Urban Child and Adolescent Mental Health Services

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.

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

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.

Autistic children and young people are at increased risk of mental health difficulties, but often face barriers when seeking help from Child and Adolescent Mental Health Services. This study aimed to (1) explore the experiences of parents/carers seeking help from Child and Adolescent Mental Health Services for their autistic child’s mental health difficulties, and (2) gain parents’ perceptions of the accessibility of Child and Adolescent Mental Health Services for their child. A mixed-methods survey design was used. In total, 300 parents/carers took part from across the United Kingdom. Quantitative data were analysed using descriptive statistics, and qualitative data using qualitative content analysis. Findings demonstrated ongoing struggles that parents/carers faced when seeking help from Child and Adolescent Mental Health Services. Those who were referred reported a lack of reasonable adjustments and offers of ineffective or inappropriate therapies. Ultimately, parents felt their child’s mental health difficulties either did not improve or declined to the point of crisis. However, there was a recognition that some professionals were kind and compassionate. There is a need for a more neuro-inclusive and personalised approach in Child and Adolescent Mental Health Services. Further research, funding and training are urgently needed to ensure support is accessible, timely and effective for autistic young people.Lay abstractAutistic children and young people are more likely to experience mental health difficulties than neurotypical peers, but also face more barriers when seeking help from Child and Adolescent Mental Health Services. Findings highlight the need for a more neuroaffirmative approach from the professionals themselves, in the adjustments offered, and in the therapies provided. Barriers to Child and Adolescent Mental Health Services for autistic children and young people include diagnostic overshadowing (i.e. assuming mental health difficulties are part of autism), high thresholds for assessment and a lack of professional knowledge about autism and care pathways. Healthcare policies should ensure that all Child and Adolescent Mental Health Services professionals receive neuroaffirmative training and that resources/funding are provided for appropriate adjustments and early support. There is also a need for further research and funding to develop and evaluate effective neuroaffirmative therapeutic interventions.

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.

Child mental health services in England: a continuing crisis

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.

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

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.

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

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.

To investigate parental help-seeking patterns prior to referral to outpatient child and adolescent mental health services (CAMHS), and whether type of symptoms or duration of mental health problems prior to referral influence help-seeking. Child mental health services in Denmark involve several sectors collaborating based on stepped-care principles. Access to CAMHS is free of charge but requires a formal referral. In this cross-sectional observational study, parents of 250 children were interviewed about pathways to outpatient CAMHS using the Children's Services Interview. The median parent-reported duration of mental health problems prior to referral to CAMHS was 6.0 (IQR 3.4-8.5) years for children referred for neurodevelopmental disorders compared to 2.8 (IQR 1.0-6.5) years for children referred for emotional disorders. Educational services were the first help-seeking contact for the majority (57.5%) but referrals to CAMHS were most frequently from healthcare services (56.4%), predominantly general practitioners. Educational services played a greater part in help-seeking pathways for children referred for neurodevelopmental disorders. The majority of children referred to CAMHS have mental health problems for years before referral. The delay in time-to-referral was most pronounced for children referred for neurodevelopmental disorders. Help-seeking pathways differ by symptom duration and type of symptoms.

BACKGROUND High-quality, large-scale healthcare research, especially those using medical records, encounters significant challenges related to technical difficulties and confidentiality issues. As a result, critical research questions about patient evaluation and treatment have been left unanswered. Moreover, the presence of stigma and increased sensitivity surrounding mental health issues have resulted in a significant delay in research progress, particularly concerning Child and Adolescent Mental Health Services (CAMHS). OBJECTIVE These challenges can be effectively addressed by generating synthetic data, which not only safeguard individual privacy but also facilitate comprehensive analyses of clinical information from EMRs and other clinical data sources. To exemplify this method, we have utilized CAMHS synthetic data for planning the allocation of mental health resources, while ensuring confidentiality. In the process, using mental health clinical data, we demonstrate how to create and successfully analyse synthetic data from large-scale EMR-based data to answer critical health care questions for policymakers and clinicians. METHODS The study was carried out on a retrospectively collected cohort comprising 6,924 distinct patients from the Child and Adolescent Mental Health Services (CAMHS) in Stavanger, Norway. The analysis included 7,730 referral periods and a total of 58,524 episodes of care. The full dataset was divided into a training cohort (n = 6184 referrals, 58524 episodes of care) and an independent, fixed test set (n = 1564 referrals, 14,610 episodes of care). A hierarchical synthetic data generation model was used to generate synthetic referral periods with the associated episodes of care based on “real-world” CAMHS data. In addition to the utility of the data, the quality and privacy risk of the generated synthetic data were assessed. RESULTS The synthetic hierarchical data generation model created reproducible synthetic CAMHS data with properties very similar to “real-world” data (KS/TVD Complement score =0.92, CS score =0.77, CS (Inter-table) score =0.75 and CSS score=0.92), while demonstrating low risk score when exposed to a set of privacy attacks (average Singleout score(univariate)=0.17, average Singleout score(multivariate)=0.04, average Linkability risk=2.5, average inference risk=0.7). The predictive model trained on synthetic data produced comparable performance to the model trained on real data in the context of classifying the intensity of care required by patients, all while maintaining the interpretability of the utilized features. (for n = 656, 1546, 3092 and 6184, average PR_AUC = 0.32, 0.33, 0.34 and 0.40 respectively, compared to PR_AUC =0.43 when using n=6184 real data records). CONCLUSIONS Synthetic data in Child and Adolescent Mental Health Services (CAMHS) balances data utility with fairness and privacy protection.It fosters trust between patients and healthcare providers while promoting collaboration among researchers by offering access to extensive and representative samples with a low risk of patient identification. This approach not only encourages data sharing but also expands the breadth of research while safeguarding patient privacy. Effective implementation of synthetic data generation methods in CAMHS depends on the model's ability to accurately identify and replicate the complex patterns present in real data, while maintaining consistency across various outputs. Therefore, selecting the appropriate technique is crucial for achieving accurate and insightful research findings in this field CLINICALTRIAL The synthetic hierarchical data generation model created reproducible synthetic CAMHS data with properties very similar to “real-world” data (for n = 656 ,KS/TVD Complement score =0.92, CS score =0.77, CS (Inter-table) score =0.75 and CSS score=0.92), while demonstrating low risk score when exposed to a set of privacy attacks (for n = 656, average Singleout score(univariate)=0.17, average Singleout score(multivariate)=0.04, average Linkability risk=2.5, average inference risk=0.7). The predictive model trained on synthetic data produced comparable performance to the model trained on real data in the context of classifying the intensity of care required by patients, all while maintaining the interpretability of the utilized features. (for n = 656, 1546, 3092 and 6184, average PR_AUC = 0.32, 0.33, 0.34 and 0.40 respectively, compared to PR_AUC =0.43 when using n=6184 real data records).

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.