Our Ways, Your Ways, Both Ways - a multi-disciplinary collaboration to develop, embed and evaluate a model of social and emotional wellbeing care for Aboriginal and Torres Strait Islander young people who experience detention - Phase 1.

The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing identifies building a strong Aboriginal and Torres Strait Islander led evidence-base to inform care as a key priority. Aboriginal and/or Torres Strait Islander adolescents in contact with the criminal justice system are a highly vulnerable group of Australians, with substantial unmet needs. There is limited evidence to inform culturally appropriate models of care that meet the social and emotional wellbeing needs of justice-involved Aboriginal and/or Torres Strait Islander adolescents. This project aims to develop, implement and evaluate an in-reach and community transitional model of social and emotional wellbeing care for Aboriginal and/or Torres Strait Islander adolescents (10-17 years old) who experience detention through close engagement with Aboriginal and/or Torres Strait Islander youth, Elders, researchers, practitioners and community members, and by drawing on culturally informed practice and knowledge systems. The project is based on a multi-level mixed methods design, with a strong focus on ongoing project evaluation (based on the Ngaa-bi-nya framework) and co-design. Co-design is facilitated through culturally safe and trauma informed participatory processes based on development of strong partnerships from project initiative, design, implementation and evaluation. Application of the landscape domain of the Ngaa-bi-nya framework for Aboriginal and Torres Strait Islander program evaluation will be explored in Phase one. Aboriginal and Torres Strait Islander adolescents with experience in detention will be engaged through one-on-one interviews with data collection through the Growth and Empowerment Measure (GEM) Youth (which will be adapted from the adult version and validated as part of this study), the Kessler Psychological Distress Scale (K-10), questions around alcohol and drug use, and narrative interviews exploring experience. Qualitative data will be analyzed using an inductive thematic approach, structured within the framework of the Ngaa-bi-nya landscape prompts. Quantitative data will be analyzed using descriptive statistics to provide a profile of the cohort. Findings from Phase one will be used to inform the development of a model of social and emotional wellbeing care that will be implemented and evaluated in Phase two.

The impact of COVID-19 on children and adolescents attending Child and Youth Mental Health Services in Queensland, Australia.

OBJECTIVE: This explorative study aims to provide insight into impacts of the COVID-19 pandemic and associated restrictions, on mental health of children and adolescents treated at Child and Youth Mental Health Services, and their parents. METHOD: The COVID-19 Mental Health Survey was disseminated to parents of children and adolescents under treatment at community Child and Youth Mental Health Services (Brisbane, Australia) between July-November 2020 throughout different stages of COVID-19 related restrictions. Parents of 110 children participated. RESULTS: Most reported child's symptoms were sadness (46%), anxiety (60%), lack of focus (61%), lack of joy in their usual activities (38%) and reduction in sleep (42%). Parental emotions were significantly correlated with their child's emotions. Parent's lack of enjoyment of usual activities had the overall strongest average correlation (0.27) but this was no longer significant once other variables were controlled for. Children who attended school remotely for some of the days had a significantly (p < .05) higher risk of having more reported symptoms. Interestingly, in later stages of the lockdown with further easing of restrictions, symptoms also tended to be more severe. CONCLUSION: Cross-sectional data on children and adolescents in Queensland, Australia with pre-existing mental health issues suggests mental health continued to deteriorate through the pandemic even as restrictions eased. Changes in schooling seem to be an especially important risk factor.

Assessing Outcomes for Cost-Utility Analysis in Children and Adolescents With Mental Health Problems: Are Multiattribute Utility Instruments Fit for Purpose?

