‘Accumulating harm and waiting for crisis’: Parents’ perspectives of accessing Child and Adolescent Mental Health Services for their autistic child experiencing mental health difficulties

Mental Health Care Reforms in Latin America: Child and Adolescent Mental Health Services in Mexico

National Health Service Child and Adolescent Mental Health Services are specialist teams that assess and treat children and young people with mental health problems. Overall, 497,502 children were referred to National Health Service Child and Adolescent Mental Health Services between 2020 and 2021, and almost one-quarter of these referrals were not successful. Unsuccessful referrals are often distressing for children and families who are turned away usually after a long waiting period and without necessarily being redirected to alternative services. The process is also costly to services because time is wasted reviewing documents about children who should have been referred for alternative help and may prevent young people who need specialist help receiving it in a timely way. The overarching aim of this study was to understand what the problems are with Child and Adolescent Mental Health Services referrals and identify solutions that could improve referral success. A key objective was to talk widely with young people and families, people working in Child and Adolescent Mental Health Services and mental health professionals so that we could understand fully what the problems were and how we might develop their solutions. We gathered individual pseudonymised patient data from nine Child and Adolescent Mental Health Services, and referral data from four National Health Service Trusts to look at what data are available and how complete it is. We report wide variation in the numbers of referrals between and within Trusts and in the proportions not being successful for treatment. Data on factors such as age and gender of children and young people referred into Child and Adolescent Mental Health Services and who made the referral are routinely collected, but ethnicity of the children and young people's reason for referral are not as well collected across all Trusts. We also conducted focus groups with over 100 individuals with differing perspectives on the Child and Adolescent Mental Health Services referral process (children and young people, parents and carers, key referrers, and Child and Adolescent Mental Health Services professionals) and asked about current difficulties within the referral process, as well as potential solutions to these. Problems identified included: confusion about what Child and Adolescent Mental Health Services is for, that is what it does and does not provide; and lack of support provided during the referral process. Possible solutions included: streamlining the referral pathways through digital technologies with accompanying standardisation of referral forms for National Health Service Child and Adolescent Mental Health Services; and early ongoing communication throughout the referral 'journey' for the referrer/family. Should consider the standardisation of and improvement to the Child and Adolescent Mental Health Services referral process following the recommendations outlined in this project. This study is registered on ClinicalTrials.gov with the identifier: NCT05412368. https://clinicaltrials.gov/study/NCT05412368. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131379) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 21. See the NIHR Funding and Awards website for further award information.

Background: There is general consensus that child and adolescent mental health services in low- and middle-income countries have an urgent need to be strengthened. However, this require not only a universal understanding of services and service needs, but also in-depth local knowledge to inform relevant service strengthening. This study sought to explore the perspectives of senior child and adolescent mental health service providers and policy-makers in one South African province to identify strengths, weaknesses, opportunities, and threats to child and adolescent mental health services.Methods: A qualitative study was conducted with 13 purposively sampled senior child and adolescent mental health service providers, senior managers, and policy-makers from the Western Cape Province, using a half-day multi-stakeholder workshop format. Verbal and written data were recorded and coded for analysis. Two independent raters performed thematic analysis.Results: The comprehensive bio-psycho-social approach and strong specialist child and adolescent mental health service units were identified as strengths. Limited capacity, workload demands, inadequate and inequitable resource allocation, poor implementation of early detection and preventative policies, and overall neglect of child and adolescent mental health services, were identified as weaknesses. Collaborative working between child and adolescent mental health and pediatric services, and increased provincial government (Department of Health) involvement, were identified as potential opportunities to develop and strengthen child and adolescent mental health services. Silo working of agencies, societal stressors, inadequate infrastructure and other resources, and lack of dedicated funding for child and adolescent mental health, were identified as threats to the development of services.Conclusions: This analysis of strengths, weaknesses, opportunities, and threats reinforced the widespread neglect of child and adolescent mental health services in South Africa and highlighted areas for further research and advocacy. There is a clear need to explore the perspectives and experiences of service users and providers to generate comprehensive multi-stakeholder evidence that may identify positive "tipping points" for improvements and strengthening of child and adolescent mental health service delivery, training, and research.

