The Longitudinal Youth in Transition Study (LYiTS) Cohort Profile: Exploration by Hospital- Versus Community-Based Mental Health Services.

OBJECTIVES: Youth face numerous challenges in receiving coordinated and continuous mental health services, particularly as they reach the age of transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). The Longitudinal Youth in Transition Study (LYiTS) follows youth prospectively as they cross this transition boundary to better understand their transition pathways and resulting symptoms and health service use outcomes. The current paper presents the baseline profile description for the LYiTS cohort and additionally examines differences in symptoms and functioning and health service utilization between youth receiving services at hospital- versus community-based CAMHS. METHODS: A cross-sectional design was used. A sample of 237 16-18-year-old youth recruited from outpatient CAMHS at two hospitals and two community sites completed self-report measures at their first of four annual assessments. A latent profile analysis was conducted to identify symptomology profiles, and youth were compared on symptoms and health service use between hospital- and community-based sites. RESULTS: Four distinct symptomology profiles were identified (subclinical, moderate internalizing, moderate externalizing, and high symptomology). Symptom profiles and functioning levels reported by youth were no different across both types of organization, although there were differences detected in health service utilization, such as type of provider seen and use of medications. CONCLUSIONS: These findings suggest that there is little difference in symptomology between youth accessing hospital versus community-based CAMHS. With growing interest in understanding the effectiveness and cost-effectiveness of different models of mental health care, these findings provide a new understanding of the clinical and service use profiles of transition-aged youth that will be explored further as this cohort is followed across the CAMHS to AMHS transition boundary.

Mixed-methods study protocol for an evaluation of the mental health transition navigator model in child and adolescent mental health services: the Navigator Evaluation Advancing Transitions (NEAT) study.

INTRODUCTION: Transition from child and adolescent mental health services (CAMHS) to community or adult mental health services (AMHS) is a highly problematic health systems hurdle, especially for transition-aged youth. A planned and purposeful transition process is often non-existent or experienced negatively by youth and their caregivers. Stakeholders, including youth and their caregivers, have demanded interventions to support more effective transitions, such a transition navigator. The transition navigator model uses a navigator to facilitate complex transitions from acute care CAMHS to community or AMHS. However, despite the widespread implementation of this model, there has been no evaluation of the programme, hindering its scalability. This paper describes the study protocol of the Navigator Evaluation Advancing Transitions study that aims to collaborate with patients, caregivers and clinicians in the evaluation of the navigator model. METHODS AND ANALYSIS: A pre and post mixed-method study will be conducted, using the Triple Aim Framework, to evaluate the navigator model. We will recruit participants from one large tertiary and two community hospitals in Toronto, Canada. For the quantitative portion of the study, we will recruit a sample of 45 youth (15 at each site), aged 16-18, and their caregivers at baseline (referral to navigator) (T1) and 6 months (T2). Youth and caregiver participants will complete a set of standardised measures to assess mental health, service utilisation, and satisfaction outcomes. For the qualitative portion of the study, semistructured interviews will be conducted at 6 months (T2) with youth, their caregivers and clinicians to better understand their experience and satisfaction with the model. ETHICS AND DISSEMINATION: Research Ethics Board (REB) approval has been obtained from the lead research sites, the University of Toronto and the Hospital for Sick Children. The results of the study will be reported in peer-reviewed publications, webinars and conferences and to all relevant stakeholders.

How have predictors, moderators, mediators, treatment response, remission and resistance been defined and measured in randomised controlled trials for adolescent depression? A scoping review protocol.

INTRODUCTION: Among randomised controlled trials for depressed adolescents, the extent of variation in how depressive symptom outcomes are defined is unknown. The variability in which potential predictors of these outcomes are tested is also unclear. This paper is a protocol describing the methods of a planned scoping review. The scoping review will examine and summarise how change in depressive symptoms have been described in RCT treatment studies to date. This review will report the measures used to describe change in depressive symptoms and whether the measure was used as a continuous or binary outcome or both. This review will describe how dichotomous outcome terms are defined to describe change in depression severity. This review will also examine predictors, moderators and mediators of change in depressive symptoms within RCTs. METHODS AND ANALYSIS: In this paper, we describe the protocol for our scoping review. Following the format outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews, a research librarian will develop an operationalised search strategy, which we will apply to the MEDLINE, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature databases. We will search for papers from inception to 6 February 2020. A hand search for key citations will also be conducted. Investigator-raters will screen articles, first via the titles and abstracts and then through full-text reviews. We will include articles with randomised control design which assess the treatment of adolescents with major depressive disorder. We will systematically extract and synthesise prespecified data which includes: definition of depression used for participant inclusion, measures used to evaluate changes in depression, type of outcome used (continuous, binary or both), definitions of dichotomous terms to denote change in depression (eg, response, remission, recovery, etc) and reported predictors/moderators/mediators of change. ETHICS AND DISSEMINATION: Ethics approval is not required. Findings will be presented in journal publications and at conferences.

Longitudinal Youth in Transition Study (LYiTS): protocol for a multicentre prospective cohort study of youth transitioning out of child and adolescent mental health services at age 18.

