Understanding ethnic differences in mental health service use for adolescents' internalizing problems: the role of emotional problem identification

"I had no idea there were psychiatric clinics for children": A qualitative study of how migrant parents reach Swedish mental health services for their children

Migrant children have repeatedly been shown to underutilize psychiatric services and to face barriers to care, yet few studies have examined the experience of migrant parents who are successful in their help-seeking efforts for their children's mental health. The aim of this study was to gain a deeper understanding of facilitators and obstacles to reaching care among migrant parents in contact with child psychiatric services. We explored how migrant parents in Stockholm, Sweden, experienced the process of reaching child mental health services. Participants were recruited from out-patient mental health clinics. Ten in-depth interviews were conducted; qualitative analysis of transcripts was undertaken using thematic content analysis. Parents described a desire to reach services but difficulties doing so on their own. We identified a strong dependence on referring agents, such as schools and child health centers, for parents to gain contact. Informants expressed a high degree of trust toward these agents. Contrary to previous studies, stigma was not described as an obstacle to help-seeking but was recognized by informants as a potential barrier to care had they not emigrated. Although participants in our study had differing educational backgrounds and residency times in Sweden, a common experience of reliance on others for reaching services was evident in the data. Our findings highlight the role of referring agents as bridging contacts between different welfare services. Understanding the specific local resources and services that are available to migrant parents, and strengthening these across different sectors, could potentially help reduce barriers to care.

Differences in Anxiety and Depression Among Migrant and Non-Migrant Primary School Children in The Netherlands

This is the first Dutch study investigating symptoms of five DSM-IV-classified anxiety disorders and depression in a large sample of pre-adolescent children with and without a migration background, adjusting for socioeconomic position (SEP) and social preference. Both are potential explanatory factors for differences in mental health among migrant children. We measured anxiety and depression scores with the self-report Revised Child Anxiety and Depression Scale (RCADS) in 2063 children (aged 8-13 years, 55% girls) in the Netherlands. Surinamese/Antillean, Turkish, and Moroccan children reported significantly higher anxiety scores than Dutch children. SEP and peer rejection partly explained higher anxiety scores. Surinamese/Antillean and Turkish children reported comparable depression scores to Dutch children, but Moroccan children reported lower depression scores after adjusting for SEP and peer rejection. Girls reported higher anxiety and depression levels across all four subgroups. Although differences between children with or without a migration background were small, these may increase in later life as the prevalence of anxiety and depression increases with age.

The effectiveness of an attention-based intervention for school-aged autistic children with anger regulating problems: A randomized controlled trial

Anger regulation is a challenge for children with autism spectrum disorders (ASD). We investigated if attention-based cognitive behavioral treatment, based on mindfulness cognitive therapy (MBCT) and dialectical behavior therapy (DBT), reduces aggressive behavior and improves anger coping in school-aged autistic children (n = 51). Children were randomized to an active-control or a treatment condition. The treatment included nine weekly sessions attention-based individual therapy. Parents in both conditions received three weekly psychoeducation group sessions to heighten awareness of expressed emotion (EE). For aggressive behavior, treatment reduced temper tantrums and arguing. No effect was found on destroying things and physical violence. For anger coping, treatment increased adaptive coping strategies of diffusion and social support seeking, but had no effect on assertion, rumination, and maladaptive coping direct anger out and avoidance. Treatment did not impact secondary outcome measures concerning children's quality of life (QoL) and parental stress-levels and psychological well-being. In conclusion, school-aged autistic children are able to acquire self-regulation skills reducing temper tantrums and arguing and increasing the use of adaptive anger coping strategies. The intervention shows potential to improve behavior and regulation, but little transfer to other domains. Limitations and future directions involving the child's social environment, including parents, siblings, and teachers are discussed. LAY SUMMARY: Children on the autism spectrum often show aggressive behavior. Treatment can train children to be more aware of their emotions. This study found that this can help reducing temper tantrums and arguing and increasing some coping skills, though no impact was found on several other domains of aggression and coping.

Changes in youth care use after the implementation of community-based support teams: repeated measurement study using registry data and data on team characteristics

OBJECTIVES

New legislation on youth care in the Netherlands led to the implementation of community-based support teams, providing integrated primary youth care. Important aims of the new Youth Act were more integrated, timely care and less use of intensive forms of care. Our aim was to study changes in youth care use in time and the role of newly introduced community-based support teams herein.

SETTING

Register data (2015-2018) on youth of a large city were linked and combined with administrative and aggregated data on team characteristics.

