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The objective was to establish how stakeholders in low- and middle-income countries (LMIC) conceptualize child mental health impact. Semi-structured interviews were conducted with 18 stakeholders from disadvantaged urban communities in Kenya, South Africa, Turkey and Brazil. Participants represented education, welfare and health care agencies; as well as community and religious groups. Data were analysed through a thematic approach and three related themes were identified. Impact was defined as a process of change, with child-centred outcomes and measures that were broader than mental health symptoms improvement. Beneficiaries were identified at child, family, community and service level. Participants wished to see strategies that ensured sustainability of impact, namely child mental health policy, stakeholder engagement, interdisciplinary working, and capacity-building for all stakeholder groups. Child mental health service transformation in LMIC, especially in areas of deprivation, needs to build on existing resources and strengths by co-producing psychosocial outcomes with a range of professional and community stakeholders. Impact on children’s mental wellbeing can be achieved through a co-ordinated strategy that involves designated policy, capacity-building, and interdisciplinary networks with meaningful community involvement.

There is limited evidence on the cultural appropriateness of first-stage psychosocial interventions for youth with mental health problems who experience conflict and disadvantage in low- and middle-income countries (LMIC).To evaluate the feasibility of such an intervention (Writing for Recovery - WfR) among youth with emerging emotional problems following internal displacement in Kenya.Fifty-four youth aged 14-17 years were randomly allocated to a six-session intervention or a waiting list control group. They completed measures of stressful life events; post-traumatic stress, depressive and anxiety symptoms; quality of life; and free text on their experience of the intervention.Young participants reported high levels of trauma exposure and emotional problems. The intervention was perceived as flexible and culturally acceptable, with reported short-term impact. This was found to have promising post-intervention effect in reducing post-traumatic stress, but not depressive or anxiety symptoms; and in enhancing quality of life scores.Similar psychosocial interventions that can be delivered by paraprofessionals are important for resource-constrained LMIC settings, but need to be integrated within a comprehensive scaled service model.

We consider how the prolonged, complex and uncertain aftermath of the COVID‐19 crisis will present challenges and opportunities for counselling and psychotherapy. Increased mental strain on populations, individuals and professionals is likely to be compounded by further constraints in therapeutic resources. Nevertheless, emerging needs and priorities will offer ground for systems thinking in linking the application of a range of therapeutic frameworks, theories to address global challenges, integration of counselling and psychotherapy into new sectors, service models for the most vulnerable, use of digital approaches, support mechanisms for professionals and interdisciplinary research.

Children in low- and middle-income countries (LMIC) have high levels of unmet mental health needs, especially in disadvantaged communities. To address this gap, we developed a child mental health service improvement programme. This was co-facilitated using interprofessional principles and values in four countries, South Africa, Kenya, Turkey and Brazil. Eighteen stakeholders from different professions were interviewed after six months on their perspectives on enabling factors and challenges they faced in implementing service plans. Participants valued the holistic case management approach and scaled service model that underpinned the service plans. Emerging themes on participants' priorities related to service user participation, integrated care, and different levels of capacity-building. We propose that an integrated care model in LMIC contexts can maximize available resources, engage families and mobilize communities. Implementation requires concurrent actions at micro-, meso- and macro-level.

Children in care experience multiple risk factors, particularly in low-income countries such as Pakistan. The aim was to establish rates of mental health problems and their relationship with posttr...

Purpose The purpose of this paper is to develop a child psychosocial framework among stakeholders in areas of disadvantage in three low- and middle-income countries (LMIC), i.e. Kenya, Turkey and Brazil, and to capture their proposed recommendations through action plans according to this framework. Design/methodology/approach Workshops were facilitated with a total of 54 participants from different disciplines. The framework addressed safety and child-centredness, quality of care, resilience-building in schools and communities, enhancing competencies within existing roles, counselling and psychological interventions, and access to mental health services. Stakeholders’ perspectives were captured through a participatory action procedure. Findings The emerging 33 categories across the framework dimensions and the three sites led to four overarching and inter-linked themes. These related to community awareness; empowerment and “mobilization” of children, young people and families; inter-agency policy and practice; and capacity-building on skills acquisition at different levels. Research limitations/implications The next stage in this service research should be full implementation and evaluation in different LMIC contexts. Practical implications It is feasible to implement such a child psychosocial framework in contexts of conflict and disadvantage, and in the absence of specialist mental health services. Active stakeholder engagement and co-production should be central to the next phase of service transformation in LMIC. Originality/value This study captured the views and experiences of stakeholders in LMIC areas of disadvantage, and demonstrated their readiness to establish interdisciplinary networks and re-focus existing services.

Children in low- and middle-income countries (LMICs) have high levels of unmet mental health needs. Barriers include stigma, lack of culturally appropriate interventions, and limited resour...

