Predictors of Service Use for Mental Health Problems Among British Schoolchildren

Background:  Most previous studies of service use in relation to mental health have examined services in the USA. We wanted to provide up-to-date findings from a general population sample of British schoolchildren.
Method:  A total of 2461 children aged 5–15 from the 1999 British Child and Adolescent Mental Health Survey were followed up for 3 years. We examine the relationship between a wide variety of potential predictors gathered in 1999 and the use of services over the following 3 years.
Results:  Contact with most services was predicted by three factors: the impact of psychopathology; contact with teachers or primary health care; and parents' and teachers' perceptions that the child had significant difficulties. Other predictors were specific to each service.
Conclusions:  Education of parents, teachers and other important adults might increase the proportion of children with impairing psychiatric disorders reaching services.     

Child Mental Health is Everybody's Business: The Prevalence of Contact with Public Sector Services by Type of Disorder Among British School Children in a Three-Year Period

Method:  A third of the children from the 1999 British Child and Adolescent Mental Health Survey were followed-up over 3 years. Parents provided summary information on service contacts in relation to mental health; selected subgroups provided more detailed information by telephone interview.
Results:  Common overlaps in service use were between health services, between teachers and educational specialists, and between the latter and CAMHS or social services. Services other than primary health care saw more children with externalising disorders, while children with anxiety disorders were less likely than children with other psychiatric disorders to be in contact with any service.
Conclusions:  Child mental health is everybody's business, and professionals need to be alert(ed) to the types of disorders that children using their service may have.     

The development of a new measure for the assessment of psychopathology in adults with intellectual disability

Background   People with intellectual disability (ID) and untreated psychiatric disorder lead unnecessarily difficult and unhappy lives. The prevalence of mental illness in children and adults with ID is greater than that found in the general population. A carer-completed checklist of psychopathology that could be used with both children and adults would help identify those individuals with ID most likely to have a mental health problem, help ensure that they receive the limited services that are usually available and also assist the process of clinical assessment, diagnosis and management.
Method   This research aimed to develop a reliable and valid carer-completed checklist of psychopathology for adults with ID by redeveloping an existing measure for children with ID, the Developmental Behaviour Checklist (DBC-P). The new checklist, The Developmental Behaviour Checklist for Adults (DBC-A) was devised by changing, deleting and adding to DBC-P items. Reliability studies were conducted with paid and family carers, and DBC-A scores were compared with the results from two other measures of psychopathology.
Results   One DBC-P item was deleted, seven items changed and 12 items added. The psychometric properties of this new checklist, the DBC for Adults with ID (DBC-A), were investigated and found to be satisfactory. Intraclass correlations for test-retest and inter-rater reliability ranged from 0.72 to 0.85, and concurrent validity with two measures of emotional and behavioural disturbance was satisfactory.
Conclusions   The carer-completed DBC-A provides a broad and comprehensive survey of the emotional and behavioural problems of adults with ID. It has satisfactory psychometric properties and therefore can be used with confidence in clinical, research and service settings, and its development allows continuous assessment of psychopathology across the lifespan for all people with ID.     

Behavioural and emotional difficulties in students attending schools for children and adolescents with severe intellectual disability

Background   For several decades, researchers and clinicians have been aware of an increased prevalence of psychiatric disorder in children with intellectual disability. However, there are few research studies exploring this issue.
Methods   The parents of 123 children attending schools for children with 'severe learning difficulties' completed the Developmental Behaviour Checklist (DBC) in order to identify those children with clinically significant behavioural and emotional problems. Comparisons were made with norms for the DBC and a range of child variables were investigated as possible correlates of disorder.
Results   Some 50.4% of the children scored above the cut-off on the DBC for psychiatric disorder. The child's severity of physical disability was related most strongly to parental ratings of behavioural and emotional problems. There were also effects for the child's age and the absence of Down's syndrome.
Conclusions   The present study confirms previous research findings of a high prevalence of behavioural and emotional difficulties amongst children with intellectual disability, and identifies a number of correlates of disorder which require further investigation.     

