Routine outcome measurement in a child and adolescent mental health service: an evaluation of HoNOSCA. The Health of the Nation Outcome Scales for Children and Adolescents

Outcomes for young people in out of home care accessing tiered mental health services in Sydney, Australia

Young people in OOHC have complex mental health concerns, therefore the South Western Sydney Local Health District (SWSLHD) has trialled a tiered model of mental health care. Under this model the OOHC mental health team (OOHC-MHT) provides specialist tier four service delivery for those with the most severe, intense mental health needs. OOHC consumers with a reduced level of severity access services at a tier three centre-based iCAMHS. This study aims to understand the characteristics of young people in OOHC accessing different service provision options in Sydney, Australia. Sixty-six OOHC consumers 8-17 years accessing mental health services across SWSLHD from January 2020-December 2021 participated in the study. Group differences in OOHC-MHT and iCAMHS outcome measures were compared. HoNOSCA scores were significantly worse for OOHC-MHT than iCAMHS, indicating more severe psychopathology for OOHC-MHT at baseline. In OOHC-MHT, HoNOSCA decreased significantly from admission to discharge and scores on the CGAS increased significantly, indicating significant improvements in psychopathology and functioning. In the iCAMHS group scores on the HoNOSCA significantly decreased indicating improved psychopathology over this period. These findings support a tiered model of service delivery for OOHC consumers, with this tailored level of care resulting in significantly improved outcomes across a range of complexity.

Family-based treatment takes longer for adolescents with mental health comorbidities: findings from a community mental health service

Children and adolescents diagnosed with an eating disorder often meet the diagnosis of another mental health disorder. In addition to eating disorders, individuals with comorbid disorders have higher suicide rates and more severe and chronic eating disorder symptoms. The present research aimed to investigate the influence of comorbid conditions on the treatment outcomes of children and adolescents that attended a public community mental health service. It was hypothesised that the patients with comorbidities would have a more extended treatment duration, slower rates of weight restoration, more hospital admissions for medical compromise, and poorer functioning than those without comorbidities. Data from 78 past patients at the Eating Disorder Program in Queensland, Australia, were analysed. Patients with comorbidities demonstrated similar recovery rates to those without comorbidities. However, those with comorbid conditions had longer episodes of treatment. The study's results support using Family Based Treatment for patients with and without comorbidities. The implications of the findings for public mental health services and directions for future research are discussed.

Long-term outcome of intensive home treatment for children and adolescents with mental health problems - 4 years after a randomized controlled clinical trial

BACKGROUND

Admission rates to child and adolescent mental health inpatient units in Germany are substantial (58.831 admissions in 2019). Historically, different treatment pathways have not been available. The evidence suggests that home treatment could be an alternative. The objective of this study was to assess the long-term stability of treatment gains among children and adolescents treated for serious mental health problems with home treatment (HT) as compared with inpatient treatment-as-usual (TAU).

METHODS

Hundred patients were enrolled and randomized into an intervention (HT n = 54) and control group (TAU n = 46). Follow-up data were available after 8.4 months (n = 78) (T3) and after 4.3 years (n = 51) (T4). The primary outcome measured was overall level of functioning, for which the Children's Global Assessment Scale (CGAS) was used. Secondary outcomes included severity of patient impairment and parental competency in dealing with their child's symptoms, measured using the Health of the Nation Outcome Scales (HoNOSCA). A qualitative interview with parents was performed at T3 and T4.

RESULTS

Treatment effects remained stable for both groups at T3 and T4 (p < .001). After 4.3 years 70% of the parents in the intervention group stated satisfaction with the treatment received, while only 36.8% of the parents within the control group rated themselves as satisfied. 43.7% of parents in the home treatment group reported that the most helpful aspect of this pathway was the prompt and intensive professional help and advice they received as primary caregivers at home.

CONCLUSIONS

Home treatment may be considered a viable alternative to inpatient care.

Routine outcome measurement in adolescents seeking mental health services: standardization of HoNOSCA in Kenyan sample

BACKGROUND

The evaluation of treatment outcomes is important for service providers to assess if there is improvement or not. The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) was developed for this use in child and adolescent mental health services. Outcome measurement in routine mental health services is limited. This paper evaluates the psychometric properties of the self and clinician rated versions of the HoNOSCA for routine use in child and adolescent mental health services in Kenya.

METHODS

Using a prospective design, the clinician- and self-rated versions of the HoNOSCA and the Paediatric Symptom Checklist (PSC) were administered at the Youth Centre at the Kenyatta National Hospital in Nairobi. Initial ratings were obtained from adolescents 12-17 years (n = 201). A sample of 98 paired ratings with 2 follow-ups were examined for measurement of change over time.

RESULTS

Our findings showed good reliability with the self-rated version of the HoNOSCA score, correlating well with the self-reported version of the PSC (r = .74, p < .001). Both versions correlated well at follow-up and were sensitive to change. Using factor analysis, the maximum likelihood factoring and Promax rotation resulted in a four-factor structure, which with a Kaiser-Meyer-Olkin measure of sampling adequacy of 0.8 explained 54.74% of total variance.

CONCLUSION

The HoNOSCA appears to be of value, and easy to use in routine settings. Our findings suggest further investigation with a larger sample.

Health of the Nation Outcome Scales for Infants field trial: concurrent validity

BACKGROUND

A review of Australian mental health services identified a gap in routine outcome measures addressing social, emotional and behavioural domains for pre-schoolers and infants. A Child and Adolescent Mental Health Information Development Expert Advisory Panel working group developed the Health of the Nation Outcome Scales for Infants (HoNOSI), a clinician-reported routine outcome measure for infants 0-47 months. Prior face validity testing showed that the HoNOSI was considered useful in measuring mental health outcomes.

AIMS

To examine the concurrent validity of the HoNOSI.

METHOD

Mental health clinicians providing assessment and treatment to infants in routine clinical practice participated in the study. The mental health status of 108 infants were rated by a minimum of 26 clinicians with the HoNOSI, the Parent-Infant Relationship Global Assessment Scale (PIR-GAS) and measures of symptom severity and distress.

RESULTS

The HoNOSI was statistically significantly correlated with the PIR-;GAS, rs = -0.73; Clinical Worry, rs = 0.77; and Severity Judgement ratings, rs = 0.85; P < 0.001. A good level of internal consistency was found. Using the COsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria for judging instrument acceptability, the HoNOSI meets the standard for both concurrent validity and internal consistency.

CONCLUSIONS

There has been a clear need for a routine outcome measure for use with infants. This study provides positive evidence of aspects of validity. These findings, along with those from the prior face validity study, support a controlled release of the HoNOSI accompanied by further research and development.

The interrater reliability of a routine outcome measure for infants and pre-schoolers aged under 48 months: Health of the Nation Outcome Scales for Infants

BACKGROUND

A review of Australian mental health services identified a gap in routine outcome measures addressing social, emotional and behavioural domains for pre-schoolers and infants. The Child and Adolescent Mental Health Information Development Expert Advisory Panel Working Group developed the Health of the Nation Outcome Scales for Infants (HoNOSI), a clinician-reported routine outcome measure for use with those aged under 4 years. Prior psychometric testing showed that the HoNOSI was considered to show face validity, and that it met the standards for concurrent validity and internal consistency.

AIMS

We aimed to investigate the interrater reliability of the HoNOSI.

METHOD

Forty-five infant mental health clinicians completed HoNOSI ratings on a set of five case vignettes.

