Child and Adolescent Mental Health within Primary Care: A Study of General Practitioners' Perceptions

Background:  Primary Care teams play an important role in the provision of mental health care to children and young people.
Methods:  We developed and distributed a questionnaire to all General Practitioners within one Health Authority area.
Results:  Many of the respondents rated as less than satisfactory their competence and their knowledge and skills in important areas of child and adolescent mental health practice. A significant minority expressed a high level of interest in child and adolescent mental health and most respondents reported that they would value further training.
Conclusions:  General Practitioners should be provided with more training and support in their role as providers of child and adolescent mental health care.     

Developing child mental health services in resource-poor countries

Despite significant gains in tackling the major causes of child mortality and evidence of an urgent need for child mental health services, resource-poor countries continue to lag behind in child and adolescent mental health service development. This paper analyses possible barriers to the development of child mental health services in resource-poor countries and attempts to proffer solutions. Obstacles identified are the magnitude of child mental health problems that remain invisible to policy makers, an absence of child mental policies to guide the process of service development, and overburdened child mental health professionals. The belief systems about mental illness also prompt help seeking in alternative health systems, thereby reducing the evidence for the burden associated with health seeking. Solutions that may support child mental health service development are the provision of adequate advocacy tools to reveal the burden, poverty alleviation, health awareness programmes, enforcing legislation, training centred within the region, and partnerships with professionals in developed countries. These solutions require simultaneous approaches to encourage service development and utilization. Reductions in child mortality in resource-poor countries will be even more dramatic in the years to come and preparations need to be made to take care of the mental health needs of the children who will survive.     

Critical review of world policies for mental healthcare for children and adolescents

PURPOSE OF REVIEW: Policy development is essential for the development of child and adolescent mental health services. The gaps in policy and knowledge on how to develop policy have hindered the development of sustainable services. RECENT FINDINGS: The WHO has now objectively identified gaps in child and adolescent mental health policy and services worldwide through its Atlas project. Others have identified the need to use evidence-based interventions in developing services and the need for ongoing evaluation. These latter elements are essential for effective policy implementation. SUMMARY: Data are now available worldwide to move forward with advocacy for child and adolescent mental health policy development.     

Child and adolescent mental health in South Africa

Mental health problems in childhood and adolescence pose a major threat to public health. Epidemiological studies in high, middle and low income countries indicate that approximately one in five children and adolescents suffer from a mental disorder. In many instances these persist into adulthood. In South Africa, HIV infection, substance use, and exposure to violence increase vulnerability to mental disorders. Child and adolescent mental health services play a key role in reducing the burden of mental disorders in childhood and later in adulthood. This paper focuses on service needs for children and adolescents in South Africa. It commences with a discussion of the prevalence of child and adolescent psychiatric disorders after which the legal and policy context of child and adolescent psychiatric services is described. A framework for child and adolescent mental health service provision is presented, following which steps for reducing the extent of unmet service need are considered. The paper concludes with a call to scale up child and adolescent mental health services in South Africa, based on the stark realities of unmet need and the constitutional rights of children and adolescents to appropriate mental health care.     

Child mental health in Latin America: present and future epidemiologic research

OBJECTIVE: This report reviews population studies of child and adolescent mental health carried out in Latin America over the past 15 years. Also considered is the issue of how to meet the needs of children and adolescents who may present mental health problems in Latin America, given that most of them live in poverty in economies that are underdeveloped, providing limited resources. METHOD: Ten studies from six different countries were identified that employed some form of randomized sampling method and used standardized instruments for assessment. The authors present a summary of the main characteristics of these studies, highlighting methodological features that may account for differences in the rates obtained. RESULTS: Overall, a similar pattern of prevalence and risk factors for mental health problems in children and adolescents in Latin American countries emerged. Moreover, rates of disorders in these children are similar to the 15 to 20% found in other countries. These findings are similar to those observed when adult mental health problems are considered. Prevention and treatment strategies are discussed and the peculiarities of the delivery of mental health services for children and adolescents are explored. CONCLUSIONS: Future research needs to focus on understanding of resilience and formal and informal mental health delivery systems of care available in different Latin American countries. Such research has high potential for ameliorating the prevention and treatment of child and adolescent mental health problems in this region of the world.     

