Feeding and exercising young minds.

Leaving child and adolescent mental health services in the MILESTONE cohort: a longitudinal cohort study on young people's mental health indicators, care pathways, and outcomes in Europe

AimsMental health issues in children and young people are a growing concern and the benefits of intervening early are well established for many mental health problems, but existing Child and Adolescent Mental Health Services (CAMHS) are often over-stretched with variable waiting times for assessment. Many children also have problems which do not reach the referral thresholds and parents are left to find advice elsewhere. Existing resources for parents are scattered across many different websites and therefore difficult to access both for parents and professionals working with young people. With this in mind, and in consultation with CAMHS Bristol and many other stake-holders (including parents themselves) we designed an easily navigable website intended as a single comprehensive portal of resources for parents of children with mental illness and difficulties.MethodQualitative research methods were used to gather information about how the website should be designed and also to gather feedback once the website was live. Focus groups were performed with parents/carers and stakeholder discussions took place to inform the design of the website. Once the website was live, surveys via a Survey Monkey link on the website and Google Analytics were used to evaluate the website.Result60,000 users have utilised the website since the launch in March 2019. Two thirds of users are women and one third are men. Most popular webpages that are visited are primary, secondary, help-in -a-crisis and self-help for young people. Positive feedback has been collected from both parents/carers and service providers. The website has continued to develop and is now a registered charity and has received community lottery funding, which will allow for further evaluation and developments.ConclusionHappyMaps has been successful in providing a single hub of information for parents/carers, GPs, CAMHS workers and teachers. Future work involves evaluating the website and attracting interest from other CAMHS teams and professionals in other areas of the UK so that they can create HappyMaps sections for their populations.

BackgroundIn the UK young people attending child and adolescent mental health services (CAMHS) are required to move on, either through discharge or referral to an adult service, at age 17/18, a period of increased risk for onset of mental health problems and other complex psychosocial and physical changes. CAMHS transitions are often poorly managed with negative outcomes for young people. Better preparation may improve outcomes and experience. This study aimed to co-produce, with young people who had transitioned or were facing transition from CAMHS, a CAMHS Transition Preparation Programme (TPP), deliverable in routine NHS settings.MethodsEighteen young people, aged 17–22, from three UK National Health Service (NHS) mental health foundation trusts participated in creative, participatory research workshops. Seven parents completed short questionnaires. Thirty clinical staff from two trusts took part in workshops to ensure deliverability of young people’s ideas. Young people were offered co-research opportunities.ResultsMost young people felt anxious, fearful and uncertain on leaving CAMHS and perceived mental health services as uncaring. Participants outlined transition procedures and drafted a range of preparation activities, centred around dedicated Transition Peer Support and a transition booklet, which should be offered to all CAMHS leavers, irrespective of discharge or transfer to an adult service. Preparation should aim to build confidence to help young people take responsibility for themselves and flourish in the adult world: coping or getting through it was not enough. Some clinicians also felt anxious at transition and recognised the potential impact on young people of poor communication and lack of understanding between services. Parents would appreciate help to support their offspring during the transition period. Clinicians cited lack of funding and inflexible NHS procedures and policies as potential barriers to the implementation of young people’s ideas. Nine young people took up co-research opportunities.ConclusionsMental health services underestimate the anxiety of CAMHS leavers. Young people have clear ideas about the preparation they require to leave CAMHS with the confidence to take responsibility for their own health care. Close collaboration of NHS staff and researchers facilitates the implementation of research findings.

Mental Health Care Reforms in Latin America: Child and Adolescent Mental Health Services in Mexico