RESULTS

Quadratic weighted kappa interrater reliability estimates showed the HoNOSI to have Almost Perfect interrater reliability for the HoNOSI total score. Of the 15 scales, one had Moderate, seven had Substantial and seven had Almost Perfect interrater reliability. Ten of the fifteen scales and the total score exceeded the COnsensus-based Standards for the Selection of Health Measurement INstruments criteria for interrater reliability (κw ≥ 0.7).

CONCLUSIONS

There has been a clear need for a routine outcome measure for use with infants and pre-schoolers. This study provides evidence of interrater reliability. The current findings, combined with the face and concurrent validity studies, support further examination of HoNOSI in real-world settings.

Evolution of Clinical Outcome During Adolescents’ Psychiatric Inpatient Care: A Prospective Multiple Informant Study

Background:

Examining the effectiveness and adequacy of adolescents’ psychiatric inpatient treatment through multiple perspectives is crucial to provide the best care.

Objectives:

The aims of the current study were to examine the consistencies and discrepancies between patients and clinicians and to understand how each group considered the timing of improvement of symptoms and psychosocial difficulties of adolescents during a psychiatric inpatient stay.

Methods:

The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA, assessing symptoms and psychosocial difficulties) was rated on a weekly basis by patients and clinicians during a psychiatric inpatient stay. Data were collected from 297 patients, 58.2% females.

Results:

Both clinicians and patients reported a significant decrease of the HoNOSCA scores from admission to discharge, revealing that inpatient treatment is perceived as helping the adolescents to alleviate their symptoms and psychosocial difficulties. However, the item-by-item analyses indicated that patients and clinicians reported difficulties in different symptoms and psychosocial domains. Moreover, the week-by-week analyses revealed discrepancies in the perception of the time-course of clinical outcome- changes between clinicians and patients, as well as between males and females, and between voluntarily and involuntarily admitted patients.

Conclusions:

By integrating perspectives of patients and clinicians and their respective timelines, as well as by taking into account the mode of admission and the patient’s gender, this study provides a deeper understanding of the evolution of clinical outcome during adolescents’ hospitalizations, which allows to adapt their treatment and therewith, to help patients more efficiently.

Nurse and patient factors: Predicting seclusion in adolescent psychiatric units

PROBLEM

Seclusion is considered a necessity when alternatives have failed. There is a consensus that seclusion has no therapeutic benefit, which justifies efforts to reduce the practice. This study aimed to identify nurse and patient variables that are predictive of seclusion on a large adolescent inpatient unit.

METHODS

Nested case controls were used to compare 72 afternoon shifts on which seclusion occurred to 216 afternoon shifts on which no seclusion occurred, between 2010 and 2013, at an Adolescent Psychiatric Inpatient Unit.

FINDINGS

Increased seclusion was predicted by a lower nurse to patient ratio, more male nurses on shift, fewer female nurses on shift, the presence of agency/temporary nurses on shift, greater combined years of mental health experience, and lower total HoNOSCA behavior subscale score. Unique predictors that increased risk of seclusion included greater number of male nurses and the presence of agency/temporary nurses, while a greater number of female nurses decreased risk of seclusion.

CONCLUSIONS

Nurses play a unique role in seclusion outcomes that are separate to patient-factors and act as both protective and risk factors for seclusion. Changes can be made to staffing to reduce seclusion and future research should investigate why these nurse-factors contribute to seclusion.

Prevalence and clinical correlates of self-harm and suicidality during admission of children in a mental health inpatient unit

Background

Self-harm and suicidality are common presentations in children and adolescents requiring a mental health inpatient admission. Although there are several studies on adolescents, there is relatively limited research into childhood self-harm and suicidality during such admissions.

Methods

A retrospective electronic file review was conducted on all children discharged from a national mental health inpatient children’s unit over a 6-year period. Several independent variables were compared between self-harm/suicidal and non-self-harm/non-suicidal children. Separate analyses investigated changes in self-harm/suicidality, functional outcomes, and risk assessment ratings between admission and discharge.

Results

A total of 105 children were included in this study. During admission, 65.7% of them reported self-harm thoughts, 61% engaged in self-harm, 50.5% expressed suicidal thoughts, and 14.3% engaged in suicidal behavior. Thoughts and acts of self-harm were associated with previous self-harm, longer admissions, and Attention Deficit Hyperactivity Disorder. Suicidality overlapped with self-harm and was strongly predicted by previous self-harm. The prevalence of self-harm and suicidal thoughts and acts significantly decreased during admission. Children in the non-self-harm group had marginally better functional outcomes upon discharge compared to those in the self-harm group. Children and parents/caregivers were similarly satisfied with treatment, irrespective of children’s self-harm/suicidality.

Conclusions

Self-harm and suicidality were widespread among children admitted to hospital. Better understanding of the mechanisms and factors related to self-harm and suicidality in this age group could help mitigate associated risks and improve existing safety strategies.

When parents and children disagree: Informant discrepancies in reports of depressive symptoms in clinical interviews

BACKGROUND

Parents and their children often disagree on the existence and severity of psychopathological symptoms, especially in major depressive disorder (MDD). Discrepant estimations pose a problem for the validity of diagnoses and illness severity with major implications for treatment evaluation.

METHODS

118 adolescents aged 13-18 years and their parents were interviewed and their reports were compared regarding the presence of a MDD diagnosis. In addition, severity ratings of depression symptoms reported in the Children's Depression Rating Scale-Revised (CDRS-R) were compared between parents and their offspring using multivariate analyses and polynomial regressions. The association between borderline features, functional impairment, and treatment history variables with parent-child agreement was assessed.

RESULTS

In 38% of the cases, parents and adolescents agreed on DSM-IV diagnostic MDD criteria, while in 53%, only the adolescent endorsed criteria for a MDD. A MDD that was endorsed by parents and adolescents was characterized by higher depression severity, higher number of previous treatments, and higher functional impairment. Using a polynomial approach, neither age nor borderline tendencies were associated with agreement.

LIMITATIONS

We did not differentiate between mother's versus father's reports and borderline features were assessed by self-report only.

CONCLUSIONS

Adolescents and their parents gave differing reports of the existence and severity of depressive symptoms. The high discrepancy levels combined with the uncertainty of previously published findings due to methodological challenges are concerning. Clinicians and researchers need to consider discrepancies in agreement in relation to diagnosis and illness severity in the context of their clinical and research decisions.

Schnittstellenkoordination von systemübergreifenden Hilfen für Kinder und Jugendliche mit psychischen Beeinträchtigungen

Zusammenfassung. Schnittstellen zwischen psychosozialen Hilfesystemen stellen Sollbruchstellen einer gelingenden systemübergreifenden Behandlung psychisch erkrankter Kinder/Jugendlicher dar. Daten zu Schnittstellenmanagement in Deutschland liegen bisher nicht vor. Ziel der Studie ASpeKT war es, zu vier Zeitpunkten (T1 Aufnahme, T2 Entlassung, T3 6 Mo und T4 12 Mo nach Entlassung) den Ist-Stand von installierten Hilfen bei psychisch erkrankten Kindern und Jugendlichen ( n=191) zu erheben, Patientenzufriedenheit zu evaluieren sowie dies an zwei, strukturell unterschiedlichen Standorten (Klinik A/Klinik B) zu vergleichen. Zu T2 erhielten 13 % der Patienten keine Hilfen. 43,6 % (A) bzw. 70,4 % (B) erhielten Psychotherapie (PT), 67,3 % (A) bzw. 80,3 % (B) Jugendhilfemaßnahmen (JH), 37,6 % (A) bzw. 16.9 % (B) schulische Unterstützung. Gute Schnittstellenkoordination ist prognostisch essentiell, um den meist noch komplexen Hilfebedarf psychisch erkrankter Kinder/Jugendlicher nach stationärer Behandlung abzubilden.

