratory tests and/or medical imaging, scheduling of follow-up appointments, referrals to other professionals, and referrals to specialised care.

RESULTS

Altogether, respondents were concerned about 47.5% of children. The top three concerns comprised growth/and or physical symptoms (22.7%), emotions (16.2%), and concentration (15.1%). All concerns were associated with some type of school doctor action (ORs: 1.66-4.27, p≤0.05); but only concerns regarding growth and/or physical symptoms were associated with all actions. Almost all concerns were associated with referrals to other professionals (ORs: 1.80-4.52, p≤0.01); emotions had the strongest association OR 4.52 (95% CI 3.00 to 6.80, p&lt;0.0001).

CONCLUSIONS

Health checks by school doctors may lead to referrals of children to other professionals especially for children's psychosocial problems. This should be considered when developing the roles, training, and multiprofessional collaboration of school health care professionals.

TRIAL REGISTRATION

NCT03178331.

Factors associated with symptom severity in Canadian youth with mental health and/or addictions concerns accessing service navigation

This study investigated the factors associated with clinical symptoms and level of functioning at baseline and after 4 months of navigation, in youth with mental health and/or addiction concerns involved with a family navigation service. Participants in this pre-post study were caregivers who accessed a mental health and addictions navigation service between March 2018 and July 2019 on behalf of their youth aged 13-26 who had mental health and/or addiction concerns. Evaluations were conducted at baseline and at 4 months after entering navigation. The dependent variable, youth mental health symptoms and functioning, was assessed by caregivers using the Symptoms and Functioning Severity Scale. The sample included 345 caregivers of youth (youth: mean age 18 years, 57% male). At intake, using multiple linear regression, caregiver strain (β = 0.481, p < 0.001), youth completion of ADLs (β = -0.156, p = 0.002) and youth motivation (β = -0.110, p = 0.021) contributed significantly to variance in symptoms and functioning (R²  = 0.373, p < 0.001). Using ANOVA to compare complete pre/post data (n = 115), there was a significant main effect of time on the youth symptoms and functioning score (F[1, 107] = 9.278, p = 0.003). Furthermore, the interaction of time, youth completion of ADLs (low vs. high at baseline) and youth motivation (low vs. high at baseline) was significant (F[1, 107] = 4.699, p = 0.032). Youth with low motivation and low completion of ADLs at baseline experienced the largest improvements in symptoms and functioning after 4 months of navigation. These findings suggest that this group of youth should be a primary target in mental health and addiction navigation.

Examining Mental Health Disorders in Overweight and Obese Pediatric Patients

INTRODUCTION

We investigated the frequency and variation in three mental health diagnoses among obese or overweight children and adolescents.

METHOD

Logistic regression was used to examine the association between the outcome variables-anxiety, depression, and adjustment disorders-with the following covariates: overweight/obesity status, sex, age, and race.

RESULTS

Findings show anxiety, depressive, and adjustment disorder diagnoses were significantly higher for overweight or obese youth in our sample. In addition, diagnosis rates for one or more of these disorders increase as children grow into adolescence. Furthermore, we found significantly higher rates of depression and significantly lower rates of anxiety among youth who live in places with higher rates of poverty.

DISCUSSION

Findings indicate a target age for providers to focus on mental health screening among overweight/obese patients: (1) early adolescence (aged 11-14 years) for depressive and adjustment disorders and (2) early childhood (aged 2-4 years) for anxiety disorder.

Facilitators and barriers of mental health help-seeking behaviours among adolescents in Oman: a cross-sectional study

OBJECTIVES

This study aimed to explore and identify facilitators and barriers to help-seeking behaviours among adolescents in Oman, by exploring the relationship between knowledge, attitude, and behaviour towards mental health help-seeking.

METHODS

A cross-sectional descriptive study was used and 424 adolescents were recruited to participate in the study. Participants were asked to complete five self-reported questionnaires, including two open-ended questions about the main motivations and barriers to seeking professional help for mental problems.

