Understanding the uptake of virtual care for first and return outpatient appointments in child and adolescent mental health services: a mixed-methods study.

OBJECTIVE: To describe patterns of virtual and in-person outpatient mental health service use and factors that may influence the choice of modality in a child and adolescent service. DESIGN: A pragmatic mixed-methods approach using routinely collected administrative data between 1 April 2020 and 31 March 2022 and semi-structured interviews with clients, caregivers, clinicians and staff. Interview data were coded according to the Consolidated Framework for Implementation Research (CFIR) and examined for patterns of similarity or divergence across data sources, respondents or other relevant characteristics. SETTING: Child and adolescent outpatient mental health service, Nova Scotia, Canada. PARTICIPANTS: IWK Health clinicians and staff who had participated in virtual mental healthcare following its implementation in March 2020 and clients (aged 12-18 years) and caregivers of clients (aged 3-18 years) who had received treatment from an IWK outpatient clinic between 1 April 2020 and 31 March 2022 (n=1300). Participants (n=48) in semi-structured interviews included nine clients aged 13-18 years (mean 15.7 years), 10 caregivers of clients aged 5-17 years (mean 12.7 years), eight Community Mental Health and Addictions booking and registration or administrative staff and 21 clinicians. RESULTS: During peak pandemic activity, upwards of 90% of visits (first or return) were conducted virtually. Between waves, return appointments were more likely to be virtual than first appointments. Interview participants (n=48) reported facilitators and barriers to virtual care within the CFIR domains of 'outer setting' (eg, external policies, client needs and resources), 'inner setting' (eg, communications within the service), 'individual characteristics' (eg, personal attributes, knowledge and beliefs about virtual care) and 'intervention characteristics' (eg, relative advantage of virtual or in-person care). CONCLUSIONS: Shared decision-making regarding treatment modality (virtual vs in-person) requires consideration of client, caregiver, clinician, appointment, health system and public health factors across episodes of care to ensure accessible, safe and high-quality mental healthcare.

Distance-Delivered Parent Training for Childhood Disruptive Behavior (Strongest Families™): a Randomized Controlled Trial and Economic Analysis.

Disruptive behavior disorders are prevalent in youth, yet most children with disruptive behavior do not have access to timely, effective treatment. Distance-delivered service (e.g., via telephone, Internet) can overcome several barriers to care. This study tested the effectiveness of a 12-week parent training program, Strongest Families™ Parenting the Active Child, delivered via written material, skill-based videos, and telephone coaching sessions, as compared to usual care in reducing child externalizing behavior. Participants were 172 primary caregivers of a 6- to 12-year-old (29% girls; M age = 8.5 years) recruited from community children's mental health clinics. Participants were randomized to either Strongest Families™ or usual care and completed measures of child externalizing behavior, parenting practices, parent distress, and intervention services consumed at baseline and 5-, 10-, 16-, and 22-months post-baseline. Growth curve analysis showed significant reductions in externalizing behavior in both conditions over time. Improvements were significantly greater at 10 months in the Strongest Families™ condition (d = 0.43). At 22 months, however, the differences were not significant and small in magnitude (d = -0.05). The intervention decreased inconsistent discipline significantly more than usual care. Parents in both conditions showed significant reductions in distress. We also conducted a cost-effectiveness analysis to assess the value for money of the Strongest Families™ program versus usual care. Distance parent training is a promising way to increase access to, and reduce costs associated with, mental health care for families with a child with disruptive behavior.

Telephone-based mental health interventions for child disruptive behavior or anxiety disorders: randomized trials and overall analysis.

OBJECTIVE: Most children with mental health disorders do not receive timely care because of access barriers. These initial trials aimed to determine whether distance interventions provided by nonprofessionals could significantly decrease the proportion of children diagnosed with disruptive behavior or anxiety disorders compared with usual care. METHOD: In three practical randomized controlled trials, 243 children (80 with oppositional-defiant, 72 with attention-deficit/hyperactivity, and 91 with anxiety disorders) were stratified by DSM-IV diagnoses and randomized to receive the Strongest Families intervention (treatment) or usual care (control). Assessments were blindly conducted and evaluated at 120, 240, and 365 days after randomization. The intervention consisted of evidence-based participant materials (handbooks and videos) and weekly telephone coach sessions. The main outcome was mental health diagnosis change. RESULTS: Intention-to-treat analysis showed that for each diagnosis significant treatment effects were found at 240 and 365 days after randomization. Moreover, in the overall analysis significantly more children were not diagnosed as having disruptive behavior or anxiety disorders in the treatment group than the control group (120 days: χ(2)(1) = 13.05, p < .001, odds ratio 2.58, 95% confidence interval 1.54-4.33; 240 days: χ(2)(1) = 20.46, p < .001, odds ratio 3.44, 95% confidence interval 1.99-5.92; 365 days: χ(2)(1) = 13.94, p < .001, odds ratio 2.75, 95% confidence interval 1.61-4.71). CONCLUSIONS: Compared with usual care, telephone-based treatments resulted in significant diagnosis decreases among children with disruptive behavior or anxiety. These interventions hold promise to increase access to mental health services. CLINICAL TRIAL REGISTRATION INFORMATION: Strongest Families: Pediatric Disruptive Behaviour Disorder, http://www.clinicaltrials.gov, NCT00267579; Strongest Families: Pediatric Attention-Deficit/Hyperactivity Disorder, http://www.clinicaltrials.gov, NCT00267605; and Strongest Families: Pediatric Anxiety, http://www.clinicaltrials.gov, NCT00267566.

Early temperament prospectively predicts anxiety in later childhood.

OBJECTIVE: To investigate the contribution of early childhood temperamental constructs corresponding to 2 subtypes of general negative emotionality-fearful distress (unadaptable temperament) and irritable distress (fussy-difficult temperament)-to later anxiety in a nationally representative sample. METHOD: Using multiple linear regression analyses, we tested the hypothesis that caregiver-reported child unadaptable temperament and fussy-difficult temperament scales of children aged 2 to 3 years (in 1995) would prospectively predict caregiver-reported child anxiety symptoms at ages 4 to 5, 6 to 7, 8 to 9, and 10 to 11 years, and child-reported anxiety at 10 to 11 years (controlling for sex, age, and socioeconomic status) in a nationally representative sample from Statistics Canada's National Longitudinal Survey of Children and Youth (initial weighted n = 768,600). RESULTS: Only fussy-difficult temperament predicted anxiety in children aged 6 to 7 years. In separate regressions, unadaptable temperament and fussy-difficult temperament each predicted anxiety at 8 to 9 years, but when both were entered simultaneously, only unadaptable temperament remained a marginal predictor. Temperament did not significantly predict caregiver- or child-reported anxiety at 10 to 11 years, suggesting that as children age, environmental factors may become more important contributors to anxiety than early temperament. CONCLUSION: Our results provide the first demonstration that early temperament is related to later childhood anxiety in a nationally representative sample.