Child Mental Health Systems Research Articles

Forgone healthcare for medically vulnerable groups during the pandemic era: experiences of family caregivers of young adults with substance use disorders in Zambia.

Scholars worldwide have defined the COVID-19 pandemic as a mass-disabling event of our time. The situation is grave for families experiencing financial hurdles while caring for young adults in recovery from addiction problems. Using semi-structured interviews with 30 purposively selected family caregivers (FCGs) of young adults with substance use disorders (SUDs) in Lusaka, Zambia, this study reveals several factors influencing forgone healthcare for this medically vulnerable group. Financial challenges and huge out-of-pocket bills; caregivers' perceived far-fetched recovery of the young adult; the cost of medication and transportation; the young adult's little perceived need for healthcare service use, their runaway and treatment elusive tendencies; caregiver concerns about contracting the virus, and the stigma associated with it; and a fragmented child and adolescent mental health system influenced forgone healthcare. The young adults were often unavailable for days and months, posing challenges to the continuity of care. Despite caregivers' acknowledgment of the availability of healthcare professionals, young adults with problematic substance use had limited access to SUD recovery services, resulting in adverse health outcomes. Results also show that most family caregivers encountered challenges in accessing and purchasing psychotropic medications, which were difficult to find during the lockdowns. Some family caregivers lost their sources of income by being laid off from work due to the pandemic and skipping work to attend to caregiving responsibilities. Most of those in self-employment had to close their business and stay home to look after their youth. Several caregivers kept their youth at home because they failed to access private residential SUD recovery services. Family caregivers mostly relied on outpatient public health services, alternative medicine from traditional healers, and faith-based healing, all of which some young adults rarely accessed because of their problematic behaviors of escaping healthcare. These identifiable risk factors, and their detrimental consequences highlight the need for interventions to improve healthcare access for this vulnerable population. Supporting FCGs of addicted young adults is crucial in ensuring the well-being of both the caregivers and care recipients. Further research is warranted to explore potential solutions, such as peer support programs, policy changes, and education initiatives for carers and recipients in the (post) pandemic era.

Australian child and adolescent mental health services

We aim to describe the Australian child and adolescent mental health system, which has its historical origins in the child guidance clinic, with recent efforts at modernisation to meet community needs and major policy innovations, including the National Disability Insurance Scheme (NDIS) and expansion of digital/telehealth services. Shared funding/responsibility across commonwealth and state/territory governments has resulted in country-wide variations, allowing innovation but also introducing fragmentation and duplication. The increase in demand outstripping supply (which was exacerbated by workforce shortages resulting from the pandemic), the lack of robust evaluation, and poor service integration (which make navigation difficult for families) are ongoing challenges.

Different perspectives in psychiatry: how family-oriented are professionals in Germany?

ΒackgroundChildren of parents with a mental illness have up to 50% chance of developing a mental illness themselves. Numerous studies have shown that preventive family-oriented interventions can decrease the risk by 40% and that professionals are a decisive factor influencing family-oriented practice. There are also substantial differences between professions in terms of their family-oriented practices. This study examines the level of family-oriented practice for different professional groups in Germany.MethodsData were used from the baseline assessment of the two-group randomized controlled multicenter trial ci-chimps as a subproject of CHIMPS-NET, which took place from January 2020 to May 2021 in 18 clinical centers in Germany. Child and adolescent mental health systems as well as adult mental health systems took part and every professional involved in the treatment was invited to participate. Data was used from 475 mental health professionals including physicians, psychologists, psychotherapists for adults and for children and adolescents, occupational/ music/ physio/ art therapists/ (social) education workers and nursing/ education service. Family-oriented mental health practice was examined using the translated version of the Family-Focused Mental Health Practice Questionnaire (FFMHPQ) with means and standard deviations calculated for each of the 18 FFMHPQ-GV subscales. ANOVAs were computed to compare professions and significant differences were examined via post hoc analyses (Scheffé). Additionally, effect sizes were calculated (Omega squared).ResultsDifferences were seen between the professions in all aspects of family-oriented practice: Both regarding organizational policy and support aspects, issues concerning working with parent-clients, as well as professional skills and knowledge aspects. Psychotherapists for children and adolescents scored the highest family-oriented practices compared to all other professional groups on almost all subscales.ConclusionThis study examines the level of family-oriented practice for different professional groups in Germany. Apart from skills and knowledge about the impact of mental illness and parenting, psychotherapists for children and adolescents had the highest scores and engaged most in family-oriented practice. Psychotherapists for adults got the least workplace support for family-oriented practice but were competent providing resources and referral information to the concerned families and feel confidence working with them. Due to these results, a training need exists to improve skills and knowledge about the impact of mental illness and parenting. Additionally, there is still potential for institutional support in promoting family-oriented work.Trial registrationThe CHIMPS-NET-study was registered with the German Clinical Trials Register on 2019–12-19 (DRKS00020380) and with Clinical Trials on 2020–4-30 (NCT04369625), the ci-chimps-study was registered with the German Clinical Trials Register (DRKS00026217) on 2021–08-27 and with Clinical Trials on 2021–11-04 (NCT05106673).

