Child and Adolescent Mental Health Volume 12, No. 1, 2007, pp. 13–20
doi: 10.1111/j.1475-3588.2006.00414.x
Child Mental Health is Everybody’s Business: The Prevalence of Contact with Public Sector Services by Type of Disorder Among British School Children in a Three-Year Period Tamsin Ford1, Helena Hamilton1, Howard Meltzer2 & Robert Goodman1 1 Department of Child and Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. E-mail:
[email protected] 2 University of Leicester, UK
Method: A third of the children from the 1999 British Child and Adolescent Mental Health Survey were followed-up over 3 years. Parents provided summary information on service contacts in relation to mental health; selected subgroups provided more detailed information by telephone interview. Results: Common overlaps in service use were between health services, between teachers and educational specialists, and between the latter and CAMHS or social services. Services other than primary health care saw more children with externalising disorders, while children with anxiety disorders were less likely than children with other psychiatric disorders to be in contact with any service. Conclusions: Child mental health is everybody’s business, and professionals need to be alert(ed) to the types of disorders that children using their service may have. Keywords: Child mental health services; epidemiology
Introduction
Method
The 1999 British Child and Adolescent Mental Health Survey was the first nationally representative epidemiological study of childhood psychiatric disorder in Great Britain involving 10,438 children aged 5–15 (Meltzer et al., 2000). The prevalence of psychiatric disorder was 10%, with a high level (20.9%) of comorbidity. A third of the children seen in the initial survey were followed-up at 20 months and 3 years. By 20 months, just over half of the children who initially had a psychiatric disorder had subsequently accessed services in relation to their mental health problems (Ford, Goodman, & Meltzer, 2003). Teachers were most commonly consulted, while contact with social service was least likely, with one fifth having been in contact with CAMHS. At 3 years, having a psychiatric disorder predicted substantially increased contact with social services, special educational needs resources, the youth justice system and some mental health services (district CAMHS and tier four, but not tier two) (Ford et al., 2005). Children with a disorder at baseline and 3 years later were more likely to have accessed services than children with a disorder at only one time point or children without a disorder. In this paper we describe the distribution of children with different types of psychiatric disorder among public sector services, in terms of broad groups (e.g. emotional disorder) and individual diagnoses (e.g. separation anxiety disorder), and the overlap in contacts between services.
Sample and design The follow-up sample comprised all those with a disorder (n ¼ 929) in the initial survey and a random third of those without disorder (n ¼ 3063). The follow-up surveys consisted of a postal questionnaire after 20 months (Time 2; completed by 2954 parents) and detailed faceto-face interviews after 3 years (Time 3, completed by 2899). Of the families selected for follow-up, 74% responded to the postal questionnaire at Time 2, with 89% of these also participating in the interviews at Time 3. Data from all three time points were available on a total of 2641 children, the sample reported in this paper. In addition, some parents were selected for more detailed telephone interviews about service use, either because of reported service contact (462 at Time 2 and 411 at Time 3) or because the parents reported persistent concerns about their child’s emotions, behaviour or concentration but had not reported seeking help (37 and 63 respectively). The two telephone surveys drew separate samples, although 169 parents were interviewed on both occasions. The telephone surveys obtained response rates of 88% (439 interviews) at Time 2 and 85% (403 interviews) at Time 3.