Dangerous Children: Assessment and Management of Risk

Background:  Workers in the field of child health appear to be presented with increasing numbers of young people who exhibit behaviours that pose a potential or actual risk to the safety of others.
Method:  A review of the current literature on the assessment and management of these children and adolescents was conducted.
Results:  A history taking check-list has been devised on the basis of what is known about current associations with background and current factors and violent acts directed to others. There is emerging evidence of interventions that may be effective in reducing long-term risks in such youths. However, these are often resource intensive and may be less effective in older children and adolescents.
Conclusions:  Faced with the challenge of assessing and managing severely conduct disordered children, child and family mental health teams should develop formalised assessment procedures and protocols for managing risk factors in a multi-agency context.     

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.     

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.     

Developing Services with Limited Resources: Establishing a CAMHS in Pakistan

Background:  There are very few mental health services in Pakistan. In 2002, the Department of Psychiatry at Aga Khan University Hospital started a separate clinic for children under the age of 15 years to meet the population needs. This service took direct referrals from other physicians as well as from parents and schools.
Method:  A DSM-IV based semi-structured interview with a uniform written format was used for an initial evaluation by a child psychiatrist. Data regarding demographic characteristics, referral source, diagnoses and treatment were collected.
Results:  A total of 290 new referrals were made to the clinic over 3 years. The most common reason for referral was aggressive behaviour, although this possibly masked other kinds of mental health problems, as indicated by the assessment. Attention deficit-hyperactivity disorder was the most frequent diagnosis, made in 25% of children.
Conclusions:  Despite the limited resources and the high level of need in developing countries, resources can be used effectively within the framework of their health and educational systems, so maximising protective factors within their communities.     

What Can the FOCUS E‐mail Discussion Group Tell Us About the Issues Facing CAMH Professionals?

Background:  The FOCUS e-mail discussion group was established in 1998 with the aim of facilitating information-sharing between professionals working in child and adolescent mental health services (CAMHS).
Method:  A content analysis was carried out on messages sent to the FOCUS e-mail discussion group between September 2004 and August 2005.
Results:  Discussion topics were widely distributed across twelve main themes, reflecting the breadth of issues discussed by CAMH professionals. The five most frequently discussed were: clinical cases; workforce issues; interventions; service policy; and service organisation.
Conclusion:  The findings demonstrate the usefulness of the FOCUS e-mail discussion group as a means of identifying the key issues facing CAMH professionals and consequently its potential to inform healthcare practice and policy.     

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.     

Child and Adolescent Mental Health Policies,Programmes and Infrastructures across Europe

To support development of effective policy and action for child and adolescent mental health (CAMH), key national and/or regional information on monitoring, evaluation, obstacles and opportunities in CAMH from 15 European countries was collected. National expert groups in each country were created to collect the data and complete a specially designed questionnaire. The data highlight that 1) the implementation and outcomes of CAMH policies and action plans are not assessed systematically in Europe, 2) prevalence data on positive mental health, mental disorders and risk, and vulnerable populations is heterogeneous and patchy across Europe, 3) children and adolescents are rarely involved in decision-making processes affecting CAMH practices, 4) CAMH issues are not included in all relevant higher education qualifications, 5) budgets dedicated to CAMH issues are not identifiable, specific or sufficient in the long term, and 6) stakeholders and the general public are not considered to be widely aware of the determinants of CAMH.     

Mental Health of Children in Palestinian Kindergartens: Resilience and Vulnerability

Background:  Exposure to adversity does not necessarily lead to the development of psychopathology in all affected children. This study examined the factors associated with resilience and vulnerability in mental health in the Gaza Strip in 2007.
Methods:  Children selected from a random sample of kindergartens (3-6 years old, N  =   350) were assessed for growth and their mothers administered an interview including a psychometric test battery.
Results:  Factors associated with resilience were maternal rated good health, higher maternal level of education, and less child exposure to traumatic events. Factors associated with vulnerability were poor maternal mental health, and male gender.
Conclusions:  Our findings highlight the importance of maternal health and education in affecting children's mental health.     

Debate: Child and adolescent mental health services in Pakistan; Do we need in-patient mental health facilities for children and young people?