RESULTS

It was found that those with positive help-seeking attitudes towards mental health were more knowledgeable about mental health, had more positive attitudes towards mental illness, and had higher intention to help seeking. On the contrary, those with higher help-seeker stereotypes had more negative attitudes towards mental illness. Having an adequate support system, being positive and knowledgeable about mental illness, and the reputation of mental health are the main factors facilitating seeking professional help. However, fear, lack of family support, and the time-consuming procedures were the main barriers emerging from the open-ended questions.

CONCLUSIONS

This study contributes by identifying facilitating factors as well as barriers in an Arabic context (Oman) to fill the exiting knowledge gap; both need to be considered when planning interventions targeting the younger individuals in this society.

Management of anxiety disorders among children and adolescents in UK primary care: A cohort study

BACKGROUND

Anxiety disorders are common in childhood and adolescence but evidence-based guidance on their management is limited in the UK. In the absence of guidelines, we examined what treatment young people with anxiety disorders receive in primary care in the year following diagnosis.

METHOD

We delineated a cohort of individuals diagnosed with anxiety disorders aged 10-18 using the Clinical Practice Research Datalink (CPRD). We estimated the annual prevalence of antidepressant and anxiolytic prescribing and referrals to mental health services in the year following diagnosis between 2003 and 2019 via Poisson models, adjusted for age, gender, and practice-level deprivation.

RESULTS

34,490 out of 52,358 (66 %) individuals were not prescribed or referred in the year following diagnosis. Those registered to practices in the most deprived compared to the least deprived areas were less likely to be referred (PR 0.80, 95%CI 0.76-0.84) and prescribed antidepressants (PR 0.77, 95%CI 0.72-0.82). Referrals increased 2003-2008 (22-28 %) and then declined until 2019 (28-21 %). Antidepressant prescribing decreased substantially between 2003 and 2005 (18-11 %) and then increased slightly between 2006 and 2019 (11-13 %). Anxiolytic prescribing declined between 2003 and 2019 (10-2 %).

LIMITATIONS

Prescriptions in the CPRD are not coupled with information about indication. Some prescriptions may therefore have been incorrectly attributed to the treatment of anxiety disorders.

CONCLUSION

The continued use of antidepressants necessitates the development of evidence-based guidance. The lower likelihood of being prescribed medication and/or referred among young people in more deprived practice populations, where incidence of anxiety disorder and other mental illnesses is higher, must also be investigated and rectified.

GPs’ and practice nurses’ views on their management of paediatric anxiety problems: an interview study

Background

Anxiety problems are common in both children and adolescents, and many affected children do not receive appropriate treatment. Understaffing of mental healthcare services and long waiting lists form major barriers. In the Netherlands, practice nurses have been introduced into general practice to support general practitioners (GPs) in the management of psychosocial problems. In this study we investigated the views of GPs and practice nurses on their management of paediatric anxiety problems.

Methods

We performed an exploratory study using semi-structured interviews with 13 GPs and 13 practice nurses in the greater Rotterdam area in 2021. Interviews were transcribed and coded into topics, which were categorized per research question.

Results

In their management of paediatric anxiety problems, both GPs and practice nurses try to explore the case and the needs of affected children and their parents. GPs rarely follow up affected children themselves. They often refer the child, preferably to their practice nurse. Practice nurses regularly initiate follow-up consultations with affected children themselves. Practice nurses reported using a variety of therapeutic techniques, including elements of cognitive behavioural therapy. In more severe cases, practice nurses refer the child to external mental healthcare services. GPs reported being satisfied with their collaboration with practice nurses. Both GPs and practice nurses experience significant barriers in the management of paediatric anxiety problems. Most importantly, long waiting lists for external mental health care were reported to be a major difficulty. Improving cooperation with external mental healthcare providers was reported to be an important facilitator.