Measures Psychiatric diagnoses at Time 1 were made according to ICD-10 criteria (World Health Organisation, 1993) using the Development and Well-being Assessment
2006 Association for Child and Adolescent Mental Health. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
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(DAWBA), which combines structured interviews with a clinical review of verbatim transcripts about reported symptoms (Goodman et al., 2000). Parents also completed the Strengths and Difficulties Questionnaire (SDQ), a well-validated and commonly used measure of common childhood psychopathology (Goodman, 2001). The SDQ consists of 25 items relating to five symptom scales covering the following areas: emotions, behaviour, activity level, peer relationships and pro-social behaviour. The first four scales can be added together to form a total difficulties score. The SDQ’s impact supplement asks the informant whether they consider the child to have a significant mental health problem; we used responses to this question as an estimate of parental concern. The postal questionnaire at the 20-month follow-up asked all parents if there had been contact with any of the following services since the initial survey for emotional, behavioural or concentration difficulties. It asked if there had been contact with Ôyour child’s teacher (form teacher or head of year), your GP, family doctor or health visitor, someone specialising in mental health (e.g. child psychologist or psychiatrist), someone concerned with your child’s general health (e.g. a hospital or community paediatrician), social services personnel (e.g. a social worker or support worker), someone working in specialist educational services (e.g. an educational psychologist), or someone else (please specify)Õ. More information about the measures used in this study is available from the authors on request. The same list was presented to parents at the 3-year followup whenever they had reported symptoms in the DAWBA interview, with parents being asked about service contacts within the previous year. The parents interviewed by telephone had also answered the briefer postal questionnaire (20 months) or face-to-face interview (3 years) on service use. The agreement between the telephone and briefer measures was generally good (j ¼ 0.24–0.59, j ‡ 0.30 for 3 out of 6 services at Time 2; j ¼ 0.30–0.55 at Time 3). Nevertheless, detailed telephone interviewing clearly provided more accurate information by screening out service contacts that were not primarily related to mental health problems and those related to routine contacts between parents and teachers. There was a telephone interview on 71% of those reporting service contact at Time 2 and 78% at Time 3. We used the best available data on each child, prioritising information from the telephone interviews when possible, and supplementing it with data from the briefer measures when there was no relevant telephone data. Telephone interviews were carried out using the Children’s Services Interview, which was developed specially for these follow-up studies (Ford et al., in press). It is the only validated British instrument for measuring service contacts, and shows high test-retest reliability and at least moderate validity when clinic notes were used as the gold standard for comparison. The interview starts with open-ended questions about any service contacts for emotional or behavioural concerns, with a series of prompts to elicit particular details such as the use of medication. This is followed by a structured screen to check for forgotten service contacts related to health (general practice, hospital outpatient or other clinics, and inpatient admissions),
education (teachers, educational psychologists, educational welfare officer, behavioural support teachers, and additional help in school), social services, youth justice and the police services. We classified services into front line services, which had a near universal coverage and a longitudinal relationship with children and their families (primary health care and teachers) and specialist services, which required either some degree of impairment and/or referral for access. Mental health services included district child and adolescent mental health services, plus counsellors working within schools and primary health care. Paediatrics included hospital and community paediatric professionals (including occupational therapy and speech therapists) and the school medical system. Specialist educational resources were all services provided by education-based professionals external to the child’s school.
Analysis The results were weighted for differential selection and selective response so that the resultant proportions reflect the rates in Britain as a whole, and cross tabulations and adjusted analysis were adjusted for complex survey design, providing F statistics as the survey adjusted equivalent of a Chi-squared test (Stata Corporation, 2003). We present descriptive data on service contacts according to individual ICD-10 diagnoses such as separation anxiety, in addition to the major groups of disorder, for instance anxiety disorder. To prevent comorbidity from confusing the picture for individual diagnoses, children with more than one diagnosis were excluded, except for the analysis of the presence/absence of disorder, which provides a reference for the whole sample. Diagnoses allocated to less than 10 children, which might provide very misleading results, are excluded from the relevant table. Excluded diagnoses included post traumatic stress disorder, social phobia, obsessive compulsive disorder, conduct disorder confined to the family context, eating and tic disorders and the subdivisions of hyperkinetic disorder.
