Ethnic factors in mental health service utilisation among people with intellectual disability in high-income countries: systematic review

Background An emerging literature suggests that ethnic and cultural factors influence service utilisation among people with intellectual disability (ID), but this has not previously been reviewed. Aims To investigate possible ethnic variation in uptake of mental health services in children, adolescents and adults with ID in high‐income countries. Method A systematic review using main databases of studies that consider ethnic influences on mental health utilisation of people with ID. Methodological quality of studies was assessed. Results Nine studies that reached selection criteria were identified. Six studies that compared two or more ethnic groups found a variation in levels of mental health service utilisation. The most consistent finding was that South Asian children, adolescents and adults with ID in the UK had lower use of mental health services than White British comparison groups. Conclusion Ethnic influences on mental health service utilisation were identified. Understanding their significance and potential negative consequences requires further investigation.     

Experiences of mental health services by people with intellectual disabilities from different ethnic groups: a Delphi consultation

Background Patient experience of those accessing mental health services has been found to be different between ethnic groups. Although the needs of people with intellectual disabilities (ID) from different ethnic communities are being increasingly recognised, little has been published about their experiences of mental health services. The aim of this study was to establish whether there are any differences in the experiences of people with ID and mental health problems from two ethnic communities in South London. Method A two‐round Delphi process was utilised. White British and Black or Black British service users from a specialist community‐based mental health service for adults with ID completed a specially compiled questionnaire. Statements on participants' experiences, including satisfaction with care, staff members' attitudes, cultural awareness and level of support, were rated using a Likert scale. Results Twenty‐four out of 32 participants (75%) completed both rounds of the Delphi consultation. Consensus (≥80% agreement with the group median) was reached for 20 items in the White group and five items in the Black group. All responses that reached consensus were positive about the services that were being received. The Black group were less positive about a range of their experiences, including the use of medication. Conclusions People with ID from two ethnic groups were able to successfully complete a Delphi consultation regarding their experiences of mental health services. Broad consensus on positive experiences of services was reached in the White group but not for the Black participants.     

Evaluation of a CAMHS in Primary Care Service for General Practice

Background:  Many CAMH Services have Tier 2 provision in primary care, but there has been little published evaluation. In a service aimed at general practice, this study examined: 1) the clinical activities of the primary mental health workers; 2) the effect of the service on referrals to specialist CAMHS; and 3) the utilisation and perceived usefulness of the service.
Method:  clinical activity data collection, evaluation of referral patterns, and a postal questionnaire.
Results:  Informal (unstructured) consultation-liaison was used more than formal consultation. Referrals to specialist CAMHS increased from practices using the service. The service was perceived as helpful and accessible.
Conclusions:  The service supported primary care staff in their work with child and adolescent mental health issues. Referrals to Tier 3 may increase as a result of the service.     

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 association between ethnicity and care pathway for children with emotional problems in routinely collected child and adolescent mental health services data

Adults from black and minority ethnic (BAME) backgrounds are less likely to access mental health services through voluntary care pathways and are more likely to access through compulsory ones. The aim of the present research was to explore the association between ethnicity and care pathway through child and adolescent mental health services (CAMHS), in terms of reason for referral and case closure, in children presenting with emotional problems. A sample of N = 11,592 children from 26 CAMHS was taken from a national routinely collected dataset (56 % female; 7 % aged 0–5 years, 40 % 6–12 years, 53 % 13–18 years, and <1 % 19–25 years). Multinomial logistic regressions showed that BAME children were consistently more likely to be referred to CAMHS through education, social, and other services than primary care, compared to White British children (odds ratio (OR) = 1.52–9.96, p < .001) and they were less likely to end treatment due to child and family non-attendance (OR = 0.59–0.79, p < .05). Similar to adults, children from BAME groups may be more likely to access CAMHS through compulsory than voluntary care pathways.     

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.     

