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Tracking Children’s Mental Health in the 21st Century: Lessons from the 2014 OCHS

Tracking Children’s Mental Health in the 21st Century: Lessons from the 2014 OCHS Canadian Psychiatric Association Association des psychiatres du Canada Perspective The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2019, Vol. 64(4) 232-236 Tracking Children’s Mental Health ª The Author(s) 2019 in the 21st Century: Lessons from Article reuse guidelines: sagepub.com/journals-permissions the 2014 OCHS DOI: 10.1177/0706743719830025 TheCJP.ca | LaRCP.ca 1 1,2 Michael H. Boyle, PhD , Laura Duncan, MA , 1 3,4 Katholiki Georgiades, PhD , Jinette Comeau, PhD , 4,5 6 7 Graham J. Reid, PhD , Warren O’Briain, MA , Robert Lampard, PhD , and Charlotte Waddell, MSc, MD, FRCP(C) ; 2014 Ontario Child Health Study Team Keywords children’s mental health, policy, data, information systems In July 2018, the only fiscal commitment retained by the children’s mental health services. At the heart of these defi- newly elected conservative government in Ontario from the ciencies is the lack of information on: 1) the prevalence of previous liberal government was to mental health and addic- children’s mental health problems in Ontario, and 2) the tions. This commitment acknowledges Ontario’s concerns characteristics and outcomes of children receiving mental about the challenges surrounding mental health in the pop- health services. In combination, the 1983 and 2014 Ontario ulation—concerns raised by the Auditor General of Ontario Child Health Studies (OCHS) addressed this lack of infor- in 2016 and Provincial Advocate for Children and Youth in mation by identifying: 1) changes in the prevalence and 2012 that draw attention to deficiencies associated with determinants of child and youth mental disorder over the Offord Centre for Child Studies & Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada Department of Sociology, King’s University College at Western University, London, Ontario, Canada Children’s Health Research Institute, Children’s Health and Therapeutics, Western University, London, Ontario, Canada Departments of Psychology, Family Medicine, and Paediatrics, Western University, London, Ontario, Canada British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada Child and Youth Mental Health Policy Branch, British Columbia Ministry of Children and Family Development, Victoria, British Columbia, Canada Children’s Health Policy Centre Faculty of Health Sciences Simon Fraser University, Vancouver, British Columbia, Canada (in alphabetical order) Tracie O. Afifi (University of Manitoba), William R. Avison (Western University), Kathryn Bennett (McMaster University), Terry Bennett (McMaster University), Khrista Boylan (McMaster University), Michael H. Boyle (McMaster University), Michelle Butt (McMaster University), John Cairney (University of Toronto), Corine Carlisle (University of Toronto), Kristin Cleverley (Centre for Addiction and Mental Health, University of Toronto), Ian Colman (University of Ottawa), Jinette Comeau (King’s University College at Western University), Charles Cunningham (McMaster University), Scott Davies(University of Toronto), Claire de Oliveira (Centre for Addiction and Mental Health, University of Toronto), Melanie Dirks (McGill University), Eric Duku (McMaster University), Laura Duncan (McMaster University), Jim Dunn (McMaster University), Mark A. Ferro (University of Waterloo), Katholiki Georgiades (McMaster University), Stelios Georgiades (McMaster University), Andrea Gonzalez (McMaster University), Geoffrey Hall (McMaster University), Joanna Henderson (Centre for Addiction and Mental Health, University of Toronto), Magdalena Janus (McMaster University), Jennifer Jenkins (University of Toronto),Melissa Kimber (McMaster University), Ellen Lipman (McMaster University), Harriet MacMillan (McMaster University), Ian Manion (Royal’s Institute of Mental Health Research), John McLennan (University of Ottawa), Amelie Petitclerc (Northwestern University), Anne Rhodes (University of Toronto), Graham Reid (Western University), Peter Rosenbaum (McMaster University), Roberto Sassi (McMaster University), Louis Schmidt (McMaster University), Cody Shepherd (Simon Fraser University), Noam Soreni (McMaster University), Peter Szatmari (Centre for Addiction and Mental Health, Hospital for Sick Children, University of Toronto), Brian Timmons (McMaster University), Juliana Tobon (McMaster University), Ryan Van Lieshout (McMaster University), Charlotte Waddell (Simon Fraser University), Li Wang (McMaster University), Christine Wekerle (McMaster University). Corresponding Author: Laura Duncan, MA, Offord Centre for Child Studies & Department of Psychiatry & Behavioural Neurosciences, McMaster University, 1280 Main Street West, MIP 201A, Hamilton Ontario L8S 4K1, Canada. Email: duncanlj@mcmaster.ca La Revue Canadienne de Psychiatrie 64(4) 233 past 30 years, and 2) the continuing challenges with access There appears to have been a geographic shift in the preva- 4-10 and targeting of children’s mental health services. lence of disorder from large urban areas to small-medium 8,9 The overall goal of health policies and programs in urban and rural areas. Finally, concerns persist about Canada to improve population health