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.

Choice and Partnership Approach to community mental health and addiction services: a realist-informed scoping review.

OBJECTIVES: The Choice and Partnership Approach (CAPA) was developed to create an accessible, child-centred and family-centred model of child and adolescent mental health service delivery that is adaptable to different settings. We sought to describe the state of evidence regarding the extent, outcomes and contextual considerations of CAPA implementation in community mental health services. DESIGN: Scoping review. DATA SOURCES: Published and grey literature were searched using MEDLINE, Embase, CINAHL, PsycINFO, Scopus and Google to 13 and 20 July 2022, respectively. ELIGIBILITY CRITERIA: We included reports focused on the implementation, outcomes (clinical, programme or system) or a discussion of contextual factors that may impact CAPA implementation in either child and adolescent or adult mental health services. DATA EXTRACTION AND SYNTHESIS: Data were extracted using a codebook that reflected the five domains of the Consolidated Framework for Implementation Research (CFIR) and reviewed for agreement and accuracy. Data were synthesised according to the five CFIR domains. RESULTS: Forty-eight reports describing 36 unique evaluations were included. Evaluations were observational in nature; 10 employed pre-post designs. CAPA implementation, regardless of setting, was largely motivated by long wait times. Characteristics of individuals (eg, staff buy-in or skills) were not reported. Processes of implementation included facilitative leadership, data-informed planning and monitoring and CAPA training. Fidelity to CAPA was infrequently measured (n=9/36) despite available tools. Health system outcomes were most frequently reported (n=28/36); few evaluations (n=7/36) reported clinical outcomes, with only three reporting pre/post CAPA changes. CONCLUSIONS: Gaps in evidence preclude a systematic review and meta-analysis of CAPA implementation. Measurement of clinical outcomes represents an area for significant improvement in evaluation. Consistent measurement of model fidelity is essential for ensuring the accuracy of outcomes attributed to its implementation. An understanding of the change processes necessary to support implementation would be strengthened by more comprehensive consideration of contextual factors.

An Innovative Model of Pediatric Emergency Department Mental Health Care: Protocol for a Multicenter Type 1 Effectiveness-Implementation Cluster Randomized Trial.

Over the past decade, visits to American and Canadian emergency departments (EDs) for child and youth mental health care have increased substantially.1,2 Acute mental health crises can occur as a result of a variety of concerns, including those that are life threatening (eg, suicide attempts), pose safety concerns (eg, suicidal intentions, aggressive behaviors, alcohol and other drug use), and are physically distressing to the child or youth (eg, panic attacks). ED health care providers play a vital role in assessing the safety and well-being of the child or youth and referring them to services for ongoing care.3,4 During the ED visit, assessment and care should pinpoint risks, inform treatment, and consider family needs and preferences as part of a patient-centered approach. Yet, this approach to care is not widely adopted in EDs. Most EDs do not require the use of pediatric-specific mental health tools to guide assessments or have patient-centered procedures in place to guide the care of patients with mental health emergencies.5-7 Our team believes these limitations have led to the provision of acute mental health care that can lack sufficient quality and efficiency. This study protocol describes a trial designed to evaluate if a novel mental health care bundle that was co-designed with parents and youth results in greater improvements in the well-being of children and youth 30 days after seeking ED care for mental health and/or substance misuse concerns compared with existing care protocols. We hypothesize that the bundle will positively impact child and youth well-being, while also providing cost-effective health care system benefits.

The Choice and Partnership Approach to community mental health and addictions services: a realist-informed scoping review protocol.

INTRODUCTION: Early identification and appropriate treatment of child and adolescent mental health disorders can often be hampered by patchwork services with poorly planned or unclear pathways. The Choice and Partnership Approach (CAPA) is an evidence-based transformational model of community (community-based or outpatient) mental health and addictions services for children and adolescents that aims to better match services to needs and to improve timely access to care. CAPA has been variably implemented across jurisdictions but has not been comprehensively evaluated for its impact on system and client outcomes. Our research question is, 'To what degree does CAPA work, for whom and under what circumstances?'. The purpose of this review is twofold: (1) to gain an understanding of the extent and outcomes of the implementation of CAPA in community mental health and addictions services; and (2) to identify the role of context as it influences the implementation of CAPA and resulting client and system outcomes. METHODS AND ANALYSIS: We will conduct a realist-informed scoping review of the literature related to CAPA in either child and adolescent or adult community mental health and addictions services. Relevant studies, reports and documentation will be identified by searching the following online databases: MEDLINE, Embase, CINAHL, PsycINFO, Academic Search Premier, ERIC, Web of Science, Cochrane, Dissertations Abstracts, NCBI Bookshelf, PubMed Central and the Canadian Health Research Collection. The search strategy was developed by a health sciences library scientist and informed by a multidisciplinary team comprising methodological and content knowledge experts. The search will gather evidence from multiple online databases of peer-reviewed literature and grey literature repositories. All articles will be independently assessed for inclusion by pairs of reviewers. The key themes derived from a thematic analysis of extracted data will be presented in a narrative overview. ETHICS AND DISSEMINATION: Research ethics review is not required for this scoping review. The results will be disseminated through meetings with stakeholders (including clients and families, clinicians and decision-makers), conference presentations and peer-reviewed publication. The results of this review will inform an overarching programme of research, policy and quality indicator development to ultimately improve mental health and addictions care and subsequent mental health outcomes for children and adolescents.

Evaluating the HEADS-ED Screening Tool in a Hospital-Based Mental Health and Addictions Central Referral Intake System: A Prospective Cohort Study.