uring the last 10 years or so, there has been a remarkable rise of interest in children’s mental health. This is good news – and we shouldn’t be too shy to celebrate, nor too afraid to dwell on a worry or two lest, in ignoring them, we find the rise begin to fall. Broadly speaking, up until the early 1990s child mental health was pretty much hidden within the preserve of the specialist professional groups. This is not to say that little was going on. A great deal about children was being learned and practised. From Freud onwards, major advances in psychoanalysis, developmental psychology, behavioural and cognitive therapy and family and group therapy were bringing to life our understanding of the minds of children. Of course, much more needed to be known (and still does) but there was undoubtedly an exhilarating sense of inquiry into the nature of children’s mental health problems and family dynamics and into how interventions could be improved to bring about change in people’s troubled lives. What was lacking, however, was any real concerted desire to make these developments known to the wider public. Children’s mental health was simply not a political issue. The fact that it lay at the heart of so many of the prevailing social problems such as crime, drug misuse, teenage pregnancy and homelessness simply didn’t seem to ring a bell. At the time poverty, child welfare and child protection were the key political preoccupations but the concept of child mental health didn’t hit the headlines. If anything, the term carried with it something pejorative – as if it was stigmatising to associate the words ‘child’ and ‘mental health’. What was clearly needed was an effort to make more of a hue and cry about what was known and what was being done – a promotional campaign that would help to make the public more aware. YoungMinds, which I and others formed in the late 1980s, played a major role in taking forward this campaign. Most of us came from within the child guidance movement which in the mid-twentieth century was very involved in D developing multi-disciplinary working. In addition to YoungMinds various similar movements were afoot in the USA and some European countries, and in the UK certain key people proved critical in taking forward the agenda. Virginia Bottomley, for example, secretary of state for health from 1992 to 1995, was a former psychiatric social worker in child guidance clinics in London. Other leading figures at this time were Dr Richard Williams, a consultant child psychiatrist and director of the NHS Health Advisory Service, Dr Bob Jezzard, also a child psychiatrist, employed as a senior adviser in the Department of Health, and Dr Zarrina Kurtz, a public health consultant who had a particular interest in child development and children’s mental health problems. I myself was a child psychotherapist working in child guidance and residential treatment. Together, with one or two others, we joined up almost as if by accident. In effect, we shined as a kind of virtual multi-disciplinary team! We all set about in our own ways to build up and tell the story of the states that children’s minds could get into, of the prevalence of their mental health problems and of the predicament of those who tried to serve them. Most importantly, we brought to much greater light the invaluable findings of Professor Michael Rutter’s and Professor Philip Graham’s epidemiological research in the 1970s. It was, of course, not by chance that the first seminal review of child and adolescent mental health services produced by the Health Advisory Service (1995) was entitled Together We Stand. Let us take just a brief review of what is currently going on. First and foremost, the government now openly acknowledges the existence of child and adolescent mental health services (CAMHS) and is committed to investing considerable sums of money in them and also to introducing an infrastructure designed to support a more systematic and forwardmoving programme. All of this is quite unprecedented and I think it is true to say that the national child and adolescent mental health service is not the Cinderella service it once was some 12 or so years ago. It may not yet be in the prince’s arms, and the ugly sisters are still around, but at least it’s in the court!

Approximately one in five children and adolescents (CA) suffer from mental disorders. This paper reports on the findings of a situational analysis of CA mental health policy and services in Ghana, Uganda, South Africa and Zambia. The findings are part of a 5 year study, the Mental Health and Poverty Project, which aims to provide new knowledge regarding multi-sectoral approaches to breaking the cycle of poverty and mental ill-health in Africa. The World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) Version 2.2 was used to collect quantitative information on mental health resources. Mental health policies and legislation were analysed using the WHO Policy and Plan, and Legislation Checklists. Qualitative data were collected through focus groups and interviews. Child and adolescent mental health (CAMH) - related legislation, policies, services, programmes and human resources are scarce. Stigma and low priority given to mental health contribute to low investment in CAMH. Lack of attention to the impoverishing impact of mental disorders on CA and their families contribute to the burden. Scaling up child and adolescent mental health services (CAMHS) needs to include anti-stigma initiatives, and a greater investment in CAMH. Clear policy directions, priorities and targets should be set in country-level CAMH policies and plans. CAMHS should be intersectoral and include consideration of the poverty- mental health link. The roles of available mental health specialists should be expanded to include training and support of practitioners in all sectors. Interventions at community level are needed to engage youth, parents and local organizations to promote CAMH.