should be guided by access to mental health agencies among children identified 2 basic principles: accountability (being answerable for with disorder: although the proportion of children with men- meeting defined objectives) and equity (reduction in poor tal disorder having service contact increased from 1983 to 12 5,8 health among disadvantaged groups). Ontario can stay true 2014, most remained without contact. The dramatic to these principles and constructively address the weak- changes in children’s mental health documented by the nesses that continue to undermine the effective provision 2014 OCHS indicate that core information on children’s of children’s mental health services in 2 ways: 1) by devel- mental health in the general population is needed at more oping an information system that measures children’s mental frequent intervals than 30 years. health in the general population every 5 years, and 2) by incorporating identical measurement into intake and Limited Information Recorded on follow-up assessments of all children accessing provincially Children’s Mental Health funded, community-based mental health agencies. These measures could be used in tandem to monitor the success In Ontario, children with mental health challenges access of our provincial response to children’s mental health needs community-based mental health agencies by way of referral and identify specific changes needed, ensuring that services (general practitioners, centralized intake) or direct requests for are responsive to the configuration of needs in the general help. Within these agencies, psychiatrists, psychologists, and population. This would be achieved by testing for parallel social workers collect information on children’s mental health changes in the epidemiology of childhood mental disorders relevant to their practice. However, there is no provision among children in the general population, and those acces- across agencies to collect the same measures of children’s sing services at children’s mental health agencies. mental health that could be used system-wide to examine the This commentary: 1) summarizes findings from the 2014 characteristics of those accessing services or the benefits OCHS to argue that core measures of children’s mental accrued by doing so. The administrative information most health be collected in the general population at regular inter- relevant to understanding children’s mental health in Ontario vals; 2) points out the limited information recorded on the is limited to diagnoses recorded by physicians at each visit mental health of children accessing community-based men- and related billing codes for services provided. This informa- tal health agencies, to argue that core measures be adminis- tion limits the identification of children with mental health tered to all children at baseline and follow-up; 3) explains challenges to the minority accessing walk-in clinics, urgent the value of collecting identical information in the general care, emergency rooms, hospitals, and physician practices. In population and community-based children’s mental health addition, the failure to implement standard assessment meth- agencies; 4) describes the content, requirements (practical ods has led to varying degrees of reliability and validity for the and scientific), and operational features for the core mea- information collected. Although health-information sures; 5) demonstrates how the core measures can be used to abstracted from administrative records has important, specific improve decision making aligned with the basic health prin- uses for health services research, it is not a viable option for ciples underlying policies and programs; and 6) concludes assessing or ensuring public accountability. with a brief summary. Although Ontario is home to the 1983 and 2014 OCHS, we believe that this commentary has broad Alignment of Core Children’s Mental relevance to other provinces and territories in Canada. Health Measures In the study of children’s mental health, there is a deep divide 2014 OCHS—Changes in Children’s Mental between the evidence and inferences on health system perfor- Health mance obtained in general population studies, such as the “Change between 1983 and 2014” is a powerful, recurring 2014 OCHS, and administrative data cumulated by service 8,9 theme in the OCHS papers. The proportion of males aged providers on patients. Differences in the approaches to defin- 4 to 11 years with attention-deficit/hyperactivity disorder ing children’s mental health and in the methods of assessment has jumped dramatically. In adolescence, there has been a and sampling of respondents have made it impossible to steep increase in anxiety and depression among males and assess the policies, programs, and services developed by gov- females and a substantial decrease in the prevalence of con- ernments to address children’s mental health needs among the duct disorder among males. The prevalence of disorder general population and for those accessing community-based among children in immigrant v. non-immigrant families mental health agencies. These 2 approaches could be aligned dropped by almost 50% from 1983, and there is strong by collecting a core set of children’s mental health measures evidence that children in poor households are at elevated in the general