Research use in children's mental health policy in Canada: maintaining vigilance amid ambiguity.

Many researchers hope to see the best available research evidence used in policy-making to address important public problems. However, policy often appears to be based on anything but the research evidence, as the problem of conduct disorder (or severe antisocial behaviour in children) shows. In Canada, few children receive effective prevention or treatment programs, and incarceration is overused, despite evidence that it is ineffective and potentially harmful. Using the example of conduct disorder, we investigated why policy-making has not reflected the research evidence, examining research use in the context of competing influences on the policy process. Qualitative methods were used to analyze data from interviews with thirty-two politicians and senior civil servants. Our allegiance to rationality wavered as we listened to policy-makers who contended with the inherent ambiguity in the policy process. They told us that they managed institutional constraints including fragmentation across levels and sectors of government, and the long-term effects of fiscal restraint. They also reconciled the competing interests of stakeholders' priorities, the public's response to negative events involving children and the media's role in shaping this response. Ideas about youth violence were morally charged, but policy-makers remained committed to improving children's lives. Day-to-day, policy-makers obtained most of their information internally and informally. Research evidence was valued and used, but as just one source of ideas and information among many. In this environment of ambiguity, creative civil servants formed partnerships with trusted researchers in order to change policy. Our findings suggest that the use of research evidence in policy-making could be enhanced if researchers learned about the competing influences on the policy process, formed research-policy partnerships, challenged the incentives within research institutions, and engaged in public debates about important problems, such as child antisocial behaviour.

A public health strategy to improve the mental health of Canadian children.

Mental health problems are the leading health problems that Canadian children currently face after infancy. At any given time, 14% of children aged 4 to 17 years (over 800,000 in Canada) experience mental disorders that cause significant distress and impairment at home, at school, and in the community. Fewer than 25% of these children receive specialized treatment services. Without effective prevention or treatment, childhood problems often lead to distress and impairment throughout adulthood, with significant costs for society. Children's mental health has not received the public policy attention that is warranted by recent epidemiologic data. To address the neglect of children's mental health, a new national strategy is urgently needed. Here, we review the research evidence and suggest the following 4 public policy goals: promote healthy development for all children, prevent mental disorders to reduce the number of children affected, treat mental disorders more effectively to reduce distress and impairment, and monitor outcomes to ensure the effective and efficient use of public resources. Taken together, these goals constitute a public health strategy to improve the mental health of Canadian children.

Gender differences in the effects of family adversity on the risk of onset of DSM-III-R social phobia.

Utilizing a random probability sample of Canadian residents aged 15-64 (n = 8116), this study assessed gender differences in the onset of social phobia and the moderating influence of gender on indicators of childhood family adversity hypothesized to increase the risk of developing the disorder. Results revealed statistically significant "gender by family adversity" interactions that varied by disorder sub-type. Among males, absence of a parent or other adult close confidant during childhood was associated with an elevated risk of developing social phobia (all diagnosed cases and the non-generalized sub-type). Risk factors unique to females included parental conflict while growing up (all diagnosed cases), childhood physical abuse by a father figure (generalized sub-type), and maternal mania (non-generalized sub-type). Results highlight the importance of distinguishing between social phobia sub-types in gender-based research as well as the use of family adversity measures that capture the parenting behaviors and mental health status of both parents.

Youth at risk of homelessness in an affluent Toronto suburb.

BACKGROUND: This study examines the characteristics and needs of 69 youth who are homeless, or at risk of homelessness at Pathway's Home Base Youth Drop-In Centre in the affluent suburb of Richmond Hill, Ontario, Canada. METHODS: A semi-structured interview examined demographics, characteristics, living arrangements, family characteristics, substance use, mental health, criminal activity and educational experiences of the youth in this sample. RESULTS: The majority of youth came from economically advantaged families and were currently residing with their parents, but were substantially more at risk than their mainstream peers in measures related to youth homelessness. The majority of Home Base youth had left home and school prematurely, been arrested in their lifetime, and used at least one illicit drug in the past 12 months. A substantial number of youth had been imprisoned, experienced physical abuse, and exhibited depressive symptomatology and suicidal ideation. CONCLUSION: Although living mainly at home and in a relatively affluent suburb, these youth have many attributes related to homelessness and may progress to homelessness without intervention.

Chronic physical health conditions and disability among Canadian school-aged children: a national profile.

OBJECTIVE: The objective of this study was to provide a national health and disability profile of Canadian school-aged children based on the World Health Organization's definitions of health condition and disability that would facilitate international comparisons of child health data. METHODS: Data were used from the National Longitudinal Survey of Children and Youth, a 1994 - 95 population-based sample of 22 831 children. FINDINGS: An estimated total of 30.3% of Canadian children aged 6 to 11 had one or more chronic physical health conditions/impairments, while 3.6% had activity-limiting conditions/impairments. Children living with one parent were significantly more likely to have activity-limiting conditions/impairments than those living with two parents. Children with conditions/impairments, particularly those with activity limitations, were significantly more likely than children without health problems to have experienced mental health conditions and learning disabilities, missed school days, received special education, visited health professionals, been hospitalized, and used prescription medication. CONCLUSION: Important differences were found among children in a number of areas as a function of overall physical health status. The findings emphasize the importance of measuring activity limitations distinctly from chronic conditions and impairments, and, perhaps, of measuring impairments distinctly from chronic conditions, and of comparing children with such health problems to children without health problems in order to obtain a more accurate picture of the impact of health on children's lives. The World Health Organization's distinct definitions of health condition and disability facilitate a dimensional approach for describing child health that can serve to clarify this field of study and improve comparability of data across countries.

