Sociodemographic factors associated with routine outcome monitoring: a historical cohort study of 28,382 young people accessing child and adolescent mental health services.

BACKGROUND: Patient-reported outcome measures (PROMs) are important tools to inform patients, clinicians and policy-makers about clinical need and the effectiveness of any given treatment. Consistent PROM use can promote early symptom detection, help identify unexpected treatment responses and improve therapeutic engagement. Very few studies have examined associations between patient characteristics and PROM data collection. METHODS: We used the electronic mental health records for 28,382 children and young people (aged 4-17 years) accessing Child and Adolescent Mental Health Services (CAMHS) across four South London boroughs between the 1st of January 2008 to the 1st of October 2017. We examined the completion rates of the caregiver Strengths and Difficulties Questionnaire (SDQ), a ubiquitous PROM for CAMHS at baseline and 6-month follow-up. RESULTS AND CONCLUSIONS: SDQs were present for approximately 40% (n = 11,212) of the sample at baseline, and from these, only 8% (n = 928) had a follow-up SDQ. Patterns of unequal PROM collection by sociodemographic factors were identified: males were more likely (aOR 1.07, 95% CI 1.01-1.13), whilst older age (aOR 0.87, 95% CI 0.87-0.88), Black (aOR 0.79 95% CI 0.74-0.84) and Asian ethnicity (aOR 0.75 95% CI 0.66-0.86) relative to White ethnicity, and residence within the most deprived neighbourhood (aOR 0.87 95% CI 0.80-0.94) were less likely to have a record of baseline SDQ. Similar results were found in the sub-group (n = 11,212) with follow-up SDQ collection. Our findings indicate systematic differences in the currently available PROMS data and highlights which groups require increased focus if we are to gain equitable PROM collection. We need to ensure representative PROM collection for all individuals accessing treatment, regardless of ethnic or socioeconomic background; biased data have adverse ramifications for policy and service level decision-making.

An approach to linking education, social care and electronic health records for children and young people in South London: a linkage study of child and adolescent mental health service data.

OBJECTIVES: Creation of linked mental health, social and education records for research to support evidence-based practice for regional mental health services. SETTING: The Clinical Record Interactive Search (CRIS) system was used to extract personal identifiers who accessed psychiatric services between September 2007 and August 2013. PARTICIPANTS: A clinical cohort of 35 509 children and young people (aged 4-17 years). DESIGN: Multiple government and ethical committees approved the link of clinical mental health service data to Department for Education (DfE) data on education and social care services. Under robust governance protocols, fuzzy and deterministic approaches were used by the DfE to match personal identifiers (names, date of birth and postcode) from National Pupil Database (NPD) and CRIS data sources. OUTCOME MEASURES: Risk factors for non-matching to NPD were identified, and the potential impact of non-match biases on International Statistical Classification of Diseases, 10th Revision (ICD-10) classifications of mental disorder, and persistent school absence (<80% attendance) were examined. Probability weighting and adjustment methods were explored as methods to mitigate the impact of non-match biases. RESULTS: Governance challenges included developing a research protocol for data linkage, which met the legislative requirements for both National Health Service and DfE. From CRIS, 29 278 (82.5%) were matched to NPD school attendance records. Presenting to services in late adolescence (adjusted OR (aOR) 0.67, 95% CI 0.59 to 0.75) or outside of school census timeframes (aOR 0.15, 95% CI 0.14 to 0.17) reduced likelihood of matching. After adjustments for linkage error, ICD-10 mental disorder remained significantly associated with persistent school absence (aOR 1.13, 95% CI 1.07 to 1.22). CONCLUSIONS: The work described sets a precedent for education data being used for medical benefit in England. Linkage between health and education records offers a powerful tool for evaluating the impact of mental health on school function, but biases due to linkage error may produce misleading results. Collaborative research with data providers is needed to develop linkage methods that minimise potential biases in analyses of linked data.

The Association Between Comorbid Autism Spectrum Disorders and Antipsychotic Treatment Failure in Early-Onset Psychosis: A Historical Cohort Study Using Electronic Health Records.