population and that in the subset of children risk for disorder when this occurs in combination with con- accessing community-based children’s mental health agen- textual factors like neighbourhood antisocial behaviour. cies. Such alignment would provide the information needed 234 The Canadian Journal of Psychiatry 64(4) to understand the scope of children’s mental health needs in by Statistics Canada (Canadian Health Survey of Children and 21 22 the general population and the adequacy of provincial Youth, Canadian Community Health Survey ); or identify responses to meet these needs. simple, unique data collection mechanisms through the inter- net or school-based anonymous assessments. We see this instrument being implemented in service agencies at intake and at the 3- or 6-month follow-up, depending on service Content, Prerequisites and Organization of length. To implement these assessments consistently, agencies a Children’s Mental Health Information would require investments in change management methods to System overcome resistance among those opposed to modifying their We believe that the core measures of children’s mental data collection processes, as well as investments into adequate, health should include 3 indicators: 1) emotional and beha- longer-term funding to support data analysis to address these vioural problems, measured as both dimensional and cate- system evaluation questions. gorical phenomena; 2) a perceived need for professional help In work associated with the 2014 OCHS, we have shown with emotional or behavioural problems; and 3) the level of that self-completed questionnaires can meet all of the functioning represented as academic achievement and social requirements discussed above and that brief problem check- competence. Although there are various ways to conceptua- lists, developed to measure children’s mental disorders as 15,16 lize children’s mental disorder, there is a general con- dimensional phenomena, can be converted to binary mea- sensus among child psychiatrists, psychologists, and service sures of mental disorder (categories) that achieve levels of providers that assessments of child mental health need to reliability and validity comparable to standardized diagnos- 17,18 revolve around problems of emotion and behaviour. The tic interviews implemented by lay interviewers in general- 23,24 underlying continua of these problem behaviours (number, population studies. An example questionnaire that intensity, frequency) provide direct insight into the severity includes measures of mental health disorder symptoms and of the mental disorder. In contrast, perceived need may be perceived need for help appears in the Appendix. linked more closelytohelpseeking andthe potentialto benefit from services provided. It speaks to child, youth, Improved Decision Making and parent subjective recognition of mental health problems. Indicators of functioning focus on elements of human capa- How might this information system be used to better align bility that are essential for engaged, productive and fulfilled policy decisions with the underlying health principles adopted lives. However, if compromised by mental disorder, they by government? In general, this system would provide the must be addressed in our service response. evidence needed to evaluate the extent to which these princi- The core indicators of the information system should: 1) be ples are operating in practice. For example, at the population operationalized in a single instrument that demonstrates reli- level, the system would track changes over time in child able and valid measurement; 2) be inexpensive and practical to mental health, its geographic distribution, and its socioeco- implement in general population surveys and as part of intake nomic determinants. On its own, population-level information and follow-up assessments completed by service agencies; 3) would provide core data for evaluating the effects of major pose minimal burden to respondents and service practitioners; government policy and program initiatives associated with and 4) represent the perspectives of youth and families on prevention and treatment (improved health outcomes) on chil- important mental health outcomes. We believe that these dren’s mental health, and inform government about changes requirements can be met by a questionnaire that is self- in socioeconomic gradients for child mental health (health completed by parents of children aged 4 to 17 and youth aged equity). Coupled with identical assessments obtained by ser- 12 to 17 in less than 7 or 8 min—a time threshold at which vice providers, the system would quantify the responsiveness survey completion rates start to drop-off. This type of instru- of community-based children’s mental health agencies to pop- ment is inexpensive to implement; poses little time burden to ulation shifts in children’s mental health need (accountabil- respondents; can be completed in almost any setting and ity). At the individual level, routine intake and follow-up adapted to various modes of administration (e.g., in person via assessments would provide evidence to assess change among tablet/computer, internet); can be computerized to eliminate children accessing community-based mental health services data entry costs; can be implemented in mental health