Adolescent Mental Health Survey Research Articles

Mental health related contact with education professionals in the British Child and Adolescent Mental Health Survey 2004

Purpose – The purpose of this paper is to describe mental health-related contact with educational professionals amongst children in the British Child and Adolescent Mental Health Survey (BCAMHS) 2004. Design/methodology/approach – BCAMHS 2004 was a community-based survey of 5,325 children aged 5-16, with follow-up in 2007. This paper reports the percentage of children with a psychiatric disorder that had mental health-related contact with education professionals (categorised as teachers or specialist education services) and the percentage with specific types of psychiatric disorders amongst those contacting services. Findings – Two-thirds (66.1 per cent, 95 per cent CI: 62.4-69.8 per cent) of children with a psychiatric disorder had contact with a teacher regarding their mental health and 31.1 per cent (95 per cent CI: 27.5-34.7 per cent) had contact with special education either in 2004 or 2007, or both. Over half of children reporting special education contact (55.1 per cent, 95 per cent CI: 50.0-60.2 per cent) and almost a third reporting teacher contact in relation to mental health (32.1 per cent, 95 per cent CI: 29.7-34.6 per cent) met criteria for a psychiatric disorder. Practical implications – Many children in contact with education professionals regarding mental health experienced clinical levels of difficulty. Training is needed to ensure that contact leads to prompt intervention and referral if necessary. Originality/value – This is the first paper to report on mental health-related service contact with education professionals in the 2004 BCAMHS survey along with its 2007 follow-up. It identifies high levels of teacher contact which represent challenges in supporting staff with training, resources and access to mental health services.

Eight-year incidence of psychiatric disorders and service use from adolescence to early adulthood: longitudinal follow-up of the Mexican Adolescent Mental Health Survey.

Half of mental disorders have their first onset before adulthood when the presence of a disorder may be particularly disruptive to developmental milestones. Retrospective prevalence estimates have been shown to underestimate the burden of mental illness and scarce data are available on the incidence of disorders throughout the adolescent period, especially in developing countries. Thus, the objective was to determine the incidence of mental disorders in an 8-year period from adolescence to young adulthood, onset of service use and their predictors in a Mexican cohort. 1071 respondents from a representative two-wave panel sample participated in the Mexican Adolescent Mental Health Survey in 2005 and in the follow-up survey in 2013. Disorders were evaluated with the World Mental Health Composite International Diagnostic Interview. 37.9% experienced the onset of a psychiatric disorder and 28.4% sought services for the first time. Substance use disorders had the greatest incidence, followed by mood and behavior disorders, anxiety disorders and lastly eating disorders. Sex, age, school dropout, childhood adversities and prior mental disorders predicted the onset of new disorders. Being female, having more educated parents and most classes of disorder predicted first time service use. These findings contribute to a paradigm shift in conceptions of mental disorder similar to how we think of common physical afflictions as near universal experiences across the life course, but less frequent at any given moment. Adolescents are particularly vulnerable. Therefore, public health policy should focus on early universal promotion of positive mental health and structural determinants of mental health.

Trajectories of Psychopathology in Relation to Mental Health Related Service Contacts over Three Years in the British Child and Adolescent Mental Health Survey 2004

Introduction Previously, a number of observational studies have found no association between contact with services and improved outcomes in children with psychopathology, despite the existence of effective interventions. The British Child and Adolescent Mental Health Survey (BCAMHS) 2004 is a study of 5,325 children aged 5-16, with data on parent-reported mental health-related public sector service contacts and psychopathology over three years, allowing exploration of the association in a large community-based dataset. Aims • Describe the trajectories of children in contact and not in contact with services over three years from 2004-2007 • Explore the association between mental health-related service contact over the study period and outcomes in terms of parent-rated psychopathology Methods This study is a secondary analysis of children's trajectories by service contact status (no contact, contact 2004 only, contact 2007 only, contact 2004 & 2007). The main measure of psychopathology over time was the well-validated Strengths and Difficulties Questionnaire. Multivariable linear regression was used to examine the association between contact and outcomes in children with a psychiatric disorder at baseline in 2004. Results Children in contact with services demonstrated the highest levels of psychopathology over time, and the 2007-only contact group displayed a trajectory of increasing difficulties. Overall, contact with services was not associated with improvement in outcomes, following adjustment for measured confounders. Conclusions The effectiveness of contact alone with services was not demonstrated in our findings. Despite methodological limitations, this underlines the need for continuing development and consistent implementation of effective interventions, alongside initiatives evaluating outcomes within services.