Background: A growing body of research is emerging examining the associations between sedentary behaviour and mental health in young people. The magnitude of the impact sedentary behaviour has on the mental health of young people has not been examined, though this has been investigated for physical health conditions. The aim of this article is to examine the associations between sedentary behaviour and mental health in young people aged 5-18 years of age using meta-analysis. Methods: Published studies in the English language were located via manual and computerised searches of PubMed, Science Direct, SPORTDiscus, PsychINFO, Medline, Web of Science, Cochrane Library, and Google Scholar databases. Included were observational studies assessing an association between at least one sedentary behaviour and at least one aspect of mental health in young people aged 5-18 years. Effect sizes (ESs) were calculated for each study and an overall effect size was computed. Average effect sizes were also calculated for moderator variables. Results: Thirty-five studies were included (n=373,512); most studies examined screen-time as sedentary behaviour and five mental health outcomes were identified (depression, anxiety, self-esteem, psychological distress, and quality of life). The summary effect was small and significant (ES = -0.30, 95% confidence intervals = -0.20, -0.45, p<0.001), suggesting that sedentary behaviour is negatively associated with mental health in young people. Moderator analysis showed that television viewing had the largest effect size (ES = -0.47, 95% confidence intervals = -0.35, -0.62, p<0.001). Moreover, depression seems to be the main mental health outcome affected by sedentary behaviour (ES = 0.55, 95% confidence intervals = 0.42, 0.68, p<0.001). Conclusions: There was a small but a significant negative association between sedentary behaviour and mental health. High levels of sedentary behaviour are associated with increased depressive symptoms. This finding is consistent with a systematic review on adults which indicated that sedentary behaviour is significantly associated with mental health problems.

Current strategies to predict psychosis identify only a small proportion of individuals at risk. Additional strategies are needed to increase capacity forpre-diction and prevention of serious mental illness, ideally during childhood and adolescence. One possible approach would be to investigate systems in which psychosis risk factors are concentrated during childhood. One notable such system is represented by Child and Adolescent Mental Health Services (CAMHS). Although psychotic disorders are uncommon in CAMHS, many risk factors for psychosis are highly prevalent in young people who enter this system. We hypothesized, therefore, that youth attending CAMHS would be a high-risk group for psychosis if followed into adulthood and, furthermore, that CAMHS systems would capture a substantial proportion of future psychosis cases. We constructed a total population cohort study of all Finns born in 1987 (N=55,875), linking together extensive register data on health care contacts from birth through age 28years. We identified all individuals diagnosed with a psychotic or bipolar disorder by age 28 (N=1,785). The risk of psychosis/bipolar disorder by age 28years was 1.8% for individuals who had not attended CAMHS during childhood or adolescence, whereas it was 12.8% for those with a history of any outpatient CAMHS contact (odds ratio, OR=7.9, 95% CI: 7.2-8.7). Furthermore, the risk of psychosis/bipolar disorder by age 28years was 2.3% for individuals without a history of inpatient CAMHS admission, whereas it was 24.0% for those with a history of inpatient CAMHS admission (OR=13.3, 95% CI: 11.9-14.9), and 36.5% for those with a history of inpatient CAMHS admission in adolescence (age 13-17years) (OR=24.2, 95% CI: 21.2-27.6). Individuals who attended CAMHS but received no mental disorder diagnosis had an equally high risk of subsequently developing a psychosis/bipolar disorder as individuals who did receive a diagnosis (OR=0.9, 99.5% CI: 0.7-1.1). Compared to other CAMHS attendees, individuals who developed psychosis or bipolar disorder were more likely to have had an initial CAMHS diagnosis of depressive or other mood disorder (OR=2.3, 99.5% CI: 1.6-3.0) and disruptive behaviour disorder (OR=1.7, 99.5% CI: 1.2-2.5). Of all psychosis/bipolar diagnoses by age 28years, 50.2% occurred in individuals who had, at some point in childhood or adolescence, attended CAMHS, indicating that CAMHS represent not only a high-risk but also a high-capacity system for prediction of psychosis/bipolar disorder. These findings suggest an enormous, untapped potential for large-scale psychosis/bipolar disorder prediction and prevention research within existing specialist CAMHS.

Lower-income, less developed countries have few child and adolescent mental health professionals and a low availability of paediatric community mental health care. Child mental health professionals in low- and middle-income countries (LMICs) must therefore balance comprehensive tertiary care for the minority and provision of child and adolescent mental health services (CAMHS) within primary health care to serve the majority. This review aimed to identify the obstacles to, and opportunities for, providing CAMHS in LMICs. Articles from PsychInfo and PubMed, published up to November 2011, were retrieved using the search terms "child and adolescent", "mental health services", "child psychiatry", "low- and middle-income countries", "low-income countries" and "developing countries". Articles were then retrieved from PubMed alone, using these search terms plus the individual country names of 154 LMICs. Fifty-four articles were retrieved from PsychInfo and 632 from PubMed. Searching PubMed with 154 LMIC names retrieved seven related articles. Inclusion criteria were (i) articles relating to CAMHS or child psychiatric services; (ii) subjects included in the articles were inhabitants of LMICs or developing countries; (iii) articles reported in English. After removal of duplicates, 22 articles remained. The contents of these articles were categorized and analysed by use of the six domains of the World Health Organization assessment instrument for mental health systems (WHO-AIMS), a tool developed to collect information on available resources within mental health systems. The provision of CAMHS in LMICs clearly needs a specific strategy to maximize the potential of limited resources. Mental health-policy and awareness campaigns are powerful measures to drive CAMHS. Training in CAMH for primary health-care professionals, and integration of CAMHS into existing primary health-care services, is essential in resource-constrained settings. A wide gap in research into CAMHS still needs to be filled. To overcome these challenges, the child mental health professional's role in LMICs must encompass both clinical and public-health-related activities.