Child and adolescent psychiatry is in a unique position to respond to the growing public health challenges associated with the large number of mental disorders arising early in life, but some changes may be necessary to meet these challenges. In this context, the future of child and adolescent psychiatry was considered by the Section on Child and Adolescent Psychiatry of the World Psychiatric Association (WPA CAP), the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP), the World Association for Infant Mental Health (WAIMH), the International Society for Adolescent Psychiatry and Psychology (ISAPP), the UN Special Rapporteur on the Right to Health, representatives of the WHO Department of Mental Health and Substance Abuse, and other experts. We take this opportunity to outline four consensus priorities for child and adolescent psychiatry over the next decade: increase the workforce necessary for providing care for children, adolescents and families facing mental disorders; reorienting child and adolescent mental health services to be more responsive to broader public health needs; increasing research and research training while also integrating new research finding promptly and efficiently into clinical practice and research training; Increasing efforts in advocacy.

Background Children in out-of-home care are consistently found to have poor mental health compared to children in the general population. However, UK research has so far failed to disentangle the impact of the care system on children’s mental health outcomes from the effects of the adverse circumstances that led to their admission to care. Objective This research investigated the association between care placement and the presence of child mental health problems after controlling for children’s pre-care experiences. It also identified factors associated with mental health problems among children in care. Participants and Setting The sample comprised three groups of children involved with child welfare services due to maltreatment, including children in out-of-home care (n = 122), reunified children (n = 82) and those who had never been in care (n = 159). Methods The mental health of the children in the three groups was compared, using information collected from their parents/foster carers and social workers. Results The odds of a child in out-of-home care having a mental health problem were not significantly higher than those of a child who had never been in care (AOR = 1.24; p = 0.462). However, the odds of a child in out-of-home care having reactive attachment disorder (RAD) were significantly higher than those of a child who had never been in care (AOR=1.92; p = 0.032). Conclusions These findings make an important contribution to international debates about whether placing children in care is beneficial or detrimental to their wellbeing, and highlight a range of inter-linking factors associated with the mental health of children in out-of-home care.

Children in low- and middle-income countries (LMIC), particularly those living in disadvantaged and conflict-ridden communities, are faced with extensive unmet health and social care needs (UNICEF, 2016). A substantial body of research has also provided evidence specifically relating to children's mental health, thereby increasing our understanding regarding the impact of cumulative and interlinked risk factors such as war, conflict and displacement, natural disasters, poverty, child labour and other forms of exploitation. Attempts to improve children's mental health in LMICs is, however, constrained by a range of factors including stigma relating to mental illness, limited policy input as reflected by the low level of specialist resources, lack of contextualised evidence regarding culturally appropriate psychosocial interventions (Patel & Rahman, 2015), and underrepresentation of LMICs in the research literature (Helal, Ahmed, & Vostanis, 2011).

Children exposed to multiple adversities are at high risk of developing complex mental health and related problems, which are more likely to be met through integrated interprofessional working. Combining the expertise of different practitioners for interprofessional care is especially pertinent in low- and middle-income countries (LMIC) in the absence of specialist resources. The aim of this study was to work with practitioners who deliver care to vulnerable children in six LMIC (Turkey, Pakistan, Indonesia, Kenya, Rwanda, and Brazil) to understand their perspectives on the content of an interprofessional training programme in building resilience for these children. Seventeen participants from different professional backgrounds, who were in contact with vulnerable children were interviewed. A thematic analytic framework was used. Four themes were identified, which were the benefits of a tiered approach to training, challenges and limitations, perceived impact, and recommendations for future training. The findings indicate the importance of co-ordinated policy, service, and training development in an interprofessional context to maximize resources; the need for cultural adaptation of skilled-based training and interventions; and the usefulness of new technologies to enhance accessibility and reduce costs in LMIC.

Background: Unaccompanied refugee minors present with disproportionately high prevalence of emotional and psychological morbidities. However, their utilization of mental health services has been shown to be significantly poorer than the indigenous population of the country they seek asylum in. Despite this, there is limited research exploring their perspectives on the barriers they face. Aims: This research aims to understand unaccompanied refugee minors' and their carers' perceptions of the barriers to utilize mental health services and to explore issues perceived to be related to poor engagement with services. Methods: Semi-structured interviews with 15 unaccompanied refugee minors and their carers were conducted. This was to elicit their views, perceptions and beliefs based on their experience of receiving treatment from a specialist mental health service in the UK. Results: Thematic analysis was used and the findings were categorised into two broad themes; the participants' perceptions of the intervention and perceptions of the professionals. Salient aspects of these are discussed. Conclusions: The findings have potential to stimulate further research into gaining a better understanding of the barriers these young people face in accessing help, and may contribute to developing services that are more efficient in engaging this vulnerable group and meeting their specific needs.

Background Despite growing evidence on the extent of child mental health problems in low-middle-income countries, the gap between need and provision remains high. Previous research in high income countries has demonstrated that evidence-based interventions can be scaled-up through community consultation, particularly by engaging key stakeholders. Aims This study aimed to explore community stakeholders’ views on children's mental health needs and culturally acceptable interventions in Kenya, to ascertain how to integrate global service standards with culturally-specific expectations. Methods Focus groups were conducted with community stakeholders (seven young people 14–17 years, seven parents, nine teachers and 11 other professionals). These participants were recruited from an urban community of internally displaced and disadvantaged families in Nakuru. Results Results indicated that Kenya faced similar challenges in meeting mental health needs as in other countries, including economic constraints, limited knowledge, stigma and systemic issues, but that these were manifested in culturally specific ways that were linked to societal and professional's attitudes and local context. Conclusions Stakeholders’ views are important in informing the planning, delivery and evaluation of interventions. However, for such interventions to be sustained, a clear therapeutic framework, evidence-base and sociocultural adaptation are likely to be important factors.