Sample selection may bias the outcome of an adolescent mental health survey: results from a five-year follow-up of 4171 adolescents

ObjectivesThe representativeness of the data is one of the main issues in evaluating the significance of research findings. Dropping out is common in adolescent mental health research, and may distort the results. Nevertheless, very little is known about the types of systematic bias that may affect studies in a) the informed consent phase and b) later in follow-up phases. Study designThe authors addressed this gap in knowledge in a five-year follow-up study on a sample of adolescents aged 13–18 years. MethodsThe data were collected using self-report questionnaires. The baseline sample consisted of 4171 adolescents, 1827 (43.8%) of whom gave consent to be contacted for a follow-up survey, but only 797 (19.1%) participated in the follow-up. Binary logistic regression models were used to explain the participation. ResultsYoung age, female gender, a high number of hobbies, good performance at school in the native language and general subjects, family disintegration such as divorce, high parental employment, and symptoms of depression and anxiety were associated with both consent and participation. However, the effect of mental health aspects was smaller than the effect of age and gender. ConclusionsThis study confirmed the possibility of systematic selection bias by adolescents' sociodemographic characteristics. The representativeness of the study sample might have been improved by more intense recruitment strategies.

How do child and adolescent mental health problems influence public sector costs? Interindividual variations in a nationally representative British sample.

Policy and practice guidelines emphasize that responses to children and young people with poor mental health should be tailored to needs, but little is known about the impact on costs. We investigated variations in service-related public sector costs for a nationally representative sample of children in Britain, focusing on the impact of mental health problems. Analysis of service uses data and associated costs for 2461 children aged 5-15 from the British Child and Adolescent Mental Health Surveys. Multivariate statistical analyses, including two-part models, examined factors potentially associated with interindividual differences in service use related to emotional or behavioural problems and cost. We categorized service use into primary care, specialist mental health services, frontline education, special education and social care. Marked interindividual variations in utilization and costs were observed. Impairment, reading attainment, child age, gender and ethnicity, maternal age, parental anxiety and depression, social class, family size and functioning were significantly associated with utilization and/or costs. Unexplained variation in costs could indicate poor targeting, inequality and inefficiency in the way that mental health, education and social care systems respond to emotional and behavioural problems.

Editorial Perspective: School exclusion is a mental health issue

Editorial Perspective: School exclusion is a mental health issue

School Mental Health Resources and Adolescent Mental Health Service Use

Although schools are identified as critical for detecting youth mental disorders, little is known about whether the number of mental health providers and types of resources that they offer influence student mental health service use. Such information could inform the development and allocation of appropriate school-based resources to increase service use. This article examines associations of school resources with past-year mental health service use among students with 12-month DSM-IV mental disorders. Data come from the U.S. National Comorbidity Survey Adolescent Supplement (NCS-A), a national survey of adolescent mental health that included 4,445 adolescent-parent pairs in 227 schools in which principals and mental health coordinators completed surveys about school resources and policies for addressing student emotional problems. Adolescents and parents completed the Composite International Diagnostic Interview and reported mental health service use across multiple sectors. Multilevel multivariate regression was used to examine associations of school mental health resources and individual-level service use. Nearly half (45.3%) of adolescents with a 12-month DSM-IV disorder received past-year mental health services. Substantial variation existed in school resources. Increased school engagement in early identification was significantly associated with mental health service use for adolescents with mild/moderate mental and behavior disorders. The ratio of students to mental health providers was not associated with overall service use, but was associated with sector of service use. School mental health resources, particularly those related to early identification, may facilitate mental health service use and may influence sector of service use for youths with DSM disorders.

