Usual care for clinicians, unusual care for their clients: rearranging priorities for children's mental health services

Implementation of significant mental health service change: perceptions and concerns of a mental health workforce in the context of transformation

Purpose

As part of an evaluation of the nationally mandated Child and Adolescent Mental Health Services (CAMHS) “transformation” in one foundation NHS trust, the authors explored the experiences of mental health staff involved in the transformation.

Design/methodology/approach

The authors employed a qualitative methodology and followed an ethnographic approach. This included observation of mental health staff involved in the transformation and informal interviews (80 h). The authors also undertook semi-structured interviews with key staff members ( n  = 16). Data were analysed thematically.

Findings

The findings fall into three thematic areas around the transformation, namely (1) rationale; (2) implementation; and (3) maintenance. Staff members were supportive of the rationale for the changes, but implementation was affected by perceived poor communication, resulting in experiences of unpreparedness and de-stabilisation. Staff members lacked time to set up the necessary processes, meaning that changes were not always implemented smoothly. Recruiting and retaining the right staff, a consistent challenge throughout the transformation, was crucial for maintaining the service changes.

Originality/value

There is little published on the perceptions and experiences of mental health workforces around the CAMHS transformations across the UK. This paper presents the perceptions of mental health staff, whose organisation underwent significant “transformational” change. Staff demonstrated considerable resilience in the change process, but better recognition of their needs might have improved retention and satisfaction. Time for planning and training would enable staff members to better develop the processes and resources necessary in the context of significant service change. Developing ways for services to compare changes they are implementing and sharing good practice around implementation with each other are also vital.

How does reorganisation in child and adolescent mental health services affect access to services? An observational study of two services in England

BACKGROUND

Child and Adolescent Mental Health Services (CAMHS) in England are making significant changes to improve access and effectiveness. This 'transformation' variously involves easier access to services through a Single Point of Access (SPA), more integrated services within CAMHS and enhanced co-provision across education and third sector or non-profit organisations.

METHODS

A mixed-methods observational study was conducted to explore the process and impact of transformation over four years in two services. Ethnographic observations and in-depth interviews were conducted and Electronic Patient Records with over one million contacts analysed. Difference-in-differences analysis with propensity score matching to estimate the causal impact of the transformation on patient access was utilised.

OUTCOMES

Spend and staffing increased across both CAMHS. The SPA had growing rates of self-referral and new care pathways were seeing patients according to expected degree of psychopathology. Third sector partners were providing increasing numbers of low-intensity interventions. Although the majority of staff were supportive of the changes, the process of transformation led to service tensions. In the first year after transformation there was no change in the rate of new patients accessing services or new spells (episodes of care) in the services. However, by year three, the number of new patients accessing CAMHS was 19% higher (Incidence Rate Ratio: 1·19, CI: 1·16, 1·21) and the rate of new spells was 12% higher (Incidence Rate Ratio: 1·12, CI: 1·05, 1·20).

INTERPRETATION

Transformation investment, both financial and intellectual, can help to increase access to CAMHS in England, but time is needed to realise the benefits of reorganisation.

A qualitative study to explore paraprofessionals' role in school-based prevention and early intervention mental health services

This study explored the role of paraprofessionals within a school-based prevention and early intervention program to promote children's engagement in learning and positive parenting practices. Study aims were designed to understand how paraprofessionals perceive their role in high-need communities and how they define their work within schools. Two focus groups were conducted with school family liaisons (SFLs) during the 2015-2016 school year. Transcribed audio recordings were coded using thematic analysis wherein 2 authors coded independently, followed by audited discussion and final consensus codes. SFLs acknowledged the importance of serving high-need communities and relationship building was central to their role. They leveraged contextual knowledge (culture, language, and neighborhood) to engage parents, allowing them to serve as effective advocates for parents/families in the school setting. Findings support the importance of paraprofessionals in prevention-focused services and highlight how leveraging shared experiences and prioritizing relationship building facilitates their work as advocates within schools.

What Makes Research Useful for Public School Educators?

In this study, we explored the extent to which educators discuss and prioritize Rogers' (Diffusion of innovations, The Free Press: New York, 1995) five attributes of innovations-relative advantage, compatibility, complexity, observability, and trialability-in the context of research use. Using a directed content analysis of 54 semi-structured interviews and exemplar quotes, we describe how educators mentioned compatibility most frequently, but also commonly invoked observability and complexity in their discussions of research use. Our results also revealed key differences between educators in executive and non-executive roles. We discuss the implications of our findings for closing the research-practice gap in school-based mental health services and psychosocial interventions.

Redesigning community mental health services for urban children: Supporting schooling to promote mental health

OBJECTIVE

This study examined a school- and home-based mental health service model, Links to Learning, focused on empirical predictors of learning as primary goals for services in high-poverty urban communities.