Measure of clinical improvement in children and adolescents with psychiatric disorders: an evaluation of multiple perspectives with HoNOSCA

Introduction

Routine outcome assessment is helpful to inform decision-making, resource allocation, and health policy design. Routine outcome assessment in the hospital setting for children and adolescents with psychiatric disorders remains limited. The clinical instrument HoNOSCA (Health of the Nation Outcome Scales for Children and Adolescents), which has recently become available in Spanish and Catalan, allows outcome assessment in this population from the perspective of patients, their parents or legal guardians, and clinicians. HoNOSCA measures 13 areas of health and psychosocial functioning.

Objectives

The aim of this study was to assess mental health outcomes in psychiatric day hospital pediatric patients from three perspectives (patient, par-ent/legal guardian, clinician), using the Spanish and Catalan versions of HoNOSCA.

Methods

We recruited patients up to 18 years old with any psychiatric disorder at the day unit of the Salut Mental Parc Taulí Hospital Universitari (Sabadell, Catalonia, Spain). We obtained admission and discharge HoNOSCA scores for the patients, their parents or legal guardians, and their clinicians.

Results

We recruited 99 patients over the study period (January 2015 to December 2017), 11 of which were lost to follow-up. Among the remaining 88, we found significant improvement in HoNOSCA scores from admission to discharge. Agreement between the HoNOSCA scores for the three different groups of evaluators (patients, parents/legal guardians, and clinicians) was weak at admission but better at discharge. In general, evaluations from patients and their parents or legal guardians had lower HoNOSCA scores (indicating a better mental health status) at admis-sion compared to those from clinicians. At discharge, however, the scores were more homogenous across the three groups of stakeholders.

Conclusions

Use of HoNOSCA allows for routine evaluation of mental health outcomes in the psychiatric day hospital setting from the perspective of pa-tients, their parents or legal guardians, and clinicians.

Clinical significance of assertive community treatment among adolescents

PURPOSE

The efficacy of assertive community treatment for children and adolescents is proven in the United States, but remains controversial in Europe. Moreover, most studies showing positive outcomes of assertive community treatment are limited to statistically significant differences and do not consider whether the treatment is also subjectively clinically meaningful for the patient. Using a naturalistic sample, the present study aims to assess statistical and clinical significance of an assertive community treatment unit for adolescents in Europe.

METHODS

Linear mixed-effects models and reliable change indices were used to respectively assess the statistical and clinical significance of assertive community treatment in 179 adolescents (mean age = 15.76, SD = 1.76) with severe mental illnesses.

RESULTS

Difficulties related to mental health (measured by the Health of the Nation Outcome Scales for Children and Adolescents, HoNOSCA) and overall functioning (measured by the Global Assessment of Functioning scale) statistically improved (all ps < 0.001) from admission to discharge. Additionally, a considerable proportion of patients (from 14% to 21%) clinically recovered to functional levels.

CONCLUSION

Our results support the fact that assertive community treatment can have convincing and positive clinical outcomes in European settings.

Mentalization and the growth of symbolic play and affect regulation in psychodynamic therapy for children with behavioral problems

Objective: Children with behavioral problems often have problems with symbolic play organization, specifically with the regulation of negative affect and its representation. One of the aims of psychodynamic therapy with these children is enhancing their symbolic and mentalizing capacities in play. This study investigated the associations between promoting mentalization, and the growth of symbolic play and affect regulation. Method: The sample included 48 children with behavioral problems, who underwent long-term psychodynamic treatment informed with mentalization principles, with good outcome. Three hundred twenty-nine sessions were coded for children's symbolic play and affect regulation strategies, and each treatment was rated for adherence to mentalizing principles. Results: Hierarchical linear modeling showed quadratic growth of variables, wherein symbolic play initially increased followed by a deceleration in change, whereas affect regulation initially decreased followed by an increase. Adherence to mentalizing principles was associated with both symbolic play and affect regulation. A two-way interaction between time in treatment and adherence to mentalization showed that in high adherent treatments, affect regulation increased towards the end of treatment, whereas in low adherent treatments, there was no change. Conclusion: Results show support for the association between adherence to mentalization and growth of affect regulation and symbolic play in psychodynamic therapy.

The effect of youth assertive community treatment: a systematic PRISMA review

BACKGROUND

During the past decades deinstitutionalisation policies have led to a transition from inpatient towards community mental health care. Many European countries implement Assertive Community Treatment (ACT) as an alternative for inpatient care for "difficult to reach" children and adolescents with severe mental illness. ACT is a well-organized low-threshold treatment modality; patients are actively approached in their own environment, and efforts are undertaken to strengthen the patient's motivation for treatment. The assumption is that ACT may help to avoid psychiatric hospital admissions, enhance cost-effectiveness, stimulate social participation and support, and reduce stigma. ACT has been extensively investigated in adults with severe mental illness and various reviews support its effectiveness in this patient group. However, to date there is no review available regarding the effectiveness of youth-ACT. It is unknown whether youth-ACT is as effective as it is in adults. This review aims to assess the effects of youth-ACT on severity of psychiatric symptoms, general functioning, and psychiatric hospital admissions.

METHOD

A systematic literature search was conducted in PubMed, Cochrane Library, PsychINFO and CINAHL published up to March 2017. To assess methodological quality of the included studies, the Oxford Centre of Evidence-Based Medicine grading system was used.

RESULTS

Thirteen studies were included in this review. There are indications that youth-ACT is effective in reducing severity of psychiatric symptoms, improving general functioning, and reducing duration and frequency of psychiatric hospital admissions.

CONCLUSIONS

The current literature on youth-ACT is limited but promising. There are indications that youth-ACT is effective in reducing severity of psychiatric symptoms, improving general functioning, and reducing duration and frequency of psychiatric hospital admissions. The effect of youth-ACT may be comparable with the effect of ACT in adults. Similar as in adult ACT, the studies on youth-ACT found effects that vary from small to large. Randomized experimental research designs are needed to further corroborate effectiveness.

HoNOSCA-D As a Measure of the Severity of Diagnosed Mental Disorders in Children and Adolescents-Psychometric Properties of the German Translation

The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), in use worldwide, is a 13-item measure assessing the biopsychosocial severity of mental health problems in children and adolescents. This article introduces the authorized German-language version of HoNOSCA, the HoNOSCA-D, and examines and discusses its psychometric properties based on a clinical sample of 1,533 children and adolescents aged 4;0 to 17;11 years. For the HoNOSCA-D total score (severity of mental health problems), internal consistency (Cronbach's alpha) was 0.63. The discriminative power of the items ranged from 0.07 to 0.44; the average interitem correlation was 0.11. Due to this stochastic independence, calculation of a total severity index is acceptable. Using factor analysis, the principal axis factoring and varimax rotation resulted in a four-factor structure, which with a Kaiser-Meyer-Olkin measure of sampling adequacy of 0.684 explained 30.62% of total variance. The convergent correlations with the German-language parent report version of the Strengths and Difficulties Questionnaire were as expected and showed a medium effect size. Gender and age differences in the HoNOSCA-D total score were small. Regarding the 13 items gender and age differences were negligible to medium. The highest severity was found for schizophrenia and psychotic disorders, followed by affective disorders and social behavior disorders. Overall, validity of HoNOSCA-D was clearly supported.