An Evaluation of a Primary Care-Based Child Clinical Psychology Service

Background: This paper describes a primary care-based clinical psychology service operating in an inner London borough that provides psychological intervention for children with emotional or behavioural difficulties and their families, and consultation and support to the primary health care teams.
Method: A comparison is made with a local secondary level child mental health service in terms of characteristics of referrals and clinical outcome. Referrers' perceptions of the primary care-based service are described.
Results and Conclusions: The findings demonstrate a useful child and adolescent mental health service for children and adolescents with a broad range of childhood difficulties within a primary care setting, which appears to overcome some of the problems often associated with referral to secondary level services.     

Children with Complex Mental Health Problems: Needs, Costs and Predictors over One Year

Background:  Little is known regarding children of greatest concern with complex mental health problems.
Method:  A one-year prospective study of psychiatric diagnosis, psychosocial functioning, need status and service receipt in 60 children identified as most concerning.
Results:  Thirty-two (53%) had two or more disorders. The mean number of needs per child was five. One year later mean needs were unchanged but with considerable individual variation. Mean weekly costs were £1017 (€1627) ( SD  = £957 (€1531)). Higher costs related to social factors rather than diagnosis or need.
Conclusions:  The mean annual cost of services to children with complex mental health problems is ten times that in other studies of children with mental health problems.     

Gender as a Moderator of the Relationship between Child Exposure to the World Trade Centre Disaster and Behavioural Outcomes

Objectives:  This study examined the moderating effect of gender on the relationship of child exposure to the World Trade Centre (WTC) disaster and child behavioural difficulties among a sample of very young children who resided in New York City on September 11, 2001.
Methods:  The authors interviewed 180 parents of children who were age five or younger on September 11th, 2001. Parents were asked to provide information concerning family demographic characteristics, their own and their children's mental health, their children's behavioural difficulties in the aftermath of the WTC disaster, the number of WTC disaster experiences their children were exposed to, and the number of stressful life events their children experienced prior to the disaster.
Results:  Gender moderated the relationship between child exposure to the WTC disaster and several behavioural outcomes. Specifically, among children who were highly exposed boys evidenced significantly higher scores on parent report measures of internalising and total behavioural difficulties relative to girls.
Conclusions:  Findings are contrary to other research on children and trauma, in which gender differences are more often reported with higher rates of internalising behaviour among girls. Future research is needed that examines how and whether younger children's vulnerabilities in the face of trauma may differ by gender.     

Ethnic variation in service utilisation among children with intellectual disability

Background   This study examined whether service utilisation among children with intellectual disability (ID) varied by ethnic cultural group.
Method   Survey carried out in four special schools in London. Information was provided by school teachers using case files, and 242 children aged 7 to 17 years with mild and moderate ID were identified. Ethnic categories were derived from self-reported main categories. Service utilisation categorised as use of: child and adolescent mental health services (CAMHS), social services, physical health and education services.
Results   Child and adolescent mental health services uptake was lower for South Asians than for White British ( P  = 0.0487). There were statistically significant differences among ethnic groups for community-based social services uptake (being the highest for the Black groups and the lowest for South Asians, P  = 0.015) and respite care uptake (being the highest for the Black and White European groups and the lowest for South Asians, P  = 0.009). In regression analysis family structure predicted CAMHS service utilisation and social service community support. Ethnicity predicted use of respite care.
Conclusions   Significant ethnic differences in service utilisation among children with ID were found for both CAMHS and social service contact. There was particularly low service use for the South Asian group. These differences might arise because of differences in family organisation, as more South Asian children lived in two-parent families, which may have been better able to provide care than single-parent families. Other factors such as variation in parental belief systems and variation in psychopathology may be relevant. Implications are discussed.     