METHOD

Teacher key opinion leaders were identified through sociometric surveys and trained, with mental health providers and parent advocates, on evidence-based practices to enhance children's learning. Teacher key opinion leaders and mental health providers cofacilitated professional development sessions for classroom teachers to disseminate 2 universal (Good Behavior Game, peer-assisted learning) and 2 targeted (Good News Notes, Daily Report Card) interventions. Group-based and home-based family education and support were delivered by mental health providers and parent advocates for children in kindergarten through 4th grade diagnosed with 1 or more disruptive behavior disorders. Services were Medicaid-funded through 4 social service agencies (N = 17 providers) in 7 schools (N = 136 teachers, 171 children) in a 2 (Links to Learning vs. services as usual) × 6 (pre- and posttests for 3 years) longitudinal design with random assignment of schools to conditions. Services as usual consisted of supported referral to a nearby social service agency.

RESULTS

Mixed effects regression models indicated significant positive effects of Links to Learning on mental health service use, classroom observations of academic engagement, teacher report of academic competence and social skills, and parent report of social skills. Nonsignificant between-groups effects were found on teacher and parent report of problem behaviors, daily hassles, and curriculum-based measures. Effects were strongest for young children, girls, and children with fewer symptoms.

CONCLUSION

Community mental health services targeting empirical predictors of learning can improve school and home behavior for children living in high-poverty urban communities.

Future Directions for Dissemination and Implementation Science: Aligning Ecological Theory and Public Health to Close the Research to Practice Gap

Dissemination and implementation science (DI) has evolved as a major research model for children's mental health in response to a long-standing call to integrate science and practice and bridge the elusive research to practice gap. However, to address the complex and urgent needs of the most vulnerable children and families, future directions for DI require a new alignment of ecological theory and public health to provide effective, sustainable, and accessible mental health services. We present core principles of ecological theory to emphasize how contextual factors impact behavior and allow for the reciprocal impact individuals have on the settings they occupy, and an alignment of these principles with a public health model to ensure that services span the prevention to intervention continuum. We provide exemplars from our ongoing work in urban schools and a new direction for research to address the mental health needs of immigrant Latino families. Through these examples we illustrate how DI can expand its reach by embedding within natural settings to build on local capacity and indigenous resources, incorporating the local knowledge necessary to more substantively address long-standing mental health disparities. This paradigm shift for DI, away from an overemphasis on promoting program adoption, calls for fitting interventions within settings that matter most to children's healthy development and for utilizing and strengthening available community resources. In this way, we can meet the challenge of addressing our nation's mental health burden by supporting the needs and values of families and communities within their own unique social ecologies.

A review of parent participation engagement in child and family mental health treatment

Engagement in child and family mental health treatment has critically important clinical, implementation, and policy implications for efforts to improve the quality and effectiveness of care. This article describes a review of the existing literature on one understudied element of engagement, parent participation. Twenty-three published articles were identified. Questions asked of the literature include what terms are used to represent parent participation engagement, how parent participation engagement is measured, what are the rates of parent participation engagement reported in studies of child and family mental health treatment, whether parent participation engagement has been found to overlap with attendance engagement, what factors have been identified as associated with parent participation engagement, whether parent participation engagement is associated with improved outcomes, and what strategies have been designed to improve PPE and whether such strategies are associated with improved outcomes. Results indicate varied terms and measures of parent participation engagement, moderate overall rates, and high overlap with measures of attendance engagement. The extant literature on factors associated with parent participation engagement was somewhat limited and focused primarily on parent-/family-level factors. Evidence of links between parent participation engagement and outcome improvements was found across some outcome domains, and strategies designed to target parent participation engagement were found to be effective overall. A framework for organizing efforts to examine the different elements of engagement is described, and findings are discussed in terms of suggestions for consistent terminology, clinical implications, and areas for the future research.

A review of parent participation engagement in child and family mental health treatment

Engagement in child and family mental health treatment has critically important clinical, implementation, and policy implications for efforts to improve the quality and effectiveness of care. This article describes a review of the existing literature on one understudied element of engagement, parent participation. Twenty-three published articles were identified. Questions asked of the literature include what terms are used to represent parent participation engagement, how parent participation engagement is measured, what are the rates of parent participation engagement reported in studies of child and family mental health treatment, whether parent participation engagement has been found to overlap with attendance engagement, what factors have been identified as associated with parent participation engagement, whether parent participation engagement is associated with improved outcomes, and what strategies have been designed to improve PPE and whether such strategies are associated with improved outcomes. Results indicate varied terms and measures of parent participation engagement, moderate overall rates, and high overlap with measures of attendance engagement. The extant literature on factors associated with parent participation engagement was somewhat limited and focused primarily on parent-/family-level factors. Evidence of links between parent participation engagement and outcome improvements was found across some outcome domains, and strategies designed to target parent participation engagement were found to be effective overall. A framework for organizing efforts to examine the different elements of engagement is described, and findings are discussed in terms of suggestions for consistent terminology, clinical implications, and areas for the future research.