Effect of managed transition on mental health outcomes for young people at the child-adult mental health service boundary: a randomised clinical trial.

BACKGROUND: Poor transition planning contributes to discontinuity of care at the child-adult mental health service boundary (SB), adversely affecting mental health outcomes in young people (YP). The aim of the study was to determine whether managed transition (MT) improves mental health outcomes of YP reaching the child/adolescent mental health service (CAMHS) boundary compared with usual care (UC). METHODS: A two-arm cluster-randomised trial (ISRCTN83240263 and NCT03013595) with clusters allocated 1:2 between MT and UC. Recruitment took place in 40 CAMHS (eight European countries) between October 2015 and December 2016. Eligible participants were CAMHS service users who were receiving treatment or had a diagnosed mental disorder, had an IQ ⩾ 70 and were within 1 year of reaching the SB. MT was a multi-component intervention that included CAMHS training, systematic identification of YP approaching SB, a structured assessment (Transition Readiness and Appropriateness Measure) and sharing of information between CAMHS and adult mental health services. The primary outcome was HoNOSCA (Health of the Nation Outcome Scale for Children and Adolescents) score 15-months post-entry to the trial. RESULTS: The mean difference in HoNOSCA scores between the MT and UC arms at 15 months was -1.11 points (95% confidence interval -2.07 to -0.14, p = 0.03). The cost of delivering the intervention was relatively modest (€17-€65 per service user). CONCLUSIONS: MT led to improved mental health of YP after the SB but the magnitude of the effect was small. The intervention can be implemented at low cost and form part of planned and purposeful transitional care.

Routine outcome measurement in adolescents seeking mental health services: standardization of HoNOSCA in Kenyan sample.

BACKGROUND: The evaluation of treatment outcomes is important for service providers to assess if there is improvement or not. The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) was developed for this use in child and adolescent mental health services. Outcome measurement in routine mental health services is limited. This paper evaluates the psychometric properties of the self and clinician rated versions of the HoNOSCA for routine use in child and adolescent mental health services in Kenya. METHODS: Using a prospective design, the clinician- and self-rated versions of the HoNOSCA and the Paediatric Symptom Checklist (PSC) were administered at the Youth Centre at the Kenyatta National Hospital in Nairobi. Initial ratings were obtained from adolescents 12-17 years (n = 201). A sample of 98 paired ratings with 2 follow-ups were examined for measurement of change over time. RESULTS: Our findings showed good reliability with the self-rated version of the HoNOSCA score, correlating well with the self-reported version of the PSC (r = .74, p < .001). Both versions correlated well at follow-up and were sensitive to change. Using factor analysis, the maximum likelihood factoring and Promax rotation resulted in a four-factor structure, which with a Kaiser-Meyer-Olkin measure of sampling adequacy of 0.8 explained 54.74% of total variance. CONCLUSION: The HoNOSCA appears to be of value, and easy to use in routine settings. Our findings suggest further investigation with a larger sample.

Clinical significance of assertive community treatment among adolescents.

PURPOSE: The efficacy of assertive community treatment for children and adolescents is proven in the United States, but remains controversial in Europe. Moreover, most studies showing positive outcomes of assertive community treatment are limited to statistically significant differences and do not consider whether the treatment is also subjectively clinically meaningful for the patient. Using a naturalistic sample, the present study aims to assess statistical and clinical significance of an assertive community treatment unit for adolescents in Europe. METHODS: Linear mixed-effects models and reliable change indices were used to respectively assess the statistical and clinical significance of assertive community treatment in 179 adolescents (mean age = 15.76, SD = 1.76) with severe mental illnesses. RESULTS: Difficulties related to mental health (measured by the Health of the Nation Outcome Scales for Children and Adolescents, HoNOSCA) and overall functioning (measured by the Global Assessment of Functioning scale) statistically improved (all ps < 0.001) from admission to discharge. Additionally, a considerable proportion of patients (from 14% to 21%) clinically recovered to functional levels. CONCLUSION: Our results support the fact that assertive community treatment can have convincing and positive clinical outcomes in European settings.

Clinical change after the implementation of the Choice and Partnership Approach within an Australian Child and Adolescent Mental Health Service.