agencies (improved health outcomes). with little involvement of service practitioners; and can be Aggregating population-level information on the service incorporated into general population surveys at modest addi- catchment area needs of children’s mental health would pro- tional cost. We see this instrument being implemented in the vide estimates of the needs of independent catchment areas. general population at 5-year cycles—a time interval suitable Bringing together these area estimates of children’s mental for identifying constancy or change in mental health need— health need with identical information collected by chil- and sampling children with enough precision in census bound- dren’s mental health service agencies could be used to assess aries associated with service catchment areas to provide reli- the principle of accountability by evaluating service access able estimates of population need. This cycle could either among children in the general population with mental health capitalize on existing data collection opportunities provided needs. This would provide estimates of coverage (the La Revue Canadienne de Psychiatrie 64(4) 235 percentage of the children in catchment areas receiving ser- Declaration of Conflicting Interests vices) and service targeting (the percentage of children The primary authors (MB, LD, KG, JC, GR, WB, RL and CW) receiving services meeting criteria for need). Bringing declared no potential conflicts of interest with respect to the together catchment area estimates of children’s mental research, authorship, and/or publication of this article. health need with service expenditure and resource alloca- tions could be used to assess the extent to which geographic Funding expenditures and human resource allocation match general The author(s) disclosed receipt of the following financial support population needs (equity). for the research, authorship, and/or publication of this article: During the preparation of this manuscript, Dr. Waddell was sup- ported by the Canada Research Chairs program; Dr. Georgiades Summary was supported by the David R. (Dan) Offord Chair in Child Studies There are high levels of children’s mental health need in and Dr. Reid was supported by the Children’s Health Research Institute, London, ON. the general population, temporal shifts in the configurations of mental disorders experienced by children and youth, and important information gaps about who receives community- ORCID iD based mental health services from agencies in Ontario and Laura Duncan, MA https://orcid.org/0000-0001-7120-6629 the types of services that are obtained by children. An infor- mation system that uses an identical instrument to measure Supplemental Material children’s mental health in the general population and in Supplemental material for this article is available online. children receiving mental health services would provide government policy makers with the evidence to assess the References extent to which the principles of accountability and equity apply to the provision of children’s mental health services. 1. Rapid policy update: Ontario PC party platform. 2018. Avail- Although many different factors influence policy develop- able from: https://occ.ca/rapidpolicy/ontario-pc-party-plat ment, evidence can only contribute to the process if the form-2018/ (Cited 2018 Nov 17). appropriate information is available. 2. Queens Printer for Ontario. Office of the Auditor General of Ontario has provided needed leadership in the past—the Ontario. 2016 Annual Report. Ottawa (ON): Queens Printer for Ontario Ministry of Community and Social Services com- Ontario; 2016:111-147. missioned the 1983 OCHS. Along with the Canadian Insti- 3. Provincial Advocate for Children and Youth. 2011/2012 tutes for Health Research, 3 Ontario ministries (Health, Report to the Legislature. Toronto, ON: Provincial Advocate Education, Children and Youth Services) contributed funds for Children and Youth; 2012. to the 2014 OCHS. The Ontario Ministry of Children and 4. Boyle MH, Offord DR, Hofmann HF, et al. Ontario child Youth Services introduced the idea of core measures by health study: I. methodology. Arch Gen Psychiatry. 1987; requesting children’s mental health centres to implement the 44(9):826-831. Brief Child and Family Phone Interview and Child and 5. Offord DR, Boyle MH, Szatmari P, et al. Ontario Child Health Adolescent Functional Assessment Scale between 1999 Study: II. Six-month prevalence of disorder and rates of service and 2015. The information system proposed here constitutes utilization. Arch Gen Psychiatry. 