Results Table 1 shows service use over the 3 years of follow-up according to the presence or absence of a psychiatric disorder at Time 1. Having a disorder at Time 1 was associated with contact with all types of services (p < .001 for each service). Over half (56.7%, 95% confidence interval 51.4–62.3%) of the children with a psychiatric disorder at Time 1 had accessed at least one service during the 3-year follow-up period. The importance of interagency working is illustrated in Figures 1 and 2, and by the fact that nearly half of the children (44%) who had accessed a specialist service were in contact with more than one specialist service, whilst a quarter of the parents in contact with front line services had been in contact with both teachers and primary care. Both figures show odds ratios for the probability of being in contact with the two types of service connected by each arrow. The size of the odds ratio and the width of the arrow indicate the strength of
Childhood psychiatric disorder in public sector services
15
Table 1. The percentage of children in contact with public sector services regarding mental health issues
Type of service Front line services Teachers Primary health care Either front line service Specialist services Mental health services SEN1resources Paediatrics Social services Any specialistservices
Total Sample % in contact (95% confidence interval)
No Psychiatric disorder at Time 1% in contact (95% confidence interval)
Psychiatric disorder at Time 1% in contact (95% confidence interval)
14.1 (12.7–15.5) 8.3 (7.2–9.4) 17.9 (16.4–19.4)
11.4 (10.1–12.9) 6.3 (5.3–7.4) 14.7 (13.2–16.3)
41.4 (36.7–45.9) 28.9 (24.5–33.3) 50.7 (45.9–55.4)
4.9 4.9 3.3 2.5 10.1
(4.1–5.7) (4.1–5.7) (2.7–4.0) (1.9–3.0) (8.9–11.1)
2.9 2.9 2.3 1.4 6.9
(2.2–3.7) (2.2–3.8) (1.8–3.1) (1.0–2.0) (5.9–8.1)
25.1 25.0 13.5 13.8 42.5
(21.1–29.1) (21.0–28.9) (10.4–16.7) (10.5–17.2) (37.0–47.9)
SEN ¼ Special educational needs.
11.98 (6.32-22.72)
Paediatric services
Mental Health Services
4.47 (2.06-9.69)
Social services 1.84 (0.83-4.11) 10.79 (6.12-19.01)
2.88 (1.39-5.94) 12.21 (6.11-24.41) Special Educational Needs Resources Figure 1. Overlap between contacts with different specialist services, adjusting for other service contacts and survey design Note: Figures are odds ratios with their 95% confidence intervals, adjusted for survey design, which indicate the probability of attending both the services joined by each arrow. The strength of the association between services is also indicated by the width of the arrow joining them.
Mental health services
Special educational needs resources
3.89 (2.36-6.41)
6.62 (4.13-10.63)
28.61 (17.87-45.81)
Primary health
10.26 (6.64-15.84) 9.99 (7.45-13.39)
Teachers
9.99 (5.77-17.28)
5.60 (2.83-11.07) 3.58 (2.02-6.36)
Paediatric services
5.31 (2.72-10.36)
Social services
Figure 2. Overlap between contact with front line services and contact with specialist services, adjusted for contact with the other front line service and survey design Note: Figures are odds ratios with their 95% confidence intervals which indicate the probability of attending both the services joined by each arrow. The strength of the association between services is also indicated by the width of the arrow joining them.
the association between any two services. Figure 1 suggests that the common overlaps among children in contact with more than one specialist services were
between paediatrics and mental health, and between education specialists and social services or mental health services. It is interesting, but not surprising, to
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note from Figure 2 that the largest overlaps between front line and specialist services are health-to-health (primary care to mental health and paediatric services) and education-to-education (teachers to special educational needs resources). Measures of the severity of the child’s psychopathology at baseline (Total SDQ score (correlation with the number of services ¼ 0.45, p < .001) and comorbidity (F ¼ 34, p < .001) were related to contact with more than one service, as was parental concern. The parents of children who had a psychiatric disorder at Time 1 who considered that their child’s difficulties were more severe, were more likely to access more services (F ¼ 3, p < .001). There were similar results for the number of services accessed according to the parent’s grading of the severity among the children without a psychiatric disorder (F ¼ 12, p < .001). Thus, both the severity of difficulties and parental concern may influence access to multiple agencies. The pattern of the major groups of disorder in relation to contact with particular services was very similar for mental health, teachers, and special educational and paediatric services, with an excess of disruptive and comorbid disorders. Children with hyperkinetic disorder were more likely than children with other disorders to be in contact with mental health services (45.0% versus 21.7%, F ¼ 19.3, p ¼ .0001), special educational needs resources (37.8% versus 22.8%, F ¼ 7.3, p ¼ .007), teachers (59.0% versus 38.4%, F ¼ 9.4 p ¼ .002) and paediatrics (27.0% versus 11.2%, F ¼ 11.5, p ¼ .0008). Similarly, children with conduct