Navigating the Maze: Facilitators and Barriers to Substance Use Treatment for Pregnant and Parenting Women in Mississippi

There are significant hurdles to placing pregnant and parenting women (PPW) with a substance use disorder into treatment programs. This study uses qualitative analysis of case notes collected by a linkage to care expert (patient navigator) from over 50 Mississippi PPW client cases. The analysis identified facilitators and barriers in the referral to treatment process. We group the observed patterns into three general categories: (1) individual factors such as motivation to change and management of emotions; (2) interpersonal relationships such as romantic partner support or obstruction; and (3) institutional contexts that include child welfare, judicial, and mental health systems. These factors intersect with one another in complex ways. This study adds to prior research on gender-based health disparities that are often magnified for pregnant and parenting women.

Including Voices of Adolescents With Chronic Conditions in the Redesign of Children's Mental Health Systems: Implications for Resource Allocation

Adolescents with chronic conditions have disparate mental health outcomes. This study aimed to explore the perspectives of adolescents with chronic conditions on mental health system redesign to improve outcomes. Within an interpretive phenomenological approach, semistructured interviews with 17 adolescents aged 10-20 years with chronic conditions were conducted. Purposive sampling and recruitment occurred at three ambulatory sites. Data were analyzed using inductive and deductive thematic analysis until information saturation was achieved. Four themes were identified: (1) Brushed off: I need to be heard, (2) I need someone I can really talk to and trust, (3) They need to reach out to us. Check in on us, and (4) the school nurse is for physical illness only. Mental health system redesign should be considered for adolescents with chronic conditions. The findings can inform future research to test innovative health care delivery models to reduce mental health disparities in this vulnerable population.

Adolescents with chronic conditions: Engagement with children's mental health systems during the Covid-19 pandemic.

The Covid-19 pandemic contributed to adverse adolescent mental health outcomes globally. Adolescents with chronic conditions have four times the odds of self-harm than peers. Little evidence exists to guide pediatric nurses on how to engage this vulnerable population with mental health support as the pandemic continues. In adults with chronic conditions, positive health assets (health access literacy, health self-efficacy, and emotional well-being) are directly related to improved patient engagement. The objective of this study was to gain a deeper understanding of engagement with mental health supports in adolescents with chronic conditions to inform practice. Using mixed methods, we surveyed and interviewed adolescents with chronic conditions aged 10-20 years. Random sampling was applied to avoid bias. Valid and reliable scales were used to measure health access literacy, health self-efficacy, and emotional well-being. Textual data were collected using a semistructured interview guide. Integrated data analysis was conducted using structural equation models and interpretive phenomenology. One hundred fifty-four participants provided numerical data and 17 participants provided textual data (mean age 15.5 years; 56% female, 5.8% agender; 56% White; 16.9% Black or African American, 4.5% Asian; 51.9% Hispanic or Latinx; 23.4% LGBTQ+). The structural model was an acceptable fit for the data (comparative fit index[CFI] = 0.97, Tucker-Lewis index[TLI] = 0.95). Participants reported higher levels of health access literacy (M = 3.88, SD = 0.848) than health self-efficacy (M = 2.98, SD = 0.646), and engagement (M = 1.78, SD = 1.71). Health access literacy predicted emotional well-being (β = .33, p < .001, 95% confidence interval [CI] [.20, .50]) and health self-efficacy (β = .52, p < .001, 95% CI [0.42, .062]). Emotional well-being positively predicted health self-efficacy (β = .21, p < .003, 90% CI [0.10, 0.033]). Health self-efficacy predicted engagement (β = .20, p < .01, 90% CI [0.07, 0.034]). Participants reported not engaging until "it was really, really bad" citing fear, stigma, and lack of connectedness with providers as barriers. Regardless of health access literacy and health self-efficacy, adolescents with chronic conditions may not engage until crisis levels. Pediatric nurses can aim to engage with this vulnerable population proactively.