anarkshire Child and Adolescent Mental Health Service (CAMHS) is a multidisciplinary community-based service in the central belt of Scotland for the children, young people and their families who live within the health board boundaries, a total population of 560,000. The CAMH service is delivered by four community-based teams each serving a defined geographical district. The current CAMH service has a staff complement of 29.6 WTE and a budget of £1,370,000, which represents 3.2% of the overall mental health budget. Child and adolescent mental health clinicians currently make up 15 WTE of the CAMHS staff group. This article describes how the service has continued to develop in spite of the significant national shortages of specialist child mental health professionals in all disciplines. It particularly focuses on the emergence of this new generic professional group whose professional backgrounds include specialist nursing, occupational therapy and social work. The child and adolescent mental health clinician structure offers: ■ an integrated career pathway for CAMHS professionals ■ retention as clinicians with increasing seniority, rather than a progression within a professional discipline which can only offer managerial positions ■ a framework of uniform pay, terms and L conditions which values and rewards the disparate professional training, qualifications and experience of senior clinicians ■ continuing professional development to consolidate changing specialist roles in order to meet more complex service demands.

Background Communication is a key component in successful talking therapies. Furthermore, the association between Speech, Language and Communication Needs (SLCN) and mental-health problems is well-established and we might expect this group to have increased difficulties accessing services. Despite this, research into potential communication barriers within Child and Adolescent Mental Health Services (CAMHS) is lacking, both generally and for SLCN children specifically. Aim This study explored the views of caregivers of children with and without SLCN to identify perceived barriers to accessing CAMHS. Key factors were considered: caregivers’ understanding of the language used by CAMHS; communication strategies used by professionals; and caregiver views of children’s mental health outcomes after accessing CAMHS. Methods An online caregiver survey was used to collect views. The survey was completed by 61 caregivers of children who had been referred to CAMHS, for reasons other than communication, 32 of whom cared for a child with SLCN. Results Caregivers generally understood the language used with them by CAMHS, although a minority reported difficulties. They were less positive about communication adjustments, discharge processes, and outcomes after accessing CAMHS. Caregivers of children with SLCN were more likely to report that their child’s mental health was poorer after CAMHS. No other differences were found between the SLCN/non-SLCN groups with communication presenting some barriers across both. Conclusions All children accessing CAMHS would benefit from increased communication adjustments in order to achieve the most effective intervention.

Providing the growing number of children and young people seeking mental health support with timely access to care poses a significant challenge. Increased use of digital technology in the delivery of children and young people's mental health services has been proposed as a means of increasing access to treatment. We conducted three interrelated studies to provide multi-perspective insights into the use of digital therapeutic interventions within children and young people's mental health services in the UK. Study 1 used semi-structured interviews and an online survey to collect the views of digital therapeutic interventions of families who self-identified as facing additional barriers to accessing mental health support (n=13). Study 2 involved eight focus groups with children and young people's clinicians, service managers, commissioners, and policy leads (n=28), exploring participants' views and experiences of implementing and sustaining digital therapeutic interventions. Study 3 was a consensus exercise which aimed to identify actions needed to bridge the gap between the development and use of digital therapeutic interventions for children and young people's mental health through focus groups with parents/carers and professionals (n=17), and three Delphi-survey rounds. Our findings revealed considerable enthusiasm for the increased use of digital mental health interventions for children and young people across stakeholder groups, but also identified key barriers to their implementation. Actions perceived to facilitate more effective implementation included: a) co-producing interventions, commissioning decisions and implementation plans with children and parents/carers, b) enhancing national guidance and local leadership, c) integration of digital offers within existing clinical pathways, and d) efforts to ensure accessibility and inclusivity. Digital therapeutic interventions offer a promising solution to the challenge of improving access to mental health support for children and young people. Strengthened guidance and leadership, sustained funding and further evidence-generation are urgently needed to enable this promise to be realised.