Economic impact of childhood psychiatric disorder on public sector services in Britain: estimates from national survey data

Approximately one in ten children aged 5-15 in Britain has a conduct, hyperactivity or emotional disorder. The British Child and Adolescent Mental Health Surveys (BCAMHS) identified children aged 5-15 with a psychiatric disorder, and their use of health, education and social care services. Service costs were estimated for each child and weighted to estimate the overall economic impact at national level. Additional health, social care and education costs associated with child psychiatric disorders totalled £1.47bn in 2008. The lion's share of the costs falls to frontline education and special education services. There are huge costs to the public sector associated with child psychiatric disorder, particularly the education system. There is a pressing need to explore ways to reduce these costs while improving health and well-being.

Online child and adolescent mental health surveys can be good enough

To assess the value and practicability of online child mental health surveys. Study 1 followed up an existing low-risk sample from the general population. Study 2 recruited a new high-risk sample via a parents' organization for children with a neurological condition. Both studies invited parents of 2-17year olds to complete the online development and well-being assessment. Pre-existing data on the Study 1 sample made it possible to examine selective participation. Response rates were low (20% for Study 1, 8% for Study 2). Participation in Study 1 was lower for parents who rented rather than owned their home, for non-traditional families, for parents living in more deprived areas, and for Asian families. Nevertheless, studies 1 and 2 generally replicated the findings of previous interviewer-based surveys with higher response rates. Online surveys can be quick and easy to carry out and can potentially generate good enough data for service planning and other purposes despite low response rates, selective participation and missing data. Web-based assessments are a useful addition to the researcher's toolbox, but they do not render the other tools redundant.

Nocturnal Enuresis Is Associated with Attention Deficit Hyperactivity Disorder and Conduct Problems

ObjectiveThere are no published prevalence estimates of elimination disorders and their association with disruptive-behavior disorders among children in the Asian region using standardized diagnostic interviews. This study was conducted to determine the prevalence of elimination disorders and its association with disruptive-behavior disorders in a representative sample of children in Seoul, Korea.MethodsThe diagnosis of enuresis and encopresis was derived from parent-reported data for "enuresis and encopresis," collected using the Diagnostic Interview Schedule for Children, from a representative sample of 6- to 12-year-old children (n=1,645) who participated in the 2005 Seoul Child and Adolescent Mental Health Survey. Prevalence data for attention deficit and disruptive-behavior disorders were collected from the same sample.ResultsThe overall 12-month prevalence of nocturnal enuresis and encopresis was 1.8% and 0.6%, respectively. Enuresis and encopresis prevalence in boys was significantly greater than that in girls. Enuresis and encopresis was most common at 7 to 9 years of age. Enuresis was significantly associated with ADHD (OR 2.6, 95% CI 1.0-6.9) and conduct disorder (CD; OR 4.7, 95% CI 1.0-22.4).ConclusionEnuresis is significantly associated with ADHD and CD, so these conditions must be assessed together during the evaluation of children with enuresis.

Epidemiology of Fears and Specific Phobia in Adolescence: Results From the Mexican Adolescent Mental Health Survey

Epidemiology of Fears and Specific Phobia in Adolescence: Results From the Mexican Adolescent Mental Health Survey

Diagnostic validity across racial and ethnic groups in the assessment of adolescent DSM‐IV disorders

We examine differential validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses assessed by the fully-structured Composite International Diagnostic Interview Version 3.0 (CIDI) among Latino, non-Latino Black, and non-Latino White adolescents in comparison to gold standard diagnoses derived from the Schedule for Affective Disorders and Schizophrenia for School-age Children (K-SADS). Results are based on the National Comorbidity Survey Replication Adolescent Supplement, a national US survey of adolescent mental health. Clinicians re-interviewed 347 adolescent/parent dyads with the K-SADS. Sensitivity and/or specificity of CIDI diagnoses varied significantly by ethnicity/race for four of ten disorders. Modifications to algorithms sometimes reduced bias in prevalence estimates, but at the cost of reducing individual-level concordance. These findings document the importance of assessing fully-structured diagnostic instruments for differential accuracy in ethnic/racial subgroups.