A population survey of mental health problems in children with epilepsy

The 1999 British Child and Adolescent Mental Health Survey, a nationwide epidemiological study of rates of psychiatric disorder in children aged 5 to 15 years, provided the opportunity to investigate the mental health of children with epilepsy. These children and their families experience disability specifically because of additional emotional, behavioural, and relationship problems, and this is the first epidemiological study that directly measures these impairments. Information was obtained by interviewing a main carer and teacher for 10,316 children; 67 children with epilepsy were identified (35 males, 32 females; mean age 10 years 2 months, SD 2 years 11 months, range 5 to 15 years), and compared with the 47 children with diabetes (27 females, 20 males; mean age 10 years 4 months, SD 3 years 4 months, range 5 to 15 years) and 10,202 controls (50% male; mean age 9 years 11 months, SD 3 years 1 month, range 5 to 15 years). DSM-IV psychiatric diagnoses were derived from the Development and Well-Being Assessment in combination with the interview and a specialist clinician rating. Parental reports of emotional and behavioural problems, their impact, and associated peer problems were also obtained. Rates of psychiatric disorder were 37% (95% confidence interval [CI] 22 to 49) in epilepsy, 11% (95% CI 2 to 19%) in diabetes, and 9% (95% CI 9 to 10%) in control children. Parents of children with epilepsy consistently reported more problems, with greater impact and associated peer problems. Epilepsy, but not diabetes, was independently (adjusted for age, sex, and severe learning difficulties) associated with all behavioural variables in regression analyses. Emotional, behavioural, and relationship difficulties are common in children with epilepsy, and constitute a significant burden to the children and their families, indicating the need for effective mental health services for these children.     

Auditory Hallucinations in Nonpsychotic Children: Diagnostic Considerations

Background:  Auditory hallucinations in childhood and adolescence are not necessarily an indication of psychosis, but are more frequently associated with a range of other mental health problems. Although not specifically linked to abuse as an aetiological factor, the literature reporting on hallucinations in children alludes to a range of family dysfunction and disruption.
Method:  This study reports on the auditory hallucinations of 13 children referred to a community-based child and family mental health service exhibiting a variety of emotional and behavioural difficulties. The presence of the hallucinations was generally revealed during the course of the initial assessment.
Results:  None of the children were considered psychotic at initial presentation; however, all were experiencing high levels of stress and/or anxiety in their lives. Following the initial assessments children were given diagnoses ranging from generalised anxiety disorder, through adjustment disorder, to posttraumatic stress disorder. The hallucinations gradually disappeared over the course of therapy. Two case studies describe the hallucinations and family histories in more detail.
Conclusions:  The present study adds further confirmation of the presence of auditory hallucinations in nonpsychotic children. The clinical presentation of the children in the present study indicates an association between hallucinations and high levels of stress and anxiety, suggesting that mental health professionals should enquire more routinely about auditory hallucinations, particularly with those children from abusive and violent backgrounds.     

Annotation: New research into general psychiatric services for adults with intellectual disability and mental illness

Background   There are a variety of models for the mental health care of adults with comorbid intellectual disability (ID) and mental illness. There has been a long-running debate as to whether this should be provided by general psychiatric or specialised ID services. A previous review concluded that there was no clear evidence to support either model with research being often of a poor quality, lacking replication, and outcome measures were often inappropriate or varied between studies. This review aims assess differences in outcome for patients with ID and mental disorders treated in general or specialised ID mental health services.
Method   A literature review was conducted using electronic databases and websites of ID and mental health organisations to locate all references where people with ID receive mental health care in general psychiatric services from 2003. No meta-analysis was attempted because of the divergent nature of the studies.
Results   People with ID (especially severe ID) have reduced access to general psychiatric services. General psychiatric inpatient care is unpopular especially with carers but can be improved by providing specially trained staff and in-reach from community ID teams. Opportunities may exist to enhance the care of people with borderline intellectual functioning within general psychiatric services.
Conclusions   Although no new randomised controlled trials have been published, the weight of research is accumulating to suggest that provision of general psychiatric services without extra help is not sufficient to meet the needs of people with ID.     