Although there has been increasing attention on the impact of risk and resilience factors on refugee children’s mental health, there has been limited evidence on the role of parental factors to inform interventions, and this predominantly relies on adult reports. The aim was to investigate the relationship between perceived parenting styles and attachment relationships and child mental health, as reported by 322 Syrian refugee minors aged between 8 and 17 years in Turkey. Child-rated scales included the Children Revised Impact of Event Scale–8 (CRIES-8), Strengths and Difficulties Questionnaire (SDQ), Security Scale and Egna Minnen Betraffande Uppfostran for Children (EMBU-C), and were used as measures of post-traumatic stress disorder (PTSD), general mental health problems, attachment relationships and perceived parenting styles, respectively. Children with secure maternal and paternal attachment perceived their parents as less rejecting, while children with secure paternal attachment also reported their parents as emotionally warmer. Attachment relationships significantly contributed in predicting PTSD after controlling for age and gender, while conduct problems were predicted by lack of emotional warmth, rejection and over-protection by both parents, in addition to insecure attachment relationships. Refugee children’s views are essential in establishing their needs and planning interventions. These should address both the impact of trauma and current family relationships.

Despite the growing importance of mental health in international and national policies, the contribution to the psychiatric evidence base from non-Western countries is sparse. Such a gap in research output between high- and low-income countries constrains improvements in public health and mental health policy and practice in developing countries, where there is perhaps the greatest unmet need. If research is to inform local mental health policy and practice, it must reflect the diverse realities of local health systems and cultural factors.

Self-harm amongst young people is an increasing problem, with looked-after young people at higher risk. Despite this, little research exists on what young people who self-harm find helpful.One hundred and twenty-six 11-21 year olds (53 who had experience of the care system and 73 who did not) were recruited from the community and NHS. All participants had self-harmed in the past 6 months. Participants completed an Audio Computer-Assisted Self-interview (ACASI) regarding their views about the support they had received, how helpful it was, and what further help they felt they needed.Looked-after young people reported the three most helpful sources of support were Child and Adolescent Mental Health Services (CAMHS), friends and pets and the least helpful were CAMHS, Accident and Emergency (AE) and Social services. For non-looked-after young people, CAMHS, counselling and Harmless (user-led support service for self-harm) were most helpful and CAMHS, cognitive behavioural therapy (CBT) and general practitioner (GP) were the least. Compared with the other group, more looked-after young people had received help from AE and CAMHS, whereas more non-looked-after young people had accessed GPs, parents, psychological therapies, self-help books and websites. More looked-after young people found support groups helpful, and more non-looked-after young people reported that distraction techniques, medication and their siblings were helpful.Young people who self-harm have mixed views about CAMHS. Differences in the pattern of access and preferences for support between looked-after and non-looked-after young people should be reflected in service availability and commissioning.Little is known about what young people who self-harm find helpful, particularly for looked-after young people. CAMHS was named amongst the most helpful and the least helpful services by both looked-after and non-looked-after young people. Social services and AE were frequently cited amongst the least helpful sources of support. Young people report finding informal support helpful, including family and friends. There appears to be a need for explorations of the reasons behind the apparent negative perception of statutory services in young people, and what is required to shift that.

1Department of Child and Adolescent Psychiatry, Al Quds University, School of Public, Consultant Psychiatrist at Child and Family Training and Counseling Center, Gaza 5314, Palestine 2Child and Family Training and Counseling Center, Gaza, Palestine 3Department of Child and Adolescent Psychiatry, School of Psychology, Greenwood Institute of Child Health, Westcotes House, Westcotes Drive, Leicester LE3 OQU, UK University of Leicester, UK *Corresponding author Abdel Aziz Thabet, MB, MD, PhD Emeritus Professor Department of Child and Adolescent Psychiatry Al Quds University School of Public Consultant Psychiatrist at Child and Family Training and Counseling Center Gaza 5314, Palestine E-mail: abdelazizt@hotmail.com

Background: Children in the UK care system often face multiple disadvantages in terms of health, education and future employment. This is especially true of mental health where they present with greater mental health needs than other children. Although transition from care – the process of leaving the local authority as a child-in-care to independence – is a key juncture for young people, it is often experienced negatively with inconsistency in care and exacerbation of existing mental illness. Those receiving support from child and adolescent mental health services (CAMHS), often experience an additional, concurrent transfer to adult services (AMHS), which are guided by different service models which can create a care gap between services. Method: This qualitative study explored care-leavers’ experiences of mental illness, and transition in social care and mental health services. Twelve care-leavers with mental health needs were interviewed and data analysed using framework analysis. Results: Sixteen individual themes were grouped into four superordinate themes: overarching attitudes towards the care journey, experience of social care, experience of mental health services and recommendations. Conclusions: Existing social care and mental health teams can improve the care of care-leavers navigating multiple personal, practical and service transitions. Recommendations include effective Pathway Planning, multiagency coordination, and stating who is responsible for mental health care and its coordination. Participants asked that youth mental health services span the social care transition; and provide continuity of mental health provision when care-leavers are at risk of feeling abandoned and isolated, suffering deteriorating mental health and struggling to establish new relationships with professionals. Young people say that the key to successful transition and achieving independence is maintaining trust and support from services.