OBJECTIVES: The objective of this study was to compare the concurrent and construct validity, as well as the sensitivity of 5 multiattribute utility instruments (MAUIs), including the Assessment of Quality of Life-6D (AQoL-6D), EQ-5D-Y, Health Utilities Index (HUI)-2 and HUI-3, and the Child Health Utility 9D, 1 generic pediatric quality of life instrument, with 3 routinely collected outcome measures in Australian mental health services (Strengths and Difficulties Questionnaire, Clinical Global Assessment Scale [CGAS] and the Health of the Nation Outcome Scale for Children and Adolescents) in children and adolescents diagnosed of internalizing (eg, anxiety/depression), externalizing (eg, attention deficit hyperactivity disorder/conduct disorders), and trauma/stress related mental disorders. METHODS: A cross-sectional survey of measures, including demographic and basic treatment information, in children/adolescents recruited via 5 child and youth mental health services in Queensland and Victoria, Australia. Measures were either proxy or self-report completed, the CGAS and the Health of the Nation Outcome Scale for Children and Adolescents were clinician completed. RESULTS: The sample included 426 participants and had a mean age of 13.7 years (range 7-18 years). Utilities (as calculated from MAUIs) were generally lower in older adolescents and those with internalizing disorders. All MAUIs and self-reported clinical measures significantly correlated with each other (absolute correlation range 0.40-0.90), with the AQoL-6D showing generally higher levels of correlations. Correlations between the MAUIs and clinician/proxy-reported measures were weak, regardless of diagnosis (absolute correlation range 0.09-0.47). Generally, EQ-5D-Y, HUI-2, and AQoL-6D were more sensitive than Child Health Utility 9D and HUI-3 when distinguishing between different severities according to clinician-assessed CGAS (effect size range 0.17-0.84). CONCLUSIONS: The study showed that the commonly used MAUIs had good concurrent and construct validity compared with routinely used self-complete measures but poor validity when compared with clinician/proxy-completed measures. These findings generally held across different diagnoses.

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.

Short research article: COVID-19 and its impact on child and youth mental health service demand in the community and emergency department.

BACKGROUND: To explore changes in child and youth mental health service (CYMHS) demand in Brisbane, Australia, following the COVID pandemic. METHODS: The number of monthly presentations and referrals to respectively the emergency department (ED) and community CYMHS were compared among 2018, 2019 and 2020. RESULTS: The study shows a marked increase in referrals to ED starting from July and in the community from May 2020. In the population referred to as community teams, the proportions of Indigenous children and those from lower socio-economic areas decreased. CONCLUSIONS: The COVID-19 pandemic has aggravated the supply and demand disparity in CYMHS, with the largest effect on the most vulnerable families.

Comparing Treatment Outcomes in Children and Adolescents With ADHD to Other Disorders Within an Australian and Dutch Outpatient Cohort.

OBJECTIVE: Previous studies at child and youth mental health services (CYMHS) suggest that children with ADHD have poorer outcomes compared to those with other diagnoses. This study investigates this in more detail. METHODS: Children with ADHD were compared to those with ASD and those with emotional disorders, on routinely collected outcomes at CYMHS in Australia (N = 2,513) and the Netherlands (N = 844). RESULTS: Where the emotional disorders group reached a similar level of emotional symptoms at the end-of-treatment as the ADHD and ASD groups, the latter two groups still had higher scores on ADHD and ASD symptoms (attention and peer problems). The poorer outcomes were mainly explained by higher severity at baseline. In Australia, an ADHD and/or ASD diagnosis also independently contributed to worse outcomes. CONCLUSION: Those with neurodevelopmental disorders within both countries had poorer outcomes than those with emotional disorders. Services should aim to optimize treatment to ensure best possible outcomes.

Characteristics and treatment outcomes of children and adolescents accessing treatment in Child and Youth Mental Health Services.

AIM: To provide insight into the characteristics and treatment outcomes of children and adolescents accessing outpatient Child and Youth Mental Health Services (CYMHS), and to explore whether outcomes differ by age, sex, and ancestry background. This information can guide how to optimize the treatment delivered at these services. METHODS: An observational retrospective study was performed based on data from 3098 children and adolescents between age 5 and 18 who received treatment at Brisbane, Australia, community CYMHS between 2013-2018. Patient characteristics, service use, and clinician and parent rated Routine Outcome Measures (ROM) were extracted from electronic health records. RESULTS: Anxiety and mood disorders were the most common mental disorders (37% and 19%). In 1315 children and adolescents (42%), two or more disorders were diagnosed, and the far majority (88%) had experienced at least one psychosocial stressor. The ROM scores improved between start and end of treatment with Cohen's d effect sizes of around 0.9. However, ~50% of the children still scored in the clinical range at the end of treatment. Outcomes did not differ over gender and Indigenous status. CONCLUSIONS: Children and adolescents accessing CYMHS have severe and complex mental disorders as reflected by high rates of comorbidity, exposure to adverse circumstances and high symptom scores at the start of treatment. Despite the clinically relevant and substantial improvement, end ROM scores indicated the presence of residual symptoms. As this increases the risk for relapse, services should explore ways to improve treatment to further reduce mental health symptoms.

Effect of Sodium Benzoate vs Placebo Among Individuals With Early Psychosis: A Randomized Clinical Trial.