Politics on the mind: assessing the state of mental health after the election

Child mental health services in England: a continuing crisis

Emotional disorders are common in children and young people and can significantly impair their quality of life. Evidence-based treatments require a timely and appropriate diagnosis. The utility of standardised diagnostic assessment tools may aid the detection of emotional disorders, but there is limited evidence of their clinical value. To assess the clinical effectiveness and cost effectiveness of a standardised diagnostic assessment for children and young people with emotional difficulties referred to Child and Adolescent Mental Health Services. A nested qualitative process evaluation aimed to identify the barriers and facilitators to using a standardised diagnostic assessment tool in Child and Adolescent Mental Health Services. A United Kingdom, multicentre, two-arm, parallel-group randomised controlled trial with a nested qualitative process evaluation. Eight National Health Service Trusts providing multidisciplinary specialist Child and Adolescent Mental Health Services. Children and young people aged 5-17 years with emotional difficulties referred to Child and Adolescent Mental Health Services, excluding emergency/urgent referrals that required an expedited assessment. In the qualitative process evaluation, 15 young people aged 16-17 years, 38 parents/carers and 56 healthcare professionals participated in semistructured interviews. Participants were randomly assigned (1 : 1) following referral receipt to intervention (the development and well-being assessment) and usual care, or usual care only. Primary outcome was a clinician-made diagnosis decision about the presence of an emotional disorder within 12 months of randomisation, collected from Child and Adolescent Mental Health Services clinical records. Secondary outcomes collected from clinical records included referral acceptance, time to offer and start treatment/interventions and discharge. Data were also self-reported from participants through online questionnaires at baseline, 6 and 12 months post randomisation, and the cost effectiveness of the intervention was investigated. One thousand two hundred and twenty-five (1225) children and young people were randomly assigned (1 : 1) to study groups between 27 August 2019 and 17 October 2021; 615 were assigned to the intervention and 610 were assigned to the control group. Adherence to the intervention (full/partial completion of the development and well-being assessment) was 80% (494/615). At 12 months, 68 (11%) participants in the intervention group received an emotional disorder diagnosis versus 72 (12%) in the control group [adjusted risk ratio 0.94 (95% confidence interval 0.70 to 1.28); p = 0.71]. Child and Adolescent Mental Health Services acceptance of the index referral [intervention 277 (45%) vs. control 262 (43%); risk ratio: 1.06 (95% confidence interval: 0.94 to 1.19)] or any referral by 18 months [intervention 374 (61%) vs. control 352 (58%); risk ratio: 1.06 (95% confidence interval: 0.97 to 1.16)] was similar between groups. There was no evidence of any differences between groups for any other secondary outcomes. The qualitative nested process evaluation identified a number of barriers and facilitators to the use of the development and well-being assessment during the trial, particularly at the assessment and diagnosis stages of the Child and Adolescent Mental Health Services pathway. It was not possible to mask participants, clinicians or site researchers collecting source data to treatment allocation. We found no evidence that completion of the development and well-being assessment aided the detection of emotional disorders in this study. Using the development and well-being assessment in this way cannot be recommended for clinical practice. To determine longer-term service use outcomes and to investigate whether receipt of a clinical diagnosis makes a difference to clinical outcomes and care/intervention receipt. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 16/96/09.

Looking after the mental health of children and young people is everybody’s business. Nurses working in primary and community care settings, in hospitals and in specialist child and adolescent mental health services (CAMHS) all have a part to play. However, there is robust evidence to suggest that pre-registration education does not adequately prepare nurses to work with children and young people with mental health difficulties. At both pre- and post-registration level, education and training opportunities are generally scarce. In a previous paper, we reviewed the development of child and adolescent mental health services in the UK (Davies et al 2002). We observed that, until recently, services have emerged in a patchy fashion, and have tended not to be seen as a priority area. We also discussed new developments in Wales, and in Cardiff and the Vale of Glamorgan in particular. In this second paper we turn specifically to the issue of education and training. We begin with a discussion of the different levels of CAMHS provision, and on the work that different groups of nurses in different ‘tiers’ do in order to provide care for children and adolescents with mental health difficulties. We then concentrate specifically on the work of children’s nurses and the work of mental health nurses. We argue that, traditionally, the education of both child health and mental health nurses has tended not to emphasise the specific areas of skill and knowledge needed to care for young people experiencing mental health problems and their families. Finally, and as we did in our first paper, we turn to local developments in south Wales, and discuss how nurses’ awareness of child and adolescent mental health issues will be progressed through the new pre