BACKGROUND: The Choice and Partnership Approach (CAPA) model has been implemented widely into Child and Adolescent Mental Health Services (CAMHS) in the United Kingdom and similar health systems in Australia and New Zealand. This study investigated whether the implementation of the CAPA model was related to changes in client clinical outcomes and response times within a regional Australian CAMHS. METHOD: Multiple measures of time, clinical diagnosis, contact and outcomes were collected at intake and discharge for 33 clients prior to and 77 following the implementation of CAPA. RESULTS: A two-tailed t-test showed that the significantly reduced waiting time was associated with the timing of CAPA implementation. The Health of the Nation Outcome Scales for Children and Adolescents information subscale showed a significant post-CAPA implementation improvement. A chi-square test for independence showed that the CAPA model group had significantly more initial clinical appointments. CONCLUSIONS: After the implementation of CAPA, the flow of young people through the service improved, with children and adolescents being seen in a more timely manner. The findings highlighted that the greater client throughput did not negatively impact upon clinical outcomes. Further prospective research with the completion of multi-informant outcome measures is recommended.

Agreement on Web-based Diagnoses and Severity of Mental Health Problems in Norwegian Child and Adolescent Mental Health Services.

OBJECTIVE: This study examined the agreement between diagnoses and severity ratings assigned by clinicians using a structured web-based interview within a child and adolescent mental health outpatient setting. METHOD: Information on 100 youths was obtained from multiple informants through a web-based Development and Well-Being Assessment (DAWBA). Based on this information, four experienced clinicians independently diagnosed (according to the International Classification of Diseases Revision 10) and rated the severity of mental health problems according to the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) and the Children's Global Assessment Scale (C-GAS). RESULTS: Agreement for diagnosis was κ=0.69-0.82. Intra-class correlation for single measures was 0.78 for HoNOSCA and 0.74 for C-GAS, and 0.93 and 0.92, respectively for average measures. CONCLUSIONS: Agreement was good to excellent for all diagnostic categories. Agreement for severity was moderate, but improved to substantial when the average of the ratings given by all clinicians was considered. Therefore, we conclude that experienced clinicians can assign reliable diagnoses and assess severity based on DAWBA data collected online.

Reliable and clinically significant change based on the Health of the Nation Outcome Scales.

To evaluate treatment outcomes of individual patients based on clinician-rated instruments, the assessment of reliable and clinically significant change (RCSC) is essential. In heterogeneous samples, RCSC underestimates treatment outcome. Therefore, the Reliable Change Index (RCI) was adjusted by a stratification into subsamples. This method was tested on the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) ratings (n = 12,547) at admission and discharge of youths (age 6-18 years) treated in ten psychiatric institutions. Based on the test-retest reliability of a subsample (n = 397), the RCI was calculated for three severity groups ("very severe," "moderately severe," and "subclinical/mild"). Individuals who accomplished reliable change during treatment and moved to a subclinical score were classified as recovered. Using the traditional RCSC calculation, the large majority (75.1%) of the sample would be considered as unchanged, 2.9% as deteriorated, 18.9% as improved, and 3.1% as recovered. Using RCI cutoff points based on the severity ratings at admission results in a more representative distribution of outcome groups, where 54.6% of the sample was stable, 7.5% worsened, 21.6% improved, and 16.3% recovered. This methodological framework for calculating RCSC for heterogeneous populations is applicable for all HoNOS instruments, making it very useful for mental health professionals.

Outcomes of inpatient psychiatric treatment for adolescents: A multiple perspectives evaluation.

Adolescent inpatient psychiatric treatment was evaluated from the multiple perspectives of clinicians, young people and parents using standardised measures and goal-based outcomes (GBOs). The sample included cases ( N = 128) discharged from a London adolescent unit between April 2009 and December 2015. Measures were completed at admission and discharge, and change in ratings was analysed to assess treatment outcomes. Ratings of clinicians and young people on the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) were compared. Adolescents demonstrated significant improvement across all measures from admission to discharge. Correlation between clinicians' and adolescents' HoNOSCA ratings was weak at admission ( r = .25) but stronger at discharge ( r = .63). Standardised effect sizes were larger for GBOs ( d = 1.73 and 3.16 for adolescent and clinician-rated goals, respectively) compared to all standardised measures ( d = 0.31-0.93). Improvement was observed across all measures of functioning and symptoms following inpatient treatment. Clinicians and young people developed better shared understanding of the problems from admission to discharge. GBOs are more sensitive to change compared to standardised measures and may be meaningfully adopted by inpatient units for routine outcome monitoring.

Validation of the Spanish and Catalan versions of the Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA).