Conclusions

In their management of paediatric anxiety problems, GPs and practice nurses experience major challenges in the cooperation with external mental healthcare providers and in the long waiting lists for these services. GPs and practice nurses believe that thanks to their shared approach more children with anxiety problems can remain treated in general practice. Future research is needed to evaluate the treatment outcomes of the shared efforts of GPs and practice nurses in their management of paediatric anxiety problems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01802-y.

Associations between child mental health, carer worry and help-seeking

Carers may not always express child mental health concerns to health professionals. Therefore, identifying factors delaying help-seeking is important. The aim of this study was to examine the relationship between carer affect and help-seeking. In a secondary analysis of data collected from school-aged children (N = 1,857, mean age = 9.85 years, 51% female), we used logistic regression to examine the associations between carer worry, help-seeking and child mental health. Regarding worry, higher levels of emotional problems (OR = 1.42, 95% CI = 1.33-1.52), conduct problems (OR = 1.24, 95% CI = 1.12, 1.36), peer problems (OR = 1.17, 95% CI = 1.05-1.27) or functional impairment (OR = 1.37, 95% CI = 1.2-.56) were associated with higher levels of carer worry. Regarding help-seeking, higher levels of functional impairment were associated with higher levels of help-seeking (OR = 1.51, 95% CI = 1.09-2.11). After controlling for mental health problems, carers who reported being worried about their child's mental health were less likely than other carers to seek help (OR = 0.13, 95% CI = 0.05-0.35). Knowledge of these factors may inform early interventions. Alongside implications for future research and practice, limitations of the study are discussed.

Cost Effects of a Health Coaching in Children and Adolescents With Mental Health and Developmental Disorders

OBJECTIVE

Health coaching (HC) aims to strengthen the role of primary care pediatricians in the treatment of children and adolescents with mental health and developmental disorders by extending consultation time and using disease-specific manuals. We evaluated the effect of HC on costs of specialized, pediatrician, and overall care.

METHODS

In a retrospective cohort study based on German health insurance claims data, we identified children aged up to 17 years with a newly diagnosed mental health and/or developmental disorder between 2013 and 2015. Patients getting HC were matched to patients receiving usual care. Costs were calculated for 1 year following the start of the treatment and compared by 2-part and gamma models. Absolute costs and cost differences were calculated with bootstrapped 95% confidence intervals (CI).

RESULTS

We compared 5597 patients receiving HC with 5597 control patients. The probability of incurring specialized care costs was similar between the groups (0.96, 95% CI: 0.88; 1.05). However, for those who did incur costs, specialized care costs were significantly lower for HC-treated patients (0.77, 95% CI: 0.63; 0.93). Accordingly, specialized care costs were lower by €-94 (95% CI: €-175; €-18), while pediatrician care costs were higher for HC-treated patients by €57 (95% CI: €49; €64). Hence, overall costs did not differ between the groups (€-59, 95% CI: €-191; €71).

CONCLUSION

Provision of HC has the potential to lower the costs of specialized care, while increasing the costs of pediatrician care. Overall costs did not differ, suggesting that the additional costs incurred by the HC were offset.

Barriers and facilitators to clinical behaviour change by primary care practitioners: a theory-informed systematic review of reviews using the Theoretical Domains Framework and Behaviour Change Wheel

BACKGROUND

Understanding the barriers and facilitators to behaviour change by primary care practitioners (PCPs) is vital to inform the design and implementation of successful Behaviour Change Interventions (BCIs), embed evidence-based medicine into routine clinical practice, and improve quality of care and population health outcomes.

METHODS

A theory-led systematic review of reviews examining barriers and facilitators to clinical behaviour change by PCPs in high-income primary care contexts using PRISMA. Embase, MEDLINE, PsychInfo, HMIC and Cochrane Library were searched. Content and framework analysis was used to map reported barriers and facilitators to the Theoretical Domains Framework (TDF) and describe emergent themes. Intervention functions and policy categories to change behaviour associated with these domains were identified using the COM-B Model and Behaviour Change Wheel (BCW).