There is increasing interest in providing resilience-building interventions in low- and middle-income countries (LMIC), but limited evidence on how young people and their carers process mental health and related supports. The aim of this study was to establish stakeholders’ conceptualization of youth mental health in a disadvantaged area of Kenya through focus groups with 7 young people aged 14–17 years and their parents, 9 teachers and 11 practitioners or community leads. The four identified themes related to definitions of both mental well-being and mental health problems; a range of contributing factors related to identity resolution, parenting, poverty and social media; attribution of responsibility at different socio-ecological levels; and required awareness, supports and interventions at these levels. Stakeholders, notably young people, are thus essential in the development and planning of user-led and culturally appropriate interventions in LMIC.

Background Since 2010, the numbers of refugees have increased and around half are under 18 years of age. It is known that experience of organised violence, displacement and resettlement increases the risk for psychiatric disorders and psychosocial impairment. This review integrates recent research into the risk and protective factors for psychopathology with service and treatment issues. Methods We draw on and critically evaluate key systematic reviews in the selected areas, innovative robust studies and relevant government reports. Results Many refugee children show resilience and function well, even in the face of substantial adversities. The most robust findings for psychopathology are that PTSD, and posttraumatic and depressive symptoms are found at higher prevalence in those who have been exposed to war experiences. Their severity may decrease over time with resettlement, but PTSD in the most exposed may show higher continuity. More severe psychiatric disorders including psychosis may also occur. Service delivery needs to take into account socioeconomic and cultural influences but, given the high level of unmet need even in high-income countries, stepped care delivery is required. The evaluation of psychological interventions, often delivered in group settings, suggests that they can be effective for many distressed children; however, for the more impaired, a greater range of disorder-specific therapies will be required. Conclusions Child and adolescent mental health clinicians and service providers need to be aware of the specific needs of this population and systems for service delivery. There are significant knowledge gaps in understanding risk and vulnerability, service delivery and treatment effectiveness.

© 2017 The British Psychological Society There is a growing appreciation that child functioning in different domains, levels, or systems are interrelated over time. Here, we investigate links between internalizing symptoms, externalizing problems, and academic attainment during middle childhood and early adolescence, drawing on two large data sets (child: mean age 8.7 at enrolment, n = 5,878; adolescent: mean age 11.7, n = 6,388). Using a 2-year cross-lag design, we test three hypotheses – adjustment erosion, academic incompetence, and shared risk – while also examining the moderating influence of gender. Multilevel structural equation models provided consistent evidence of the deleterious effect of externalizing problems on later academic achievement in both cohorts, supporting the adjustment-erosion hypothesis. Evidence supporting the academic-incompetence hypothesis was restricted to the middle childhood cohort, revealing links between early academic failure and later internalizing symptoms. In both cohorts, inclusion of shared-risk variables improved model fit and rendered some previously established cross-lag pathways non-significant. Implications of these findings are discussed, and study strengths and limitations noted. Statement of contribution What is already known on this subject? Longitudinal research and in particular developmental cascades literature make the case for weaker associations between internalizing symptoms and academic performance than between externalizing problems and academic performance. Findings vary in terms of the magnitude and inferred direction of effects. Inconsistencies may be explained by different age ranges, prevalence of small-to-modest sample sizes, and large time lags between measurement points. Gender differences remain underexamined. What does this study add? The present study used cross-lagged models to examine longitudinal associations in age groups (middle child and adolescence) in a large-scale British sample. The large sample size not only allows for improvements on previous measurement models (e.g., allowing the analysis to account for nesting, and estimation of latent variables) but also allows for examination of gender differences. The findings clarify the role of shared-risk factors in accounting for associations between internalizing, externalizing, and academic performance, by demonstrating that shared-risk factors do not fully account for relationships between internalizing, externalizing, and academic achievement. Specifically, some pathways between mental health and academic attainment consistently remain, even after shared-risk variables have been accounted for. Findings also present consistent support for the potential impact of behavioural problems on children's academic attainment. The negative relationship between low academic attainment and subsequent internalizing symptoms for younger children is also noteworthy.

Purpose – The purpose of this paper is to examine students’ understandings of mental health and their learning preferences, in order to provide guidance for developing targeted mental health education. Design/methodology/approach – A study-specific self-administered questionnaire was used at two English schools (n=980; ages 11-18), incorporating a combination of open-ended and fixed-choice items. Data were subject to content analysis, cross-tabulation of frequencies and statistical analyses. Findings – Overall, students understood mental health in terms of personal attributes or disorder, however older students were more likely to talk about relationships. Males were less likely to say they wanted to learn about mental health than females, believing they had no need to learn more. White students were also less interested in learning about mental health than Indian students. Overall, students said they would not use social media to learn, however Indian students were most likely to want to use it. Younger students preferred school-based learning to online. Research limitations/implications – The questionnaires were study specific and self-report. However interesting demographic variations in responses were found, worthy of further exploration. Social implications – Policymakers should consider targeted mental health interventions in schools and research the potential roles/barriers of the internet and social media. Long-term possible benefits relate to improved preventative strategies within schools. Originality/value – Previous research has focused on the delivery of mental health promotion/education in schools, whereas the current study drew on a large sample of students to understand how they define mental health for themselves, as well as how they prefer to learn about it.

