Highlights in child mental health research: October 2019

• Alternative models of mental health care refer to services that are community-based, less restrictive and do not involve time as an inpatient in hospital (p. 1). These include multisystemic therapy, case management, home treatment, family preservation and crisis intervention.
• Very little is known about the experiences of children, young people and their parents with alternative models of mental health care and their satisfaction with the care provided. This systematic review, led by researchers in the UK, aimed to explore this research gap.
• The systematic review synthesised 19 studies on the experiences and satisfaction with alternative models of mental health care for children and young people and their parents. The studies came from UK (n=8), US (n=5), Australia (n=3), Canada (n=2) and Denmark (n=1).

Key findings

• Findings suggested that “synthesized models may be suitable alternatives to inpatient settings” (p. 7). Two multi-disciplinary community-based models were identified as a promising alternative to inpatient care. A recovery-oriented model and support discharge service were also identified as effective models and preferred by children, young people and their parents.
• Stigma and fear of opening up were barriers experienced by children and young people to their engagement with mental health crisis services and improved mental health outcomes.
• Parents and carers reported eight barriers to accessing alternative services:
  • “Lack of communication from providers
  • Inadequate support from crisis services
  • Fear of confidentiality breaches
  • Lack of involvement with care planning
  • Concerns over the inconsistency of crisis services establishing whether their children are in crisis or not
  • Perception of not being listened to
  • Concerns that their parental experiences and observations are not taken into account
  • Reluctance to become involved with help-seeking” (p.7)
• The research suggests that intervention initiatives should focus on community-based models. Community-based models were effective at improving mental health outcomes and preferred by children, young people and their families.
• The authors note that there is a lack of clarity in practice and research about what constitutes a mental health crisis for children and young people, and how best to detect and treat such a crisis.
• The authors note that their review was limited to English language studies, which missed relevant articles published in other European languages (German, Swedish), and that the included qualitative studies were based on small samples with mothers and their children. Further research is needed to address these issues, including the experiences of fathers.
• Vusio and colleagues (2019) also highlight the need for research to establish the criteria for when children and young people are experiencing mental health crisis, and appropriate interventions and treatment for them during crisis.

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Highlights:

• There is strong evidence that early intervention provided in university-based clinical specialist settings can improve cognitive, communication, social skills and adaptive behaviour for children with autism spectrum disorder (ASD)(p. 1200).
• Very little is known about how effective early intervention is when it is delivered in community-based settings. This meta-analysis aimed to explore this research gap.
• Community-based settings were defined as an intervention in the community associated with a university or hospital or treatment received from a local school.
• The meta-analysis synthesised 33 quantitative studies involving 1713 participants on community-based early intervention and examined the combined impact on cognitive, communication, social skills and adaptive behaviour outcomes for children with ASD.

Key findings:

• The research found that there were only small gains in cognitive, communication, social skills and adaptive behaviour outcomes for children with ASD receiving early intervention in a community setting, compared to peers who received no treatment.
• The gains made on key outcomes were substantially smaller than when early intervention is provided in university-based clinical specialist settings, reported in previous research (p. 1206). The authors interpret is to suggest that there is a large gap between research and practice.
• The authors note that the most effective community-based early intervention models for children with ASD had been developed in collaboration with universities and hospitals.
• The authors note that their meta-analysis was limited to studies that reported the findings using standardised scores, which may have missed relevant articles that employed other measures. Further research is needed to address this issue.
• Nahmias and colleagues (2019) highlight the need to provide community providers with high-quality training and supervision. The authors also propose strengthening partnerships between community providers and university stakeholders in the area.

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Highlights:

• A wealth of research has shown than experiences of racial discrimination (racism) has negative impacts on population health. Research also suggests that there may be a critical period in child development during which time experiences of adversity may have lasting effects on health and well-being (p.1).
• Aboriginal and Torres Strait Islander (ATSI) children are known to experience disproportionate levels of racism, and have been shown to be aware of such racism when they are as young as 8 years old.
• No previous research has investigated whether exposure to racism from a younger age increases the risk of negative physical and mental health outcomes for ATSI children. This study aimed to explore this research gap.
• Quantitative data analysis was conducted on a national longitudinal cohort survey of 1255 children to examine whether ATSI children exposed to racial discrimination at an early age (4-5 years) had poorer physical and mental health outcomes compared to peers exposed to racism during middle childhood (7 years).

Findings

• Almost 7% of ATSI children aged 4-5 years had experienced racial discrimination and 3% of ATSI children aged 7 years.
  
• ATSI children exposed to racism at an early age (4-5 years) had a significantly higher risk of poor mental health outcomes (but not physical health outcomes) than their peers exposed to racism during middle childhood (7 years).
  ATSI children exposed to racism at an early age or during middle childhood had an increased risk of having poorer mental health outcomes and being underweight or obese, compared to peers who had no exposure to racism.
• The authors suggest a potential protective factor for young ATSI children is that they may not be as aware of racism until they reach 8-10 years old.
  
• On the other hand, children exposed to racism later (at 7 years) had an increased risk of having behavioural issues at school than those exposed earlier (4-5 years).
• The authors suggest that there may be different mechanisms that influence the impact of racism on mental health outcomes than the impact of racism on behaviour.
• The authors underscore the need to address complex interactions between racism, mental health outcomes and “neurological, environmental and genetic factors” (p. 5).
• The authors note that their longitudinal study was limited in the use of parent reports of exposure to racism, which may not reflect the children’s perceptions and experiences of racism. The authors also note that the sample was not nationally-representative. Further research is needed to address these issues.
• Cave and colleagues (2019) highlight the need to integrate the impacts of racism into programs that aim to support early child development and social and emotional well-being of ATSI children and their families.

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Highlights:

• International studies have identified a treatment gap for child mental health, such that many children with mental health problems do not have access to high-quality mental health care (p.1).
• Many studies have reported different interventions aimed at reducing the treatment gap for access to specific types of child mental health disorders.
• No review had examined the overall effectiveness of interventions for increasing access to treatment for children with all types of mental health needs along the care pathway. This systematic review and meta-analysis aimed to explore this research gap.
• The study included 34 randomised controlled trial (RCT) interventions for children and adolescents (aged less than 19 years). Interventions were: (a) universal school-based interventions aimed at improving access for all children (n=13); or (b) targeted to engage children who were identified as high-risk and took place in health care settings (n=21).

Findings

• There was strong evidence that targeted interventions for at-risk individuals in contact with health services increased their access to mental health care and satisfaction.
• The evidence was mixed for school-based interventions improving access to mental health care. The strongest evidence was that school-based interventions improved knowledge and attitudes for participating students compared to controls, but did not improve access to care or health outcomes.
• Telephone or letter appointment reminders and interventions to engage and motivate patients or improve service provider communication skills significantly improved access to mental health care for at-risk individuals compared to controls.
• The authors note that their review was limited to English language studies, and did not examine retention in treatment. Further research is needed to address these issues, including whether children remain in treatment once they have overcome barriers to access.
• Werlen and colleagues (2019) highlight the need for practice to focus on improving access to mental health care for children who are not already identified as high-risk (i.e. from the general population). The authors suggest that interventions are needed that identity children from the general population and then engage them with health services.
• The authors also suggest that interventions that target multiple barriers to access simultaneously may be more likely to improve children’s access to mental health care.

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