RESULTS

Four thousand three hundred eighty-eight reviews were identified. Nineteen were included. The average quality score was 7.5/11. Reviews infrequently used theory to structure their methods or interpret their findings. Barriers and facilitators most frequently identified as important were principally related to 'Knowledge', 'Environmental context and resources' and 'Social influences' TDF domains. These fall under the 'Capability' and 'Opportunity' domains of COM-B, and are linked with interventions related to education, training, restriction, environmental restructuring and enablement. From this, three key areas for policy change include guidelines, regulation and legislation. Factors least frequently identified as important were related to 'Motivation' and other psychological aspects of 'Capability' of COM-B. Based on this, BCW intervention functions of persuasion, incentivisation, coercion and modelling may be perceived as less relevant by PCPs to change behaviour.

CONCLUSIONS

PCPs commonly perceive barriers and facilitators to behaviour change related to the 'Capability' and 'Opportunity' domains of COM-B. PCPs may lack insight into the role that 'Motivation' and aspects of psychological 'Capability' have in behaviour change and/or that research methods have been inadequate to capture their function. Future research should apply theory-based frameworks and appropriate design methods to explore these factors. With no 'one size fits all' intervention, these findings provide general, transferable insights into how to approach changing clinical behaviour by PCPs, based on their own views on the barriers and facilitators to behaviour change.

SYSTEMATIC REVIEW REGISTRATION

A protocol was submitted to the London School of Hygiene and Tropical Medicine via the Ethics and CARE form submission on 16.4.2020, ref number 21478 (available on request). The project was not registered on PROSPERO.

Availability and implementation of guidelines in European child primary health care: how can we improve?

BACKGROUND

Clinical guidelines are important for providing high-quality child primary health care. We aimed to assess the availability, use and achieved delivery of guidelines in the European Union (EU).

METHODS

We used a case study design to ascertain expert views on guidelines in six countries representing the EU. The experts completed an online questionnaire (response 49%), asking about their perception of guideline availability and implementation regarding three topics that represent prevention and care, i.e. vaccination, assessment of mental health and asthma care.

RESULTS

According to the respondents all countries had guidelines available for asthma care. For vaccination and mental health assessment respondents agreed to a lesser degree that guidelines were available. Implementation of guidelines for vaccination was mostly perceived as intended, but implementation of the guidelines for mental health assessment and asthma care was limited. Notable barriers were complexity of performance, and lack of training of professionals and of financial resources. Important facilitators for guideline implementation were the fit with routine practice, knowledge and skills of professionals and policy support. We found no clear relationship of guideline availability and implementation with type of child primary health care system of countries, but strong governance and sufficient financial resources seemed important for guideline availability.

CONCLUSIONS

Availability and implementation of clinical guidelines in child primary health care vary between EU countries. Implementation conditions can be strongly improved by adequate training of professionals, stronger governance and sufficient financial resources as facilitating factors. This can yield major gains in child health across Europe.

Longitudinal changes of mental health problems in children and adolescents treated in a primary care-based health-coaching programme – results of the PrimA-QuO cohort study

Background

In Germany, 19.1% of boys and 14.5% of girls are affected by mental health problems (MHP). Paediatricians are usually the first in line to be contacted but they often do not feel adequately trained to diagnose and treat MHP in primary care. A major statutory health insurance fund introduced a health coaching (HC) programme to strengthen primary care consultation for MHP. The HC includes a training concept for paediatricians, standardised guidelines for actions and additional payments. The aim of this study was to investigate the potential effects of the HC programme on the change of MHP in children and adolescents.

Methods

A prospective cohort study was conducted in Bavaria, Germany, in 2018 and 2019. Data were collected at 2 points 1 year apart using an online questionnaire. Parents of patients with developmental disorder of speech and language, head/abdominal pain, conduct disorder or non-organic enuresis were approached by their health insurance. Families treated according to the HC programme form the intervention group while all others serve as controls. MHP was assessed using the Strengths and Difficulties Questionnaire (SDQ) as a child self-assessment (SDQ-S)/or external assessment by parents (SDQ-P). Determinants of SDQ total score were analysed using linear mixed effects models.