© 2015 Society for Adolescent Health and Medicine. Purpose Although extensive evidence indicates that being younger within a school cohort is associated with poorer academic functioning, much less is known about such relative age effects (RAEs) for mental health - the focus of the current investigation. Methods Data from 23,379 11- to 13-year-olds attending state-maintained secondary schools in England were analyzed to investigate RAEs on mental health measured using the Strengths and Difficulties Questionnaire. Participants were grouped into oldest, middle, and youngest thirds of their academic year based on their month of birth relative to their cohort. Hierarchical linear regression analysis evaluated RAEs and gender- or deprivation-related moderation of such effects. Results Relatively younger adolescents had significantly more emotional symptoms and peer problems compared with relatively older individuals in a year group, although effect sizes were small. These effects were not moderated by gender or deprivation. Impact of mental health difficulties on other aspects of functioning was also greater among relatively younger children. Larger RAEs are observed in the younger cohort (11-12 years) compared with those in the 12- to 13-year-olds, thereby indicating that RAEs might attenuate with age. Conclusions Being relatively younger than classmates is associated with increased internalizing symptoms, poorer peer relationships, and higher impact of mental health difficulties on functioning at school and home. The findings support wider inclusion of relative age in understanding mental health difficulties and its inclusion as a potential risk factor in studies investigating the development of psychopathology, especially for internalizing symptoms. Possible mechanisms of the effects detected are discussed.

We report on a randomized controlled trial of Targeted Mental Health in Schools (TaMHS), which is a nationally mandated school-based mental health program in England. TaMHS aimed to improve mental ...

Aims: To investigate the impact of war trauma On child mental health; the mediating role of different coping strategies. Methods: The sample was selected randomly from the five localities of the Gaza Strip that had been exposed to war16 months earlier. Children completed the Gaza Traumatic Events Checklist20 items-War on Gaza, UCLA PTSD scale, Birleson Depression Scale, Child Revised Manifest Anxiety Scale, and Kidcope for children. Results: Children reported many traumatic events (mean = 4). One third (32.5%) had partial and 12.4% had full criteria of PTSD. Children living in families with low family monthly income reported more emotional problems. There was significant association between exposure to traumatic events and developing PTSD. The rates of significant anxiety and depressive symptoms were 20.5% and

The aim of the study was to investigate the prevalence of mental health problems and quality of life among Palestinian disable children. The sample consisted of 391 disable Palestinian children in the Gaza Strip which was selected randomly from the data base of two NGOs working with such group of children. The age of children ranged from 6 - 18 years with mean age (11.73). Instruments: The children and adolescents demographic data were collected by questionnaire include sex, age, class, and place of residence, Gaza Child Health Study Scales (parents and children forms), and The Pediatric Quality of Life Inventory generic core (version 4.0) scale. The results showed that children reported mean conduct disorder was 1.33; oppositional disorder was 5; mean overanxious was 6.75; separation anxiety mean was 6.36; and depression was 7.57. There were statistically significant differences toward boys in depression. According to parents, mean conduct disorder mean was 1.94; mean oppositional disorder was 6.09; mean overanxious was 7.47; separation anxiety mean was 6.48; and mean depression was 9.6. The study showed that mean depression in boys was 10.4 compared to 8.9 in girls. There were statistically significant differences toward boys in depression. Parents of children with physical disabilities reported more overanxious problems in their children compared to other parents with other types of disabilities (vision, mental, and multiple). Also, parents of children with physical disability had more separation anxiety than other groups (mental and multiple disabilities). Quality of life of children was scored by children themselves; mean emotional functioning was 8.24; mean social functioning was 6.65; school functioning mean was 9.17; and cognitive functioning was 8.57. The study showed that mental health problems rated by children such as conduct disorder was positively correlated with emotional and cognitive functioning; oppositional disorder was correlated with emotional, social, and cognitive function; overanxious disorder was correlated emotional, school, and cognitive functioning; separation anxiety was correlated emotional functioning; and depression was correlated emotional, social, and cognitive functioning.

Background: Case-mix classification is a focus of international attention in considering how best to manage and fund services, by providing a basis for fairer comparison of resource utilization. Yet there is little evidence of the best ways to establish case mix for child and adolescent mental health services (CAMHS).Aim: To develop a case mix classification for CAMHS that is clinically meaningful and predictive of number of appointments attended and to investigate the influence of presenting problems, context and complexity factors and provider variation.Method: We analysed 4573 completed episodes of outpatient care from 11 English CAMHS. Cluster analysis, regression trees and a conceptual classification based on clinical best practice guidelines were compared regarding their ability to predict number of appointments, using mixed effects negative binomial regression.Results: The conceptual classification is clinically meaningful and did as well as data-driven classifications in accounting for number of appointments. There was little evidence for effects of complexity or context factors, with the possible exception of school attendance problems. Substantial variation in resource provision between providers was not explained well by case mix.Conclusion: The conceptually-derived classification merits further testing and development in the context of collaborative decision making.