Stepping Up to the Plate—The Role of Pediatricians in Addressing the Child and Adolescent Mental Health Crisis

This commentary discusses how pediatricians can become involved in improving the mental health system for children and adolescents.

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 Color of Child Protection in America: Antiracism and Abolition in Child Mental Health.

This article illuminates the color of child protection by exposing the risks of racist and white supremacist harm intrinsic to the child welfare, public education, and juvenile injustice systems, specifically when they intersect with the child mental health system. Relying on bold and radical frameworks, such as abolition, critical race theory, and decolonization, it positions child mental health providers to confront the color of child protection while protecting minoritized children against these systems of harm. These frameworks inspire a daily antiracist practice whereby child mental health providers challenge racist inequities and the historical arcs driving them; protect minoritized children and families against the systems of care designed to harm them; and work toward the longer-term goal of abolishing these systems altogether. In a white supremacist society, child mental health providers have no choice but to engage in such antiracist practices in order to uphold their fundamental oath to first do no harm. The failure to do so amounts to negligence and malpractice.

California's multi‐billion plan for youth MH to include 40,000 new workers

Less than a year following the California Legislature's infusion of multibillions to support a behavioral health initiative for youth, California Gov. Gavin Newsom last week announced a master plan to overhaul the state's mental health system for children. The $4.7 billion plan will provide Californians ages 0–25 with increased access to mental health and substance use supports.

Collaboration among vocational rehabilitation and mental health leaders: Supporting the vocational success of transition-age youth with serious mental health conditions

BACKGROUND: The ability of vocational rehabilitation, adult mental health and child mental health service systems to collaborate regarding the employment and career development goals of transition-age youth has not been explored nor has attention been paid to strategies that would increase this collaboration. OBJECTIVE: This qualitative study asks leaders from these three systems to describe collaborative activities that support better vocational services for transition-age youth with serious mental health conditions and discuss barriers and facilitators to collaboration. METHODS: Qualitative interviews were conducted with 39 formal and informal leaders in vocational rehabilitation (n = 16), child mental health (n = 13), and adult mental health (n = 10) systems as part of a larger study of interorganizational relationships. RESULTS: A primary barrier was lack of knowledge about the services and policies of each other’s systems. Another barrier was differences in philosophy about employment and the special needs of transition-age youth with mental health needs. CONCLUSIONS: In addition to specific activities that would encourage greater interaction across three systems, results underscore the need for the child mental health system and vocational rehabilitation system to increase their involvement with and knowledge about one another. This would include training child mental health providers about employment and career development services, vocational rehabilitation providers about the role of mental health in the youngest workers, and both being involved in transition-planning that directly addresses vocational goals and support needs.

The Development of Young Peoples' Internalising and Externalising Difficulties Over the First Three-Years in the Public Care System.

Although we know there are high rates of mental health difficulties amongst young people in out-of-home care (i.e. social welfare-involved children), there is limited evidence on the longitudinal development of these problems, particularly from when they enter the care system. Using the routinely collected carer-reported strengths and difficulties questionnaire, we explored internalising (emotional and peer) and externalising (conduct and hyperactivity) difficulties for 672 young people across their first 3years in the UK care system (2-16yrs, 51% boys, 76% Caucasian). In all cases stable profiles (resilient or chronic) were most common, while changing profiles (recovery or delayed) were less common. Findings showed that entry into the care system is not enough of an intervention to expect natural recovery from mental health difficulties. Number of placements and being separated from siblings were associated with greater difficulties. Implications for child welfare and mental health systems are discussed.

A situational analysis of child and adolescent mental health services and systems in the Western Cape Province of South Africa

