Brief intervention: a promising framework for child and youth mental health?

There is a discrepancy between the demand for mental health treatment amongst children, young people and their carers, and the capacity of the current service system to provide evidence based interventions. Innovative models of care are required to redress this discrepancy. One such model is the single session model, which provides a single or small number of solution focused sessions targeting one or two identified problems. Single session interventions have been trialled across a range of presenting concerns including child and youth mental health services. This paper provides a rationale for offering a brief focused intervention as part of a broader Child and Youth Mental Health Service, and introduces a model of how brief intervention fits within a broader system of care.

Experiences of consumers, carers and clinicians during borderline personality disorder presentations to the emergency department-An integrative review.

INTRODUCTION: People with a borderline personality disorder (BPD) diagnosis or symptoms may experience emotional crises which necessitate use of the emergency department (ED). No existing reviews focus specifically on experiences of consumersa, carersb and clinicians in relation to ED presentations by people diagnosed with BPD. AIM/QUESTION: The aim of this study was to synthesise knowledge on consumer, carer and clinician experiences of BPD in the ED. METHOD: An integrative review methodology was chosen as it best captures the complexity of varied perspectives and emergent phenomena from diverse literature sources. EMBASE, CINAHL, PsycInfo and Medline were searched for papers published before 16 February 2022. RESULTS: Nine papers met the inclusion criteria (five qualitative, one quantitative, one mixed methods and two letters to the editor). Key themes were barriers to timely and adequate care, and stigmatising attitudes and practices towards people diagnosed with BPD. Negative attitudes were perceived to perpetuate harmful outcomes and further ED visits. DISCUSSION: Predominantly negative ED experiences were expressed by clinicians, consumers and carers. Further work is needed in ED models of care and staff education to improve the experience of care for consumers, carers and clinicians alike. IMPLICATIONS FOR PRACTICE: Opportunities for change will exist through co-designed innovation, education, advocacy and leadership.

Consumer perspectives of telehealth in ambulatory care in an Australian health network.

We aimed to explore consumer experiences of ambulatory telehealth services and whether consumer experiences differed according to whether they received their consultation using telephone or video technology. We conducted structured telephone interviews with patient consumers who had received a recent remote consultation by telephone or video call, at local ambulatory allied health or multidisciplinary services within a large public metropolitan public health network. Respondents were asked about their recent experience and future choices in relation to telehealth. Responses from consumers who received telephone and video consultations were compared. Consumers from community rehabilitation, community health, allied health outpatients, multidisciplinary specialist clinics and mental health services participated (n = 379), of whom 245 received a telephone consultation (65%) and 134 a video consultation (35%). Almost half of respondents (49%) expressed preference for future face-to-face care and 29% reported they would choose to use telehealth over face-to-face consultation for a similar appointment again. Many commented that they would be influenced by the type of consultation required and expressed a desire to have a choice. Approximately 80% of both groups reported they had achieved the desired outcome from their telehealth consultation. Consumers using video were more likely to experience technical issues. Telehealth met the needs of most consumers, and responses were similar for telephone and video consultations.

Overview of the national mental health benchmarking project.

OBJECTIVE: This paper provides an overview of the National Mental Health Benchmarking Project (NMHBP) which explored the value of benchmarking within the four main program areas of public sector mental health (general adult, child and adolescent, older persons and forensic). The NMHBP involved a series of forums which enabled participating organizations to benchmark themselves against each other, with a view to understanding variability in performance against a range of key performance indicators (KPIs). METHOD: Twenty-three mental health organizations took part in the NMHBP. The forums culminated in each mental health organization documenting its performance against relevant KPIs. The processes, impacts and outcomes of the NMHBP were evaluated via a multi-methods evaluation. RESULTS: There was considerable variability across program streams for many of the KPIs, much of which could be explained by contextual factors. Within program streams there was considerable intra-organization variability. Participants found the examination of intra-organization variability on particular indicators to be useful. CONCLUSIONS: The NMHBP has shown that benchmarking is possible. Managers and clinical leaders will need to champion benchmarking and highlight its utility in relation to quality improvement and service development if the accountability goals of the Fourth National Mental Health Plan are to be realized.