PARTICIPANTS

Data on 126 095 youth (0-18 years) were available for analyses.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary, specialised and residential youth care use were the primary outcomes.

RESULTS

Generalised estimating equations analyses adjusted for individual characteristics demonstrated that over 4 years, use of primary youth care increased from 2.2% to 8.5% (OR 1.70; 99% CI 1.67 to 1.73), specialised youth care decreased from 7.2% to 6.4% (OR 0.98; 99% CI 0.97 to 1.00) and residential youth care increased slightly (OR 1.04; 99% CI 1.01 to 1.06). Gender, age, family status, migrant background and educational level were all associated with the types of youth care use and also with some trends in time. Likelihood to receive care increased in time for preschool and younger children but did not improve for migrant children.Case load, team size, team turnover, team performance and transformational leadership showed significant associations with different types of youth care use but hardly with trends in time.

CONCLUSION

Patterns of youth care use changed towards more locally provided primary youth care, slightly less specialised and slightly more residential youth care. Furthermore, youth care use among younger children increased in time. These trends are partly in line with the trends intended by the Youth Act. Little evidence was found for the role of specific team characteristics on changes in youth care use in time.

Correlates of help-seeking by parents for the socioemotional development of their 3-year-old children: a longitudinal study

OBJECTIVES

Timely parental help-seeking regarding their child's socioemotional development is associated with a lower rate and lower severity of psychosocial problems in later life. This study aimed to examine the correlates of parental help-seeking for the socio-emotional development of 3-year-old children.

DESIGN

Retrospective cohort study.

SETTING

Community-based survey in Rotterdam.

PARTICIPANTS

Of 2305 parents and their 2-year-old children at baseline, 1507 who completed follow-up questionnaires were included in the analyses when children were 3 years old.

OUTCOME MEASURES

Parental help-seeking regarding their child's socioemotional development and types of formal and informal help sources (eg, general practitioner, internet) used in the past 12 months were measured. Hierarchical logistic regression models were applied to identify factors correlates of parental help-seeking among 13 predisposing, enabling and need factors according to Andersen's behavioural model.

RESULTS

In total, 22.6% of parents reported help-seeking in the past 12 months for socioemotional development of their 3-year-old child; 6.8% addressed formal help sources and 17.5% addressed informal help sources. General practitioner (2.7%) and family (12.5%) were the most frequently used formal and informal sources, respectively. In the full model, predisposing factors associated with higher odds of parental help-seeking were child's other western ethnic background (OR=1.66, 95% CI 1.02 to 2.68) and parental age ≤29 years old (OR=1.71, 95% CI 1.01 to 2.92). No associated factors were found among enabling factors. The need factors associated with higher odds of parental help-seeking were having previous help-seeking (OR=2.52, 95% CI 1.83 to 3.48) and discussing child's socioemotional development in the well-child visit (OR=2.47, 95% CI 1.73 to 3.53).

CONCLUSIONS

Predisposing and need factors were associated with parental help-seeking for socioemotional development of 3-year-old children. The findings can be used to further develop support for parents accessing adequate information, prevention and anticipatory care with regards to the child's socio-emotional development.

Teacher-reported emotional and behavioural problems and ethnic background associated with children's psychosocial care use: a longitudinal population-based study

Approximately, 15% of children in Western countries suffer from emotional and behavioural problems. However, not all children receive the psychosocial care they need, especially children with a non-Western background experience an unmet need for care. This might be because parents of non-Western children report a lower need for care than parents of Western children, unrelated to the actual need. This study examined the association between teacher-reported problems and psychosocial care use, independent of mother-reported problems. Further, the role of ethnic background in this association was investigated. The study sample of 9-year-old children was retrieved from the Generation R Study (N = 3084), a prospective, population-based cohort of children born in Rotterdam, the Netherlands. Teacher- and mother-reported problems were measured via questionnaire when the children were  6/7 years old. Psychosocial care use was mother-reported at the research centre when children were 9 years old (8.1%). Hierarchical logistic regressions showed significant positive associations between teacher-reported total, externalising and internalising problems and later psychosocial care use. These associations were independent of mother-reported problems. Children with a non-Western background used less care, but ethnic background did not moderate the association between teacher-reported problems and care use. Our findings suggest that teachers might have an important role, next to parents, in the identification of problems and children's access to care. This may be particularly important for non-Western children, as they use less psychosocial care than Western children, despite other research showing that they generally display higher levels of problems. Directions for future research and implications are discussed.