OBJECTIVES: We evaluated the use of a mental health (MH) screening tool in a hospital-based centralized MH referral telephonic intake process. The tool is used to guide psychosocial screening in several domains: home; education; activities and peers; drugs and alcohol; suicidality; emotions, thoughts, and behaviors; and discharge resources (HEADS-ED). We wanted to understand the use of the tool to guide next step in care decision-making over the telephone. METHODS: Intake workers used the HEADS-ED tool to guide the assessment processes, identified areas of MH need, and made decisions about next step in care. We completed a retrospective chart review of all callers to the intake system over 4 months to gather initial decision at intake and subsequent steps in treatment. χ2 and analysis of variance tests were used to examine differences between HEADS-ED scores and next step in care. RESULTS: A total of 674 patients aged 3 to 19 years (mean age = 11.7 years, SD = 0.6; girls = 50.0%) called for services. Significant mean differences were found on total HEADS-ED scores between treatment options (F4,641 = 75.76; P < .001). Decision validity indicated that 86% (n = 506 of 587) of initial referrals matched treatments that were actually received. Uptake of the tool was 100%, and interrater reliability indicated strong agreement between raters (intraclass correlation coefficient = 0.82; P < .001). CONCLUSIONS: With our results, we support the use of the HEADS-ED tool in a telephone-based MH intake system to help guide the initial assessment and inform decision-making about fit of next step in care, both within the health center-based MH system and in the community.

Effectiveness of Day Treatment for Disruptive Behaviour Disorders: What is the Long-term Clinical Outcome for Children?

OBJECTIVE: The present study investigates the clinical long-term outcomes (2½ to 4 years post-discharge) of children aged 12 and under with a primary diagnosis of a Disruptive Behaviour Disorder (DBD) who attended a short-term day treatment program using best-practice treatment strategies. This study compared children's admission, discharge, and follow-up test scores on standardized measures of behaviour and functioning, as rated by parents. METHOD: Measures of clinical symptoms in the children and parent report of stress were used. To test for treatment effects across time, two repeated-measures ANOVAs were calculated. RESULTS: There was significant treatment change across time points on measures of social problems, externalizing symptoms, levels of aggression, intensity of problems, and symptoms of ADHD. CONCLUSIONS: Children with DBD who attended a short-term day treatment program using best-practice treatment strategies showed significant improvement in their behaviour at home. These improvements were relatively long lasting. The current study lends support to the effectiveness of day treatment and the idea that severe DBD can be treated using multi-modal, intensive, and evidence-based treatment techniques resulting in long-term change.

Youth Homelessness: The Relationships among Mental Health, Hope, and Service Satisfaction.

INTRODUCTION: This paper reports a mental health assessment of 60 homeless youth. Our study explored the mental health needs of youth accessing an overnight youth shelter (maximum stay 8 weeks). METHODS: Participants completed an interview (45 to 120 minutes in duration) using one demographic form and one of two standardized questionnaires (Youth Self Report, Adult Self Report). Questions assessed youth mental health symptoms, examined various contacts that youth made with mainstream society (services, family), and identified potential motivating factors (hope, service satisfaction) that may play a role in fostering street survival during adolescence. RESULTS: Forty-eight percent of the youth were clinically symptomatic and most youth accessed a range of general health services. CONCLUSION: However, those most in need had significantly less service satisfaction, less hope about the future, and had not accessed mental health services.

Day treatment for disruptive behaviour disorders: can a short-term program be effective?

OBJECTIVE: The present study investigates the effectiveness of a short-term day treatment program for children with a primary diagnosis of a Disruptive Behaviour Disorder (DBD) using best-practice treatment strategies. This study, using a wait list control, compared children's admission and discharge test scores on standardized measures of behaviour and functioning, as rated by parents. METHOD: A repeated measures MANOVA was used to evaluate symptom change. RESULTS: The treatment group was found to have improved significantly more than the waitlist group on parent reports of externalizing behaviour, aggression, social problems, hyperactivity and parent stress. CONCLUSIONS: Children with DBD who attended a short-term day treatment program using best-practice treatment strategies showed significant improvement in their behaviour at home. The current study lends support to the idea that severe DBD can be treated using multi-modal, intensive and evidence-based treatment techniques.

Representations of attachment relationships, the self, and significant others in middle childhood.

INTRODUCTION: This research examines the interrelations of attachment security, feelings towards the self, and attributions about others in middle childhood. METHODS: Five-to nine-year-old children (n=176) completed the Separation Anxiety Test, which provided a measure of attachment security and a puppet interview was used to assess feelings towards the self. A subset of 89 participants received vignettes of social situations with ambiguous outcomes to assess the emotional valence of children's attributions. RESULTS: Secure children saw themselves more positively than insecure children. Children who were secure made more positive attributions about the intentions of others, regardless of whether the protagonist was a peer, parent, or teacher. CONCLUSION: The results suggest that attachment style is related to feelings about the self and attributions about the social behavior of others, and thus may provide a foundation for generalized social expectations that underlie working models of social behavior of significant others.

Line-of-duty injury or illness in an Air National Guard unit.

Line-of-duty injuries or illnesses (LODs) suffered by members of Air National Guard units may demonstrate the status of unit safety, unit readiness and deployability, a potentially significant area of unit expenditures, and areas of needed health promotion. This descriptive pilot study was conducted at the unit commander's request to investigate an apparent doubling of the expected number of LODs over a recent quarterly period. Twenty cases were investigated. The vast majority of LODs were musculoskeletal in nature. Decreased fitness level (identified as increased body mass index) among males and increased age were related to increased LODs. Recommendations are given to improve tracking, identify individuals at increased risk, provide pretraining assessment, and institute health promotion focused on musculoskeletal injuries.