Stress, social support and depression in single and married mothers.

BACKGROUND: This study examined the effect of stress and social support on the relationship between single-parent status and depression. METHOD: A secondary data analysis of the 1994-95 National Population Health Survey was conducted. Single and married mothers who participated in the survey were derived from the general sample (N = 2,921). Logistic regression techniques were used to assess the mediating and moderating effects of stress and social support on the relationship between family structure and depression. RESULTS: Bivariate analyses showed that, compared to married mothers, single mothers were more likely to have suffered an episode of depression (12-month prevalence), to report higher levels of chronic stress, more recent life events and a greater number of childhood adversities. Single mothers also reported lower levels of perceived social support, social involvement and frequency of contact with friends and family than married mothers. The results of the multivariate analyses showed that, together, stress and social support account for almost 40% of the relationship between single- parent status and depression. We also found a conditional effect of stress on depression by family structure. Life events were more strongly related to depression in married than in single mothers. CONCLUSIONS: A substantial part of the association between single-parent status and depression can be accounted for by differences in exposure to stress and social support. Our results suggest that it is important to examine multiple sources of stress, as exposure to both distal and proximal stressors were higher among single mothers. Limitations and directions for future research are discussed.

The prevalence of treated and untreated mental disorders in five countries.

We analyzed survey data from Canada, Chile, Germany, The Netherlands, and the United States to study the prevalence and treatment of mental and substance abuse disorders. Total past-year prevalence estimates range between 17.0 percent (Chile) and 29.1 percent (U.S.). Many cases are mild. Although disorder severity is strongly related to treatment, one- to two-thirds of serious cases receive no treatment each year. Most treatment goes to minor and mild cases. Undertreatment of serious cases is most pronounced among young poorly educated males. Outreach is needed to reduce barriers to care among serious cases and young people at risk of serious disorders.

Child psychiatric epidemiology and Canadian public policy-making: the state of the science and the art of the possible.

Epidemiological studies have characterized the high burden of suffering that child psychiatric disorders cause--14% of children (1.1 million in Canada) have clinically important disorders at any given time. In this review, we summarize the recent research and discuss several unresolved scientific issues that must be addressed to make epidemiology more useful to policy-makers. We then discuss implications for policy-making to improve children's mental health outcomes. Overall, given the high prevalence rates, increasing clinical services alone will not suffice; rather, a multifaceted mix of strategies is required.

Should postpartum depression be targeted to improve child mental health?

OBJECTIVE: To evaluate whether postpartum depression (PD) is an appropriate target to prevent poor child outcomes. METHOD: Criteria are proposed for evaluating the appropriateness of targeting PD. The target factor should (1) be a causal factor for the negative outcome, (2) have high attributable risk for the negative outcome, (3) be alterable, and (4) be easily and accurately identified through screening. The associated intervention should (5) have characteristics to facilitate dissemination, (6) have low risk for adverse impact, and (7) be acceptable to key stakeholders. RESULTS: PD is given a mixed endorsement as an appropriate target for a prevention intervention. Positive characteristics include that PD is moderately prevalent, it is linked with poor child outcomes, it requires inexpensive screening for detection, it is alterable through treatment interventions that may be realistically disseminated, and its treatment is likely to have popular and political support. However, efforts to detect syndromal depression may be costly, strength of the link between PD and poor child outcomes is undetermined, and risks associated with the intervention have not been investigated. CONCLUSIONS: Further study is required to assess the appropriateness of PD as a prevention target for improving child outcomes. These provisional criteria may be useful for evaluating other proposed prevention targets.

Child well-being in single-mother families.

OBJECTIVES: Children from single-mother families are at increased risk of psychosocial morbidity. This article examines the strength of association between single-mother family status and child outcome, both alone and controlling for other sociodemographic and personal (maternal/family) variables. METHOD: Data from the Canadian National Longitudinal Survey of Children and Youth Cycle 1 (1994-1995) were used. Children aged 6 to 11 years in single-mother and two-parent families were included (n = 9,398). Child functioning measures included social impairment, psychiatric problems, and math score. RESULTS: Single-mother family status on its own is a significant predictor of all child difficulties, but the explained variance is limited and the effect size decreases when other variables known to influence child functioning are included. Household income, a sociodemographic variable, is inversely associated with social impairment and positively associated with math score. Hostile parenting and maternal depression are the personal variables most strongly associated with social impairment and psychiatric problems. Children in single-mother families where there is hostile parenting are at significantly increased risk of psychiatric problems. CONCLUSIONS: The results suggest that children from single-mother families develop difficulties for the same reasons as children from two-parent families. Specific interventions for single-mother families may be warranted in the areas of parenting and other areas of concentrated risk.

Broken homes, parental psychiatric illness, and female delinquency.

Fifty-nine families with delinquent daughters were compared with 59 families, matched on socioeconomic class, with daughters of the same age who were not delinquent. The frequency of broken homes was found to be the strongest distinguishing factor between probands and controls. Parental disabilities appeared to play a part in the incidence of delinquency among girls, particularly when the disabilities result in a broken home.