Urban Child and Adolescent Mental Health Services weaves together different strands of mental health work undertaken in one inner-city Child and Adolescent Mental Health Service by professionals working in a range of ways. In particular, it provides examples of how an urban CAMH service has been responsive to, and influenced by, local circumstances, resources and knowledge. The book explores the relationship between professionals and the community context, which provides the background to the lives of individual service users and the families they serve, and how this relationship is integral to the development of a responsive service. The chapters cover a range of settings and approaches, addressing the social, cultural, political and community contexts impacting on children, young people and families. In this way Urban Child and Adolescent Mental Health Services explores challenges and issues emerging in a responsive approach to child and family work in all community settings whether they be urban, suburban or rural. Urban Child and Adolescent Mental Health Services is intended for mental health and social care professionals involved in therapeutic, social and pastoral work with children, young people, families and communities. The book will be of interest to policy-makers, mental health and social care professionals, health visitors, general practitioners, nurses and midwives , as well as to trainees in these professions including trainee clinical psychologists, social workers or psychoanalytic and systemic psychotherapists. It will also appeal to those interested in responsive communities and critical approaches to therapeutic interventions in mental health work, psychology, psychotherapy and counselling.

BackgroundResearch has shown a strong association between suicide and mental disorders, and people in contact with services for mental health and substance use are known to be at high risk of suicide. Still, few studies have previously described suicide among young people in contact with Child and Adolescent Mental Health Services.AimThe aim of this study is to examine the prevalence of contact and suicide rates by gender and age groups, and to describe patient demographics and service utilization in secondary mental health services.MethodsAll young people in contact with Child and Adolescent Mental Health Services in the year prior to death in the period 2008–2018 were identified by linking the Norwegian Cause of Death Registry and the Norwegian Patient Registry. We estimated the prevalence of contact and suicide rates among those with and without contact, by gender and age groups. Characteristics of treatment contact were compared between boys and girls. Variables with significant differences were entered into a multivariate logistic regression model using gender as an outcome.ResultsMore girls (39.7%) than boys (11.8%) had contact with Child and Adolescent Mental Health Services in the year prior to death. Among girls, suicide rates per 100,000 patients increased linearly in the age groups 10–13, 14–16, and 17–19 years: 5, 22, and 38 per 100,000 patients, respectively. Among boys, the suicide rate increased sharply from 7 per 100,000 patients in the age group 14–16 years to 40 per 100,000 patients in the 17–19-year-old group. In the age-adjusted multivariate model, boys were 4.07 (1.22–14.44, p = 0.024) times more likely to have terminated contact at the time of death.ConclusionThis study shows gender differences in both suicide rates and service utilization among young people in contact with Child and Adolescent Mental Health Services before suicide, and future studies should focus on identifying the causes of these gender differences in service contact.

Treatment Intensity in Child and Adolescent Mental Health Services and Health Care Reform in Norway, 1998–2006