disorder were more likely than children with other disorders to be in contact with social services (17.4% versus 9.9% F ¼ 5.5, p ¼ .02), teachers (50.9% versus 31.0%, F ¼ 20.0 p ¼ .0001) and special educational needs resources (29.9% versus 19.6%, F ¼ 7.4, p ¼ .007). Finally, children with comorbid disorders were statistically more likely than children with a single diagnosis to be in contact with mental health services (38.6% versus 21.5%, F ¼ 11.8, p ¼ .0007); paediatrics (24.7% versus 10.6%, F ¼ 11.9, p ¼ .0006); teachers (56.7% versus 37.3% F ¼ 11.4, p ¼ .0008), and special educational needs resources (33.8% versus 22.6%, F ¼ 5.11, p ¼ .02). In contrast, children with anxiety disorders were less likely than children with other psychiatric disorders to use special education needs resources (18.0% versus 29.8%, F ¼ 6.9, p ¼ .009), teachers (33.7% versus 46.7%, F ¼ 7.5, p ¼ .007), and social services (8.9% versus 17.2%, F ¼ 5.4, p ¼ .02). There were similar trends for anxiety disorder and mental health services (20.4% versus 28.4%, F ¼ 3.7, p ¼ .06). Lack of power may explain the lack of any similar associations with depression, as there were only 50 cases. Table 2 shows the proportion of children with individual diagnoses attending each service. The high proportion of children with pervasive developmental disorders attending all services apart from primary health care is striking, as is the lack of contacts for children with anxiety disorders. Children with specific phobia were particularly unlikely to be in contact with services, despite the existence of evidence-based interventions. Children with separation anxiety were more likely to be in contact with special educational needs professionals and paediatricians than mental health
services, possibly in relation to school refusal and somatisation respectively. Interestingly, children with the other anxiety diagnoses were no more likely to see paediatricians than children without these disorders. The highest proportion of children attending mental health services were those with hyperkinetic and pervasive developmental disorders, while contact with social services for children with hyperkinetic disorder seems to be driven by comorbidity with conduct disorder. The proportion of children with unsocialised conduct disorder in contact with mental health, special education and social services was higher than the average for disorders in general. In contrast, fewer than expected children with socialised conduct disorder were in contact with mental health services, although they did have high rates of contact with special education and social services. Perhaps this reflects reluctance on behalf of the latter group and their families to engage, despite difficulties at school. Finally, children with depression were more likely to be in contact with primary care than expected if compared to the rates of contact for children with any psychiatric disorder (33.4% versus 28.9%), whereas the opposite was true for teachers (34.3% versus 41.4%).
Discussion Our findings in the context of the literature The prevalence of service contact among British children with impairing psychiatric disorder over the 3 years was 57% if front line services were included and 43% for specialist services alone. Both these proportions lie in the middle of the wide range of rates (16– 71%, median 36.2%) reported in the literature (Anderson et al., 1987; Angold et al., 2002; Burns et al., 1995; Cuffe et al., 1995; Fergusson, Horwood, & Lynskey, 1993; Gomez-Beneyeto et al., 1994; Haines et al., 2002; Leaf et al., 1996; McGee et al., 1990; Meltzer et al., 2000; Rutter, Tizard, & Whitmore, 1970; Zahner et al., 1992). In contrast, the proportion of children with impairing psychiatric disorder in contact with specialist mental health services (25%) was towards the top third of the range reported in the literature (8–33%, median 13.3%) (Burns et al., 1995; Cohen et al., 1991; Fergusson et al., 1993; Gasquet et al., 1999; GomezBeneyeto, 1994; Kataoka, Zthang, & Wells, 2002; Laitinen-Krispijn et al., 1999; North, 2001; Offord et al., 1987; Sourander et al., 2001; Staghezza-Jaramillo et al., 1995; Zwaanswijk et al., 2003). Although fewer British school children access mental health, it is possible that our current service configuration is fairly effective at targeting those in greatest need. As the duration studied influences the estimate of the rate of service contact, the most appropriate comparison to make is with the Great Smoky Mountain Study report of specialist service contact, which also gathered data prospectively over 3 years (Farmer et al., 2003). Calculated as a percentage of the total child population (irrespective of the presence or absence of a psychiatric disorder), a higher proportion of the children from the Great Smoky Mountain Study were in contact with every specialist service compared to our British findings, although the figures for social services are fairly similar (all specialist services combined Great Smoky Mountain Study 34% versus Britain 10%; education
NOS not otherwise specified. 3PDD pervasive developmental disorder. 2
Notes: 1These figures are supplied for reference and include the 115 children with comorbid diagnoses.