Outcome measurement in outpatient and day-care mental health facilities for children and adolescents in Spain remains limited, in part due to a lack of validated scales. To address this issue, we translated HoNOSCA (glossary, score sheet, self-rated questionnaire, and parent/legal guardian questionnaire) into Spanish and Catalan using a reverse translation approach. We ascertained the validity and psychometric quality of the HoNOSCA in Spanish by assessing correlation with the Children's Global Assessment Scale (C-GAS). We recruited 64 participants 7-17 years of age in five day-care Psychiatry hospitals in Catalonia (Spain). Two evaluators administered both instruments twice, two weeks apart. Patients and parents/legal guardians completed the corresponding HoNOSCA versions. We calculated Cronbach's alpha for assessing internal consistency, intra-class correlation coefficients (ICC) for inter-rater and test-retest reliability, and Pearson's correlation coefficients for validity. We found that all HoNOSCA versions in Spanish presented satisfactory internal consistency, inter-rater and test-retest reliability. Concurrent validity for HoNOSCA-Glossary was also acceptable, with Pearson's coefficients of -0.543 and -0.519 for evaluators in the first administration, and of -0.675 and -0.685 in the second administration. HoNOSCA was also successfully translated into Catalan; acceptability was determined using cognitive interviews.

Young Australians with moderate to severe mental health problems: client data and outcomes at Children and Young People's Mental Health.

AIM: Almost a quarter of young Australians experience a mental health issue that may become chronic if left untreated. Children and Young People's Mental Health (CYPMH) is a specialist tertiary service for young people with moderate to severe mental health problems on the Central Coast in Australia. This paper presents an overview of client data and service use collected over a 1 year period specific to the Youth Mental Health (YMH) component of the service. METHOD: Client data, including demographic characteristics, service usage, presenting issues and standardized outcome measures, were analysed using SPSS. Clinicians routinely collect MH-OAT (Mental Health Outcomes and Assessment Tools) measures at different points in a client's episode of care, and each of these measures was analysed separately. Wilcoxon Z and a series of McNemar's tests were used to report on the difference between admission and discharge scores. RESULTS: During a designated 1 year period, 830 referrals to YMH were received. The most prevalent presenting issue was suicidal ideation followed by deliberate self-harm and depression. A comparison of admission and discharge outcome scores shows significant improvement by discharge on a range of measures. Specifically, analysis identified significant differences between admission and discharge HoNOSCA (Health of the Nation Outcomes Scales for Children and Adolescents) and CGAS (Children's Global Assessment Scale) scores for young people aged 12-17 and HONOS (Health of the Nation Outcomes Scale) scores for young people aged 18-24. CONCLUSION: The clinical outcomes for young people are positive with improvements seen on a range of measures.

HoNOSCA-D As a Measure of the Severity of Diagnosed Mental Disorders in Children and Adolescents-Psychometric Properties of the German Translation.

The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), in use worldwide, is a 13-item measure assessing the biopsychosocial severity of mental health problems in children and adolescents. This article introduces the authorized German-language version of HoNOSCA, the HoNOSCA-D, and examines and discusses its psychometric properties based on a clinical sample of 1,533 children and adolescents aged 4;0 to 17;11 years. For the HoNOSCA-D total score (severity of mental health problems), internal consistency (Cronbach's alpha) was 0.63. The discriminative power of the items ranged from 0.07 to 0.44; the average interitem correlation was 0.11. Due to this stochastic independence, calculation of a total severity index is acceptable. Using factor analysis, the principal axis factoring and varimax rotation resulted in a four-factor structure, which with a Kaiser-Meyer-Olkin measure of sampling adequacy of 0.684 explained 30.62% of total variance. The convergent correlations with the German-language parent report version of the Strengths and Difficulties Questionnaire were as expected and showed a medium effect size. Gender and age differences in the HoNOSCA-D total score were small. Regarding the 13 items gender and age differences were negligible to medium. The highest severity was found for schizophrenia and psychotic disorders, followed by affective disorders and social behavior disorders. Overall, validity of HoNOSCA-D was clearly supported.

Can the Health of the Nation Outcome Scales for Children and Adolescents predict the necessity of inpatient stay during assertive community treatment?

Understanding the trajectories of youths within Child and Adolescents Mental Health Service (CAMHS) is of primary importance. Our objective is to assess the usefulness of the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) to predict inpatient (IP) stay for youths followed by assertive community treatment (ACT) teams. 82 youths followed exclusively by ACT and 42 who needed IP were assessed with the HoNOSCA at admission to the program. The HoNOSCA allowed the computing of three scores: a total score, an externalizing symptoms (Ext) score and an emotional problems (Emo) score. Logistic regressions revealed that the three HoNOSCA scores at admission of ACT predicted later need for hospitalization. Using ROC curve analyses, we set up cut off scores with appropriate sensitivity and specificity for the HoNOSCA Total and Ext to optimally predict the need for hospitalization. This study revealed that the HoNOSCA may be a useful tool to predict the need for later IP during ACT. Such knowledge is important to set up the best therapeutic strategies.