Depression and anxiety are leading causes of morbidity in children and adolescents worldwide. In Pakistan, young people are exposed to many chronic adversities including violence, social and economic inequalities, and are at greater risk of developing mental health problems. Yet there is a lack of trained human resources, in-patient child and adolescent mental healthcare facilities, and training opportunities in child and adolescent psychiatry and mental health in Pakistan. Given the poor economic condition of the country, which has been made even worse by the COVID-19 pandemic, it is very unlikely that dedicated resources will be made available in near future to develop specialist child and adolescent mental health services in Pakistan. To bridge this treatment gap, we propose a multitiered, transdiagnostic, task-shifting strategy-based model for child and adolescent mental health services in Pakistan.     

Parental Perceptions of the Assessment of Autistic Spectrum Disorders in a Tier Three Service

Background:  Little is known about the satisfaction of the parents of children receiving child and adolescent mental health services in general, and autistic spectrum services in particular.
Method:  This audit examined parent and carer perceptions of the Autistic Spectrum Disorder assessments undertaken by the multi-agency team in a Tier Three CAMHS in Manchester. Forty families completed a brief questionnaire.
Results:  The majority of parents and carers reported satisfaction with the service (95%), although responses highlighted areas in both the assessment process and the service facilities that needed improvement.
Conclusions:  Useful information with both local and national applications can be gathered quickly in an easily replicated manner.     

Need for Child Mental Health Consultation and Paediatricians' Perception of these Services: A Survey in the West Midlands

Background:  High rates of psychopathology have been noted in children presenting to GP surgeries and paediatricians. However, paediatricians do not always recognise this and when they do the Child and Adolescent Mental Health Service (CAMHS) is often unable to meet their consultation needs.
Method:  This postal survey looked at paediatricians' perception of the need for child psychiatry consultation in the West Midlands.
Results:  The survey confirmed that paediatricians see a significant proportion of children with mental health problems and the findings showed that their need for child psychiatry consultation was not being adequately met. Lack of access to CAMHS was a significant issue.
Conclusions:  This has implications not only for further development of consultation services within CAMHS but also for improving training in child psychiatry for paediatricians in a more formalised way.     

A note on racial bias in the admission of children and adolescents to state mental health facilities versus correctional facilities in New York.

OBJECTIVE: In response to several studies suggesting that there is racial bias in the admission of proportionately more white children and adolescents to the child and adolescent mental health system than to the juvenile justice system, the authors tested whether white children and adolescents would be overrepresented compared with black children and adolescents in mental health facilities and underrepresented compared with black children and adolescents in juvenile correctional facilities when ethnic distribution in the general population was controlled. METHOD: Ethnicity, age, and sex of all white, black, and Hispanic 10-18-year-olds admitted in a 1-year period to facilities of the Office of Mental Health and facilities of the correctional system (the Division for Youth) of New York State were converted into rates per 100,000 population by using U.S. census data for the state. Admission rates per 100,000 population for ethnicity, age, sex, and source of referral were then compared in the two types of facilities. RESULTS: There were no meaningful differences in population-corrected admission rates among black, white, and Hispanic children and adolescents in the state mental health system. In contrast, there was a vast preponderance of black children and adolescents admitted to the state juvenile correctional system. The systems have different points of entry: 100% of the juvenile justice admissions versus 17% of the mental health admissions were referred by the courts. CONCLUSIONS: Analysis of demographic variables failed to support an allegation of racial bias in admission to the child and adolescent public mental health system in New York State.     

The Impact of Primary Mental Health Workers on Referrals to CAMHS

Background:  This paper describes the impact of a new primary mental health team within the existing child and adolescent health service on referrals and attendance rates.
Method:  100 referrals to CAMHS from prior to the PMHT and 100 referrals prior to the evaluation were examined and classified as appropriate or inappropriate for CAMHS. Information was also gathered as to whether the child and/or family attended for their appointment with CAMHS.
Results and Conclusions:  a large increase in attendance and decrease in non-attendance rates to CAMHS was seen. The referrals to CAMHS have become more appropriate for a psychiatry service. However, the service provoked a mixed response from Tier 1 professionals. Recommendations are made for the skills needed by primary mental health workers and further evaluative techniques.     

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.