Benchmarking the cost efficiency of community care in Australian child and adolescent mental health services: implications for future benchmarking.

OBJECTIVE: The purpose of this study was to benchmark the cost efficiency of community care across six child and adolescent mental health services (CAMHS) drawn from different Australian states. METHOD: Organizational, contact and outcome data from the National Mental Health Benchmarking Project (NMHBP) data-sets were used to calculate cost per "treatment hour" and cost per episode for the six participating organizations. We also explored the relationship between intake severity as measured by the Health of the Nations Outcome Scales for Children and Adolescents (HoNOSCA) and cost per episode. RESULTS: The average cost per treatment hour was $223, with cost differences across the six services ranging from a mean of $156 to $273 per treatment hour. The average cost per episode was $3349 (median $1577) and there were significant differences in the CAMHS organizational medians ranging from $388 to $7076 per episode. HoNOSCA scores explained at best 6% of the cost variance per episode. CONCLUSIONS: These large cost differences indicate that community CAMHS have the potential to make substantial gains in cost efficiency through collaborative benchmarking. Benchmarking forums need considerable financial and business expertise for detailed comparison of business models for service provision.

Benchmarking child and adolescent mental health organizations.

OBJECTIVE: This paper describes aspects of the child and adolescent benchmarking forums that were part of the National Mental Health Benchmarking Project (NMHBP). These forums enabled participating child and adolescent mental health organizations to benchmark themselves against each other, with a view to understanding variability in performance against a range of key performance indicators (KPIs). METHOD: Six child and adolescent mental health organizations took part in the NMHBP. Representatives from these organizations attended eight benchmarking forums at which they documented their performance against relevant KPIs. They also undertook two special projects designed to help them understand the variation in performance on given KPIs. RESULTS: There was considerable inter-organization variability on many of the KPIs. Even within organizations, there was often substantial variability over time. The variability in indicator data raised many questions for participants. This challenged participants to better understand and describe their local processes, prompted them to collect additional data, and stimulated them to make organizational comparisons. These activities fed into a process of reflection about their performance. CONCLUSIONS: Benchmarking has the potential to illuminate intra- and inter-organizational performance in the child and adolescent context.

Health of the Nation Outcome Scales for Infants field trial: concurrent validity.

BACKGROUND: A review of Australian mental health services identified a gap in routine outcome measures addressing social, emotional and behavioural domains for pre-schoolers and infants. A Child and Adolescent Mental Health Information Development Expert Advisory Panel working group developed the Health of the Nation Outcome Scales for Infants (HoNOSI), a clinician-reported routine outcome measure for infants 0-47 months. Prior face validity testing showed that the HoNOSI was considered useful in measuring mental health outcomes. AIMS: To examine the concurrent validity of the HoNOSI. METHOD: Mental health clinicians providing assessment and treatment to infants in routine clinical practice participated in the study. The mental health status of 108 infants were rated by a minimum of 26 clinicians with the HoNOSI, the Parent-Infant Relationship Global Assessment Scale (PIR-GAS) and measures of symptom severity and distress. RESULTS: The HoNOSI was statistically significantly correlated with the PIR-;GAS, rs = -0.73; Clinical Worry, rs = 0.77; and Severity Judgement ratings, rs = 0.85; P < 0.001. A good level of internal consistency was found. Using the COsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria for judging instrument acceptability, the HoNOSI meets the standard for both concurrent validity and internal consistency. CONCLUSIONS: There has been a clear need for a routine outcome measure for use with infants. This study provides positive evidence of aspects of validity. These findings, along with those from the prior face validity study, support a controlled release of the HoNOSI accompanied by further research and development.

The interrater reliability of a routine outcome measure for infants and pre-schoolers aged under 48 months: Health of the Nation Outcome Scales for Infants.