Epidemiology of Fears and Specific Phobia in Adolescence

Specific phobia is among the most common disorders in the general adolescent population, but also among the least studied. The objectives of this study were to estimate the prevalence of specific fears among adolescents, the proportion of those with fears who meet criteria for specific phobia, and the proportion who recognize their fears as excessive and to identify comorbidity with other disorders and factors associated with severity and treatment. 3,005 youth aged 12 to 17 years participated in the Mexican Adolescent Mental Health Survey, a stratified multistage probability sample representative of adolescents living in Mexico City in 2005. Fears, specific phobia, and 20 other DSM-IV psychiatric disorders were evaluated with the adolescent computerized version of the World Mental Health Composite International Diagnostic Interview, administered by trained lay interviewers in the participants' homes. Descriptive, logistic regression, and discrete-time survival analyses were employed. Most adolescents reported at least 1 fear (76.5%); 36.5% of those met lifetime criteria for specific phobia, and 27.3% met criteria in the prior 12 months. Blood-injection-injury and animal fears were the most common types. Females were more likely to report any fear, to have more fear types, and to meet diagnostic criteria. Increased numbers of fears were associated with increased odds of meeting specific phobia criteria and with increased impairment. Among teens with specific phobia, 71.3% recognized their fear as excessive, 9.7% to 12.3% reported severe impairment, and only 6.5% had received treatment. Severity of impairment and comorbid disorders were associated with treatment seeking. The large percentage of adolescents meeting diagnostic criteria coupled with the low proportion with serious impairment suggests that current diagnostic thresholds may be too low or not developmentally sensitive. Future research should address the nature of impairment for adolescents with specific phobia. Early detection and timely treatment are important given that specific phobia is persistent and highly comorbid and that few individuals seek treatment.

Is there potential for the treatment of children with ADHD beyond psychostimulants?

The past decades have seen a tremendous rise in the use of methylphenidate in children and adolescents. While the overall prevalence of psychotropic drug use in children and adolescents in the Netherlands doubled between 1995 and 2001, that of methylphenidate alone almost rose sixfold in those years [1]. Between 2001 and 2006, a further large increase was observed in the prescription rates of methylphenidate, not only in children and adolescents but also in adults [2]. While rates of methylphenidate use are still clearly highest amongst boys aged 6–11 years, the most rapid increase in prevalence rate of methylphenidate use has actually been seen in girls. Between 1996 and 2006 this has risen more than 11.5-fold in girls, according to a pharmacoepidemiological study conducted in the North of the Netherlands [3]. To put this into perspective: the latter study pointed out that the use of methylphenidate in girls in 2006 was almost double that of boys back in 1996. The increased use of methylphenidate contrasts with the lack of long term data on safety and effectiveness. Much of our knowledge about treatment periods of longer than a year comes from following up one study, the Multimodal Treatment of attention deficit/hyperactivity (ADHD) study (MTA) study. Although it should not be forgotten that all MTA data beyond the initial controlled period of 14 months has been strictly observational, so far long term benefits of optimized and well controlled methylphenidate treatment during a limited period of time of 14 months have been hard to demonstrate [4]. Thus, while on one hand, there are clear short-term benefits of methylphenidate for the treatment of ADHD, the uncertainty of long term benefits and risks remains an urgent challenge for the scientific and clinical community. What promise may alternative treatments offer for children with ADHD? Food-based interventions may be one option. In 2009, this Journal had published promising effects of a restricted elimination diet in reducing symptoms of ADHD versus a waiting list control group [5]. Results were recently confirmed in a larger scale Lancet study by the same group of investigators, in which there was a control group that received instructions for a healthy diet [6]. However, the difficulty of establishing a truly blinded control intervention constitutes perhaps the biggest design challenge in trying to more firmly demonstrate the efficacy of food-based treatments for ADHD. Ideally, well-designed and controlled replication studies should be conducted by independent groups who did not develop the intervention themselves. Another alternative treatment option that has now seen a number of randomized controlled trials is electroencephalogram (EEG)-based neurofeedback. This issue (Bakhshayesh et al.) contains a small-scale, but elegantly designed randomized controlled trial of EEG neurofeedback versus a sham condition (biofeedback aimed at forehead muscle relaxation). Importantly, children and parents were not explicitly informed about the two treatment conditions. Results indicated both specific effects of EEG neurofeedback (reduction of inattention symptoms on parent rating scales and reaction time in neuropsychological tests), as well as non-specific factors (regarding hyperactivity and impulsivity), which were similarly improved in the children receiving the sham treatment. Another study in this issue (Benjet et al.), using an epidemiological approach (based on interview data of more than 3,000 adolescents from the Mexican Adolescent Mental Health Survey) once more reminded us that it is not all genetics and neurobiology that determines mental disorders. Rather, it pointed to the important role of family dysfunctioning for the development of psychopathology. As the authors conclude, their study findings at least indirectly provide further evidence for the importance of family focused intervention and prevention efforts. With the ever rising prescription rates of methylphenidate, all too easily impressions of overtreatment rather than undertreatment of ADHD in children may arise. However, many children with impairing ADHD still receive no proper treatment [7]. Thus, effective and easy-to-implement screening questionnaires that can identify those children who are at risk of having ADHD or other behavioral disorders are crucial. The Strengths and Difficulties Questionnaire (SDQ) is one well-known example of a brief screening instrument. Ullebo and colleagues [8] in this issue describe that already the use of the 5-item-only SDQ hyperactivity- inattention subscale has adequate sensitivity for detecting ADHD combined subtype. Are we overtreating children with methylphenidate? There may be both over- and undertreatment. It remains an enormous challenge for the scientific community to more precisely establish the long-term risks and benefits of methylphenidate treatment and also to determine in which cases treatment with psychostimulants or alternative treatments are warranted. Well-designed studies involving alternative treatments remain urgently needed.