Importance: There is evidence that sodium benzoate (BZ) may be an effective adjunctive treatment for schizophrenia. The clinical efficacy of BZ has been investigated in chronic schizophrenia; however, the efficacy of this agent has not been studied in individuals with early psychosis. Objective: To examine the clinical efficacy of the adjunctive use of BZ for symptoms in people with early psychosis. Design, Setting, and Participants: Using a placebo-controlled double-masked parallel-group design, this randomized clinical trial was conducted from August 2015 to July 2018. Participants aged between 15 and 45 years experiencing early psychosis were enrolled from 5 major clinical sites in Queensland, Australia. Data analysis was conducted from October 2018 to February 2020. Interventions: Participants were randomized 1:1 (50 participants in each group) to receive 500 mg of sodium benzoate twice daily or placebo for 12 weeks. Main Outcomes and Measures: The primary efficacy outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 12 weeks. The key secondary efficacy measures were (1) the Clinical Global Impression score, (2) the Hamilton Depression Rating Scale for depression, (3) functioning as assessed by the clinician-rated Global Assessment of Function, and (4) the Assessment of Quality of Life Scale. The PANSS subscale scores and impact on selected amino acid concentrations were also assessed. Results: The study comprised 100 participants with a mean (SD) age of 21.4 (4.1) years, of whom 73 (73%) were male individuals. The mean (SD) baseline PANSS score was 75.3 (15.4). We found no improvement in total PANSS score in the BZ group compared with the placebo group. The end result of least-squares mean difference (SE) for total PANSS was -1.2 (2.4) (P = .63). There were no differences in any subscales of the PANSS, any secondary measures, nor any amino acid concentrations. The dose of BZ was well tolerated without any clinically significant treatment-emergent adverse event differences between BZ and placebo groups. Conclusions and Relevance: In this randomized clinical trial, there was no evidence that adjunctive use of 500 mg of BZ twice daily is an effective treatment for individuals with early psychosis. Trial Registration: anzctr.org.au Identifier: ACTRN12615000187549.

Vanuatu Psychiatry Mentorship Programme: a case illustrating cultural and clinical considerations.

OBJECTIVES: The objectives of this article are to describe a case highlighting challenges in managing an acute psychiatric presentation, the process of mentorship and the significance of cultural matters influencing family engagement in Vanuatu. METHOD: Case description. RESULTS: This case highlights resourcing constraints facing a small mental health team in the Pacific, the clinical significance of the concept of tabu in a ni-Vanuatu context and the importance of family decision making processes in ni-Vanuatu culture. CONCLUSION: A structured mentoring programme to foster mental health capacity development in Vanuatu can support psychiatric decision-making in complex cases, reflection on the role of culture in formulation and family engagement, and mutual learning.

The Vanuatu Psychiatry Mentorship Programme: supporting the development of a fledgling mental health service in the Pacific.

OBJECTIVE: To describe the Vanuatu Psychiatry Mentorship Programme (VPMP) set up to support the sole mental health doctor and local nurses developing mental health service capacity in Vanuatu. METHOD: Following a request from Vanuatu, the VPMP was set up under the auspices of the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (the College) with three components: regular online supervision, yearly onsite visits and advice over the Internet on an as-required basis. RESULTS: Onsite visits undertaken by three VPMP psychiatrists provided opportunities for mentoring and teaching activities related to clinical psychiatry, community liaison, social and ethical considerations and mental health policy matters. Online supervision sessions were initially hampered by technology difficulties. Ad hoc advice over the Internet allowed more rapid responses in complex acute psychiatry cases. CONCLUSIONS: Structured mentoring programmes can play a role in supporting the development of mental health capacity in low-resourced Pacific nations. Such programmes are likely to be more useful for Pacific participants if they are flexible, ongoing, sustained by support from the College and reviewed regularly.

Protocol update and statistical analysis plan for CADENCE-BZ: a randomized clinical trial to assess the efficacy of sodium benzoate as an adjunctive treatment in early psychosis.

BACKGROUND: CADENCE-BZ is a multi-centre, parallel-group, double-blind randomized controlled trial designed to examine the clinical efficacy and safety of an accessible food preservative, sodium benzoate, as an add-on treatment for patients with early psychosis. The original study protocol was published in 2017. Here, we describe the updated protocol along with the Statistical Analysis Plan (SAP) for the CADENCE-BZ trial prior to study completion. METHODS AND MATERIALS: Two important changes were made to the original protocol: (1) improvements to our statistical analysis plan permitted a reduction in sample size; and (2) a revision in the secondary outcomes with the intent of reducing redundancy and excluding those measures that were not appropriate as outcomes. CONCLUSIONS: We provide the updated SAP prior to the completion of the study with the intent of increasing the transparency of the data analyses for CADENCE-BZ. The final participants are currently completing the study and the results will be published in the near future. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12615000187549 ). Registered on 26th February 2015.