Predictors of rate of change for children and youth with emotional disorders: a naturalistic observational study

BACKGROUND

To examine demographic and clinical characteristics as potential predictors of change for children and youth with emotional disorders treated at two child and adolescent mental health outpatient services (CAMHS) in Norway.

METHODS

The study was of naturalistic observational type with "treatment as usual" (TAU). The sample consisted of 84 children and youth with emotional disorders. The Health of the Nation Outcome Scale (HONOSCA), and the Children's Global Assessment Scale (CGAS) were administered at intake (T0), during the assessment (T1) and approximately six months after assessment (T2). Change was analysed by means of the linear mixed models procedure.

RESULTS

For the HONOSCA total score, youths with a diagnosis of depression had statistically higher symptom severity levels at baseline and significantly lower change rates as compared to youths with an anxiety disorder.

CONCLUSIONS

The current study adds to the limited knowledge of predictors of rate of change for children and adolescents with emotional disorders treated within CAMHS. Our results point to a special need to improve clinical care for depressed children and adolescents. Important limitations comprising the external validity of the study concern missing data, a small study sample, and lack of information regarding the content and extent of the service provided.

Multi-dimensional Treatment Foster Care in England: differential effects by level of initial antisocial behaviour

Multi-dimensional Treatment Foster Care (MTFC), recently renamed Treatment Foster Care Oregon for Adolescents (TFCO-A) is an internationally recognised intervention for troubled young people in public care. This paper seeks to explain conflicting results with MTFC by testing the hypotheses that it benefits antisocial young people more than others and does so through its effects on their behaviour. Hard-to-manage young people in English foster or residential homes were assessed at entry to a randomised and case-controlled trial of MTFC (n = 88) and usual care (TAU) (n = 83). Primary outcome was the Children's Global Assessment Scale (CGAS) at 12 months analysed according to high (n = 112) or low (n = 59) baseline level of antisocial behaviour on the Health of the Nation Outcome Scales for Children and Adolescents. After adjusting for covariates, there was no overall treatment effect on CGAS. However, the High Antisocial Group receiving MTFC gained more on the CGAS than the Low group (mean improvement 9.36 points vs. 5.33 points). This difference remained significant (p < 0.05) after adjusting for propensity and covariates and was statistically explained by the reduced antisocial behaviour ratings in MTFC. These analyses support the use of MTFC for youth in public care but only for those with higher levels of antisocial behaviour. Further work is needed on whether such benefits persist, and on possible negative effects of this treatment for those with low antisocial behaviour.Trial Registry Name: ISRCTNRegistry identification number: ISRCTN 68038570Registry URL: www.isrctn.com.

Predictors and Moderators of Clinical Outcomes in Adolescents with Severe Mental Disorders After an Assertive Community Treatment

Previous studies have shown that stressful life events (SLEs), gender, social functioning and pretreatment severity are some of the predictors and/or moderators of treatment outcome in psychiatric care. The current study explored the effect of these predictors and moderators on the treatment outcome related to assertive community treatment (ACT) proposed to young people with severe mental disorders. 98 patients were assessed for externalizing and emotional difficulties, at admission and then at discharge of an ACT. Analyses revealed significant improvements in terms of symptomatology. In particular, regression analyses showed that pretreatment severity is a significant predictor of the outcome on emotional symptoms and is moderated by SLE on the outcome on externalizing symptoms. Furthermore, higher social functioning proved to predict better outcome on externalizing symptoms. Our results further evidence that these factors can explain inter-individual differences in outcome related to ACT. The theoretical and clinical implications of these results are discussed.

Assessment of the therapeutic alliance of youth and parents with team members in youth residential psychiatry

Although therapeutic alliance is widely acknowledged as a key component for therapeutic change, its role is almost unknown in youth residential psychiatry. A likely reason for the lack of research is the absence of assessment tools and procedures for youth residential settings. This study assesses the psychometric properties of the Dutch version of the Family Engagement Questionnaire (FEQ), an alliance measure completed by team members. In addition, agreement among team members is explored. Eleven youth psychiatric day and inpatient units participated. Parent counsellors and case managers of 86 patients from 6 to 17 years old reported on the therapeutic alliance. Exploratory factor analysis of team members' reports resulted in meaningful structures, with child and parent alliance scales primarily corresponding to the conceptualization of the developers and earlier factor analysis. Internal reliability and validity were good for most of the subscales. The hypothesis that team members would show low levels of agreement in their reports of the therapeutic alliance was confirmed, demonstrating the need to include multiple team members in assessment procedures. Overall, this study underscores the psychometric properties of the Dutch version of the FEQ. Team members in residential youth psychiatric settings are encouraged to reflect regularly with their colleagues on the youth and parent therapeutic alliance.

Evaluating change in symptomatic and functional level of children and youth with emotional disorders: a naturalistic observation study

The objective of the study is to describe the changes in symptomatic and functional impairment for children and youth with emotional disorders treated at child and adolescent mental health outpatient services (CAMHS) in Norway. The study was of naturalistic observational type in which the treatment can be classified as "treatment as usual" (TAU). The Strengths and Difficulties Questionnaire (SDQ), the Health of the Nation Outcome Scale (HONOSCA) and the Children's Global Assessment Scale (CGAS) were used as measures of change. The information from multiple informants allowed the evaluation of change from different perspectives. The sample consisted of 84 children and youth with emotional disorders treated at two CAMHS in the North of Norway. The SDQ, the HONOSCA and the CGAS were administered at intake (T0), during assessment (T1) and approximately, 6 months after T1 (T2). Change was analysed by means of the Linear Mixed Models procedure. The results show that children and youth with emotional disorders experience a statistically significant improvement per month during outpatient treatment according to nearly all the measures of change. For the clinician rated scores, change rates during active assessment/treatment were larger than during the waitlist period. Evaluating change from the perspective of clinical significance showed that only a small proportion of the subjects had change scores that were statistically reliable and clinically significant. Whether an actual change has occurred is uncertain for the majority of patients.

Home treatment – insbesondere für expansive Jungen?

Einleitung: Bisher finden sich wenige aussagekräftige Studien zur spezifischen Indikation und Effektivität von Home treatment (HT) bei kinder- und jugendpsychiatrischen Störungsbildern. Methodik: 92 Patienten, im Alter von 5–17 Jahren, wurden in einer Interventionsstudie (primäre Zielgröße: Verweildauer) in eine Interventions- (verkürzter stationärer Aufenthalt, gefolgt von intensivem HT verbunden mit fakultativ nutzbaren Klinikbehandlungselementen) und eine Kontrollgruppe (stationäre Regelbehandlung) randomisiert. Zielgrößen zu T1 (innerhalb von 14 Tagen nach Randomisierung), T2 (Abschluss der Behandlung) und T3 (∅ 8.4 Monats-Follow-up) waren: das psychosoziale Funktionsniveau (Children’s Global Assessment Scale [CGAS], Health of the Nation Outcome Scales for Children and Adolescents [HoNOSCA]), die Schwere der Symptomatik (Strengths and Difficulties Questionnaire [SDQ]) sowie das Ausmaß der Beeinträchtigung (Columbia Impairment Scale [CIS]). Anhand einer multiplen Regressionsanalyse wurde geprüft, inwiefern Behandlungssetting, Störungsbild, Alter oder Geschlecht Einfluss auf Behandlungseffektivität haben können. Ergebnisse: Bei Kindern überwogen externalisierende Störungsbilder, bei Jugendlichen internalisierende Störungsbilder. Patienten der Interventions- und der Kontrollgruppe benannten gleichermaßen einen positiven Behandlungserfolg von T1 nach T2. HT zeigte sich dabei signifikant effektiver bei Jugendlichen (versus Kindern; SDQ p = .017), Jungen (versus Mädchen; CIS p = .009, SDQ p < .001) und externalisierenden Störungsbildern (SDQ p = .005). Schlussfolgerung: Home treatment sollte bei Jungen mit externalisierenden Störungsbildern als Alternative zur stationären Aufnahme erwogen werden.