P1-435 Why do British Indian children have an apparent mental health advantage

BackgroundPrevious studies document a mental health advantage in British Indian children, the causes of which are unknown.MethodsOur subjects were 13 836 White children and 361 Indian children aged 5–16 years...

The association of chronic adversity with psychiatric disorder and disorder severity in adolescents

The purpose of this paper is to estimate the impact of chronic adversity on psychopathology in adolescents, taking into account the type of adversity, number of adversities experienced and type of psychiatric disorder, as well as to estimate the impact on severity of the disorder. A total of 3,005 male and female adolescents from the Mexican Adolescent Mental Health Survey aged 12-17years were interviewed in a stratified multistage general population probability survey. Assessment of 20 DSM-IV disorders, disorder severity and 12 chronic childhood adversities were assessed with the adolescent version of the World Mental Health Composite International Diagnostic Interview (WMH-CIDI-A). Family dysfunction adversities including abuse presented the most consistent associations between chronic adversity and psychopathology and their impact was generally non-specific with regard to the type of disorder. Parental divorce, parental death and economic adversity were not individually associated with psychopathology. Among those with a psychiatric disorder, sexual abuse and family violence were associated with having a seriously impairing disorder. The odds of having a psychiatric disorder and a serious disorder increased with increasing numbers of adversities; however, each additional adversity increased the odds at a decreasing rate. While the study design does not allow for conclusions regarding causality, these findings suggest general pathways from family dysfunction to psychopathology rather than specific associations between particular adversities and particular disorders, and provide further evidence for the importance of family-focused intervention and prevention efforts.

Why do British Indian children have an apparent mental health advantage?

Previous studies document a mental health advantage in British Indian children, particularly for externalising problems. The causes of this advantage are unknown. Subjects were 13,836 White children and 361 Indian children aged 5-16 years from the English subsample of the British Child and Adolescent Mental Health Surveys. The primary mental health outcome was the parent Strengths and Difficulties Questionnaire (SDQ). Mental health was also assessed using the teacher and child SDQs; diagnostic interviews with parents, teachers and children; and multi-informant clinician-rated diagnoses. Multiple child, family, school and area factors were examined as possible mediators or confounders in explaining observed ethnic differences. Indian children had a large advantage for externalising problems and disorders, and little or no difference for internalising problems and disorders. This was observed across all mental health outcomes, including teacher-reported and diagnostic interview measures. Detailed psychometric analyses provided no suggestion of information bias. The Indian advantage for externalising problems was partly mediated by Indian children being more likely to live in two-parent families and less likely to have academic difficulties. Yet after adjusting for these and all other covariates, the unexplained Indian advantage only reduced by about a quarter (from 1.08 to .71 parent SDQ points) and remained highly significant (p < .001). This Indian advantage was largely confined to families of low socio-economic position. The Indian mental health advantage is real and is specific to externalising problems. Family type and academic abilities mediate part of the advantage, but most is not explained by major risk factors. Likewise unexplained is the absence in Indian children of a socio-economic gradient in mental health. Further investigation of the Indian advantage may yield insights into novel ways to promote child mental health and child mental health equity in all ethnic groups.