13.5 (10.7–17.0) 2.3 (1.8–3.1) 7.8 (4.3–13.8) 11.7 (3.8–30.8) 2.8 (0.4–17.3) 7.7 (1.1–39.1) 7.8 (2.6–21.1) 15.5 (5.0–35.1) 15.0 (5.7–34.1) 9.5 (5.7–15.6) 13.3 (7.7–22.0) 9.3 (1.3–44.9) 0 4.3 (0.6–25.2) 48.7 (24.8–74.2) 13.8 (10.8–17.5) 1.4 (1.0–2.0) 7.2 (3.8–13.2) 3.8 (0.5–22.7) 2.8 (0.4–17.3) 0 13.3 (5.8–27.8) 10.0 (2.5–32.7) 3.7 (0.5–22.3) 18.3 (12.7–25.7) 17.1 (10.6–26.5) 31.3 (11.2–62.1) 18.4 (6.0–44.1) 12.8 (4.2–33.2) 50.2 (25.9–74.3) 25.0 (21.3–29.1) 2.9 (2.2–3.8) 13.2 (8.2–26.7) 16.1 (6.2–35.0) 2.7 (0.4–16.8) 8.2 (1.1–40.9) 20.5 (9.9–37.7) 10.1 (2.5–33.1) 34.3 (19.1–53.6) 26.4 (20.0–34.1) 25.2 (17.4–35.2) 41.4 (17.2–70.6) 35.5 (16.7–60.1) 16.0 (6.1–35.9) 55.9 (30.4–78.7) 25.1 (21.3–29.3) 2.9 (2.2–3.7) 16.6 (11.9–24.1) 9.0 (2.7–26.3) 8.0 (2.6–22.2) 15.8 (4.0–46.0) 15.5 (6.4–33.0) 11.5 (2.8–35.3) 33.9 (18.8–53.1) 24.2 (17.8–32.1) 28.2 (19.6–38.7) 32.1 (11.6–63.0) 10.8 (2.7–34.8) 8.0 (2.0–27.0) 33.1 (14.1–60.0) (36.9–46.0) (10.1–12.9) (27.4–40.7) (29.4–62.3) (15.5–38.0) (12.8–45.7) (27.3–51.1) (22.6–48.3) (46.6–70.3) (44.2–57.6) (49.0–65.8) (40.8–81.7) (25.4–60.3) (15.1–43.7) (35.2–80.7) 41.4 11.4 33.7 45.3 25.1 26.0 38.5 34.3 59.0 50.9 57.6 63.7 41.8 27.1 60.1 459 2002 132 26 37 13 40 19 26 147 90 11 17 24 14 Any psychiatric disorder1 No psychiatric disorder1 Any anxiety Separation anxiety Specific phobia Generalised anxiety disorder Anxiety disorder NOS2 Depression Hyperkinetic disorder Any conduct disorder Oppositional defiant disorder Unsocialised conduct disorder Socialised conduct disorder Conduct disorder NOS2 PDD3
28.9 (24.5–33.5) 6.3 (5.3–7.4) 24.1 (18.2–31.1) 30.7 (18.2–47.0) 14.1 (7.0–26.4) 21.1 (9.6–40.2) 25.1 (15.1–38.5) 33.4 (21.5–47.8) 36.4 (25.7–48.6) 31.9 (26.0–38.5) 37.3 (29.3–46.0) 37.8 (19.5–60.4) 21.0 (9.7–39.7) 20.8 (10.6–36.7) 29.2 (12.5–54.5)
Paediatrics Social services Special educational needs resources Mental health services Teachers Primary health care Number with the disorder ICD 10 diagnosis
Table 2. The percentage (95% confidence interval) of children with each diagnosis at Time 1 in contact with specialist services excluding the 115 children with more than one disorder (Figures in bold type were NOT statistically more likely than children without that disorder to be seen at the 5% level)
Childhood psychiatric disorder in public sector services
17
24% versus 5%; mental health services 14% versus 5%; paediatrics 10% versus 3% and social services/welfare 4% versus 3%). The rates of contact with special educational services in the Great Smoky Mountain Study and Britain might be more similar if school based mental health services were excluded from education in the former, although reclassifying school counsellors as mental health services would serve to widen the gap between the proportions of children in contact with specialist mental health services. The greater number of children in contact with paediatrics in the Great Smoky Mountain Study may reflect the primary care role of many paediatricians in America. Contact with non-mental health specialist services, particularly front line services, has been less studied, but comparison of our findings with the literature reveals that the proportion of children in contact with education tends to be greater according to other investigators, possibly because of differences in the classification of school based mental health services (Angold et al., 2002; Farmer et al., 1999, 2003; Haines et al., 2002; Leaf et al., 1996; Zahner & Daskalakis, 1997). Thus, the published rate of contact for children with psychiatric disorder is 3–38%, median 33%, as compared to 25% for our sample of British school children with psychiatric disorder. The published rate of contact for the entire population of school children (with or without disorder) is 8–24%, median 12%, as compared with 5% for our sample of British school children. The number of British school children in contact with social services was similar to the range quoted in the literature, but there were only five relevant studies (Angold et al., 2002; Farmer et al., 1999, 2003; Leaf et al., 1996; Zahner & Daskalakis., 1997). It is possible that more British children with psychiatric disorders were in contact with paediatric services, despite the presence of a strong primary care system (children with psychiatric disorder 6–13%, median 7.5%, British children with psychiatric disorder 14%; whole sample 2–10%, median 2.8%, whole sample of British children 3%) (Angold et al., 2002; Leaf et al., 1996; Farmer et al., 1999, 2003; Zahner & Daskalakis, 1997). However, we included contacts with professionals such as speech