Clinical Utility of the 2 New Scales of the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA): A Naturalistic, Prospective Study in a Psychiatric Unit for Adolescents

OBJECTIVES

The goal of this study was to assess the clinical usefulness of the emotional symptoms (Emo) and externalizing problems (Ext) scales compared with the Total score on the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA).

METHODS

The HoNOSCA was rated at admission and discharge for 260 adolescent inpatients. The primary outcomes assessed were (a) the sensitivity of the 3 HoNOSCA scores to clinical improvement; and (b) the between diagnoses discriminative value of these scores.

RESULTS

Analyses of variances [2 (time: admission vs. discharge) × 5 (diagnostic groups)] revealed a main effect of time for the 3 scores, a main effect of the diagnostic group for the Total and Ext scores, and an interaction effect between time and diagnosis for the Emo score. A moderate correlation was observed between the change in Ext and Emo scores between admission and discharge.

DISCUSSION

These 2 new scales of the HoNOSCA demonstrated good clinical utility and the ability to assess different aspects of clinical improvements. A significant discriminative value of both scores was observed.

SIGNIFICANT OUTCOMES

The clinical utility of the 2 new scales on the HoNOSCA was established. These 2 new scales provided a sensitive measure of clinical outcome for assessing improvement between admission and discharge on a psychiatric inpatient unit for adolescents, regardless of diagnostic group, and captured additional information about clinical improvements. Adolescents with psychosis and conduct disorders presented with higher externalizing symptoms than those with other disorders, as rated on the HoNOSCA, at admission and discharge. The Emo score differentiated between clinical improvement in patients with psychosis versus eating disorders.

LIMITATIONS

The sample in this study represented a homogeneous population of adolescent inpatients, so that further research is needed before these findings can be generalized to outpatients. In addition, the small number of patients in some diagnostic groups did not allow for their inclusion in some of the statistical analyses.

Improving patient care for attention deficit hyperactivity disorder in children by organizational redesign (Tornado program) and enhanced collaboration between psychiatry and general practice: a controlled before and after study

Background

Implementation of clinical guidelines for diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents is a challenge in practice due to insufficient availability of mental health specialists and lack of effective cooperation with primary care physicians. The Tornado program aims to reduce time between referral and start of treatment in eligible patients. This study aims to assess the effectiveness and efficiency of this program.

Methods/design

This is a non-randomized controlled before-after study involving 90 outpatients (6-18 years old) suspected of uncomplicated ADHD, which were recruited by ten mental health teams. The Tornado program, provided by three teams, combines accelerated-track diagnosis and treatment planning. This is followed by psychoeducation at a mental health center and pharmacological treatment by primary care physicians, who received an online e-learning module for this purpose. The control group consists of patients of seven other teams, who receive care as usual. Primary outcome is the patients' time between referral to the mental health or pediatric center and start of treatment. Secondary outcomes include severity of ADHD symptoms; functional status; health-related quality of life; treatment adherence; indicators of diagnostic procedures and treatments; patient, parent, and professional experiences and satisfaction with care; and an economic evaluation. The study is powered to detect a difference of 36 days.

Discussion

This study will provide insight into the effectiveness and efficiency of the Tornado program, an accelerated-track program in mental healthcare.

Trial registration

Netherlands Trial Register http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2505. Trial status: active data collection.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0155-3) contains supplementary material, which is available to authorized users.

Clinical practitioner's attitudes towards the use of Routine Outcome Monitoring within Child and Adolescent Mental Health Services: a qualitative study of two Child and Adolescent Mental Health Services

Routine Outcome Monitoring (ROM) is held as a greatly important part of practice across many Health Care Services, both in the NHS and in private practice. Yet despite this, there has been little research into the attitudes of practitioners towards ROM. This paper looks at the attitudes of 50 clinicians from two Child and Adolescent Mental Health Services in greater London. The findings showed that although the practitioners were not overwhelming positive in their attitudes to ROM, neither were they overwhelming negative, and many of their concerns involved practical issues surrounding ROM that are potentially soluble. Practitioner engagement in ROM is key if ROM is to be used constructively to reflect on practice.

The French adaptation of the Health of the Nation Outcome Scale for Children and Adolescents Self-Rated Form (F-HoNOSCA-SR): validation and clinical routine use

The current study aimed to explore the validity of an adaptation into French of the self-rated form of the Health of the Nation Outcome Scales for Children and Adolescents (F-HoNOSCA-SR) and to test its usefulness in a clinical routine use. One hundred and twenty nine patients, admitted into two inpatient units, were asked to participate in the study. One hundred and seven patients filled out the F-HoNOSCA-SR (for a subsample (N=17): at two occasions, one week apart) and the strengths and difficulties questionnaire (SDQ). In addition, the clinician rated the clinician-rated form of the HoNOSCA (HoNOSCA-CR, N=82). The reliability (assessed with split-half coefficient, item response theory (IRT) models and intraclass correlations (ICC) between the two occasions) revealed that the F-HoNSOCA-SR provides reliable measures. The concurrent validity assessed by correlating the F-HoNOSCA-SR and the SDQ revealed a good convergent validity of the instrument. The relationship analyses between the F-HoNOSCA-SR and the HoNOSCA-CR revealed weak but significant correlations. The comparison between the F-HoNOSCA-SR and the HoNOSCA-CR with paired sample t-tests revealed a higher score for the self-rated version. The F-HoNSOCA-SR was reported to provide reliable measures. In addition, it allows us to measure complementary information when used together with the HoNOSCA-CR.

The use of HoNOSCA in a child and adolescent mental health service

OBJECTIVES

To assess the health and social functioning of patients attending a Child and Adolescent Mental Health Service (CAMHS) and to measure the impact of attendance using the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA).

METHOD

HoNOSCA was completed on 73 consecutive patients attending for initial assessment with a review assessment being completed after six months or at discharge from the clinic if this occurred sooner on 53 of these. The impact of attendance at the clinics was determined by comparing initial and review mean HoNOSCA Scores.

RESULTS

Of the 53, 66% were male and 34% female. Boys were more highly rated with regard to aggressive behaviour, performance in peer relationships and family life relationships whilst girls were rated as having more nonorganic and emotional symptoms. Older children showed the highest rates of poor school attendance, non accidental (self) injury and emotional problems while younger children showed the greatest aggressive behaviour and language skill problems. An improvement in the total HoNOSCA score from initial assessment to review was seen in 92%. There was an improvement in the HoNOSCA mean score from initial assessment to review.

CONCLUSIONS

Age, sex and symptom profiles of patients attending the service were similar to other CAMHS. Attendance at CAMHS produces improvements in patient outcomes over a six month period as measured using HoNOSCA, which proved to be a useful if somewhat time consuming tool.

Multidimensional Treatment Foster Care for Adolescents in English care: randomised trial and observational cohort evaluation

BACKGROUND

Children in care often have poor outcomes. There is a lack of evaluative research into intervention options.

AIMS

To examine the efficacy of Multidimensional Treatment Foster Care for Adolescents (MTFC-A) compared with usual care for young people at risk in foster care in England.