Postdeployment, Self-Reporting of Mental Health Problems, and Barriers to Care

PURPOSE.  This study explored the relationship between self-reported mental health symptoms and help-seeking behaviors of active-duty Air Force members.
DESIGN AND METHODS.  Mixed-methods approach reviewed 200 postdeployment surveys from active-duty members assigned to Eglin Air Force Base, Florida, USA. Chi-square analysis examined significance between self-reporting mental health problems and accessing treatment.
FINDINGS.  As the rate of self-reported mental health symptoms increased, active-duty members were less inclined to seek help. There were inconsistencies among gender for self-reporting and accessing services.
PRACTICE IMPLICATIONS.  Air Force psychiatric nurses need to be at the forefront of outreach services when treating combat-stressed troops.     

Child and adolescent psychiatry in general practice.

OBJECTIVE: This review discusses the role of general practitioners and primary care health staff in the assessment, treatment and prevention of child and adolescent psychiatric disorders and to consider implications for service delivery. METHOD: Literature review. Papers were selected as having an empirical evidence base or as describing and documenting new initiatives in general practice. RESULTS: A small proportion of about 3% of children present to general practice with behavioural or emotional problems, but psychiatric disorders in the context of somatic presentations are considerably more common. They are probably higher than in the general population reflecting an increased tendency by children with disorders to consult. Recognition by general practitioners is limited and few children with disorders are referred to specialist clinics. However, referrals are mostly appropriate: the more severely affected children in difficult psychosocial circumstances. A number of pilot studies have shown the feasibility and potential usefulness of setting up shifted specialist clinics in primary care and of training primary care doctors and other staff in the recognition or management of child mental heath problems. CONCLUSION: Primary care is an appropriate resource to help increase attention to child and adolescent mental health problems. Its potential requires further development and rigorous evaluation. Areas lending themselves to development include: improved medical undergraduate teaching and postgraduate training; suitable information and advice-giving on child mental health problems by the primary care team; the development of specific child and adolescent psychiatric interventions for use in the primary care setting; careful and discriminating development of shifted outpatient clinics for selected child psychiatric disorders; the development of focused protocols for referral to specialist services; further development of mental health promotion clinics in primary care.     

Mental health problems in children and adolescents referred to a national epilepsy center

This study aimed to investigate the occurrence of psychiatric morbidity in children and adolescents referred to a tertiary national epilepsy center (inpatient unit) and the extent of the unmet need for psychiatric services in this group. Participants were 74 children and adolescents aged 9-15 referred from February 2001 to October 2002 (67% response rate). The multi-informant (parent, teacher, self-report) Strengths and Difficulties Questionnaires (SDQs) were answered before or at admission. Patients with severe mental retardation or pervasive developmental disorder were excluded. We found a large proportion (77%) with a possible or probable psychiatric disorder. The parents, teachers, and adolescents themselves had higher mean SDQ scores than a British community sample on total difficulties, emotional symptoms, conduct problems, hyperactivity-inattention, peer problems, and impairment, but not self-reported conduct problems. Nearly 80% of the children who probably had a psychiatric disorder had no contact with the psychiatric service.     

Looked After Children in Residential Homes

Background: Looked after children in residential children's homes constitute a particularly vulnerable group who are known to have high rates of mental health problems and limited access to services.
Method: A survey was undertaken in Leeds to determine what proportion of these children are involved with mental health services, and to look at the different ways in which child and adolescent mental health services across the city are currently working with this group.
Results: Of the 177 children in residential children's homes in August 2000, 64% had had some contact with child mental health services in the previous 5 years and 27% were in current contact. Thirty-six percent had had no contact with services over the past five years.
Conclusions: It was anticipated from a review of the literature that a higher proportion of children would have been currently in contact with services. The findings suggest that the pattern of services offered to this group of children is changing, with an increase in consultation with, and training of, staff in residential children's homes. The paper ends with a discussion of whether or not this is a positive change and how CAMH resources might best be utilised in the future.     