Results

Cross-sectional (n = 1090) and longitudinal analyses (n = 599) were performed. At baseline, a total of 23.5% had an SDQ total score “at risk” (SDQ-S > 15/SDQ-P > 13). There were no significant differences between intervention and controls. After full adjustment for all potential confounders, higher SDQ scores indicating more problems were significantly associated with male sex (2.000, p < 0.001) whereas a high parental education level was significantly associated with decreased SDQ scores (-2.127, p =0.034). There was a significant improvement in the control group over time (-0.814, p = 0.001) while the SDQ scores in the intervention group remained stable (-0.012, p = 0.020).

Conclusion

This evaluation of the HC programme could not prove a clinically relevant intervention’s effect on the MHP developmental course. Nevertheless, (HC) paediatricians have crucial potential to improve the care of MHP patients. Targeting families with less access to support measures might help reduce the burden of MHP and be a step towards continuous improvement of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01780-1.

Screening for PTSD and functional impairment in trauma-exposed young children: evaluation of alternative CBCL-PTSD subscales

The Child Behavior Checklist (CBCL 1.5–5 years) posttraumatic stress disorder (PTSD) subscale by Dehon & Scheeringa (2006) as a screener for PTSD in trauma-exposed young children has yielded inconsistent results so far. Therefore, the aim of this study was to create and examine the validity of alternative CBCL-PTSD subscales and compare them to the existing CBCL-PTSD subscale based on the DSM-5 PTSD diagnostic criteria for children 6 years and younger. Further, the CBCL-PTSD subscales were examined regarding their usefulness in screening for posttraumatic stress-related functional impairment. The sample comprised 116 trauma-exposed young children (Mage = 3.42 years, SDage = 1.21 years, female = 49.1%). The psychometric properties of the existing CBCL-PTSD subscale as well as the alternative subscales based on expert rating (CBCL-PTSD-17) and based on variable importance (CBCL-PTSD-6) were evaluated by means of receiver operating characteristic curves, sensitivity, specificity, positive predictive values, and negative predictive values. Area under the curves for all three investigated CBCL-PTSD subscales were good to excellent for PTSD and functional impairment. Further, all three CBCL-PTSD subscales showed high sensitivity for PTSD and functional impairment. Considering the length and the performance of the three investigated subscales, the CBCL-PTSD-6 appears to be a promising and clinically useful CBCL-PTSD subscale as a screener for PTSD and functional impairment due to the easiest and most practicable application. For purposes of discriminant validation of the CBCL-PTSD-6, young children without a history of trauma should be compared to young children with trauma history.

Enhancing the primary care pediatrician's role in managing psychosocial issues: a cross sectional study of pediatricians and parents in Israel

Background

Psychosocial issues are an integral part of children's health and well-being, and it is widely acknowledged that pediatricians should be involved in their management. We examined the current perception of the pediatrician’s role in the management of psychosocial problems in Israel from the perspective of parents and pediatricians, and identified possible barriers.

Methods

We assessed parents' and pediatricians' perspectives through a cross sectional survey. 1000 parents with children under 10 were randomly selected from a large database representing the Israeli population and phone-surveyed by a polling company. Due to a low response-rate (5.4%), there was an overrepresentation of married parents and underrepresentation of parents with primary or secondary education. 173 Pediatricians were recruited both at a medical conference and by a web-based questionnaire.

Results

55% of the parents reported they were concerned with at least one psychosocial problem, yet less than 50% of them discussed these issues with the pediatrician. 59.9% of the parents did not perceive psychosocial problems as relevant to the pediatrician's role. Pediatricians with some previous training related to psychosocial issues were more likely to report on a lack of professional confidence (p = .037) and insufficient available resources (p = .022) as barriers to their involvement, while pediatricians who had no training were more likely to report on the parents' perception of their role as the barrier to involvement (p = .035).