METHOD

A two-arm single (assessor) blinded randomised controlled trial (RCT) embedded within an observational quasi-experimental case-control study involving 219 young people aged 11-16 years (trial registration: ISRCTN 68038570). The primary outcome was the Child Global Assessment Scale (CGAS). Secondary outcomes were ratings of educational attendance, achievement and rate of offending.

RESULTS

The MTFC-A group showed a non-significant improvement in CGAS outcome in both the randomised cohort (n = 34, adjusted mean difference 1.3, 95% CI -7.1 to 9.7, P = 0.75) and in the trimmed observational cohort (n = 185, adjusted mean difference 0.95, 95% CI -2.38 to 4.29, P = 0.57). No significant effects were seen in secondary outcomes. There was a possible differential effect of the intervention according to antisocial behaviour.

CONCLUSIONS

There was no evidence that the use of MTFC-A resulted in better outcomes than usual care. The intervention may be more beneficial for young people with antisocial behaviour but less beneficial than usual treatment for those without.

Behandelt zu Hause Gesund werden

Fragestellung: Evaluation zweier Behandlungsformen für psychisch erkrankte Kinder und Jugendliche mit Indikation zur stationären Behandlung: (1) verkürzter stationärer Aufenthalt mit sich anschließender Hometreatmentbehandlung verzahnt mit Klinikelementen aus dem stationären Spektrum (BeZuHG = Behandelt zu Hause gesund werden) (2) stationäre Regelbehandlung (TAU). Methodik: 100 konsekutiv stationär aufgenommene Kinder und Jugendliche wurden in die Studie eingeschlossen und in die Interventionsgruppe (BeZuHG) oder die Kontrollgruppe (stationäre Behandlung) randomisiert. Soziodemographische Daten, ICD-10 und DSM-IV Diagnose, Fragebögen zum psychosozialen Funktionsniveau, Schwere der Symptomatik und Ausmaß der Beeinträchtigung vor und nach der Behandlung wurden erhoben und in Bezug auf Machbarkeit, Outcome, Kontaktfrequenz und Akzeptanz der Familien für beide Behandlungsformen evaluiert. Ergebnisse: Patienten der BeZuHG-Behandlung zeigten gleich gute Behandlungs-Ergebnisse wie stationär behandelte Patienten bei gleichzeitig signifikanter Reduktion der stationären Verweildauer in der BeZuHG-Gruppe. Eine Akzeptanz des BeZuHG-Settings war von den Familien gegeben, eine bessere Einbindung der Eltern in die Behandlung war möglich. Schlussfolgerungen: Sektorenübergreifende Konzepte sollten regelhaft in das Spektrum kinder- und jugendpsychiatrischer Behandlungen integriert werden. Weitere Evaluation ist erforderlich, die Stabilität des Behandlungsergebnisses muss in einem 1-Jahres-Follow-up überprüft werden.

Early tailored assertive community case management for hard-to-engage adolescents suffering from psychiatric disorders: an exploratory pilot study

AIM

The study aims to evaluate the effects of assertive community treatment (ACT) on the mental health and overall functioning of adolescents suffering from severe psychiatric disorders and who refuse any traditional child psychiatric care. There are a few studies evaluating the effects of ACT on a population of adolescents with psychiatric disorders. This short report highlights the impact of an ACT programme tailored to the needs of these patients, not only as an alternative to hospitalization, but also as a new form of intervention for patients that are difficult to engage.

METHODS

The effect of ACT on 35 adolescents using the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) as a measuring tool in pre- and post-intervention was evaluated.

RESULTS

The results show that the intervention was associated with a significant improvement on the HoNOSCA overall score, with the following items showing significant amelioration: hyperactivity/focus problems, non-organic somatic symptoms, emotional symptoms, scholastic/language skills, peer relationships, family relationships and school attendance.

CONCLUSION

ACT appears as a feasible intervention for hard-to-engage adolescents suffering from psychiatric disorders. The intervention seems to improve their mental health and functioning. This pilot study may serve as a basis to prepare a controlled study that will also take the costs of the intervention into account.

Measuring reliable change of emotional and behavioural problems in children

The purpose of this study was to estimate true treatment effect measured by clinicians using the Health of the Nation Outcome Scale for Children and Adolescent (HoNOSCA) corrected for regression to the mean (RTM), and for ceiling and floor effects. The present study was based on routine clinical data from a national database in which HoNOSCA is scored before and after therapy in order to show the treatment effect. We constructed a modified score to correct for the potential bias due to RTM, and used Generalized Linear Models analysis to adjust for the ceiling and floor effect. Our study showed that if these corrections are implemented in routine outcome measurement of children diagnosed with Hyperkinetic Disorder (HKD), the estimate of change in total HoNOSCA score after adjustment is clearly smaller in absolute value than the absolute difference estimate. If RTM and the ceiling/floor effect is ignored it will lead to misinterpretation of the results.

IQ as a moderator of outcome in severity of children's mental health status after treatment in outpatient clinics

BACKGROUND

Psychotherapy is an effective treatment for mental health disorders, but even with the most efficacious treatment, many patients do not experience improvement. Moderator analysis can identify the conditions under which treatment is effective or whether there are factors that can attenuate the effects of treatment.

METHODS

In this study, linear mixed model analysis was used to examine whether the Full Scale IQ (FSIQ), Performance IQ (PIQ) and Verbal IQ (VIQ) on the Wechsler Intelligence Scale for Children - Third Edition, moderated outcomes in general functioning and symptom load. A total of 132 patients treated at three outpatient child and adolescent mental health services (CAMHS) were assessed at three different time points. The Children's Global Assessment Scale (CGAS) and the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) were used to measure the severity of impairments in general functioning and symptom load. IQ was assessed at the start of treatment.

RESULTS

Moderator analysis revealed that the FSIQ × time interaction predicted changes in CGAS scores (p < .01), and that the PIQ × time interaction predicted changes in HoNOSCA scores (p < .05). The slopes and intercepts in HoNOSCA scores covaried negatively and significantly (p < .05). The same pattern was not detected for the CGAS scores (p = .08).

CONCLUSIONS

FISQ and PIQ moderated change in general functioning and symptom load, respectively. This implies that patients with higher IQ scores had a steeper improvement slope than those with lower scores. The patients with the highest initial symptom loads showed the greatest improvement, this pattern was not found in the improvement of general functioning.

Agreement on Web-based Diagnoses and Severity of Mental Health Problems in Norwegian Child and Adolescent Mental Health Services

OBJECTIVE

This study examined the agreement between diagnoses and severity ratings assigned by clinicians using a structured web-based interview within a child and adolescent mental health outpatient setting.

METHOD

Information on 100 youths was obtained from multiple informants through a web-based Development and Well-Being Assessment (DAWBA). Based on this information, four experienced clinicians independently diagnosed (according to the International Classification of Diseases Revision 10) and rated the severity of mental health problems according to the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) and the Children's Global Assessment Scale (C-GAS).

RESULTS

Agreement for diagnosis was κ=0.69-0.82. Intra-class correlation for single measures was 0.78 for HoNOSCA and 0.74 for C-GAS, and 0.93 and 0.92, respectively for average measures.

CONCLUSIONS

Agreement was good to excellent for all diagnostic categories. Agreement for severity was moderate, but improved to substantial when the average of the ratings given by all clinicians was considered. Therefore, we conclude that experienced clinicians can assign reliable diagnoses and assess severity based on DAWBA data collected online.