Assessing the Effects of Maternal Symptoms and Homelessness on the Mental Health Problems in their Children

Objective:  This study examines the longitudinal association between measures of child well being and maternal posttraumatic stress disorder symptoms, homelessness, substance abuse, and other psychiatric conditions.
Method:  A sample of 142 mothers who were veterans of the US armed forces were assessed at program entry and every three months thereafter for one year. A repeated-measures with mixed-effects analytic strategy was used to assess the association of children's mental health, school enrolment and attendance with measures of maternal psychiatric symptoms and homelessness.
Results:  Significant associations between mothers' psychiatric symptoms and child well-being were identified. However, the multivariable mixed-models suggest that increased depression and anxiety symptoms among children were associated primarily with mothers' PTSD, and not depression, symptoms.
Conclusions:  These findings provide evidence of an association between maternal and child mental health and may suggest that treating maternal PTSD symptoms may also benefit children, regardless of whether the child was also exposed to the traumatic experience.     

Unmet Mental Health Service Needs Among Norwegian Children and Adolescents

Background:  The Norwegian 10 year mental health plan identifies important roles for public health nurses in the early identification, care and referral of children and adolescents with mental health problems. This study aims to identify the extent to which public health nurses are meeting these needs.
Method:  Over a 4 week period the mental health needs of 3065 children who were seen by publich health nurses were identified.
Results:  Achieving the ongoing Norwegian mental health plan may require better access to trained professionals in the public health sector, further expansion of specialised mental health services, and efforts to improve inter-agency collaboration.     

Cognitive Therapy for Children, Young People and Families: Considering Service Provision

Background:  This article presents a case for the development of cognitive therapy services for children, adolescents and their families.
Method:  The theoretical basis of cognitive therapy is described, and illustrated with a case. The article continues by exploring the context for service development, with a specific emphasis on evaluating the evidence-base for using cognitive therapy with children and adolescents. Consideration is also given to adapting cognitive therapy to the child's developmental level, and the evidence for the efficacy of cognitive-behavioural family approaches.
Conclusions:  The article concludes by arguing that there is a need to address mental health difficulties in young people by providing effective treatment approaches. The development of cognitive therapy services would support the further evaluation of this therapeutic approach.     

Five Years On: Public Sector Service Use Related to Mental Health in Young People with ADHD or Hyperkinetic Disorder Five Years After Diagnosis

Background:  Little is known about ongoing service use among young people with ADHD, but this information is important to the development of services to support these young people.
Methods:  A cohort of young people with ADHD or hyperkinetic disorder ( n  = 115) was followed up five to seven years after diagnosis. Details are presented of their use of public sector services over the 12 months preceding reassessment, compared to young people with ADHD from a large epidemiological study.
Results:  Most children remained in contact with CAMHS, with high rates of contact with schools, educational professionals and the criminal justice system. Nearly all had taken medication at some point, while many still were using it. There were low reported rates of psychological and group interventions within the last twelve months, but this does not rule out earlier access to such treatments.
Conclusions:  Children with ADHD utilise long-term support from public sector services, and cross agency strategies or clinics may help to optimise functioning.     

Change in children’s emotional and behavioural problems over a one-year period

Although children with emotional or behavioural problems are at increased risk of future problems, knowledge of factors associated with persistence and change in child problems, once these problems exist, is limited. Using repeated measures analyses of variance, the present study investigated the association of parental problem recognition, professional and informal service use, and sociodemographic factors with change in child problems over a one-year period, in a sample of 360 children and adolescents with emotional and behavioural problems. Higher overall problem levels were found in children (aged 4–11 years at baseline) versus adolescents (aged 12–17 years), in boys, and in children with less educated parents, which indicates the need to address preventive actions at these groups. Although rates of service use were low, children who had been in contact with general practitioners or mental health services had higher overall problem levels, suggesting that children who need it most end up receiving professional care. Although child emotional and behavioural problems decreased significantly over time, this change was not associated with utilisation of professional or informal services. Our findings imply the need for methodologically sound research into the effectiveness of professional and informal services for child emotional and behavioural problems.