1987;44(9):832-836. little time burden on service practitioners and no impediment 6. Boyle MH, Offord DR. Prevalence of childhood disorder, per- to the collection of clinical information most relevant to their ceived need for help, family dysfunction and resource alloca- practice and objectives. There would certainly be start-up tion for child welfare and children’s mental health services in challenges to overcome associated with informed consent; Ontario. Can J of Behav Sci. 1988;20:374-388. the protection of privacy; the institution of consistent meth- 7. Boyle MH, Georgiades K, Duncan L, et al. The 2014 ods for collecting, processing and transmitting data for Ontario Child Health Study—Methodology. Can J Psychia- system-wide evaluation; and the establishment of ways for try. Forthcoming. individual agencies to track outcomes if practitioners and 8. Georgiades K, Duncan L, Wang L, et al. Six-month prevalence administrators wished to do so. These challenges are well of mental disorders and service contacts among children and worth addressing in view of the potential benefits to plan- youth in Ontario: evidence from the 2014 Ontario Child Health ning associated with the proposed information system. Study. Can J Psychiatry. Forthcoming. Surely it is time be strategic in our planning for children’s 9. Comeau J, Georgiades K, Wang L, et al. Changes in the mental health, linking what we do (process) to what we prevalence of child mental disorders and perceived need for achieve (outcomes) with the goal of better addressing chil- professional help between 1983 and 2014: evidence from the dren’s mental health needs. Ontario Child Health Study. Can J Psychiatry. Forthcoming. 10. Duncan L, Georgiades K, Birch S, et al. Children’s mental Acknowledgements health need and expenditures in Ontario: Findings from the 2014 Ontario Child Health Study. Can J Psychiatry. The authors would like to acknowledge Nancy Pyette for technical assistance with editing and proofreading the manuscript. Forthcoming. 236 The Canadian Journal of Psychiatry 64(4) 11. Deber R. Thinking about accountability. Healthc Policy. 2014; 22. Statistics Canada. Canadian Community Health Survey: 10(SP):12-24. Annual component (CCHS), Ottawa (ON): Statistics Canada; 12. Lane H, Sarkies M, Martin J, et al. 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Ottawa (ON): Statistics Canada; 2018. port_Final.pdf (Cited 2018 Nov 17). http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie Pubmed Central

Tracking Children’s Mental Health in the 21st Century: Lessons from the 2014 OCHS

Boyle, Michael H.; Duncan, Laura; Georgiades, Katholiki; Comeau, Jinette; Reid, Graham J.; O’Briain, Warren; Lampard, Robert; Waddell, Charlotte; ,
Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie , Volume 64 (4) – Apr 12, 2019
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1497-0015
DOI
10.1177/0706743719830025
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Abstract

Canadian Psychiatric Association Association des psychiatres du Canada Perspective The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2019, Vol. 64(4) 232-236 Tracking Children’s Mental Health ª The Author(s) 2019 in the 21st Century: Lessons from Article reuse guidelines: sagepub.com/journals-permissions the 2014 OCHS DOI: 10.1177/0706743719830025 TheCJP.ca | LaRCP.ca 1 1,2 Michael H. Boyle, PhD , Laura Duncan, MA , 1 3,4 Katholiki Georgiades, PhD , Jinette Comeau, PhD , 4,5 6 7 Graham J. Reid, PhD , Warren O’Briain, MA , Robert Lampard, PhD , and Charlotte Waddell, MSc, MD, FRCP(C) ; 2014 Ontario Child Health Study Team Keywords children’s mental health, policy, data, information systems In July 2018, the only fiscal commitment retained by the children’s mental health services. At the heart of these defi- newly elected conservative government in Ontario from the ciencies is the lack of information on: 1) the prevalence of previous liberal government was to mental health and addic- children’s mental health problems in Ontario, and 2) the tions. This commitment acknowledges Ontario’s concerns characteristics and outcomes of children receiving mental about the challenges surrounding mental health in the pop- health services. In combination, the 1983 and 2014 Ontario ulation—concerns raised by the Auditor General of Ontario Child Health Studies (OCHS) addressed this lack of infor- in 2016 and Provincial Advocate for Children and Youth in mation by identifying: 1) changes in the prevalence and 2012 that draw attention to deficiencies associated with determinants of child and youth mental disorder over the Offord Centre for Child Studies & Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada Department of Sociology, King’s University College at Western University, London, Ontario, Canada Children’s Health Research Institute, Children’s Health and Therapeutics, Western University, London, Ontario, Canada Departments of Psychology, Family Medicine, and Paediatrics, Western University, London, Ontario, Canada British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada Child and Youth Mental Health Policy Branch, British Columbia Ministry of Children and Family Development, Victoria, British Columbia, Canada Children’s Health Policy Centre Faculty of Health Sciences Simon Fraser University, Vancouver, British Columbia, Canada (in alphabetical order) Tracie O. Afifi (University of Manitoba), William R. Avison (Western University), Kathryn Bennett (McMaster University), Terry Bennett (McMaster University), Khrista Boylan (McMaster University), Michael H. Boyle (McMaster University), Michelle Butt (McMaster University), John Cairney (University of Toronto), Corine Carlisle (University of Toronto), Kristin Cleverley (Centre for Addiction and Mental Health, University of Toronto), Ian Colman (University of Ottawa), Jinette Comeau (King’s University College at Western University), Charles Cunningham (McMaster University), Scott Davies(University of Toronto), Claire de Oliveira (Centre for Addiction and Mental Health, University of Toronto), Melanie