This article presents the characteristics of 83 looked after and 67 adopted children at the time of their first assessment by a designated mental health team in the context of potential appropriate...

Background Recent initiatives have emphasized the ongoing need to include children in healthcare research, which is relevant to the development of both paediatric and mental healthcare services. Our aim was to contribute children and their parents' perceptions and experiences of Child and Adolescent Mental Health Services (CAMHS), with the objective of providing guidance for those wishing to improve inclusivity and empowerment. Method We performed a thematic analysis of interview data taken from 11 children (9 boys, 2 girls, aged 8–12) and their parents (12 mothers, 2 fathers), who had recently been referred to CAMHS for mental health and educational problems. Results Three core themes emerged from the data. Fear of the unknown refers to emotional apprehension due to uncertainty of what happens in CAMHS. However children also provided useful reassurances for future service users. Therapeutic engagement refers to the importance of being listened to and building up good relationships with professionals. Finally making services acceptable was discussed in terms of issues of accessibility, session tolerances and suggestions for the development of child-centred services. Conclusions Children were able to provide potentially useful opinions of CAMHS. In a time of limited resources it is imperative that the voices of children and their parents are acknowledged in order to improve accessibility and experiences within CAMHS.

Background: Unaccompanied refugee adolescents are a small but clinically significant group. This group is vulnerable with physical and psychiatric needs which are often not met. There are several barriers to providing care for this group, originating with the refugees but also due to service provision. Aims: The aim of this research is to appreciate the views and perceptions that unaccompanied minors hold about mental health and services. Method: Fifteen unaccompanied adolescents engaged with mental health services were interviewed, and thematic analysis was employed to explore relevant issues. Discussion: Their views reflected a range of opinions on mental health and the treatments they received, but many held negative attitudes toward mental health and had a lack of trust in services. This could be explained by their descriptions of their experiences within their home country of psychiatric care, their experiences of being a refugee/asylum-seeker or cultural differences. Conclusion: We argue it is important to engage this group in the development of policy and practice in child mental health, and in developing services.

Most studies examining adolescent alcohol and substance use or abuse hardly include samples from developing countries. To bridge some gap, the prevalence and associated social correlates of alcohol and substance use and abuse was examined among a cohort of school-going adolescents sampled from seven developing countries. Alcohol and substance abuse was measured using the CRAFFT instrument, independent socio-demographic correlates were determined using regression models. A total of 2454 adolescents completed the study, among which 40.9% reported using either alcohol or at least one other substance during the previous 12 months. This was mostly alcohol (37.8%), followed by marijuana/hashish (8.6%) and other substances (8.1%). Among the adolescents who reported using at least one substance, 45% (18.3% of total sample) had CRAFFT scores indicative of problematic or hazardous substance use. Several personal and family factors were independently associated with use/abuse, and the modifiable nature of these factors calls for appropriate intervention strategies.

School-based interventions involving teacher training programmes have been shown to benefit teachers’ ability to identify and manage child mental health problems in developed countries. However, very few studies have been conducted in low-income countries with limited specialist services. The aim of the study was to evaluate the impact of the training programme on teachers’ knowledge and awareness. A total of 114 primary school teachers from five schools in Karachi participated in a two-day (10–12 hours) workshop to provide them with an understanding of common child mental health problems and train them in basic skills. Their pre- and post-training knowledge was evaluated through a rating scale and open-ended questions. Single tailed t-test, involving paired differences, was applied for participants’ scores. Pre-/post-training differences were statistically significant. The training sessions were associated with an improvement in teachers’ knowledge and awareness of various signs and symptoms of common ch...

Early detection of child mental health problems in schools is critical for implementing strategies for prevention and intervention. The development of an effective measure of mental health and well-being for this context must be both empirically sound and practically feasible. This study reports the initial validation of a brief self-report measure for child mental health suitable for use with children as young as 8 years old (“Me & My School” [M&MS]). After factor analysis, and studies of measurement invariance, 2 subscales emerged: emotional difficulties and behavioral difficulties. These 2 subscales were highly correlated with corresponding constructs of the Strengths and Difficulties Questionnaire (SDQ) and showed correlations with attainment, deprivation, and educational needs similar to ones obtained between these demographic measures and the SDQ. Results suggest that this school-based self-report measure is psychometrically sound, and has the potential of contributing to school mental health surveys, evaluation of interventions, and recognition of mental health problems within schools.