This study examined the relationship of age and gender with risk of arrest among adolescents and young adults who were intensive adolescent users of public mental health services. Data were obtained from the Massachusetts Department of Mental Health (DMH) and juvenile and criminal courts. Participants were youths receiving DMH adolescent case management services sometime in 1994-1996 who were born between 1976 and 1979 (781 males and 738 females). They were cross-matched to document arrests between age seven and 25. The study examined age at first arrest, age-specific risk, and the relationship between arrest history and arrest risk by gender and age. Most males (69%) and almost half the females (46%) were arrested by age 25. First arrest was most common before age 18. As in the general population, males' arrest patterns were more concerning than those of females, although patterns were of concern in both groups. Most female arrestees had multiple arrests, many as adults. No gender differences were observed for several factors, including risk of first arrest over age 18. Risk was far greater for those arrested in the previous year than for those never arrested. Findings justify concerns of public mental health systems regarding justice system involvement of adolescent clients. Risk of first arrest was significant from early adolescence through age 24, indicating a need for arrest prevention into young adulthood. The heightened arrest risk at all ages among those who were recently arrested demarcates a population in need of immediate intervention.

BackgroundChildren and adolescents’ mental health problems have been largely assessed with conventional symptom scales, for example, Strengths and Difficulties Questionnaire (SDQ) given that it is one of the mostly widely used measures in specialist Child and Adolescent Mental Health Services (CAMHS). However, this emphasis on symptom scales might have missed some important features of the mental health challenges that children and young people experience including day to day functioning and life satisfaction aspect (i.e. qualify of life).MethodThe study examined longitudinal association between a young person’s self-perceptions of quality of life and mental health difficulties and referral to specialist CAMHS service using a population cohort study (Targeted Mental Health in Schools service data) nested within a large-scale linkage between school (National Pupil Data base) and child mental health service administrative data (South London and Maudsley NHS Foundation Trust children and adolescent mental health services health records). Cox proportional hazard regression to estimate crude and adjusted hazard ratios (HRs) for the association between participant psychopathology, and incidence of CAMHS referral.ResultsPupils experiencing more behavioural difficulties, had an increased incidence of CAMHS referral (adjusted hazard ratio 1.1, 95% confidence interval 1.0–1.2). However, pupils who reported higher health related quality of life had a lower incidence of CAMHS referral over the follow-up period (adjusted hazard hario 0.94, 95% confidence interval 0.9–0.98).ConclusionChildren and young people’s perception of their quality of life should be considered at the stages of a clinical needs assessment.

uring the last 10 years or so, there has been a remarkable rise of interest in children’s mental health. This is good news – and we shouldn’t be too shy to celebrate, nor too afraid to dwell on a worry or two lest, in ignoring them, we find the rise begin to fall. Broadly speaking, up until the early 1990s child mental health was pretty much hidden within the preserve of the specialist professional groups. This is not to say that little was going on. A great deal about children was being learned and practised. From Freud onwards, major advances in psychoanalysis, developmental psychology, behavioural and cognitive therapy and family and group therapy were bringing to life our understanding of the minds of children. Of course, much more needed to be known (and still does) but there was undoubtedly an exhilarating sense of inquiry into the nature of children’s mental health problems and family dynamics and into how interventions could be improved to bring about change in people’s troubled lives. What was lacking, however, was any real concerted desire to make these developments known to the wider public. Children’s mental health was simply not a political issue. The fact that it lay at the heart of so many of the prevailing social problems such as crime, drug misuse, teenage pregnancy and homelessness simply didn’t seem to ring a bell. At the time poverty, child welfare and child protection were the key political preoccupations but the concept of child mental health didn’t hit the headlines. If anything, the term carried with it something pejorative – as if it was stigmatising to associate the words ‘child’ and ‘mental health’. What was clearly needed was an effort to make more of a hue and cry about what was known and what was being done – a promotional campaign that would help to make the public more aware. YoungMinds, which I and others formed in the late 1980s, played a major role in taking forward this campaign. Most of us came from within the child guidance movement which in the mid-twentieth century was very involved in D developing multi-disciplinary working. In addition to YoungMinds various similar movements were afoot in the USA and some European countries, and in the UK certain key people proved critical in taking forward the agenda. Virginia Bottomley, for example, secretary of state for health from 1992 to 1995, was a former psychiatric social worker in child guidance clinics in London. Other leading figures at this time were Dr Richard Williams, a consultant child psychiatrist and director of the NHS Health Advisory Service, Dr Bob Jezzard, also a child psychiatrist, employed as a senior adviser in the Department of Health, and Dr Zarrina Kurtz, a public health consultant who had a particular interest in child development and children’s mental health problems. I myself was a child psychotherapist working in child guidance and residential treatment. Together, with one or two others, we joined up almost as if by accident. In effect, we shined as a kind of virtual multi-disciplinary team! We all set about in our own ways to build up and tell the story of the states that children’s minds could get into, of the prevalence of their mental health problems and of the predicament of those who tried to serve them. Most importantly, we brought to much greater light the invaluable findings of Professor Michael Rutter’s and Professor Philip Graham’s epidemiological research in the 1970s. It was, of course, not by chance that the first seminal review of child and adolescent mental health services produced by the Health Advisory Service (1995) was entitled Together We Stand. Let us take just a brief review of what is currently going on. First and foremost, the government now openly acknowledges the existence of child and adolescent mental health services (CAMHS) and is committed to investing considerable sums of money in them and also to introducing an infrastructure designed to support a more systematic and forwardmoving programme. All of this is quite unprecedented and I think it is true to say that the national child and adolescent mental health service is not the Cinderella service it once was some 12 or so years ago. It may not yet be in the prince’s arms, and the ugly sisters are still around, but at least it’s in the court!