BACKGROUND: A review of Australian mental health services identified a gap in routine outcome measures addressing social, emotional and behavioural domains for pre-schoolers and infants. The Child and Adolescent Mental Health Information Development Expert Advisory Panel Working Group developed the Health of the Nation Outcome Scales for Infants (HoNOSI), a clinician-reported routine outcome measure for use with those aged under 4 years. Prior psychometric testing showed that the HoNOSI was considered to show face validity, and that it met the standards for concurrent validity and internal consistency. AIMS: We aimed to investigate the interrater reliability of the HoNOSI. METHOD: Forty-five infant mental health clinicians completed HoNOSI ratings on a set of five case vignettes. RESULTS: Quadratic weighted kappa interrater reliability estimates showed the HoNOSI to have Almost Perfect interrater reliability for the HoNOSI total score. Of the 15 scales, one had Moderate, seven had Substantial and seven had Almost Perfect interrater reliability. Ten of the fifteen scales and the total score exceeded the COnsensus-based Standards for the Selection of Health Measurement INstruments criteria for interrater reliability (κw ≥ 0.7). CONCLUSIONS: There has been a clear need for a routine outcome measure for use with infants and pre-schoolers. This study provides evidence of interrater reliability. The current findings, combined with the face and concurrent validity studies, support further examination of HoNOSI in real-world settings.

International consensus on a standard set of outcome measures for child and youth anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder.

A major barrier to improving care effectiveness for mental health is a lack of consensus on outcomes measurement. The International Consortium for Health Outcomes Measurement (ICHOM) has already developed a consensus-based standard set of outcomes for anxiety and depression in adults (including the Patient Health Questionnaire-9, the Generalised Anxiety Disorder 7-item Scale, and the WHO Disability Schedule). This Position Paper reports on recommendations specifically for anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder in children and young people aged between 6 and 24 years. An international ICHOM working group of 27 clinical, research, and lived experience experts formed a consensus through teleconferences, an exercise using an adapted Delphi technique (a method for reaching group consensus), and iterative anonymous voting, supported by sequential research inputs. A systematic scoping review identified 70 possible outcomes and 107 relevant measurement instruments. Measures were appraised for their feasibility in routine practice (ie, brevity, free availability, validation in children and young people, and language translation) and psychometric performance (ie, validity, reliability, and sensitivity to change). The final standard set recommends tracking symptoms, suicidal thoughts and behaviour, and functioning as a minimum through seven primarily patient-reported outcome measures: the Revised Children's Anxiety and Depression Scale, the Obsessive Compulsive Inventory for Children, the Children's Revised Impact of Events Scale, the Columbia Suicide Severity Rating Scale, the KIDSCREEN-10, the Children's Global Assessment Scale, and the Child Anxiety Life Interference Scale. The set's recommendations were validated through a feedback survey involving 487 participants across 45 countries. The set should be used alongside the anxiety and depression standard set for adults with clinicians selecting age-appropriate measures.

On the meaning of change in a clinician's routine measure of outcome: HoNOSCA.

OBJECTIVE: With the advent of routine outcomes across Australia and New Zealand, clinicians, managers, parents and children will be interested in change on these measures. This paper presents a number of approaches and the implications. METHOD: Health of the Nations Outcome Scales for Children and Adolescents (HoNOSCA) collected during clinical practice for 911 patients were examined for changes over time, clinical significance, treatment status, effect size, and reliable and clinically significant change. RESULTS: Statistically significant changes in symptom severity were found related to treatment status and to changes in the number of clinically significant scales. An effect size of almost one standard deviation was noted and the proportion of patients who improved was examined. While the reliable change index was calculated, there are clinical complications with this approach. The impact of the capacity to change on specific scales illustrates a critical issue in describing outcomes. CONCLUSION: From a number of perspectives, change in HoNOSCA total and scale scores is valid. However, several clinical dilemmas must be faced in deciding which approach should be used. The implications of these choices may affect clinicians, patients, carers and managers in understanding change.

Factors associated with dropout and diagnosis in child and adolescent mental health services.

OBJECTIVE: Dropout from child and adolescent mental health services has ramifications for children, families and the services themselves. Understanding the factors that are associated with dropout for different diagnoses has the potential to assist with tailoring of services to reduce dropout. The aim of the current study was to identify such factors. METHOD: A file audit was conducted for all referrals to a child and adolescent mental health service over a 12 month period, yielding 520 subjects for analysis (264 male, 256 female, mean age = 12.6 years). Parent, child and service variables of interest were recorded as were diagnoses, which were categorized into 25 superordinate categories. RESULTS: Almost 50% of subjects dropped out of treatment. Factors associated with dropout varied across diagnosis, and no factor was associated with dropout for all diagnoses. CONCLUSION: There are differences in the factors that were associated with dropout for different disorders. This is a useful finding in terms of understanding and preventing dropout in child and adolescent mental health settings, but more research is needed.