Dirks (McGill University), Eric Duku (McMaster University), Laura Duncan (McMaster University), Jim Dunn (McMaster University), Mark A. Ferro (University of Waterloo), Katholiki Georgiades (McMaster University), Stelios Georgiades (McMaster University), Andrea Gonzalez (McMaster University), Geoffrey Hall (McMaster University), Joanna Henderson (Centre for Addiction and Mental Health, University of Toronto), Magdalena Janus (McMaster University), Jennifer Jenkins (University of Toronto),Melissa Kimber (McMaster University), Ellen Lipman (McMaster University), Harriet MacMillan (McMaster University), Ian Manion (Royal’s Institute of Mental Health Research), John McLennan (University of Ottawa), Amelie Petitclerc (Northwestern University), Anne Rhodes (University of Toronto), Graham Reid (Western University), Peter Rosenbaum (McMaster University), Roberto Sassi (McMaster University), Louis Schmidt (McMaster University), Cody Shepherd (Simon Fraser University), Noam Soreni (McMaster University), Peter Szatmari (Centre for Addiction and Mental Health, Hospital for Sick Children, University of Toronto), Brian Timmons (McMaster University), Juliana Tobon (McMaster University), Ryan Van Lieshout (McMaster University), Charlotte Waddell (Simon Fraser University), Li Wang (McMaster University), Christine Wekerle (McMaster University). Corresponding Author: Laura Duncan, MA, Offord Centre for Child Studies & Department of Psychiatry & Behavioural Neurosciences, McMaster University, 1280 Main Street West, MIP 201A, Hamilton Ontario L8S 4K1, Canada. Email: duncanlj@mcmaster.ca La Revue Canadienne de Psychiatrie 64(4) 233 past 30 years, and 2) the continuing challenges with access There appears to have been a geographic shift in the preva- 4-10 and targeting of children’s mental health services. lence of disorder from large urban areas to small-medium 8,9 The overall goal of health policies and programs in urban and rural areas. Finally, concerns persist about Canada to improve population health should be guided by access to mental health agencies among children identified 2 basic principles: accountability (being answerable for with disorder: although the proportion of children with men- meeting defined objectives) and equity (reduction in poor tal disorder having service contact increased from 1983 to 12 5,8 health among disadvantaged groups). Ontario can stay true 2014, most remained without contact. The dramatic to these principles and constructively address the weak- changes in children’s mental health documented by the nesses that continue to undermine the effective provision 2014 OCHS indicate that core information on children’s of children’s mental health services in 2 ways: 1) by devel- mental health in the general population is needed at more oping an information system that measures children’s mental frequent intervals than 30 years. health in the general population every 5 years, and 2) by incorporating identical measurement into intake and Limited Information Recorded on follow-up assessments of all children accessing provincially Children’s Mental Health funded, community-based mental health agencies. These measures could be used in tandem to monitor the success In Ontario, children with mental health challenges access of our provincial response to children’s mental health needs community-based mental health agencies by way of referral and identify specific changes needed, ensuring that services (general practitioners, centralized intake) or direct requests for are responsive to the configuration of needs in the general help. Within these agencies, psychiatrists, psychologists, and population. This would be achieved by testing for parallel social workers collect information on children’s mental health changes in the epidemiology of childhood mental disorders relevant to their practice. However, there is no provision among children in the general population, and those acces- across agencies to collect the same measures of children’s sing services at children’s mental health agencies. mental health that could be used system-wide to examine the This commentary: 1) summarizes findings from the 2014 characteristics of those accessing services or the benefits OCHS to argue that core measures of children’s mental accrued by doing so. The administrative information most health be collected in the general population at regular inter- relevant to understanding children’s mental health in Ontario vals; 2) points out the limited information recorded on the is limited to diagnoses recorded by physicians at each visit mental health of children accessing community-based men- and related billing codes for services provided. This informa- tal health agencies, to argue that core measures be adminis- tion limits the identification of children with mental health tered to all children at baseline and follow-up; 3) explains challenges to the minority accessing walk-in clinics, urgent the value of collecting identical information in the general care, emergency rooms, hospitals, and physician practices. In population and community-based children’s mental health addition, the failure to implement standard assessment meth- agencies; 4) describes the content, requirements (practical ods has led to varying degrees of reliability and validity for the and scientific), and