Bridging the Gap in Psychiatric Care for Children with a School-Based Psychiatry Program

Family-centred care interventions for children with chronic conditions: A scoping review

INTRODUCTION

Children with chronic conditions have greater health care needs than the general paediatric population but may not receive care that centres their needs and preferences as identified by their families. Clinicians and researchers are interested in developing interventions to improve family-centred care need information about the characteristics of existing interventions, their development and the domains of family-centred care that they address. We conducted a scoping review that aimed to identify and characterize recent family-centred interventions designed to improve experiences with care for children with chronic conditions.

METHODS

We searched Medline, Embase, PsycInfo and Cochrane databases, and grey literature sources for relevant articles or documents published between 1 January 2019 and 11 August 2020 (databases) or 7-20 October 2020 (grey literature). Primary studies with ≥10 participants, clinical practice guidelines and theoretical articles describing family-centred interventions that aimed to improve experiences with care for children with chronic conditions were eligible. Following citation and full-text screening by two reviewers working independently, we charted data covering study characteristics and interventions from eligible reports and synthesized interventions by domains of family-centred care.

RESULTS

Our search identified 2882 citations, from which 63 articles describing 61 unique interventions met the eligibility criteria and were included in this review. The most common study designs were quasiexperimental studies (n = 18), randomized controlled trials (n = 11) and qualitative and mixed-methods studies (n = 9 each). The most frequently addressed domains of family-centred care were communication and information provision (n = 45), family involvement in care (n = 37) and access to care (n = 30).

CONCLUSION

This review, which identified 61 unique interventions aimed at improving family-centred care for children with chronic conditions across a range of settings, is a concrete resource for researchers, health care providers and administrators interested in improving care for this high-needs population.

PATIENT OR PUBLIC CONTRIBUTION

This study was co-developed with three patient partner co-investigators, all of whom are individuals with lived experiences of rare chronic diseases as parents and/or patients and have prior experience in patient engagement in research (I. J., N. P., M. S.). These patient partner co-investigators contributed to this study at all stages, from conceptualization to dissemination.

Cognitive-affective drivers of fixation in threat assessment

Pathological fixation - preoccupation with a person or a cause that is accompanied by deterioration in social and occupational functioning - has been found to precede most cases of targeted violence. It is clinically observed and theorized to have three different cognitive-affective drivers: delusion, obsession, or extreme overvalued belief. Each driver is explained, and case examples are provided in the context of threat assessment. Extreme overvalued belief as a new concept is discussed in detail, both its historical provenance and its demarcation from delusions and obsessions. Threat management for each separate cognitive-affective driver is briefly summarized, based upon current clinical findings and research. Emphasis is placed upon understanding both the categorical and dimensional nature (intensity) of these cognitive-affective drivers, and suggested guidelines are offered for the assessment of such in a clinical examination by a forensic psychiatrist or psychologist.

National Trends in Mental Health Care for US Adolescents

Importance

The prevalence of adolescent depression and other internalizing mental health problems has increased in recent years, whereas the prevalence of externalizing behaviors has decreased. The association of these changes with the use of mental health services has not been previously examined.

Objective

To examine national trends in the care of different mental health problems and in different treatment settings among adolescents.

Design, Setting, and Participants

Data for this survey study were drawn from the National Survey on Drug Use and Health, an annual cross-sectional survey of the US general population. This study focused on adolescent participants aged 12 to 17 years interviewed from January 1, 2005, to December 31, 2018. Data were reported as weighted percentages and adjusted odds ratios (aORs) and analyzed from July 20 to December 1, 2019.

Main Outcomes and Measures

Time trends in 12-month prevalence of any mental health treatment or counseling in a wide range of settings were examined overall and for different sociodemographic groups, types of mental health problems (internalizing, externalizing, relationship, and school related), and treatment settings (inpatient mental health, outpatient mental health, general medical, and school counseling). Trends in the number of visits and nights in inpatient settings were also examined.

Results

A total of 47 090 of the 230 070 adolescents across survey years (19.7%) received mental health care. Of these, 57.5% were female; 31.3%, aged 12 to 13 years; 35.8%, aged 14 to 15 years; and 32.9%, aged 16 to 17 years. The overall prevalence of mental health care did not change appreciably over time. However, mental health care increased among girls (from 22.8% in 2005-2006 to 25.4% in 2017-2018; aOR, 1.11; 95% CI, 1.04-1.19; P = .001), non-Hispanic white adolescents (from 20.4% in 2005-2006 to 22.7% in 2017-2018; aOR, 1.08; 95% CI, 1.03-1.14; P = .004), and those with private insurance (from 19.4% in 2005-2006 to 21.2% in 2017-2018; aOR, 1.11; 95% CI, 1.04-1.18; P = .002). Internalizing problems, including suicidal ideation and depressive symptoms, accounted for an increasing proportion of care (from 48.3% in 2005-2006 to 57.8% in 2017-2018; aOR, 1.52; 95% CI, 1.39-1.66; P < .001), whereas externalizing problems (from 31.9% in 2005-2006 to 23.7% in 2017-2018; aOR, 0.67; 95% CI, 0.62-0.73; P < .001) and relationship problems (from 30.4% in 2005-2006 to 26.9% in 2017-2018; aOR, 0.75; 95% CI, 0.69-0.82; P < .001) accounted for decreasing proportions. During this period, use of outpatient mental health services increased from 58.1% in 2005-2006 to 67.3% in 2017-2018 (aOR, 1.47; 95% CI, 1.35-1.59; P < .001), although use of school counseling decreased from 49.1% in 2005-2006 to 45.4% in 2017-2018 (aOR, 0.86; 95% CI, 0.79-0.93; P < .001). Outpatient mental health visits (eg, private mental health clinicians, from 7.2 in 2005-2006 to 9.0 in 2017-2018; incidence rate ratio, 1.30; 95% CI, 1.23-1.37; P < .001) and overnight stays in inpatient mental health settings (from 4.0 nights in 2005-2006 to 5.4 nights in 2017-2018; incidence rate ratio, 1.18; 95% CI, 1.02-1.37; P = .03) increased.

Conclusions and Relevance

This study's findings suggest that the growing number of adolescents who receive care for internalizing mental health problems and the increasing share who receive care in specialty outpatient settings are placing new demands on specialty adolescent mental health treatment resources.

Increasing Access to Psychiatric Services in Schools: The Bridge Program

One in 5 youth experience a psychiatric disorder in any given year, but fewer than half of these youth receive mental health services. This lack of service utilization is often attributed to structural and perceptual barriers, and school-based mental health programs have been proposed as a means of addressing these barriers and increasing youths' access to services. While universal prevention programs and targeted treatments may benefit most youth receiving services in schools, collaborations between schools and child psychiatry may benefit youth with the most severe symptoms and the greatest impairment. This article describes the Bridge Program, a school-based psychiatric program funded by a county-wide mental health tax initiative designed to provide psychiatric services in local schools without any out-of-pocket expenses for youth and families within 10 days of referral. Two case reports provide a description of the delivery of psychiatric services through the Bridge Program. Future research is needed to compare the feasibility and effectiveness of different approaches to increasing access to youth psychiatric care.