The aggressive child.

Aggression in children is a common transdiagnostic symptom associated with a wide range of developmental and mental health problems. It emerges early and without intervention, may increase in severity as the child grows stronger. Aggressive children are more likely to experience physical and mental illness, unemployment, poverty and forensic problems as adults. Strategies to prevent aggression must address risk factors: low maternal education, adolescent pregnancy, in utero exposure to tobacco and alcohol, poverty, coercive parenting, childhood maltreatment and bullying victimisation. The aggressive child requires a comprehensive assessment to identify and manage underlying or comorbid problems, to understand the reasons for the aggressive behaviour and to detect modifiable factors that exacerbate or perpetuate the aggression. Psychosocial interventions include parenting skills training and child-directed cognitive behavioural therapy, whereas pharmacotherapy may be used to treat underlying developmental or mental health problems or to manage the aggression.

The efficacy of sodium benzoate as an adjunctive treatment in early psychosis - CADENCE-BZ: study protocol for a randomized controlled trial.

BACKGROUND: Psychotic disorders affect up to 3% of the population and are often chronic and disabling. Innovation in the pharmacological treatment of psychosis has remained stagnant in recent decades. In order to improve outcomes for those with psychotic disorders, we present a protocol for the trial of a common food preservative, sodium benzoate, as an adjunctive treatment in early psychosis. METHODS: Persons experiencing early psychosis (n = 160) will be recruited through hospitals and community mental health services in Queensland, Australia. Patients will be randomized to receive either 12-week treatment with 1000 mg (500 mg twice daily (BD)) sodium benzoate or placebo. Patients will undergo fortnightly outcome assessments, in addition to weekly ongoing capacity to consent, drug compliance and safety assessments. The primary outcome measure is the Positive and Negative Syndrome Scale (PANSS) total score. Secondary outcomes are Global Assessment of Function (GAF), Assessment of Quality of Life Scale (AQOL), the Activity and Participation Questionnaire (APQ6), International Physical Activity Questionnaires (IPAQ), Simple Physical Activity Questionnaire (SIMPAQ), Physical Activity Questionnaire, Clinical Global Impression (CGI), Hamilton Depression rating Scale-17 items (HDRS), Opiate Treatment Index (OTI) and the Patients' Global Impression of Improvement (PGI-I). As a tertiary objective, changes from baseline to endpoint in to serum markers related to D-alanine, L-alanine, D-serine, L-serine, glycine and glutamate will be investigated. DISCUSSION: Consumers and clinicians are keen to help develop better treatments for those with psychosis. This study, part of the wider Cadence clinical trials platform will examine if a safe and accessible food preservative can help optimize outcomes in those with psychosis. TRIAL REGISTRATION: Australian New Zealand Clinical Trials registry (ANZCTR), ACTRN12615000187549 . Registered on 26 February 2015.

E-CYMHS: an expansion of a child and youth telepsychiatry model in Queensland.

OBJECTIVES: The purpose of this study was to describe the evolution of the E-Child and Youth Mental Health Service (E-CYMHS), which supports regional and rural mental health services by providing access to consultant child and adolescent psychiatrists to isolated staff in regional areas, where access to specialist psychiatric services is limited. CONCLUSIONS: E-CYMHS provides a level of parity in mental health care between metropolitan, regional and remote services through the provision of regular videoconferencing services with child and adolescent psychiatrists and senior allied health clinicians. The three key features which underpin the success of the service are: 1. A central co-ordinator of services; 2. Provision of support outside regular videoconference times; and 3. Routine outreach visits that foster community capacity-building. E-CYMHS has been well received by the regional mental health services it supports, and the total provision of services has more than doubled over the last three years. It is anticipated that as telepsychiatry is increasingly viewed as a credible alternative to traditional means of patient care, this trend is likely to continue.

Australian national trends in stimulant dispensing: 2002-2009.