operational features for the core mea- information collected. Although health-information sures; 5) demonstrates how the core measures can be used to abstracted from administrative records has important, specific improve decision making aligned with the basic health prin- uses for health services research, it is not a viable option for ciples underlying policies and programs; and 6) concludes assessing or ensuring public accountability. with a brief summary. Although Ontario is home to the 1983 and 2014 OCHS, we believe that this commentary has broad Alignment of Core Children’s Mental relevance to other provinces and territories in Canada. Health Measures In the study of children’s mental health, there is a deep divide 2014 OCHS—Changes in Children’s Mental between the evidence and inferences on health system perfor- Health mance obtained in general population studies, such as the “Change between 1983 and 2014” is a powerful, recurring 2014 OCHS, and administrative data cumulated by service 8,9 theme in the OCHS papers. The proportion of males aged providers on patients. Differences in the approaches to defin- 4 to 11 years with attention-deficit/hyperactivity disorder ing children’s mental health and in the methods of assessment has jumped dramatically. In adolescence, there has been a and sampling of respondents have made it impossible to steep increase in anxiety and depression among males and assess the policies, programs, and services developed by gov- females and a substantial decrease in the prevalence of con- ernments to address children’s mental health needs among the duct disorder among males. The prevalence of disorder general population and for those accessing community-based among children in immigrant v. non-immigrant families mental health agencies. These 2 approaches could be aligned dropped by almost 50% from 1983, and there is strong by collecting a core set of children’s mental health measures evidence that children in poor households are at elevated in the general population and that in the subset of children risk for disorder when this occurs in combination with con- accessing community-based children’s mental health agen- textual factors like neighbourhood antisocial behaviour. cies. Such alignment would provide the information needed 234 The Canadian Journal of Psychiatry 64(4) to understand the scope of children’s mental health needs in by Statistics Canada (Canadian Health Survey of Children and 21 22 the general population and the adequacy of provincial Youth, Canadian Community Health Survey ); or identify responses to meet these needs. simple, unique data collection mechanisms through the inter- net or school-based anonymous assessments. We see this instrument being implemented in service agencies at intake and at the 3- or 6-month follow-up, depending on service Content, Prerequisites and Organization of length. To implement these assessments consistently, agencies a Children’s Mental Health Information would require investments in change management methods to System overcome resistance among those opposed to modifying their We believe that the core measures of children’s mental data collection processes, as well as investments into adequate, health should include 3 indicators: 1) emotional and beha- longer-term funding to support data analysis to address these vioural problems, measured as both dimensional and cate- system evaluation questions. gorical phenomena; 2) a perceived need for professional help In work associated with the 2014 OCHS, we have shown with emotional or behavioural problems; and 3) the level of that self-completed questionnaires can meet all of the functioning represented as academic achievement and social requirements discussed above and that brief problem check- competence. Although there are various ways to conceptua- lists, developed to measure children’s mental disorders as 15,16 lize children’s mental disorder, there is a general con- dimensional phenomena, can be converted to binary mea- sensus among child psychiatrists, psychologists, and service sures of mental disorder (categories) that achieve levels of providers that assessments of child mental health need to reliability and validity comparable to standardized diagnos- 17,18 revolve around problems of emotion and behaviour. The tic interviews implemented by lay interviewers in general- 23,24 underlying continua of these problem behaviours (number, population studies. An example questionnaire that intensity, frequency) provide direct insight into the severity includes measures of mental health disorder symptoms and of the mental disorder. In contrast, perceived need may be perceived need for help appears in the Appendix. linked more closelytohelpseeking andthe potentialto benefit from services provided. It speaks to child, youth, Improved Decision Making and parent subjective recognition of mental health problems. Indicators of functioning focus on elements of human capa- How might this information system be used to better align bility that are essential for engaged, productive and fulfilled policy decisions with the underlying health principles adopted lives. However, if compromised by mental disorder, they by government? In general, this system would provide the must be addressed in our service response. evidence needed