Differences in dropout between diagnoses in child and adolescent mental health services.

Dropout from treatment is a significant problem in child and adolescent mental health services, and findings regarding the role of possible contributing factors are inconsistent. It is argued that this inconsistency may be the result of the confounding effects of different definitions of dropout, and different dropout rates for different diagnoses. A file review of 520 new cases over a 12-month period in a large Child and Adolescent Mental Health Service in Melbourne, Australia was performed. Information was collected about the intake, parents, family, child, diagnoses and treatment. A significant relationship was found between diagnosis and dropout rate, with clients experiencing family problems or conduct disorder and ADHD being more likely to dropout, and those experiencing negative life events, anxiety disorders or those not having a diagnosis being less likely to dropout. These findings offer potential directions for services to consider specific strategies for retaining their clients. Possible reasons for these findings, methodological issues and future research directions are discussed.

The young adult Strengths and Difficulties Questionnaire (SDQ) in routine clinical practice.

Expansion of the youth mental health sector has exposed a need for an outcome measure for young adults accessing services. The Strengths and Difficulties Questionnaire (SDQ) is a widely used consumer and carer outcome measure for children and adolescents. The aim of this study was to evaluate the psychometric properties of a young adult SDQ. The young adult SDQ was introduced for routine clinical practice at Eastern Health Child and Youth Mental Health Service (EH-CYMHS), complementing the well-established adolescent and child versions. Data for adolescents (aged 12-17) and young adults (aged 18-25) where both self-report and parent SDQs had been completed at entry point to the service were extracted from a two-year period. Overall, paired cases involved 532 adolescents and 125 young adults. Across both self-report and parent SDQs, a similar pattern of results was found between adolescents and young adults on mean scores, inter-scale correlations, internal consistency, and inter-rater agreement. The findings of the current study support the use of the young adult SDQ in public mental health as an instrument whose psychometric properties, to date, appear consistent with those of the adolescent version. Further investigation is warranted.

Homeless youth: Barriers and facilitators for service referrals.

Young people who are homeless and experiencing mental health issues are reluctant to use relevant services for numerous reasons. Youth are also at risk of disengaging from services at times of referral to additional or alternative services. This study aimed to identify barriers and facilitators for inter-service referrals for homeless youth with mental health issues who have already engaged with a service. Qualitative, semi-structured interviews were conducted with homeless youth (n = 10), homelessness support workers (n = 10), and mental health clinicians (n = 10). Barriers included: resource shortages; programs or services having inflexible entry criteria; complexity of service systems; homeless youth feeling devalued; and a lack of communication between services, for example, abrupt referrals with no follow up. Referral facilitators included: services providers offering friendly and client-centred support; supported referrals; awareness of other services; and collaboration between services. Relationships with service providers and inter-service collaboration appeared essential for successful referrals for homeless youth. These facilitating factors may be undermined by sector separation and siloing, as well as resource shortages in both the homelessness and mental health sectors. Service transitions may be conceptualised as a genuine service outcome for homeless youth, and as a basis for successful future service provision.

Reviewing the learning organisation model in a child and adolescent mental health service.

From 1995 onwards, a child and adolescent mental health service (CAMHS) applied Senge's learning organisation model. This review compared service performance with that of peer services 5 years later and explored whether any differences were associated with the application of this model. The comparison methodology used quantitative analysis of external data from the Department of Human Services, together with qualitative analysis of material including interviews with CAMHS directors and service managers. Results showed high evaluation activity and high quality, efficiency and efficacy of care compared with other services. Several restraints to the optimal application of the model were identified, including inadequate training of new managers, service overload, major external organisational change and limited investment in information systems. Other outcomes are discussed.

Curative Factors in Adolescent Day Programs: Participant, Therapist, and Parent Perspectives.