OBJECTIVE: Internationally there has been an increase in the prescriptions of stimulant medication. The aim of this study was to examine longitudinal national trends of stimulant dispensing in Australia between 2002 and 2009. METHOD: Government databases were retrospectively reviewed for all dispensed stimulant prescriptions between 2002 and 2009. Prescriptions were converted to defined daily dose (DDD)/1000 population/day using census data. Utilization of dexamphetamine and methylphenidate were analysed by source (subsidized or non-subsidized), prescriber (general practitioner, psychiatrist or other specialists), gender and age of patient. RESULTS: Between 2002 and 2009, dispensing of stimulants in Australia increased 87% from 2.93 to 5.47 DDD/1000 population/day. Dexamphetamine remained the most commonly dispensed stimulant, with rates of dispensing falling 13% from 2.02 to 1.75 DDD/1000 population/day. Dispensed prescriptions of methylphenidate increased 300% from 0.45 in 2002 to 1.81 DDD/1000 population/day in 2009, attributable to the availability of long-acting preparations. Dispensing of stimulants to males was four-fold greater than to females. There was substantial dispensing of dexamphetamine to those older than 25 years. CONCLUSIONS: Stimulant dispensing in Australia increased between 2002 and 2009 as a result of increased dispensing of long-acting preparations of methylphenidate. Further research is required to determine if the increase in stimulant dispensing in Australia is clinically appropriate.

What is the burden of chronic cough for families?

BACKGROUND: The burden of children's chronic cough to parents is largely unknown. The objectives of this study were as follows: (1) to determine the burden of chronic cough using a purposely designed questionnaire, and (2) to evaluate psychological (child's anxiety and parental emotional distress) and other influences on the reported burden of cough. METHODS: Parents of children newly referred for chronic cough completed three questionnaires (Spence anxiety scale; depression, anxiety, and stress 21-item scale [DASS]; and burden of cough questionnaire) at enrollment. The last 79 parents also completed these questionnaires at follow-up. RESULTS: Median age of the 190 children recruited was 2.6 years. The number of medical consultations for coughing illness in the last 12 months was high: > 80% of children had > or = 5 doctor visits and 53% had > 10 visits. At presentation, burden scores correlated to parental DASS scores when their child was coughing. Stress was the largest contributor to parents' emotional distress. Parental anxiety and depression scores were within published norms. Scores on all three DASS subscales reduced significantly when the children ceased coughing. At follow-up, the reduction in burden scores was significantly higher in the "ceased coughing" group (n = 49) compared to the "still coughing" group (n = 32). CONCLUSIONS: Chronic cough in children is associated with a high burden of recurrent doctor visits, parental stress, and worries that resolve when cough ceases. Parents of children with chronic cough did not have above-average anxiety or depression levels. This study highlights the need to improve the management of children with chronic cough, including clinicians being cognizant of the emotional distress of the parents.

Use of the Massachusetts Youth Screening Instrument to assess mental health problems in young people within an Australian youth detention centre.

AIM: To screen for mental health problems in an Australian adolescent forensic population, evaluate the Massachusetts Youth Screening Instrument Version 2 (MAYSI-2) in providing a preliminary assessment of those needs, and to explore the level of mental health problems in vulnerable populations within detention. METHODS: Over a 6-month period, all young people admitted into detention were referred for screening by the MAYSI-2, a 7-scaled instrument developed to identify young people within the youth justice system at greatest risk for serious mental, emotional or behavioural disorders. RESULTS: High levels of mental health problems and trauma were reported, with 75.0% of males and 90.0% of females, and 81.2% of Indigenous and 75.0% of non-Indigenous youth screening above the clinical cut-off for at least one scale. Males screened highest on the Alcohol and Drug Use (58.9%), Angry-Irritable (28.2%) and Somatic Complaints (28.2%). Females screened highest on the Alcohol and Drug Use (67.5%), Somatic Complaints (45.0%), Depressed-Anxious (42.5%) and Suicide Ideation (30.0%) scales, with significantly higher rates than males on the Depressed-Anxious, Somatic Complaints and Suicide Ideation scales. No significant differences in screening rates were reported between Indigenous and non-Indigenous youth. CONCLUSIONS: This study confirmed the high rates of mental health problems in adolescents within youth detention. Appropriate use of screening tools improves our understanding and targets treatment of mental health problems in this cohort. We have reservations in recommending the MAYSI-2 as a valid screening tool for Indigenous young people in youth detention and recommend the development of a more appropriate screening tool.

A comparative assessment of suicide risk for young people in youth detention.

The aim of this study was to compare levels of agreement in the assessment of suicide risk by detention center staff procedures compared with those completed by a mental health clinician. Over a 6-month period, 64 young people (mean age 15.0 years; SD+/-1.3) assessed as being acutely suicidal were referred for a clinical mental health assessment and completion of the Adolescent Suicide Questionnaire (ASQ). Cohen's kappa statistic was used to determine inter-judgmental agreement between the detention center, a clinical assessment and ASQ scores. Weak levels of agreement existed in the assessment of suicide. We recommend further work in this area and broad discussion toward development of national guidelines to standardize the assessment of suicide risk for young people in youth detention.