to evaluate the extent to which these princi- The core indicators of the information system should: 1) be ples are operating in practice. For example, at the population operationalized in a single instrument that demonstrates reli- level, the system would track changes over time in child able and valid measurement; 2) be inexpensive and practical to mental health, its geographic distribution, and its socioeco- implement in general population surveys and as part of intake nomic determinants. On its own, population-level information and follow-up assessments completed by service agencies; 3) would provide core data for evaluating the effects of major pose minimal burden to respondents and service practitioners; government policy and program initiatives associated with and 4) represent the perspectives of youth and families on prevention and treatment (improved health outcomes) on chil- important mental health outcomes. We believe that these dren’s mental health, and inform government about changes requirements can be met by a questionnaire that is self- in socioeconomic gradients for child mental health (health completed by parents of children aged 4 to 17 and youth aged equity). Coupled with identical assessments obtained by ser- 12 to 17 in less than 7 or 8 min—a time threshold at which vice providers, the system would quantify the responsiveness survey completion rates start to drop-off. This type of instru- of community-based children’s mental health agencies to pop- ment is inexpensive to implement; poses little time burden to ulation shifts in children’s mental health need (accountabil- respondents; can be completed in almost any setting and ity). At the individual level, routine intake and follow-up adapted to various modes of administration (e.g., in person via assessments would provide evidence to assess change among tablet/computer, internet); can be computerized to eliminate children accessing community-based mental health services data entry costs; can be implemented in mental health agencies (improved health outcomes). with little involvement of service practitioners; and can be Aggregating population-level information on the service incorporated into general population surveys at modest addi- catchment area needs of children’s mental health would pro- tional cost. We see this instrument being implemented in the vide estimates of the needs of independent catchment areas. general population at 5-year cycles—a time interval suitable Bringing together these area estimates of children’s mental for identifying constancy or change in mental health need— health need with identical information collected by chil- and sampling children with enough precision in census bound- dren’s mental health service agencies could be used to assess aries associated with service catchment areas to provide reli- the principle of accountability by evaluating service access able estimates of population need. This cycle could either among children in the general population with mental health capitalize on existing data collection opportunities provided needs. This would provide estimates of coverage (the La Revue Canadienne de Psychiatrie 64(4) 235 percentage of the children in catchment areas receiving ser- Declaration of Conflicting Interests vices) and service targeting (the percentage of children The primary authors (MB, LD, KG, JC, GR, WB, RL and CW) receiving services meeting criteria for need). Bringing declared no potential conflicts of interest with respect to the together catchment area estimates of children’s mental research, authorship, and/or publication of this article. health need with service expenditure and resource alloca- tions could be used to assess the extent to which geographic Funding expenditures and human resource allocation match general The author(s) disclosed receipt of the following financial support population needs (equity). for the research, authorship, and/or publication of this article: During the preparation of this manuscript, Dr. Waddell was sup- ported by the Canada Research Chairs program; Dr. Georgiades Summary was supported by the David R. (Dan) Offord Chair in Child Studies There are high levels of children’s mental health need in and Dr. Reid was supported by the Children’s Health Research Institute, London, ON. the general population, temporal shifts in the configurations of mental disorders experienced by children and youth, and important information gaps about who receives community- ORCID iD based mental health services from agencies in Ontario and Laura Duncan, MA https://orcid.org/0000-0001-7120-6629 the types of services that are obtained by children. An infor- mation system that uses an identical instrument to measure Supplemental Material children’s mental health in the general population and in Supplemental material for this article is available online. children receiving mental health services would provide government policy makers with the evidence to assess the References extent to which the principles of accountability and equity apply to the provision of children’s mental health services. 1. 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Journal

Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie – Pubmed Central

Published: Apr 12, 2019

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