Parents' and Clinicians' Perception of Severity of Referral Problems.

BACKGROUND: Referral meetings are commonly used in CAMH Services to allocate a priority rating that reflects urgency, and thus severity, of the referral. Whilst it is recognised that a system is needed to manage the current level of demand, the literature suggests that decisions about severity are often inaccurate. METHOD: The current study aimed to evaluate a CAMHS referral system by looking at whether the priority ratings allocated by the Multi-Disciplinary Team (MDT) accorded with the parents' and the individual clinician's perception of the severity of the child's difficulties. Data were taken from the Service's outcome database. RESULTS: The results showed that priority ratings did not reflect the parents' and the individual clinician's perception of the problem. It is therefore suggested that the current system for prioritising referrals requires some reform. CONCLUSION: There is discussion of procedures that might improve the accuracy of the priority rating process, such as using scores on standardised measures as part of the decision-making process.

Patients' satisfaction with community treatment: a pilot cross-sectional survey adopting multiple perspectives.

ACCESSIBLE SUMMARY: Patients' satisfaction is scarcely studied within the context of community treatment for adolescents. Thus, this study adopts a multiple perspective on patients' satisfaction (including service users as well as staff members). The results highlighted that all informants (patients, foster carers in foster homes and professional caregivers from community treatment teams) perceived the patients to be satisfied, with foster carers reporting the highest patient satisfaction rate. Considering the patient satisfaction rate from multiple perspectives provides complementary understandings. Clinical outcomes and, specifically, a reduction in emotional difficulties were related to patient's satisfaction, but only from the patients' perspective. ABSTRACT: Community treatment (CT) teams in Switzerland provide care to patients who are unable to use regular child and adolescent mental health services (i.e. inpatient and outpatients facilities). No study has considered patients' self-rated satisfaction alongside with staff members' perspectives on patient satisfaction. Thus, adopting a cross-sectional survey design, we collected patients' satisfaction using the Client Satisfaction Questionnaire (CSQ-8), rated by multiple informants (patients, foster carers in foster homes and professional caregivers from CT teams). Professional caregivers assessed clinical outcomes using the Health of the Nation Outcome Scale for Children and Adolescents. The results indicated that all informants were satisfied with the community treatment teams. The satisfaction scores were not correlated across informants; however, the alleviation of emotional symptoms was correlated with patients' satisfaction. This study indicated that the use of a combined approach including the views of service users and professionals gives important complementary information. Finally, in our sample, lower emotional symptoms were linked to enhanced patient satisfaction. This study demonstrated the importance of considering multiple perspectives to obtain the most accurate picture of patients' satisfaction. Second, focusing on the reduction of emotional symptoms might lead to a higher degree of patients' satisfaction.

The French adaptation of the Health of the Nation Outcome Scale for Children and Adolescents Self-Rated Form (F-HoNOSCA-SR): validation and clinical routine use.

The current study aimed to explore the validity of an adaptation into French of the self-rated form of the Health of the Nation Outcome Scales for Children and Adolescents (F-HoNOSCA-SR) and to test its usefulness in a clinical routine use. One hundred and twenty nine patients, admitted into two inpatient units, were asked to participate in the study. One hundred and seven patients filled out the F-HoNOSCA-SR (for a subsample (N=17): at two occasions, one week apart) and the strengths and difficulties questionnaire (SDQ). In addition, the clinician rated the clinician-rated form of the HoNOSCA (HoNOSCA-CR, N=82). The reliability (assessed with split-half coefficient, item response theory (IRT) models and intraclass correlations (ICC) between the two occasions) revealed that the F-HoNSOCA-SR provides reliable measures. The concurrent validity assessed by correlating the F-HoNOSCA-SR and the SDQ revealed a good convergent validity of the instrument. The relationship analyses between the F-HoNOSCA-SR and the HoNOSCA-CR revealed weak but significant correlations. The comparison between the F-HoNOSCA-SR and the HoNOSCA-CR with paired sample t-tests revealed a higher score for the self-rated version. The F-HoNSOCA-SR was reported to provide reliable measures. In addition, it allows us to measure complementary information when used together with the HoNOSCA-CR.