Mental health disorders often develop during childhood and adolescence, causing long term and debilitating impacts at individual and societal levels. Local, early, and precise assessment and evidence-based treatment are key to achieve positive mental health outcomes and to avoid long-term care. Technological advancements, such as computerized Clinical Decision Support Systems (CDSSs), can support practitioners in providing evidence-based care. While previous studies have found CDSS implementation helps to improve aspects of medical care, evidence is limited on its use for child and adolescent mental health care. This paper presents challenges and opportunities for adapting CDSS design and implementation to child and adolescent mental health services (CAMHS). To highlight the complexity of incorporating CDSSs within local CAMHS, we have structured the paper around four components to consider before designing and implementing the CDSS: supporting collaboration among multiple stakeholders involved in care; optimally using health data; accounting for comorbidities; and addressing the temporality of patient care. The proposed perspective is presented within the context of the child and adolescent mental health services in Norway and an ongoing Norwegian innovative research project, the Individualized Digital DEcision Assist System (IDDEAS), for child and adolescent mental health disorders. Attention deficit hyperactivity disorder (ADHD) among children and adolescents serves as the case example. The integration of IDDEAS in Norway intends to yield significantly improved outcomes for children and adolescents with enduring mental health disorders, and ultimately serve as an educational opportunity for future international approaches to such CDSS design and implementation.

Mental health problems are one of the most pressing public health concerns of our time. Sweden has seen a sharp increase in mental disorders among children and youth during the last decade. The evidence base for treatment of psychiatric conditions has developed strongly. Clinical practice guidelines aim to compile such evidence and support healthcare professionals in evidence-based clinical decision-making. In Sweden, the national guidelines for the treatment of depression and anxiety disorders in children and adolescents were launched in 2010. The aim of this study was two folded, (i) to explore to what extent these guidelines were known and adhered to by health professionals in Child and Adolescent Mental Health Services and (ii) to investigate factors influencing implementation of the guidelines informed by the Consolidated Framework for Implementation Research. A qualitative approach was used, and data were collected through interviews with 18 health professionals in Child Mental Health Services in Sweden and a combination of conventional and directed content analyses was used. The Consolidated Framework for Implementation Research guided and structured data collection and analysis. The guidelines were largely unknown by health professionals in Child Mental Health Services in all the clinics investigated. Adherence to guideline recommendations was reported as very low. Barriers to implementation were found in relation to the characteristics of the intervention, outer setting, inner setting and characteristics of the individuals involved. The government initiative to develop and disseminate the guidelines seems to have made very little impact on health professionals' clinical practice. The guidelines were poorly aligned with the health professionals' knowledge and beliefs about effective mental health services for children and youth with depression and anxiety disorders. Suggestions for future efforts to improve the development and implementation of guidelines in Child Mental Health Services settings are given.