Prevalence, morbidity and service need among South Asian and white adults with intellectual disability in Leicestershire, UK

Background Previous reports have suggested that South Asian and white UK populations have different prevalences of intellectual disability (ID), related psychological morbidity and service use. The aim of the present study was to compare these rates among South Asian and white adults in Leicestershire, UK. Method This cross‐sectional study is comprised of two parts. The analysis of prevalence is based on data from all South Asian and white adults known to the Leicestershire Learning Disabilities Register in 1991, with population denominators being drawn from the 1991 census. The other analyses use data collected from the most recent semi‐structured home interviews, carried out between 1987 and 1998, with 206 South Asian and 2334 white adults. Results The prevalence of ID in adults in Leicestershire is 3.20 per 1000 in South Asians and 3.62 per 1000 in whites. Among adults with ID, South Asians have similar prevalences of disabilities to whites and significantly lower skill levels. South Asians show similar levels of psychological morbidity, but make significantly lower use than whites of psychiatric services, residential care and respite care. South Asians use community services as extensively as whites, but feel that they have a substantially greater unmet need, especially with regard to social services. Conclusion South Asian and white populations have similar prevalences of ID and related psychological morbidity. Culturally appropriate services for South Asian adults may need to focus on skill development and community care.     

Attitudes To and Knowledge of CAMHS: Differences Between Pakistani and White British Mothers

Background: Research suggests that there are differences in the problems that are referred to Child and Adolescent Mental Health Services (CAMHS) by White British and Asian families as well as differences in how these services are accessed. There is a need for more information about how different ethnic communities perceive and access CAMH services.
Method: White British or Pakistani mothers of children between 0–20 years at an urban health centre were invited to complete a study-specific questionnaire written in English (with verbal translation provided when needed). Data were collected on awareness and experience of, and willingness to use CAMH services; severity of problems before referral is considered and additional factors that influence service use.
Results: In comparison to White British mothers, Pakistani mothers were found to be less likely to consider a referral for problems judged as mild or moderate. There was no difference for severe problems. Qualitative factors that would enhance the use of CAMH services by Pakistani mothers include the availability of culture and gender matched therapists, and better access to translation facilities.
Conclusions: The study highlights service needs and expectations of mothers of Pakistani origin, and emphasises the need for relevant, inclusive and culturally sensitive services.     

Service Contacts Among the Children Participating in the British Child and Adolescent Mental Health Surveys

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 for emotional, behavioural and concentration difficulties, with more detailed information being obtained by telephone interview for selected subgroups.
Results:  Having a psychiatric disorder predicted substantially increased contact with social services, special educational needs resources, the youth justice system and mental health services (district CAMHS and tier four, but not tier two). Of those children with psychiatric disorders, 58% had been in contact with at least one of these services for help with emotional, behavioural or concentration difficulties, including 23% who had been in contact with mental health services.
Conclusions:  British children attend a wide variety of services for help with emotional, behavioural and concentration difficulties. The proportion seeing specialist mental health services is higher than that generally reported in the research literature.     

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.     

When is Sessional Monitoring More Likely in Child and Adolescent Mental Health Services?

Sessional monitoring of patient progress or experience of therapy is an evidence-based intervention recommended by healthcare systems internationally. It is being rolled out across child and adolescent mental health services (CAMHS) in England to inform clinical practice and service evaluation. We explored whether patient demographic and case characteristics were associated with the likelihood of using sessional monitoring. Multilevel regressions were conducted on N = 2609 youths from a routinely collected dataset from 10 CAMHS. Girls (odds ratio, OR 1.26), older youths (OR 1.10), White youths (OR 1.35), and youths presenting with mood (OR 1.46) or anxiety problems (OR 1.59) were more likely to have sessional monitoring. In contrast, youths under state care (OR 0.20) or in need of social service input (OR 0.39) were less likely to have sessional monitoring. Findings of the present research may suggest that sessional monitoring is more likely with common problems such as mood and anxiety problems but less likely with more complex cases, such as those involving youths under state care or those in need of social service input.     

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.     

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.     

Development of a Scale to Assess the Attitudes of Paediatric Staff to Caring for Children with Medically Unexplained Symptoms: Implications for the Role of CAMHS in Paediatric Care

Background:  Children with medically unexplained symptoms (MUS) represent a challenge for paediatricians and typically undergo extensive in-patient investigations for symptoms such as abdominal pain. This can delay access to psychological services. This study aims to develop and evaluate a scale to assess the attitudes of paediatric staff to caring for children with MUS and to explore factors influencing those attitudes.
Method:  In this cross-sectional survey, 118 health professionals at one UK hospital with experience of caring for children with MUS completed an attitude questionnaire developed for the study.
Results:  Factor analysis identified four factors that explained significant variance in staff perceptions of care: rewarding nature of care; demanding nature of care; parental influence; children's need for skilled support. The combined subscales formed the MUS-Q.
Conclusion:  Paediatric staff found caring for children with MUS difficult and would welcome more support from CAMHS. The MUS-Q proved a reliable tool to evaluate staff attitudes.     