Translation and standardization of the HoNOSCA (Health of the Nation Outcome Scales for Children and Adolescents) scale in a Greek sample

The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) is a brief measure of outcomes. Evidence for the effectiveness of patient treatments conducted in mental health services is limited in Greece. Thus, in an attempt to employ an easily administered and valid outcome measure, to assess outcomes in clinical practice for children and adolescents, but also to be able to compare the results across countries, the HoNOSCA was the measure of choice. In this study we have translated and validated it in a Greek sample. We have investigated the inter-rater reliability, intraclass correlation, concurrent validity, and clinical change across time, of the HoNOSCA Greek translation. The results show that the Greek translation of HoNOSCA is a reliable and valid instrument. It can be used for clinical, managerial, research and audit purposes, but, most importantly, to facilitate multinational clinical research and comparison of data with other countries.

Benchmarking the cost efficiency of community care in Australian child and adolescent mental health services: implications for future benchmarking

OBJECTIVE

The purpose of this study was to benchmark the cost efficiency of community care across six child and adolescent mental health services (CAMHS) drawn from different Australian states.

METHOD

Organizational, contact and outcome data from the National Mental Health Benchmarking Project (NMHBP) data-sets were used to calculate cost per "treatment hour" and cost per episode for the six participating organizations. We also explored the relationship between intake severity as measured by the Health of the Nations Outcome Scales for Children and Adolescents (HoNOSCA) and cost per episode.

RESULTS

The average cost per treatment hour was $223, with cost differences across the six services ranging from a mean of $156 to $273 per treatment hour. The average cost per episode was $3349 (median $1577) and there were significant differences in the CAMHS organizational medians ranging from $388 to $7076 per episode. HoNOSCA scores explained at best 6% of the cost variance per episode.

CONCLUSIONS

These large cost differences indicate that community CAMHS have the potential to make substantial gains in cost efficiency through collaborative benchmarking. Benchmarking forums need considerable financial and business expertise for detailed comparison of business models for service provision.

Admissions to acute adolescent psychiatric units: a prospective study of clinical severity and outcome

BACKGROUND

Several countries have established or are planning acute psychiatric in-patient services that accept around-the-clock emergency admission of adolescents. Our aim was to investigate the characteristics and clinical outcomes of a cohort of patients at four Norwegian units.

METHODS

We used a prospective pre-post observational design. Four units implemented a clinician-rated outcome measure, the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), which measures mental health problems and their severity. We collected also data about the diagnoses, suicidal problems, family situations, and the involvement of the Child Protection Service. Predictions of outcome (change in HoNOSCA total score) were analysed with a regression model.

RESULTS

The sample comprised 192 adolescents admitted during one year (response rate 87%). Mean age was 15.7 years (range 10-18) and 70% were girls. Fifty-eight per cent had suicidal problems at intake and the mean intake HoNOSCA total score was 18.5 (SD 6.4). The largest groups of main diagnostic conditions were affective (28%) and externalizing (26%) disorders. Diagnoses and other patient characteristics at intake did not differ between units. Clinical psychiatric disorders and developmental disorders were associated with severity (on HoNOSCA) at intake but not with outcome. Of adolescents ≥ 16 years, 33% were compulsorily admitted. Median length of stay was 8.5 days and 75% of patients stayed less than a month. Compulsory admissions and length of stay varied between units. Mean change (improvement) in the HoNOSCA total score was 5.1 (SD 6.2), with considerable variation between units. Mean discharge score was close to the often-reported outpatient level, and self-injury and emotional symptoms were the most reduced symptoms during the stay. In a regression model, unit, high HoNOSCA total score at intake, or involvement of the Child Protection Service predicted improvement during admission.

CONCLUSIONS

Acute psychiatric in-patient units for adolescents effectively meet important needs for young people with suicidal risks or other severe mental health problems. These units may act in suicide prevention, stabilizing symptom severity at a lower level within a short stay. It is important to explore the differences in outcome, compulsory admissions, and length of stay between units.

Evaluating the outcomes of adolescent day programs in an Australian child and adolescent mental health service

Adolescent day programs (ADPs) are an increasingly used approach to treating adolescents with mental health issues. However, there is a dearth of studies empirically examining the outcomes of adolescent day programs. This study retrospectively examined the mental health functioning of 84 adolescents, pre- and post-treatment, who in addition to their ongoing outpatient treatment had participated in an ADP during a five-year period. Their functioning was compared to matched adolescents who participated only in outpatient treatment during the same time period. Statistical and clinical examinations revealed the reported outcomes following ADP treatment were at least comparable, and sometimes significantly better, when compared to the reported outcomes following outpatient treatment excluding ADP involvement. This study, while having some methodological shortcomings, provides some evidence for the efficacy of ADPs.

On the meaning of change in a clinician's routine measure of outcome: HoNOSCA

OBJECTIVE

With the advent of routine outcomes across Australia and New Zealand, clinicians, managers, parents and children will be interested in change on these measures. This paper presents a number of approaches and the implications.

METHOD

Health of the Nations Outcome Scales for Children and Adolescents (HoNOSCA) collected during clinical practice for 911 patients were examined for changes over time, clinical significance, treatment status, effect size, and reliable and clinically significant change.

RESULTS

Statistically significant changes in symptom severity were found related to treatment status and to changes in the number of clinically significant scales. An effect size of almost one standard deviation was noted and the proportion of patients who improved was examined. While the reliable change index was calculated, there are clinical complications with this approach. The impact of the capacity to change on specific scales illustrates a critical issue in describing outcomes.

CONCLUSION

From a number of perspectives, change in HoNOSCA total and scale scores is valid. However, several clinical dilemmas must be faced in deciding which approach should be used. The implications of these choices may affect clinicians, patients, carers and managers in understanding change.

Clinician-rated mental health in outpatient child and adolescent mental health services: associations with parent, teacher and adolescent ratings

BACKGROUND

Clinician-rated measures are used extensively in child and adolescent mental health services (CAMHS). The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) is a short clinician-rated measure developed for ordinary clinical practice, with increasing use internationally. Several studies have investigated its psychometric properties, but there are few data on its correspondence with other methods, rated by other informants. We compared the HoNOSCA with the well-established Achenbach System of Empirically Based Assessment (ASEBA) questionnaires: the Child Behavior Checklist (CBCL), the Teacher's Report Form (TRF), and the Youth Self-Report (YSR).

METHODS

Data on 153 patients aged 6-17 years at seven outpatient CAMHS clinics in Norway were analysed. Clinicians completed the HoNOSCA, whereas parents, teachers, and adolescents filled in the ASEBA forms. HoNOSCA total score and nine of its scales were compared with similar ASEBA scales. With a multiple regression model, we investigated how the ASEBA ratings predicted the clinician-rated HoNOSCA and whether the different informants' scores made any unique contribution to the prediction of the HoNOSCA scales.

RESULTS

We found moderate correlations between the total problems rated by the clinicians (HoNOSCA) and by the other informants (ASEBA) and good correspondence between eight of the nine HoNOSCA scales and the similar ASEBA scales. The exception was HoNOSCA scale 8 psychosomatic symptoms compared with the ASEBA somatic problems scale. In the regression analyses, the CBCL and TRF total problems scores together explained 27% of the variance in the HoNOSCA total scores (23% for the age group 11-17 years, also including the YSR). The CBCL provided unique information for the prediction of the HoNOSCA total score, HoNOSCA scale 1 aggressive behaviour, HoNOSCA scale 2 overactivity or attention problems, HoNOSCA scale 9 emotional symptoms, and HoNOSCA scale 10 peer problems; the TRF for all these except HoNOSCA scale 9 emotional symptoms; and the YSR for HoNOSCA scale 9 emotional symptoms only.