Children's use of psychosocial care in a population-based longitudinal study: less likely for girls, children with a non-Western background and children with a high quality of life

Knowledge on determinants of children's psychosocial care use is important to improve their access to care. This study examined the independent contributions of need and predisposing factors to psychosocial care use in 9-year-old children, guided by the Gateway Provider Model. Data of the Generation R Study, a prospective cohort of children born in Rotterdam, the Netherlands, were analysed using multivariable logistic regression (n = 4714). Need (quality of life, presence and type of emotional/behavioural problems) and predisposing factors (sex, ethnic background and maternal educational level) were measured using parent questionnaires at multiple time points between ages 1.5 and 9 years. Psychosocial care use was parent-reported at 9 years old (9.6% among children with Western background, 7.3% among children with non-Western background). Having emotional/behavioural problems at 5 and 9 years old was associated with more care use, while having a higher quality of life, being a girl and having a Moroccan/Turkish or other non-Western background were associated with less care use. Externalising and internalising problems, as well as several types of problems, at 5 and 9 years old were associated with psychosocial care use. Stratified analyses revealed that, in children with non-Western backgrounds, only a poorer psychosocial quality of life was associated with psychosocial care use. To conclude, girls with a Western background and children with a non-Western background were less likely to receive care compared to their peers. Children with parent-reported emotional/behavioural problems at 5 and 9 years old and decreased quality of life at 5 years old were more likely to receive psychosocial care use at 9 years old. Our findings hold relevance for preventive policies.

Psychometric Properties of the Parent Version of the Revised Child Anxiety and Depression Scale in a Clinical Sample of Turkish Children and Adolescents

The Revised Child Anxiety and Depression Scale-Parent version (RCADS-P) is a self-report questionnaire that assesses dimensions of DSM-based anxiety and depressive disorders in children and adolescents. The present study examined the psychometric properties of the Turkish version in a clinical sample of 483 children and adolescents. The child and parent versions of the RCADS, parent versions of the Screen for Child Anxiety Related Emotional Disorders, the Strengths and Difficulties Questionnaire and Adolescent Symptom Inventory-Depression Scale were administered. Current psychiatric diagnoses were assessed via the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present Version. The RCADS-P demonstrated high internal consistency and test-retest reliability, and good convergent, divergent, and discriminant validity. Confirmatory factor analysis supported the DSM-related six-factor structure. With its demonstrated favorable psychometric properties, the Turkish RCADS-P is currently the only validated parent-report instrument that assesses DSM-based anxiety and depressive disorders in children and adolescents in Turkey.

Acceptance of guidance to care at the emergency department following attempted suicide

BACKGROUND

Research, aimed at improving the continuity of care after hospital discharge following attempted suicide focuses on the effectiveness of the interventions. Little attention has been paid to patients who immediately decline guidance to advised post-discharge care. We aimed to identify differences between accepters and decliners of guidance to care (GtC) in relation to the characteristics of patients who presented at the emergency department (ED) of an urban hospital in the Netherlands after attempted suicide.

METHOD

This cross-sectional study included all patients who presented at the ED of OLVG-West Amsterdam with a suicide attempt or intentional self-harm and were referred for psychiatric evaluation. Data were collected over a period of twenty months using a semi-structured questionnaire. Subgroups were described in relation the acceptance of GtC using univariate and multivariate logistic regression analyses.

RESULTS

In total, 257 patients were included. GtC was accepted by 77%. Suicide attempters who reported loneliness as reason for the attempt showed a positive relation to acceptance. No indication was found that patients at higher risk for suicide are more reluctant to accept GtC. Suicide attempters with a non-Western ethnicity, especially patients with a Turkish/Moroccan ethnicity, declined contact by the GtC nurse significantly more often. In addition, patients who currently did not receive care were significantly more often of non-Western ethnicity and younger than 25.

CONCLUSION

Acceptance of GtC is high among patients who presented at the ED after attempted suicide. The patients who were the most reluctant to accept GtC were young suicide attempters of non-Western ethnicity who were not in current care. As this study is the first to address the acceptance of GtC, we point out two lines of inquiry for further research. First, reasons to accept or decline need to be investigated further since only interventions that are accepted by patients have a chance to improve clinically relevant outcome. Second, follow-up research is warranted comparing the adherence to advised post-discharge care and attempted or completed suicide among accepters versus decliners of GtC in various ethnic and sociodemographic subgroups.