Women with intellectual disability at risk of adverse pregnancy and birth outcomes

Background   An increasing number of women with intellectual disability (ID) have children. Cross-sectional, clinical population data suggest that these women face an increased risk of delivering preterm and/or low birthweight babies. The aim of this study was to explore the prevalence of poor pregnancy and birth outcomes in women with ID and/or self-reported learning difficulties in an antenatal population.
Methods   A total of 878 pregnant women attending their first antenatal clinic visit were 'screened' for ID. Pregnancy and birth outcomes data were extracted from medical records post-partum. These data included pregnancy-related health conditions, including pre-eclampsia and gestational diabetes, and birth outcomes, including gestational age, birthweight, Apgar score and admission to neonatal intensive care and/or special care nursery.
Results   A total of 57 (6.5%) pregnant women with ID and/or self-reported learning difficulties were identified. These women experienced an unusually high rate of pre-eclampsia (odds ratio = 2.85). Their children more often had low birthweights (odds ratio = 3.08), and they were more frequently admitted to neonatal intensive care or special care nursery (odds ratio = 2.51).
Conclusion   Further research is needed to understand the reasons for the adverse findings of this study and identify potentially changeable factors contributing to adverse pregnancy and birth outcomes for women with ID and/or self-reported learning difficulties and their children. To ensure quality antenatal care, health professionals may need to consider innovations such as extended consultation times, communication aids and audio-taping consultations.     

ADHD ‐ Do Guidelines Translate Into Service?

Background:  ADHD is a condition with wide ranging implications for children diagnosed with it, health professionals and the agencies setting benchmarks for good practice.
Aim:  We set out to measure the adherence of our service to guidelines and to identify service needs.
Method:  An audit of cases referred and diagnosed with ADHD during 2004–2005.
Results:  The service scored well in areas of assessment and management with stimulants. Potential areas to be addressed included age of referral, differences in referrals across ethnic groups, providing psychosocial interventions coupled with medication and shared care.
Conclusion:  It is possible to provide a service that adheres as closely as possible to the guidelines.     

The role of ethnicity in clinical psychopathology and care pathways of adults with intellectual disabilities

The objective of this study was to explore whether people with intellectual disability from ethnic minority groups have higher rates of mental health problems and access different care pathways than their White counterparts. Clinical and socio-demographic data were collected for 806 consecutive new referrals to a specialist mental health service for people with intellectual disabilities in South London. Referrals were grouped according to their ethnic origin. The analyses showed that there was an over-representation of referrals from ethnic minority groups with diagnoses of schizophrenia spectrum disorder. In addition, Black participants were more likely to have an autistic spectrum disorder. Referrals of ethnic minority groups were considerably younger than White referrals, and less likely to be in supported residences. The results are discussed in the context of cultural and familial factors in particular ethnic groups that may play an important role in accessing and using mental health services.     

Improving Attendance at Child and Adolescent Mental Health Services for Families from Socially Disadvantaged Communities: Evaluation of a Pre-Intake Engagement Intervention in the UK

Non-attendance of families is a common problem in child and adolescent mental health services (CAMHS). We report on the development and pilot evaluation of a pre-intake intervention designed to enhance initial engagement at inner-city CAMHS in London, UK. Families receiving the intervention (N = 107) were significantly less likely to miss first appointments compared with contemporaneous (N = 62) or historical (N = 163) control groups. The intervention had similar effects for white and minority ethnic families, and for those from the most and least deprived parts of the locality. Recommendations are made for routine provision of empirically-supported engagement strategies, informed by consultations with service users and providers.     

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.     

Paediatric Liaison Work by Child and Adolescent Mental Health Services

Background:  Although psychiatric morbidity is common amongst paediatric patients, little is known about the availability of CAMH paediatric liaison services.
Method:  We surveyed all Trusts with specialist CAMH services and paediatric units in Greater London, enquiring about the nature of liaison that CAMHS provide.
Results:  We found that although liaison paediatric work was common, dedicated paediatric liaison services were provided by only a minority of specialist multidisciplinary CAMHS. Their work involved most aspects of child psychopathology, and included emergencies and children with joint physical and psychiatric problems. About 2/3 of paediatricians were satisfied with CAMHS liaison services, but virtually all desired to see them developed further. There were few indications of co-ordination between specialist multidisciplinary CAMHS and other paediatric psychosocial support services.