therapists and occupational therapists for mental health problems, which not all investigators have done (Cohen et al., 1991; Staghezza-Jaramillo et al., 1995; Leaf et al., 1996). Finally, others also report that children commonly access more than one service (Farmer et al., 1999, 2003; Meltzer et al., 2000; Zahner & Daskalakis 1997). Although the proportion of children with disorders who are not seen by specialist services may seem high, it is worth noting that levels of contact are roughly in line with other psychiatric and paediatric specialities. The few published studies suggest that a similar proportion of adults with psychiatrist disorder reach specialist services (7–29%) (Huxley, 1996; Kessler et al., 1994; Newman et al., 1996; Regier et al., 1993). The Department of Health sponsored morbidity survey of 10,000 adults aged 16–64 living in private households in Great Britain reported that only 37% of those with a neurotic disorder had consulted their general practitioner about a mental health issue, and only 3% had attended secondary mental health care in the previous year (Meltzer et al., 1995). Rates of service contact were
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Tamsin Ford et al.
higher among those with a psychotic disorder, with 82% receiving some kind of mental health intervention in the previous year.
The policy and clinical implications Mental health problems lead to a substantial number of contacts with all public sector services, not just mental health services illustrating that mental health really is Ôeverybody’s businessÕ (Department of Health, 2004). Our findings underline the importance of all professionals working with children, particularly primary health care professionals and teachers, having basic skills in the identification and management of minor difficulties, and knowledge about how to access more specialised services for the children they can not manage themselves. It also has implications for CAMHS in terms of the training and supervision of these professionals and it is clear that even given the planned expansion of CAMHS, it is neither possible nor desirable that CAMHS should strive to see four times as many children as services are currently treating. A population-based study will contain a higher proportion of children with difficulties at the milder end of the spectrum compared to children seen in clinical practice, some of whom may improve without intervention or who could be managed at Tier 1 with adequate supervision or support. It is naı¨ve to assume that children in contact with services infallibly have all their needs met (Harrington, Kerfoot, & Verduyn, 1999), and public sector services deal with problems perceived to be mental health issues that do not necessarily conform to ICD diagnostic labels, such as deliberate self-harm. However, the presence of impairing psychiatric disorder could be used as a proxy for mental health problems, with the acknowledgement that it is an imperfect measure, and the estimated rates of contact with specialist and front line services could also be used to provide a rough estimate of unmet need (Jenkins, 2001). Arguably, it may be harder for primary care (and other non-mental health specialists) to intervene with children than with adults who have mental health problems, given the clear split between severe mental illness and common mental disorder in adults, and the greater reliance on psychopharmacological treatments as opposed to more time consuming psychological interventions for which additional training may be required. However, the recognition of difficulties alone may be an important intervention in its own right, while a recent review of the management of child mental health problems in primary care pointed to the potential of educational interventions to improve the confidence and skills of primary care professionals (Bernard & Garralda, 1995; Bower et al., 2001). In addition, there is the potential to train non-mental health specialists to use standardised assessments to identify children with psychiatric disorder and facilitate families helping their child through the use of appropriate therapy programs described in books or CD ROMs. Children who did not respond to this approach would then be prime candidates for referral to specialists. The relatively high rates of contact with non-mental health agencies also reflect the wide-ranging impact of psychiatric disorders on children and their families and expand the findings of Knapp, Scott and Davies (1999)