Appropriate assessment of ethnic differences in adolescent use of psychotropic medication: multilevel analysis of discriminatory accuracy

OBJECTIVE

In the present study, we used a multilevel approach to investigate the role of maternal country of birth (MCOB) in predicting adolescent use of psychotropic medication in Sweden.

DESIGN

Using the Swedish Medical Birth Register we identified all 428,314 adolescents born between 1987 and 1990 and who were residing in Sweden in the year they turned 18. We applied multilevel logistic regression analysis with adolescents (level 1) nested within MCOBs (level 2). Measures of association (odds ratio) and measures of variance (intra-class correlation (ICC)) were calculated, as well as the discriminatory accuracy by calculating the area under the Receiver Operator Characteristic (AU-ROC) curve.

RESULTS

In comparison with adolescents with Swedish-born mothers, adolescents with mothers born in upper-middle, lower-middle and low-income countries were less likely to use psychotropic medication. However, the variance between MCOBs was small (ICC = 2.5 in the final model) relative to the variation within MCOBs. This was confirmed by an AU-ROC value of 0.598.

CONCLUSIONS

Even though we found associations between MCOB and adolescent use of psychotropic medication, the small ICC and AU-ROC indicate that MCOB appears to be an inaccurate context for discriminating adolescent use of psychotropic medication in Sweden.

A Population-Based Study of Postpartum Mental Health Service Use by Immigrant Women in Ontario, Canada

OBJECTIVE

Postpartum mental disorders are twice as common among immigrant women compared to nonimmigrant women in developed countries. Immigrant women may experience barriers to access and use of postpartum mental health services, but little is known about their service use on a population level. We described postpartum mental health service use of immigrant mothers living in Ontario, Canada, comparing to a referent group of mothers who were either born in Canada or had lived in Ontario or another Canadian province since 1985.

METHOD

Among all women in Ontario, Canada, delivering a live infant from 2008 to 2012 (n = 450,622), we described mental health service use within 1 year postpartum, including mental health physician visits, psychiatric emergency department visits, and psychiatric hospitalization. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) comparing immigrant women to the referent group were adjusted for maternal age, parity, income, rurality, mental health services in prior 2 years, and maternal and newborn health.

RESULTS

Immigrant women (n = 123,231; 27%) were less likely to use mental health services than women in the referent group (14.1% vs. 21.4%; aOR, 0.59; 95% CI, 0.58 to 0.61), including for physician-based (13.9% vs. 21.1%; aOR, 0.59; 95% CI, 0.58 to 0.61) and emergency department (0.6% vs. 1.3%; aOR, 0.63; 95% CI, 0.57 to 0.68) services. Hospitalization risk was lower among immigrants (0.20% vs. 0.33%) but became similar after covariate adjustment (aOR, 0.92; 95% CI, 0.79 to 1.06).

CONCLUSIONS

Underuse of postpartum mental health services may be contributing to the high burden of postpartum mental disorders among immigrant women.

Differences in ADHD medication usage patterns in children and adolescents from different cultural backgrounds in the Netherlands

PURPOSE

Differences in incidence and prevalence of ADHD medication use between ethnic groups have been reported. Goal of this study was to determine whether there are also differences in usage patterns of ADHD medication among native Dutch children and adolescents and those with a Moroccan, Turkish and Surinam cultural background in the Netherlands between 1999 and 2010.

METHODS

In a cohort of ADHD patients <19 years (N = 817) incident use and discontinuation of ADHD medication were measured for ethnicity and adjusted for age, gender and socio-economic status.

RESULTS

A significant higher proportion of ADHD-diagnosed patients from Moroccan (32 %) and Turkish (42 %) cultural background never used ADHD medication compared to Dutch natives (21 %). One-fifth of native Dutch and Turkish patients already used ADHD medication before the ADHD diagnosis date. Discontinuation of ADHD medication within 5 years was significantly higher in Moroccan [HR 2.4 (95 % CI 1.8-3.1)] and Turkish [HR 1.7 (95 % CI 1.1-2.6)] patients. A sensitivity analysis with a zip code-matched comparison between Dutch natives and non-natives showed similar results, suggesting this effect is probably not explained by socio-economic status (SES).

CONCLUSION

Differences are found in prescribing and use of ADHD medication between patients with a different cultural background. Native Dutch and Turkish patients start more frequently with ADHD medication before the ADHD diagnose date, which can be an indication of differences in either referral patterns and/or access to care. A higher percentage of patients with a Moroccan and Turkish cultural background never start using ADHD medication at all and discontinuation rate is higher compared to Dutch natives and Surinamese.