Conclusions

Parents tend to avoid the discussion of psychosocial concerns in pediatric settings due to their perception that it's irrelevant to the pediatrician's role. Trained pediatricians feel unconfident in their ability to manage psychosocial issues and report on a lack of suitable resources. These findings suggest current pediatric mental-health training is insufficient to equip pediatricians with the knowledge and skills required to their involvement in psychosocial problems, and imply necessary changes to environment of community-based pediatrics. In order to change the practice of pediatricians in the community to enable them to address a variety of psychological issues, appropriate training is needed, through all stages of the pediatrician’s professional life, including medical school, pediatric residency and continuous medical education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-022-00537-6.

A novel application of the Lego® Serious Play® methodology in mental health research: Understanding service users' experiences of the 0-19 mental health model in the United Kingdom

AIM

The 0-19 model is an example of a service that has been retransformed in line with UK's recent policies. However, there is limited qualitative research exploring young people's experiences with the accessibility and acceptability of retransformed models through more participatory qualitative approaches. This study aimed to understand service users' experiences of accessibility and acceptability with the 0-19 model and its service provision. In addition, we also aim to outline the process and application of the Lego® Serious Play® methodology to the context of children and young people's mental health research and reflect on the usefulness of this novel approach and its potential for further research use.

METHODS

A qualitative methodology based on the Lego® Serious Play® approach was used to investigate service users' perceptions of the accessibility and acceptability of the 0-19 model. This novel approach is viewed as a facilitator of engagement, which also stimulates critical thinking and reflective practice. All interviews were thematically analysed.

RESULTS

Seven participants constructed 14 models and provided metaphorical narratives for them besides engaging in group discussions. Thematic analysis of the participants' models and narratives resulted in six identified themes: accessibility, doors into the unknown, let it out, overcoming obstacles, less is sometimes better and satisfaction with the 0-19 model and its provision.

CONCLUSION

Participants in this study perceived the 0-19 model as acceptable and, to a degree, accessible. Participants identified a range of barriers to accessibility, such as inconvenient locations, long waiting and inflexible working times.

Evaluation of a supported education and employment program for adolescents and young adults with mental health problems: A study protocol of the StAB project

The majority of mental illnesses begins in childhood, adolescence and young adulthood before the age of 25. The transition from adolescence to adulthood is a particularly vulnerable time for adolescents with mental illness, affecting psychosocial functioning and participation in work life. Therefore, they need-in contrast to classic standard vocational interventions-a long-term, holistic and individually oriented vocational rehabilitation program. With the innovative model project "Start in education and employment (StAB)", adolescents and young adults with mental illnesses are to be supported with regard to their vocational perspectives and participation by a new type of individualized, holistic, long-term job coaching. It follows the Individual Placement and Support (IPS) concept, as a manualized form of the Supported Employment Approach and is based on the "first place-then train" principle. In order to evaluate the effectiveness and feasibility of the StAB program, a double-centre prospective single arm evaluation study in a mixed-methods design will be conducted. The focus is on quantitative research analysing pre-post-effects of the StAB intervention in a two-year observational study. Young people between 15 and 25 years with a psychiatric diagnosis who are currently in receipt of means-tested benefits or are entitled to them will be recruited. The study will take place in two major cities in the north-western part of Germany, Bielefeld and Dortmund. We expect to contribute to gain more empirical data about the implementation of Supported Employment and Education to severely mentally ill adolescents and young adults in German settings. Moreover, these results may also provide the scientific foundation for future measures focusing the improvement of vocational rehabilitation for young people with mental illness. The study was registered in the German Clinical Trials Register (DRKS00027576) on March 10, 2022.

Child and adolescent mental health services in the Western Cape Province of South Africa: the perspectives of service providers

BACKGROUND

Current work in the field point to the need to strengthen child and adolescent mental health services (CAMHS) globally, and especially in low- and middle-income countries (LMICs). Policy development, planning and service provision must be relevant to the needs of stakeholders at grassroots level, and should include their perspectives. This study set out to explore the perspectives and lived experiences of service providers, including their recommendations to strengthen CAMHS in South Africa.