There is emerging evidence that sea swimming can have a positive impact on the mental health of adults. Less is known about how this intervention can impact young people's mental health. The aim of this study was to explore young service users and staff's perspectives on sea swimming in the child and adolescent mental health services. Fourteen participants were interviewed (eight young people and six staff members). Data were analysed using reflexive thematic analysis and five themes were identified. A preference for sea swimming was demonstrated by young people in comparison to other therapies. Young people reported an enhanced (and sustained) sense of well-being after sea swimming. They were able to relate the act of entering cold water to their recovery journey, acknowledging the importance of leaving their comfort zone. A sense of social cohesion was also described. Staff members acknowledged the risks of open sea swimming but highlighted the importance of positive risk taking, given the benefits of this novel intervention. Owing to the positive impact sea swimming can have on the physical and psychological health of young people, there is potential for this novel intervention to be used more frequently within the services.

IntroductionWorldwide, one in five children and adolescents suffer from mental health disorders, while facing limited opportunities for treatment and recovery. Growing up, they face multiple challenges that might contribute to the development of mental disorders. Uganda is a developing country with a history of prolonged civil and regional wars associated with child soldiers, large numbers of refugees and internally displaced people due to natural disasters and unrests, and a large infectious disease burden mainly due to acute respiratory tract infections, malaria and HIV/AIDS.ObjectiveThis paper aims to examine the current status of child and adolescent mental health services in Uganda.MethodologyA scoping review approach was used to select studies on child and adolescent mental health services (CAMHS) in Uganda. A search of MEDLINE, Wiley and PubMed databases was conducted using eligibility criteria. The papers were summarized in tables and then synthesized using the Frameworks for monitoring health systems performance designed by the World Health Organisation (WHO). This was done according to the Preferred Reporting Items for Systematic Review and M-Analyses Extension for Scoping Review (PRISMA-ScR) guidelines.ResultsTwelve studies were identified; five of them used qualitative methods and focused mostly on the current limitations and strengths of CAMHS in Uganda, while six quantitative studies investigated the effects of new interventions. One study used a mixed-methods approach. In summary, the papers outlined a need for collaboration with the primary health sector and traditional healers to ensure additional human resources, as well as the need to focus on groups such as orphans, HIV/AIDS-affected youth, former child soldiers and refugees. ConclusionRelatively few studies have been conducted on CAMHS in Uganda, and most of those that exist are part of larger studies involving multiple countries. CAMHS in Uganda require improvement and needs to focus especially on vulnerable groups such as orphans, HIV/AIDS-affected youth and former child soldiers.

BackgroundFew cost-utility studies of child and adolescent mental health services (CAMHS) use quality adjusted life years (a combination of utility weights and time in health state) as the outcome to enable comparison across disparate programs and modalities. Part of the solution to this problem involves embedding preference-based health-related quality of life (PBHRQOL) utility instruments, which generate utility weights, in clinical practice and research. The Child Health Utility (CHU9D) is a generic PBHRQOL instrument developed specifically for use in young people. The purpose of this study was to assess the suitability of the CHU9D as a routine outcome measure in CAMHS clinical practice.MethodsTwo hundred caregivers of children receiving community mental health services completed the CHU9D alongside a standardised child and adolescent mental health measure (the Strengths and Difficulties Questionnaire – SDQ) during a telephone interview. We investigated face validity, practicality, internal consistency, and convergent validity of the CHU9D. In addition, we compared the utility weights obtained in this group with utility weights from other studies of child and adolescent mental health populations.ResultsParticipants found the CHU9D easy and quick to complete. It demonstrated acceptable internal consistency, and correlated moderately with the SDQ. It was able to discriminate between children in the abnormal range and those in the non-clinical/borderline range as measured by the SDQ. Three CHU9D items without corollaries in the SDQ (sleep, schoolwork, daily routine) were found to be significant predictors of the SDQ total score and may be useful clinical metrics. The mean utility weight of this sample was comparable with clinical subsamples from other CHU9D studies, but was significantly higher than mean utility weights noted in other child and adolescent mental health samples.ConclusionsInitial validation suggests further investigation of the CHU9D as a routine outcome measure in CAMHS is warranted. Further investigation should explore test-retest reliability, sensitivity to change, concordance between caregiver and child-completed forms, and the calibration of the utility weights. Differences between utility weights generated by the CHU9D and other utility instruments in this population should be further examined by administering a range of PBHRQOL instruments concurrently in a mental health group.