CONCLUSION

This study supports the concurrent validity of the HoNOSCA. It also demonstrates that parents, teachers and adolescents all contribute unique information in relation to the clinician-rated HoNOSCA, indicating that the HoNOSCA ratings reflect unique perspectives from multiple informants.

The Effectiveness of a Community Intensive Therapy Team on Young People's Mental Health Outcomes

BACKGROUND

  UK-wide concerns about availability, cost, efficacy and inappropriate use of psychiatric inpatient provision for adolescents have led to the development of new models of intensive community based care.

METHOD

  This paper describes the Fife Intensive Therapy Team (FITT) model and provides an analysis of HoNOSCA (Health of the Nation Outcomes Scale for Children and Adolescents) data for 57 patients to evaluate the effectiveness of the service.

RESULTS

  Following intervention by the FITT, a substantial and significant reduction in HoNOSCA scores was recorded.

CONCLUSIONS

  The apparent success of the model has implications for the future development of acute mental health services for young people.

Depressive disorders among adolescents managed in a child and adolescent mental health service

OBJECTIVE

The aims were to describe the prevalence and treatment of depressive disorders among case-managed adolescents attending a regional Child and Adolescent Mental Health Service (CAMHS).

METHOD

An observational study was conducted in a regional CAMHS over a 3-month period. Clinicians recorded treatment of their case-managed adolescents aged 12-18 years at the end of each calendar month. The Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) and Children's Global Assessment Scale (CGAS) were collected at the beginning of the study period or at entry into the service, and repeated at discharge from the service or at the conclusion of the study period. Adolescents also completed the Reynold's Adolescent Depression Scale, 2nd edition.

RESULTS

Depressive disorders were the most common clinician diagnosis reported (22%). There was no statistically significant difference in treatment for depressed compared to non-depressed adolescents. There was a statistically significant improvement in both the HoNOSCA scores (p <0.001) and CGAS scores (p <0.001) for the whole sample.

CONCLUSION

Treatment appeared to be the same in type for depressed compared to non-depressed adolescents case managed within CAMHS.

An examination of frequent nursing interventions and outcomes in an adolescent psychiatric inpatient unit

Little is known about which nursing interventions used in adolescent psychiatric inpatient treatment demonstrate improvements in outcome in the 'real world' setting, despite an increase in external outcomes reporting requirements.This paper examines nursing and other multidisciplinary interventions commonly used at the Youth Inpatient Unit, Christchurch, New Zealand, in relation to improvements in outcomes as measured by the Health of the Nation Outcome Scales for Children and Adolescents, utilizing data gathered prospectively as part of an ongoing quality assurance and outcomes project. We found the majority of interventions investigated were utilized equally across diagnostic groups, although stress management and problem-solving education was used more for patients with mixed affective disorders. Further, the results contribute to growing evidence toward the value of providing medication and problem-solving education to this population. Mental health nurses working with children and adolescents should be supported to utilize and develop their unique skill set to offer targeted interventions and to examine their practice to identify the most valuable interventions for their patients within this developmental context.

The child and adolescent psychiatry trials network (CAPTN): infrastructure development and lessons learned

BACKGROUND

In 2003, the National Institute of Mental Health funded the Child and Adolescent Psychiatry Trials Network (CAPTN) under the Advanced Center for Services and Intervention Research (ACSIR) mechanism. At the time, CAPTN was believed to be both a highly innovative undertaking and a highly speculative one. One reviewer even suggested that CAPTN was "unlikely to succeed, but would be a valuable learning experience for the field."

OBJECTIVE

To describe valuable lessons learned in building a clinical research network in pediatric psychiatry, including innovations intended to decrease barriers to research participation.

METHODS

The CAPTN Team has completed construction of the CAPTN network infrastructure, conducted a large, multi-center psychometric study of a novel adverse event reporting tool, and initiated a large antidepressant safety registry and linked pharmacogenomic study focused on severe adverse events. Specific challenges overcome included establishing structures for network organization and governance; recruiting over 150 active CAPTN participants and 15 child psychiatry training programs; developing and implementing procedures for site contracts, regulatory compliance, indemnification and malpractice coverage, human subjects protection training and IRB approval; and constructing an innovative electronic casa report form (eCRF) running on a web-based electronic data capture system; and, finally, establishing procedures for audit trail oversight requirements put forward by, among others, the Food and Drug Administration (FDA).

CONCLUSION

Given stable funding for network construction and maintenance, our experience demonstrates that judicious use of web-based technologies for profiling investigators, investigator training, and capturing clinical trials data, when coupled to innovative approaches to network governance, data management and site management, can reduce the costs and burden and improve the feasibility of incorporating clinical research into routine clinical practice. Having successfully achieved its initial aim of constructing a network infrastructure, CAPTN is now a capable platform for large safety registries, pharmacogenetic studies, and randomized practical clinical trials in pediatric psychiatry.

Physical aggression during admission to a child and adolescent inpatient unit: predictors and impact on clinical outcomes

OBJECTIVE

Aggressive behaviour is common in young people admitted to child and adolescent inpatient services. Little is known about how physical aggression during admission influences patient outcomes. The aim of the present study was to identify predictors of aggression in a child and adolescent inpatient unit and examine differences in clinical outcomes between aggressive and non-aggressive patients.

METHOD

Episodes of aggression occurring within a child and adolescent inpatient unit were prospectively documented between October 2004 and December 2005. Patient factors (demographics, diagnoses, clinical history) were examined as predictors of aggression. Outcomes for admissions in which more than one episode of physical aggression occurred were compared to those in which no aggression occurred. Outcomes assessed were changes in symptom severity (as rated by the Health of the Nation Outcome Scales for Children and Adolescents) length of stay, and initiation of medications.

RESULTS

A total of 134 patients were admitted during the study period (61.9% female, mean age=13.8 years, SD=2.9); 31 patients (23.1%) exhibited physical aggression during admission and 20 of these exhibited more than one episode of physical aggression. Factors that predicted persistent physical aggression included history of aggression, use of medications at presentation and absence of self-harm. Persistent aggression was also associated with increased length of stay, but did not compromise improvements in clinical symptom ratings between admission and discharge or lead to increased medication prescribing.

CONCLUSION

Contrary to hypotheses and existing research, aggression during admission does not appear to be a barrier to clinical improvement. Further research is necessary to clarify how aggressive children can receive the most benefit from inpatient admission while minimizing the risks to the patient and those around them.

Use of the HoNOSCA scale in the teamwork of inpatient child psychiatry unit

The aims of this study were to introduce the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) into the clinical practice, to assess the possibilities to use HoNOSCA in the interdisciplinary teamwork of child psychiatric inpatient unit and to analyse differences in evaluation of HoNOSCA among team members scoring different diagnostic groups of children. HoNOSCA was translated into Lithuanian and team members were trained to use the scale. Inter-rater reliabilities between various pairs of specialists and between all members of the team were calculated using intraclass correlations calculated for each item of the scale and total score. Scoring differences in children with externalized and internalized disorders between psychiatrists-psychologists versus nurses-caretakers were analysed using t-test. The analysis showed that intraclass correlations estimates of reliability of the HoNOSCA discharge scores were highest for ratings by child psychiatrists-psychologists and nurses-caretakers. Analysis of ratings of patients with externalized and internalized disorders types showed differences in scoring disruptive/aggressive behaviours, self-care and family relationship scales. HoNOSCA had satisfactory inter-rater reliability in clinical multidisciplinary practice of child psychiatric inpatient unit. Implementing HoNOSCA in routine clinical practice and analysis of the rating differences among the multidisciplinary team members was useful to highlight possibilities for improvement of quality of services provided and building more constructive teamwork.