in relation to conduct disorder. From a policy perspective, many agencies in addition to mental health services have a part to play in minimising the cost to the individual and society of the impact of childhood psychiatric disorders, including interventions not directly aimed at improving mental health (Jenkins, 2001). Schools in particular have a huge role to play in the promotion of mental health and are an obvious vehicle through which to deliver universal programs aimed at promoting important coping skills and enhancing access to social support (Jenkins, 2001). Policies aimed at promoting the mental health of parents, particularly mothers in the early postnatal period, and supporting the task of parenting are of particular salience to child mental health. Nearly half of the children in contact with specialist services and a quarter of those in contact with front line services were using more than one service, illustrating how vital it is for agencies to collaborate to prevent duplication of effort and stop children from falling through gaps in service provision. The failure to work effectively together may have limited the development of services for children with mental health problems, in addition to impairing effective intervention in individual cases (Harrington et al., 1999). In an article commenting on trends and issues in American child and adolescent mental health services, Glied and Cuellar (2003) suggest that the lack of a single accountable agency to take the lead may explain the poor coordination, duplication and redundancy that commonly arise between agencies supporting children with mental health problems. As stated above, many agencies may directly or indirectly influence the mental health of people of all ages, but CAMHS is the only agency that has child mental health as its main function, and so arguably CAMHS should take the lead in the coordination and organisation of services. Finally, there were subtle differences between services in the diagnoses of the children using them. Consideration of the types of case likely to approach non-mental health services could inform the provision of training to non-mental health professionals by emphasising the type of difficulties that they are most likely to encounter. In addition, our findings provide evidence that children with anxiety disorders are not likely to access services, despite the existence of evidence-based interventions that may alleviate distress and improve functioning. If there were resources available to treat these children, perhaps we should consider routine screening for anxiety disorders.
Limitations This study benefits from a nationally representative sample, clear definitions of services and the prospective collection of service contacts. However, our methodology depends on parental recall of service contacts, and parents may not be aware of all service contacts, especially with older children and particularly with some agencies, for example with school counsellors and the police. However, the eldest individuals in the sample were only 18 years of age by the three-year follow up so that it is unlikely that many contacts took place without the parentsÕ knowledge. Equally parent and child reports of service use show reasonable levels of agreement (Stiffman et al., 2000). In addition, parents may not
Childhood psychiatric disorder in public sector services accurately remember the professional background of the person they saw. The current study works at the level of the type of service rather than discipline, which may arguably be easier for parents to understand and recall. If parents were confused in the telephone interviews, we took the details of the service and the professional and contacted them directly. As the majority of those reporting service contacts were interviewed over the telephone, we are confident that we have classified the types of services reasonably accurately, but residual misclassification of services due to confident but inaccurate parental recall no doubt occurred in a minority of cases. This study was not set up to measure the efficacy of service contact, so we are unable to comment on this important question. However, there is an urgent need for study in this area. Finally, despite an enormous initial sample, due to attrition over the follow-up period, there were too few children with rarer disorders to permit meaningful descriptions of service contact.
Acknowledgements The Department of Health funded the original and follow-up surveys and Tamsin Ford was supported by a clinical training fellowship from the Wellcome Trust at the time the work was carried out.
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