INTRODUCTION: Transition between health services is widely recognised as a problematic hurdle. Yet, the factors necessary for successful transition out of child and adolescent mental health services (CAMHS) as youth reach the service boundary at age 18 are poorly understood. Further, fragmentation and variability among the services provided by mental health organisations serve to exacerbate mental illness and create unnecessary challenges for youth and their families. The primary aim of the Longitudinal Youth in Transition Study (LYiTS) is to describe and model changes in psychiatric symptoms, functioning and health service utilisation at the transition out of CAMHS at age 18 and to identify key elements of the transition process that are amendable to interventions aimed at ensuring continuity of care. METHODS AND ANALYSIS: A prospective longitudinal cohort study will be conducted to examine the association between psychiatric symptoms, functioning and mental health and health service use of youth aged 16-18 as they transition out of child mental health services at age 18. We will recruit a sample of (n=350) participants from child and adolescent psychiatric programmes at two hospital and two community mental health sites and conduct assessments annually for 3 years using standardised measures of psychiatric symptoms, functioning and health service utilisation. ETHICS AND DISSEMINATION: Ethics approval has been obtained at all four recruitment sites. We will disseminate the results through conferences, open access publications and webinars.

Potential Reduction of Symptoms With the Use of Persuasive Systems Design Features in Internet-Based Cognitive Behavioral Therapy Programs for Children and Adolescents With Anxiety: A Realist Synthesis.

BACKGROUND: Internet-based cognitive behavioral therapy (iCBT) for children and adolescents is a persuasive system that combines 3 major components to therapy-therapeutic content, technological features, and interactions between the user and program-intended to reduce users' anxiety symptoms. Several reviews report the effectiveness of iCBT; however, iCBT design and delivery components differ widely across programs, which raise important questions about how iCBT effects are produced and can be optimized. OBJECTIVE: The objective of this study was to review and synthesize the iCBT literature using a realist approach with a persuasive systems perspective to (1) document the design and delivery components of iCBT and (2) generate hypotheses as to how these components may explain changes in anxiety symptoms after completing iCBT. METHODS: A multi-strategy search identified published and gray literature on iCBT for child and adolescent anxiety up until June 2019. Documents that met our prespecified inclusion criteria were appraised for relevance and methodological rigor. Data extraction was guided by the persuasive systems design (PSD) model. The model describes 28 technological design features, organized into 4 categories that help users meet their health goals: primary task support, dialogue support, system credibility support, and social support. We generated initial hypotheses for how PSD (mechanisms) and program delivery (context of use) features were linked to symptom changes (outcomes) across iCBT programs using realist and meta-ethnographic techniques. These hypothesized context-mechanism-outcome configurations were refined during analysis using evidence from the literature to improve their explanatory value. RESULTS: A total of 63 documents detailing 15 iCBT programs were included. A total of six iCBT programs were rated high for relevance, and most studies were of moderate-to-high methodological rigor. A total of 11 context-mechanism-outcome configurations (final hypotheses) were generated. Configurations primarily comprised PSD features from the primary task and dialogue support categories. Several key PSD features (eg, self-monitoring, simulation, social role, similarity, social learning, and rehearsal) were consistently reported in programs shown to reduce anxiety; many features were employed simultaneously, suggesting synergy when grouped. We also hypothesized the function of PSD features in generating iCBT impacts. Adjunct support was identified as an important aspect of context that may have complemented certain PSD features in reducing users' anxiety. CONCLUSIONS: This synthesis generated context-mechanism-outcome configurations (hypotheses) about the potential function, combination, and impact of iCBT program components thought to support desired program effects. We suggest that, when delivered with adjunct support, PSD features may contribute to reduced anxiety for child and adolescent users. Formal testing of the 11 configurations is required to confirm their impact on anxiety-based outcomes. From this we encourage a systematic and deliberate approach to iCBT design and evaluation to increase the pool of evidence-based interventions available to prevent and treat children and adolescents with anxiety.

Factors influencing service use among homeless youths with co-occurring disorders.

OBJECTIVE: Given high rates of co-occurring mental and substance use disorders among homeless youths and poorly understood facilitators of and barriers to service use, this study explored factors influencing service use among homeless youths with co-occurring disorders. METHODS: Focus groups were conducted with 23 youths age 18 to 26 with co-occurring disorders. Group discussion was audio-recorded and transcribed verbatim, and transcripts were examined with thematic content analysis. RESULTS: The factors identified as influencing service use were grouped into three broad categories: individual (motivation, support, and therapeutic relationship), program (flexibility and comprehensiveness of services and availability of harm reduction services), and systemic (stigma and accessibility). CONCLUSIONS: Multilevel factors appear to influence service use among homeless youths with co-occurring disorders. Given the lack of evidence to support specific treatments in this population, these findings may be used to guide the development of thoughtfully designed interventions to engage homeless youths with co-occurring disorders.

Does low reading achievement at school entry cause conduct problems?

Conduct problems place children at increased risk for a broad array of negative health and social outcomes that include conduct disorder, injuries and violence, school failure, substance abuse, depression, and suicide. Prevention interventions have the potential to interrupt the chain of events linking early conduct problem symptoms to future negative life outcomes, but have received much less emphasis than interventions designed to treat established cases of disorder. Reading problems are a well-established correlate of conduct disorder. However, whether or not reading problems cause conduct disorder continues to be debated. If they are in fact a causal risk factor this would justify the design and evaluation of interventions designed to enhance reading skills and/or remediate problems. In this paper we use logistic regression techniques to evaluate the relation between reading achievement at school entry and conduct problems 30 months later, in a representative, non-clinic sample of kindergarten and grade one children, in Ontario, Canada. The findings show that an eight point increase in reading scores (equivalent to an moderate effect size of 0.5) would result in a 23 per cent decrease in the risk of conduct problems 30 months later, after controlling for gender, income and baseline conduct problem symptoms. We conclude that reading problems may contribute to the early onset of conduct disorder. Randomized experimental studies designed to evaluate the effects of reading programmes in non-clinic samples of children are needed to: (i) establish whether the link between reading problems at school entry and conduct disorder is causal; and (ii) determine whether reading intervention programmes are an effective conduct disorder prevention strategy.