Adolescent day programs (ADPs) have treatment outcomes as good as, or better than, regular outpatient treatment for adolescents who present with emotional, behavioral, social, and psychiatric disorders. However, they may be more costly, and the mechanisms of change within them are unknown. Identification of the most important curative factors could enable the streamlining of these programs. This descriptive study examined the perceptions of curative factors in ADP treatment as rated by 38 participants, 51 of their parents, and 14 clinicians. Findings were variable across informant groups. Adolescent respondents reported Universality, Acceptance, Learning from Interpersonal Action, Decision Making, Altruism, Guidance, and Instillation of Hope to be equally the most helpful curative factors in the program. Clinicians ranked Acceptance to be the most important factor, followed by Decision Making, Self-Understanding, Vicarious Learning, and Universality. Parents ranked Acceptance, Universality, Guidance, and Instillation of Hope as being most helpful. The findings provide directions for the enhancement of ADPs.

Routine outcome measurement in youth mental health: a comparison of two clinician rated measures, HoNOSCA and HoNOS.

Mental health services engagement in routine outcome measurement has created a demand for a coherent infrastructure. Two clinician instruments for adolescents (HoNOSCA) and adults (HONOS) are used across many countries. However, the increasing emphasis on youth suggests protocols with historically driven age divisions may obscure outcomes. The current study examines these instruments' congruence with regard to youth mental health. Members of national mental health expert panels rated four vignettes before discussing perceived strengths and weaknesses. The instruments were strongly correlated and HoNOSCA resulted in more severe symptom scores. Most subscales and scales correlated as predicted with some important exceptions. 'Problems with family relationships', tracked by HoNOSCA, did not correlate with its HoNOS counterpart. Qualitative feedback indicated using the HoNOSCA scale 'School attendance' for vocational attendance would improve its applicability to young people. The instruments have a strong relationship. While either could be used, HoNOS will underestimate symptom severity in youth. The importance of family relationships for young people suggests that HoNOSCA is preferable. While sited in the Australian context, these findings should be applicable to other countries using these instruments, and should interest services considering the continuity of youth presentations and their outcomes.

Evaluating the outcomes of adolescent day programs in an Australian child and adolescent mental health service.

Adolescent day programs (ADPs) are an increasingly used approach to treating adolescents with mental health issues. However, there is a dearth of studies empirically examining the outcomes of adolescent day programs. This study retrospectively examined the mental health functioning of 84 adolescents, pre- and post-treatment, who in addition to their ongoing outpatient treatment had participated in an ADP during a five-year period. Their functioning was compared to matched adolescents who participated only in outpatient treatment during the same time period. Statistical and clinical examinations revealed the reported outcomes following ADP treatment were at least comparable, and sometimes significantly better, when compared to the reported outcomes following outpatient treatment excluding ADP involvement. This study, while having some methodological shortcomings, provides some evidence for the efficacy of ADPs.

Olfactory impairments in child attention-deficit/hyperactivity disorder.

OBJECTIVE: This study compared unilateral olfactory identification abilities in children with and without attention-deficit/hyperactivity disorder (ADHD) and evaluated the utility of the University of Pennsylvania Smell Identification Test (UPSIT) as a potential screening tool for the diagnosis of ADHD. METHOD: Subjects comprised 44 children with DSM-IV ADHD (aged 7-16 years) from 2 Melbourne, Australia, hospital outpatient clinics and 44 healthy children matched for age and sex. The children were assessed from March 2004 to October 2004 for olfactory identification ability using the UPSIT, and behavioral data were gathered using the Rowe Behavioral Rating Inventory. Background and demographic data were also obtained through hospital records and parental interview. RESULTS: Children with ADHD demonstrated significantly poorer olfactory identification ability compared to healthy controls (p < .01). A significant right nostril advantage for smell identification was evident in the control group (p < .01), whereas significant right nostril impairment was evident among the children with ADHD (p < .01). CONCLUSION: The results provide the first evidence of olfactory identification deficits in children with ADHD. As such deficits implicate orbitofrontal regions, this finding is consistent with previous reports of prefrontal compromise in children with ADHD.