BackgroundEven though child and adolescent mental health is a global health priority, services are very limited, particularly in low- and middle-income countries (LMIC), and therefore need comprehensive strengthening. This requires knowledge of the hardware elements of the system (human resources, financing, medicines, technology, organisational structure, service infrastructure, and information systems). This study sought to examine these elements of child and adolescent mental health (CAMH) services and systems in the Western Cape Province of South Africa.MethodsThe World Health Organization Assessment Instrument of Mental Health Systems (WHO-AIMS) version 2.2 of 2005 was adapted to identify key variables of interest in CAMH. Data were collected for the calendar year 2016 and focused on the public health sector. We outlined findings based on best available data across the six domains of the WHO-AIMS.ResultsIn domain 1, we found no provincial CAMH policy or implementation plans to support the national CAMH policy and were unable to identify a CAMH-specific budget. In domain 2, there was no dedicated provincial leadership structure for CAMH, and no dedicated or ‘child- and adolescent-friendly’ mental health services at primary or secondary care levels. At tertiary level, there were only three specialist CAMH teams. The majority of CAMH resources were based in the City of Cape Town, with limited resources in the rural districts. Essential medicines were available in all facilities, and the majority of children and adolescents had access to free services. In domain 3, data were limited about the extent of training offered to primary healthcare staff, and little or no psychosocial interventions were available in primary care. Domain 4 identified a small and variable CAMH workforce across all levels of care. In domain 5, few public health campaigns focused on CAMH, and little evidence of formal intersectoral collaboration on CAMH was identified. Domain 6 identified significant limitations in health information systems for CAMH, including lack of child- and adolescent-specific and disaggregated data to establish baselines for policy development, monitoring, evaluation and CAMH research.ConclusionsThis study identified significant structural weaknesses in CAMH and presents a clear call for action to strengthen services and systems in the province and in South Africa. it would be important to expand research also to include provider and user perspectives for service strengthening.

A New Acute-At-Home Child and Adolescent Clinical Service: Evaluation of Impact.

Objective An Acute at Home (AAH) clinical service was implemented to reduce emergency and inpatient admissions to the regional tertiary child and adolescent mental health system. This paper examines describes the served the population and impact on emergency and inpatient admissions. Methods Analysis of re-admission rates for those enrolled before and after the May 2019 implementation of the AAH service in comparison over the same time period to an unexposed comparison group. In addition the groups were compared on clinical and demographic variables comparing those exposed and those not exposed to the AAH service. Results The results indicated that the AAH group experienced reduced rates of readmission and lengths of stay post-exposure. Family composition, sex, seven Adverse Childhood Experience survey items, and nine Western Canada Waitlist Child Mental Health Priority Criteria Score items distinguished those exposed to AAH compared to those who were not. Thirteen of 19 independent variables indicated greater pathology in the AAH group with less likelihood of potential of danger to self. Conclusion The present results indicate a substantial benefit of the AAH service via reducing readmissions and lengths of stay. The quantitative measures warrant a careful qualitative examination of the AAH processes along with ongoing monitoring of the program’s effect.

Bridging the gap between the emergency department and outpatient care: feasibility of a short-term psychiatric crisis intervention for children and adolescents.

Child and adolescent mental health systems are facing limited resources of available psychosocial interventions, often leading to long waiting lists for acceptance to treatment. We describe the feasibility of a short-term (8–10 sessions) psychological crisis intervention (CI) protocol for children and adolescents aged 8–17 years (n = 30, mean ± standard deviation 12.9 ± 2.4 years) who were referred to an outpatient mental health clinic due to suicidal ideation, aggression, severe anxiety, or extreme family conflict. The participants were assessed before and after the CI, and at a 3–6-months follow-up visit. The psychiatric assessments included clinical evaluation by a senior psychiatrist, and the completion of self-report questionnaires by both the participants and their parents. Following the establishment of the CI unit, the waiting lists for urgent cases were reduced from a median of 84 days in the two preceding years to 23 days in the following 3 years (H[2] = 18.5, p < 0.0001) for patients of the CI unit. A 1-year psychiatric follow-up after the end of the CI revealed that 72% did not require additional psychotherapy. The overall clinical evaluation measures (clinical evaluation, parents-report and child report) improved and had been preserved at the 3–6-months follow-up. Our results demonstrate the feasibility of a short-term CI protocol for expediting admission to treatment for urgent psychiatric cases.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00787-021-01896-2.

HEALTH EQUITY IN CHILD AND ADOLESCENT PSYCHIATRY FOR BLACK AND LATINX CHILDREN AND FAMILIES: WHAT IS MY ROLE?

This Clinical Perspectives aims to: 1) describe health disparities in child mental health care of Black and Latinx children and their families; 2) examine the definition of health equity work as it applies to child and adolescent psychiatrists, with a focus on early career psychiatrists (ECPs) and psychiatry trainees; 3) exemplify how psychiatrists have paved their professional careers to perform health equity work in child and family mental health systems, discussing challenges and opportunities specific to trainees and ECPs; and 4) equip attendees with tools and knowledge to bolster their health equity work in child and adolescent psychiatry.