OBJECTIVE: In a sample of children and adolescents with first-episode psychosis, we investigated whether multiple treatment failure (MTF, defined as the initiation of a third trial of novel antipsychotic due to nonadherence, adverse effects, or insufficient response) was associated with comorbid autism spectrum disorders. METHODS: Data were from the electronic health records of 638 children (51% male) aged from 10 to 17 years with first-episode psychosis (per ICD-10 criteria) from January 1, 2008, to November 1, 2014, referred to mental health services in South London, United Kingdom; data were extracted using the Clinical Record Interactive Search (CRIS) system. The effect of autism spectrum disorder comorbidity on the development of MTF during a 5-year period was modeled using Cox regression. RESULTS: There were 124 cases of MTF prior to the age of 18 (19.4% of the sample). Comorbid autism spectrum disorders were significantly associated with MTF (adjusted hazard ratio = 1.99; 95% CI, 1.19-3.31; P = .008) after controlling for a range of potential confounders. Other factors significantly associated with MTF included higher age at first presentation (P = .001), black ethnicity (P = .03), and frequency of clinical contact (P < .001). No significant association between other comorbid neurodevelopmental disorders (hyperkinetic disorder or intellectual disability) and MTF was found. CONCLUSIONS: Children with first-episode psychosis and comorbid autism spectrum disorders at first presentation are less likely to have a beneficial response to antipsychotics.

Trajectories of childhood internalizing and externalizing psychopathology and psychotic-like experiences in adolescence: A prospective population-based cohort study.

Adolescent internalizing and externalizing psychopathology is strongly associated with adult psychiatric morbidity, including psychotic disorders. This study examined whether internalizing or externalizing trajectories (continuity/discontinuity of symptoms) from middle childhood were associated with adolescent psychotic-like experiences (PLEs). Prospective data were collected from a community sample of 553 children (mean age = 10.4 years; 50% male) and their primary caregivers. Participants completed questionnaire reports of internalizing and externalizing psychopathology and PLEs at baseline, and again approximately 2 years later. Logistic regression was used to examine the association of adolescent PLEs with four trajectories of internalizing and externalizing psychopathology (persistent, incident, remitting, and none), controlling for a range of potential confounders and sampling bias. Significant associations were identified between adolescent PLEs and the incident internalizing (adjusted odds ratio [adj. OR] = 2.96; 95% confidence interval [CI] = 1.60-5.49) and externalizing psychopathology (adj. OR = 2.14; 95% CI = 1.11-4.14) trajectories, as well as the persistent internalizing (adj. OR = 1.90; 95% CI = 1.13-3.18) and externalizing (adj. OR = 1.81, 95% CI = 1.02-3.19) trajectories. Children with remitting psychopathology trajectories were no more likely to present later PLEs than those who never experienced psychopathology. While for many individuals symptoms and illness remit during development without intervention, this study provides important insights regarding potential targets and timing for delivery of early intervention and prevention programs.

Persisting psychotic-like experiences are associated with both externalising and internalising psychopathology in a longitudinal general population child cohort.

BACKGROUND: Persisting psychotic-like experiences (PLEs) are associated with an increased risk of internalising symptoms in adolescence. Whether this association holds similarly for externalising symptoms, and from mid-childhood, is unclear. This prospective study investigated the extent to which PLE persistence was associated with internalising and externalising psychopathology in a community sample of children aged 9-11years at study commencement. METHODS: 8099 children (mean age 10.4years) completed questionnaires assessing PLEs, externalising and internalising symptoms. A subsample of 547 children completed reassessment, on average, two years later. RESULTS: Two-thirds (66%) of children reported PLEs at baseline. Approximately two years later, PLEs persisted in 39% of those children. After adjustment for previous psychopathology and other potential confounds, children with persisting PLEs were at higher risk for internalising (odds ratio [OR]=1.94; 95% confidence interval [CI] 1.13-3.34) and externalising (OR=1.97; 95% CI 1.19-3.26) psychopathology than children whose PLEs remitted; and, than children who never presented PLEs. CONCLUSIONS: Persistent PLEs from mid-childhood are associated with later internalising and externalising psychopathology in the general population, whereas transitory PLEs may be part of a spectrum of normative childhood development. Interventions that target persistent PLEs may contribute to a reduction in common childhood psychopathology.