Background.In order to compare estimates by one assessment scale across various cultures/ethnic groups, an important aspect that needs to be demonstrated is that its construct across these groups is invariant when measured using a similar and simultaneous approach (i.e., demonstrated cross-cultural measurement invariance). One of the methods for evaluating measurement invariance is testing for differential item functioning (DIF), which assesses whether different groups respond differently to particular items. The aim of this study was to evaluate the cross-cultural measurement invariance of the Revised Child Anxiety and Depression Scale (RCADS) in societies with different socioeconomic, cultural, and religious backgrounds.Methods.The study was organised by the International Child Mental Health Study Group. Self-reported data were collected from adolescents residing in 11 countries: Brazil, Bulgaria, Croatia, Indonesia, Montenegro, Nigeria, Palestinian Territories, the Philippines, Portugal, Romania and Serbia. The multiple-indicators multiple-causes model was used to test the RCADS items for DIF across the countries.Results.Ten items exhibited DIF considering all cross-country comparisons. Only one or two items were flagged with DIF in the head-to-head comparisons, while there were three to five items flagged with DIF, when one country was compared with the others. Even with all cross-culturally non-invariant items removed from nine language versions tested, the original factor model representing six anxiety and depressive symptoms subscales was not significantly violated.Conclusions.There is clear evidence that relatively small number of the RCADS items is non-invariant, especially when comparing two different cultural/ethnic groups, which indicates on its sound cross-cultural validity and suitability for cross-cultural comparisons in adolescent anxiety and depressive symptoms.

Quality of life is typically reduced in children with mental health problems. Understanding the relationship between quality of life and mental health problems and the factors that moderate this association is a pressing priority. This was a cross-sectional study involving 45,398 children aged 8-13 years from 880 schools in England. Self-reported quality of life was assessed using nine items from the KIDSCREEN-10 and mental health was assessed using the Me and My School Questionnaire. Demographic information (gender, age, ethnicity, socio-economic status) was also recorded. Quality of life was highest in children with no problems and lowest in children with both internalising and externalising problems. There was indication that quality of life may be reduced in children with internalising problems compared with externalising problems. Approximately 12 % children with mental health problems reported high quality of life. The link between mental health and quality of life was moderated by gender and age but not by socio-economic status or ethnicity. This study supports previous work showing mental health and quality of life are related but not synonymous. The findings have implications for measuring quality of life in child mental health settings and the need for approaches to support children with mental health problems that are at particular risk of poor quality of life.