SIMON WILE SYMPOSIUM: FOCUS ON DIVERSITY AND EQUITY THROUGH A PEDIATRIC COLLABORATIVE AND INTEGRATED CARE LENS

The goal of this year’s Simon Wile Symposium will be to focus on diversity, equity, and inclusion through the lens of pediatric collaborative and integrated care. National experts will share their experiences and perspectives in building systems to collaborate with pediatric primary care providers (PCPs), working within and improving regional child health and mental health systems to improve health equity. Given national trends of focus on systemic racism and on racial and ethnic disparities, our Center for Inclusive Child Care (CICC) committee discussed possible invitees who had developed innovative programs to target improved access to care for children in Black, Indigenous, and People of Color (BIPOC) and Latinx populations. The literature on child psychiatry access programs was also reviewed, resulting in the current Symposium submission. Presentations this year will focus on programs that are as follows: 1) evaluating the impact of social determinants on ADHD symptoms among a racially and ethnically diverse population of preschoolers in primary care settings; 2) implementing collaborative and integrated care through a Federally Qualified Health Center for a racially and ethnically diverse population of children; and 3) targeting improving health equity among racially and ethnically diverse populations including BIPOC and Latinx populations. As child and adolescent psychiatrists continue to work to address the significant child mental health needs in communities across the country, we have increasingly found child psychiatry collaborative and integrated care to be a valuable tool in helping pediatric PCPs care for children and families struggling with mental health issues. We believe that this can also be a valuable tool in improving health equity. Our speakers will share innovations in their access programs that have allowed them to reach new and underserved populations, better engage PCPs, and carefully build systems of collaborative care.

Autism Spectrum Screening Checklist (ASSC): The Development of a Scale to Identify High-Risk Individuals Within the Children's Mental Health System.

Autism Spectrum Disorder (ASD) is a complex childhood onset neurodevelopmental disorder that has become the fastest growing developmental disability. Due to the increased demand for diagnostic assessments and subsequent increased wait times, standardized screening as part of regular clinical practice is needed. More specifically, there is an important need for the development of a more streamlined screening tool within an existing assessment system to identify those at greatest risk of having ASD. The current study utilized data from ~17,000 assessments obtained within the province of Ontario, based on the interRAI Child and Youth Mental Health (ChYMH) and Child and Youth Mental Health and Developmental Disability (ChYMH-DD), to develop a scale to identify children who have a higher likelihood of having autism. The scale was then tested on a trial population with data from the interRAI Early Years instrument. Further analyses examined the predictive validity of the scale. The Autism Spectrum Screening Checklist (ASSC) was found to be a good predictor of ASD with a sensitivity of 0.73 and specificity of 0.62, at the recommended cut-point of 2+. The results were consistent across several age ranges, specifically from 2 to 21 years of age. The ASSC scale provides an initial screen to help identify children and youth at heightened risk for autism within larger populations being assessed as part of routine practice. The main goal for the development and implementation of the ASSC scale is to harness the power of the existing interRAI assessment system to provide a more efficient, effective screening and referral process. This will ultimately help improve patient outcomes through needs-based care.

Child and adolescent mental health services and systems in low and middle-income countries: from mapping to strengthening.

Most of the world's children and adolescents live in low and middle-income countries (LMICs) where mental health services are very limited. Here, we reviewed literature over the last 18 months describing the current landscape of child and adolescent mental health services and systems (CAMHSS) in LMICs, and present findings from systems strengthening research. The challenges in CAMHSS are well described with little change over the last two decades. Fortunately, research has started to move from 'mapping' towards systems 'strengthening'. Using the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS) framework, we reviewed recent CAMHSS innovations. Clinical care and human resource innovations focused on primary care with validation of screening tools, training and task-sharing for capacity-building. Intersectoral collaboration emerged as a priority domain for strengthening, alongside a theme around the importance of participatory research to inform policy reforms. The potential role of digital technology to strengthen CAMHSS was identified as an emerging theme. There is an urgent need to increase the priority of CAMHSS in LMICs. This will require innovations at multiple levels aimed at all CAMHSS domains, with active participation of all relevant local stakeholders to ensure the translation of research into policy and practice.

A call for de-policing crisis responses: Distressed children and youth caught between the mental health and police systems

In this paper, we present the outcomes of a narrative study of 13 interviews with six child and youth mental healthpractitioners and seven caregivers with a child between 12 and 24 years old involved with the mental health system and with a history of police involvement. The focus of the interviews was on the experiences of young people involved with the mental health system, and their caregivers, with police encounters. Two categories of themes emerged. Presented here are the outcomes that show the contradictions between the child and youth mental health and police systems as contributing factors to the stigmatization and criminalization of psychiatrically distressed children and youth. A call is made for a collaboration between the mental health and police systems rooted in a commitment for de-policing crisis responses in child and youth mental health.