Exposure to alcohol, drugs and tobacco and the risk of subsequent suicidality: Findings from the Mexican Adolescent Mental Health Survey

Aims To examine whether the association between prevalence measures of suicidality and substance abuse/dependence among adolescents (1) is attenuated when temporal priority of exposure and outcome are taken into account, (2) extends to substance use (i.e. without disorder), (3) applies to tobacco use and dependence independent of illicit drugs and alcohol use/disorder, and (4) is confounded by comorbid mental illness. Design Discrete-time survival models were applied to retrospectively reported age of onset of first suicidal ideation, plan and attempt and age of onset of first substance use and disorder. Participants 3005 adolescents aged 12–17 residing in the Mexico City Metropolitan Area in 2005. Measurements The World Mental Health computer-assisted adolescent version of the Composite International Diagnostic Interview was used to assess suicidal outcomes and psychiatric disorders including substance dependence/abuse. Findings Use of and dependence on tobacco is as strong a predictor of subsequent suicidality as is use of and dependence with abuse of alcohol and drugs. The association between substance use and subsequent suicidality is not fully accounted for by comorbid mental illness. Conclusion Efforts to reduce the use as well as the abuse of alcohol, drugs and tobacco may help reduce the risk of subsequent suicidal behaviors among adolescents in Mexico.

Trends in Recognition of and Service Use for Attention-Deficit Hyperactivity Disorder in Britain, 1999–2004

National data suggest that attention-deficit hyperactivity disorder (ADHD) is underdiagnosed in Britain and that parental factors determine service use. This situation may have changed in recent years following policy and research recommendations. This study investigated changes in rates and correlates of service use for ADHD in Britain between 1999 and 2004. Use of various services by children aged five to 16 with ADHD (N=176) who were identified in the cross-sectional, nationally representative 2004 British Child and Adolescent Mental Health Survey was examined. The 2004 sample was compared with a community sample identified in a similar survey conducted in 1999. Most parents (90%) of children with ADHD recognized the presence of a problem, and 55% thought that their child had hyperactivity. Past-year contacts with education-based professionals exceeded those with professionals in specialist health services (74% versus 51%). One-third of children with ADHD were taking medication. Child factors, including severity of ADHD and a comorbid emotional or behavioral disorder, were the main determinants of service use. Parental burden was also associated with specialist service use. Specialist service use increased over five years after adjustment for severity and parental perceptions and burden (odds ratio=1.76, 95% confidence interval=1.13-2.75, p=.013). Barriers to care for ADHD in Britain appear to have been reduced in recent years. Medication for ADHD appears to be used cautiously, and the study found little empirical evidence of overuse. There is a need for health services to provide training and support for education-based professionals to help them recognize and manage children with ADHD.

Does problem behaviour affect attrition from a cohort study on adolescent mental health?

Most surveys are plagued by significant numbers of non-respondents. In psychiatric epidemiology, differences in levels of psychopathology are often assumed between respondents and non-respondents. However, studies on attrition are rare, especially in child and adolescent populations. The present study sought to estimate the association of depression, anti-social behaviour with attrition from a cohort study among adolescents. The adolescent mental health cohort study (AMHC) is a prospective follow-up study on prevalence and determinants of mental health problems and risk behaviour among Finnish adolescents at two study sites. Subjects of the final baseline sample (n = 3278) were reached for a 2-year follow-up. Differences in data collecting methods between the study sites yielded different response rates (78% vs. 51%). Chi-square statistics and logistic regression models were computed to estimate the effect of two types of problem behaviour on attrition. Depression at baseline was associated with higher probability of attrition at follow-up. School performance was a stronger predictor of attrition than problem behaviour. The models predicted non-response in the study site with mainly school-based surveys but not in the study site with mainly postal surveys. Internalizing problem behaviour may be underrepresented in adolescent mental health surveys. School performance is strongly associated with attrition. Hence, special attention should be paid to designing questionnaires targeting adolescents.