The alarming global increase of persons forcibly displaced because of persecution, conflict, violence or human rights violation poses a number of challenges to health and other public sector services. Approximately 51.2 million individuals fall into this broad group, largely consisting of 33 million internally displaced, 17 million refugees and 1.2 million asylum seekers. Conflicts are no longer confined to regions, with the Syrian refugee crisis, for instance, spreading especially to Southern Europe, where Syrian refugees have already exceeded 1.5 million in Turkey alone, of whom 250,000 live in camps. Children under 18 years constitute around 50% of the refugee population, with a total of 25,000 unaccompanied minors applying for asylum annually across 80 countries. In recent years, there has been increasing evidence on the prevalence of mental disorders in refugee children and the underpinning risk factors, but knowledge remains relatively limited about resilience building, treatment and service efficacy. Studies arise from post‐conflict areas or from Western countries with newly arrived (asylum seeking) or resettled (refugee) children and young people. The characteristics of these groups, societal contexts and service systems obviously differ, requiring a range of approaches. Most epidemiological studies have focused on post‐traumatic stress disorder, but when they have been extended to other conditions such as depression, the impact of both past trauma and current life adversities on child psychopathology has clearly emerged1. The mediating effect of parental mental illness and parenting capacity is prominent1, although surprisingly there has been less attention so far to the role of the quality of attachment relationships, including those with extended family members. Unaccompanied children have an elevated risk of psychopathology and lower service engagement compared to refugee children living with their parents2. There has been less research on factors that promote mental health or that moderate stressors in this population, despite the acknowledgement of their direct relevance to planning interventions. Although not always theoretically driven, such studies have identified individual (spirituality, coping strategies, internal locus of control), family (financial circumstances, family acceptance and support) and community factors (neighbourhood safety, social support networks, school retention)3. These are important findings, but currently we lack a coherent model that connects them in order to inform the development of interventions and services. In terms of children's multiple needs, services often aspire to a socio‐ecological model, but this is not usually supported by research evidence, as most studies are still based on self‐reports, and programmes are rarely implemented at individual, family and community levels. Interventions usually draw on a variety of psychological frameworks, which are largely trauma‐focused, whether implemented individually or with groups, but without incorporating the family and community level4. They largely target re‐experiencing and reconstructing trauma‐related cognitions and emotions, and findings are not always exclusively based on refugee children, but rather on children exposed to war and political conflict, and living in a range of circumstances. The theoretical clarity and fidelity of interventions varies considerably, as well as their developmental perspective if adapted from adult programmes, or the demarcation between universal and targeted prevention5. Overall, the clinical and socio‐ecological fields are gradually converging. Therefore, we need to conceptualize intervention programmes and service development for refugee children in an integrated context. We should also take into consideration the vacuum or limitations of public services in most countries, where there is a huge mismatch between refugee numbers and resources, with this gap usually filled in part by non‐governmental organizations (NGOs) of varying philosophies, missions, structures and funding streams. The development of a comprehensive model should also be informed by organizational, in particular implementation theory. The framework proposed by Greenhalgh et al5 is useful, as it defines sequential stages, each with its own domains, i.e. innovation, adoption by individuals, assimilation by the system, diffusion, and dissemination. A service distinction should be made between displaced refugee children in low‐income countries and those resettled in high‐income health care systems, as well as between the acute and the resilience building phases. In low‐income countries, the humanitarian crisis is usually tackled by the United Nations, governmental departments and international NGOs, and this period remains fluid in terms of acute needs and mobility. Group‐based, particularly school interventions where possible, are the most cost‐effective. A number of modalities have been used, and a small number of studies have employed experimental designs such as randomized controlled trials6. These have been based on play, creative‐expressive, cognitive‐behavioural, narrative exposure, interpersonal, and grief‐focused therapies, with a tendency to broaden their scope from only focusing on trauma7. This is a useful baseline, but it needs to be maximized through existing systems, predominantly communities and schools; non‐specialist health community workers or lay counsellors supporting parents as mediators; and local empowerment8. The delivery of interventions in the absence of specialist professionals is another key challenge. In reality, the majority of interventions can only be delivered by suitably trained teachers, NGO staff and volunteers, or lay counsellors, who would thus integrate new skills to their “therapeutic key working role” to form the crucial links with the other eco‐levels9. This raises implications for consultancy, training and sustainability, e.g. through supervision, which will be the main focus of specialists in addition to using their sparse resources for acute and severe cases. Trauma‐focused interventions require a varying degree of skills and training, and this is a major practice issue in balancing treatment fidelity with a large‐scale impact on children. Practitioners and volunteers should be clear on the objectives at different stages of trauma exposure. A tiered model can be clinically and economically effective. Psychoeducation on symptom recognition and management (for example, nightmares) can be put in place relatively early through schools or community settings, preferably by involving parents, who may require additional input in their own right. For children who require a more active intervention, groups of relatively brief duration can be implemented by non‐specialist facilitators under clinical supervision, aiming at trauma re‐processing, and these should suffice for a substantial proportion of children. Those children who either do not respond or present with comorbid disorders that necessitate pharmacological treatment or more prolonged therapies, such as depression, should be the focus of the available specialist resources. When children are resettled in low‐ or middle‐income countries with limited specialist resources, similar approaches to those discussed previously can be adopted, particularly if they are placed in a relatively concentrated area. In high‐income countries, service models for a range of vulnerable children with complex needs should be applied, namely direct access, outreach work, and links with refugee charities and employment training10. The balance of interventions has gradually shifted from predominantly focusing on the pre‐flight trauma to more emphasis on resettlement factors, such as acquiring a new language and communication, socio‐cultural adjustment and identity, peer relationships (which can lead to bullying and further victimization), and school inclusion. Schools still provide an effective entry route into mental health services. Multi‐faceted case management can be provided in addition to the described therapeutic interventions, and this can include parenting input or liaison with adult mental health services. Unaccompanied minors require policies and systems equivalent to those for children in public care, e.g. appropriately trained residential staff and foster carers. Reliance on interpreters for a variety of languages makes their training and consistent relationship with services essential. Following recognition and referral to the appropriate service, a number of practice considerations should be made. Refugee children are likely to have different constructs of mental ill health, attributions that associate it with their asylum applications, and fears of stigma and deportation. Engaging them and alleviating such misconceptions is thus a major step towards a successful outcome. Their psychological mindedness will vary, as many refugee children first experience predominantly somatizing symptoms, and may require several attempts before accepting a trauma‐focused treatment. Involving their carers and initially setting goals of, for instance, risk management while developing a trusting relationship can lead to a therapeutic phase, while they also become more adjusted in their country of reception. In conclusion, refugee children and young people pose a significant public health challenge across the world. Their complex needs require closer collaboration between mental health and non‐statutory services to maximize their respective skills and resources. A comprehensive multi‐modal service should include clear care pathways, case management, evidence‐based trauma‐focused interventions, consultancy, and training. Panos Vostanis School of Psychology, University of Leicester, Leicester, UK

Background: An increasing number of children are placed in foster care (i.e., a kin or nonkin family home other than the biological parent) due to experiences of physical, sexual, emotional, or psychological abuse, and/or neglect. Children in foster care are at increased risk for a host of negative outcomes encompassing emotional, behavioral, neurobiological, and social realms. Methods: Areas of risk and vulnerability among foster children are described, including emotional and behavioral deficits, impaired neurobiological development, and social relationship deficits. Evidence suggesting the significance of family placement changes and prenatal exposure to substances as contributing mechanisms is presented. Based on a systematic search of the PsycINFO database (to March 2012), eight efficacious evidence-based interventions for foster families are summarized. Findings: Although the development of evidence-based interventions that improve outcomes for foster children has lagged behind the delivery of interventions in other service sectors (e.g., mental health and educational sectors), several interventions across childhood and adolescence offer promise. Service system constraints offer both challenges and opportunities for more routine implementation of evidence-based interventions. Conclusions: Given the increased likelihood of poor outcomes for foster children, increased efforts to understand the pathways to vulnerability and to implement interventions shown to be effective in remediating risks and improving outcomes for this population are indicated. Evaluation of efficacious interventions in countries outside of the United States is also needed. © 2012 The Authors. Journal of Child Psychology and Psychiatry © 2012 Association for Child and Adolescent Mental Health.