METHODS

Using focus group discussions (FGDs) and semi-structured individual interviews (SSIIs), qualitative data were collected from 46 purposefully selected multidisciplinary health service providers across the Western Cape, one of the nine provinces of South Africa. Audio-recorded data were entered into NVivo 11 (QSR), and thematic analysis was performed by two independent raters.

RESULTS

Results highlighted a significant lack of CAMH resources, poor intersectoral collaboration, limited access to training, absence of consistency and uniformity in service delivery, weak support for staff, and high rates of negative attitudes of staff. External factors contributing to poor CAMHS identified by service providers included poor socioeconomic circumstances, high rates of HIV/AIDS, substance use and stigma. The eight recommendations to strengthen CAMHS included a need to (1) increase CAMH staffing, (2) provide dedicated CAMHS at secondary care and child-friendly infrastructure at primary care, (3) review current service focus on number of patients seen versus quality of care provided to children, (4) formalise intersectoral collaborations, (5) increase learning opportunities for trainees, (6) employ a lead professional for CAMHS in the province, (7) increase support for staff, and (8) acknowledge staff initiatives.

CONCLUSIONS

Findings underlined the need for quality improvement, standardisation and scale-up of mental health services for children and adolescents in South Africa. Whilst we used the Western Cape as a 'case study', we propose that our findings may also be relevant to other LMICs. We recommend that the perspectives of service users, including children and adolescents, be sought to inform service transformation.

Early detection of anxiety problems in childhood: Spanish validation of the brief Spence Children's Anxiety Scale for parents

The small percentage of children with anxiety problems who receive psychological treatment, and the negative psychological consequences associated with these problems highlight the need for early detection. Although assessment instruments with appropriate measurement properties exist, they tend to be extensive, making it difficult to apply them in clinical settings, schools, or primary care practices. This study aimed to adapt the Spanish brief version for parents of the Spence Children's Anxiety Scale (SCAS-P-8). For this purpose, information on 215 children between 8 and 12 years of age was reported by 163 parents. The Spanish version of the SCAS-P-8 adequately fit a one-factor structure, χ² = 44.25; df = 19; comparative fit index = .97; Tucker-Lewis index = .96; root mean square error of approximation: .07 (.04, .09); standardized root mean squared residual = .08. Evidence of internal consistency of the total SCAS-P-8 score was good (α = 0.82), and the direct correlations obtained between the SCAS-P-8 and internalizing problems showed evidence of convergent validity. Moreover, the appropriate measurement properties of the SCAS-P-8 were shown to be independent of gender. Differences in sociodemographic variables and SDQ-P between children with anxiety symptoms and those without anxiety symptoms were also discussed. Information reported by parents can help the clinician carry out an accurate diagnosis. A brief assessment scale can be easily applied in schools or primary care settings.

School-based screening for childhood anxiety problems and intervention delivery: a codesign approach

OBJECTIVES

A very small proportion of children with anxiety problems receive evidence-based treatment. Barriers to access include difficulties with problem identification, concerns about stigma and a lack of clarity about how to access specialist services and their limited availability. A school-based programme that integrates screening to identify those children who are most likely to be experiencing anxiety problems with the offer of intervention has the potential to overcome many of these barriers. This article is a process-based account of how we used codesign to develop a primary school-based screening and intervention programme for child anxiety problems.

DESIGN

Codesign.

SETTING

UK primary schools.

PARTICIPANTS

Data were collected from year 4 children (aged 8-9 years), parents, school staff and mental health practitioners.

RESULTS

We report how the developed programme was experienced and perceived by a range of users, including parents, children, school staff and mental health practitioners, as well as how the programme was adapted following user feedback.

CONCLUSIONS

We reflect on the mitigation techniques we employed, the lessons learnt from the codesign process and give recommendations that may inform the development and implementation of future school-based screening and intervention programmes.