Primary care service use during adolescence and young adulthood: Tertiary care cohort affected by chronic health conditions.

OBJECTIVE: To understand use of family physician services and emergency department visits by adolescents and young adults with chronic health conditions. DESIGN: Longitudinal retrospective observational cohort study using administrative health data. SETTING: Chronic care clinics at a tertiary care pediatric hospital in Calgary, Alta. PARTICIPANTS: In total, 1326 adolescents who were between 12 and 15 years old in 2008, who were observed until 2016, and who received medical services for chronic conditions were enrolled in the study. Eligible participants had at least 4 visits to the same chronic disease clinic in any 2-year window before age 18. MAIN OUTCOMES MEASURES: Group-based trajectory modeling was used to identify groups of adolescents with distinct patterns of health care use (for visits to emergency departments and to primary care practices), while 2 tests explored trajectory group differences (eg, sex, location of residence). RESULTS: Median age was 14 years (range 12 to 17 years) at study entry, and 22 years (range 14 to 24 years) at study exit. Half were female and most (85.4%) lived in an urban area. Median observation period was 8.7 person-years (range 1.3 to 9.1 years). Group-based trajectory modeling identified 5 distinct trajectory groups of primary care use and 4 groups of emergency services use. Groups differed by sex and location of residence in each trajectory model. CONCLUSION: Many adolescents increased their use of emergency services between the ages of 12 and 24 years, with distinct patterns of primary care use being observed. Association of additional patient- and system-level factors (eg, disease severity, distance to nearest family physician office) should be explored.

Supporting the Transition to Postsecondary Institutions for Students with Mental Health Conditions: A Scoping Review.

Objective: To conduct a scoping review to identify programs and interventions to support youth with mental health conditions (MHCs) with their transition to postsecondary institution (PSI). Method: A database search of MEDLINE, PsycINFO, Embase, SocINDEX, ERIC, CINHAL, and Education Research Complete was undertaken. In this review, MHC was defined as a mental, behavioural, or emotional condition, or problematic substance use, and excluded neurodevelopmental or physical disorders. Two reviewers independently screened studies and extracted the data. Included studies are described and a risk-of-bias assessment was conducted on included studies. Results: Nine studies were included in this review, describing eight unique interventions. Sixty-two percent of interventions were nonspecific in the MHCs that they were addressing in postsecondary students. These interventions were designed to support students upon arrival to their PSIs. Peer mentorship, student engagement, goal setting, and interagency collaboration were some of the strategies employed. However, the overall quality and level of evidence in these studies was low and the effectiveness of these programs was not established. Conclusion: The volume of research identified was limited, no reliable nor policy informing conclusions can yet be made about the impact of these interventions as the evaluation methods, quality of the research methodologies, and the levels of evidence available were of low-quality. Future randomized control trials are required that are designed to target and improve transitions from secondary education to PSIs for those with MHCs.

Objectif: Mener une étude de la portée afin d'identifier les programmes et interventions qui soutiennent les jeunes souffrant de troubles de santé mentale (TSM) dans leur transition à une institution post-secondaire (IPS). Méthode: Une recherche des bases de données MEDLINE, PsycINFO, Embase, SocINDEX, ERIC, CINHAL, et Education Research Complete a été entreprise. Dans cette revue, les TSM étaient définis comme un trouble mental, comportemental ou émotionnel, ou une utilisation de substances problématique et excluaient les troubles neurodéveloppementaux ou physiques. Deux réviseurs ont examiné indépendamment les études et extrait les données. Les études incluses sont décrites et une évaluation du risque de biais a été menée sur les études incluses. Résultats: Neuf études ont été incluses dans cette revue, qui décrivaient huit interventions uniques. Soixante-deux pour cent des interventions étaient non spécifiques dans les TSM qu'ils abordaient chez les élèves du post-secondaire. Ces interventions étaient conçues pour soutenir les élèves à leur arrivée à leur IPS. Le mentorat par les pairs, l'engagement des élèves, l'établissement de buts, et la collaboration inter-agence étaient certaines des stratégies employées. Toutefois, la qualité globale et le niveau des données probantes de ces études étaient faibles et l'efficacité de ces programmes n'a pas été établie. Conclusion: Le volume de recherche identifié était limité, rien de fiable ni aucune politique éclairant les conclusions ne peut encore révéler l'impact de ces interventions comme méthodes d'évaluation, la qualité des méthodologies de recherche, et les niveaux des données probantes disponibles étaient de faible qualité. Il faut de futurs essais randomisés contrôlés qui sont conçus pour cibler et améliorer les transitions de l'éducation secondaire aux IPS pour ceux qui souffrent de TSM.

Community based Primary Care for Adolescents and Young Adults Transitioning From Pediatric Specialty Care: Results from a Scoping Review.

BACKGROUND: Ongoing primary care during adolescence is recommended by best practice guidelines for adolescents and young adults (AYAs; ages 12-25) with chronic conditions. A synthesis of the evidence on the roles of Primary Care Physicians (PCPs) and benefits of primary care is needed to support existing guidelines. METHODS: We used Arksey and O'Malley's scoping review framework, and searched databases (MEDLINE, EMBASE, PsychINFO, CINAHL) for studies that (i) were published in English between 2004 and 2019, (ii) focused on AYAs with a chronic condition(s) who had received specialist pediatric services, and (iii) included relevant findings about PCPs. An extraction tool was developed to organize data items across studies (eg, study design, participant demographics, outcomes). RESULTS: Findings from 58 studies were synthesized; 29 (50%) studies focused exclusively on AYAs with chronic health conditions (eg, diabetes, cancer), while 19 (33%) focused exclusively on AYAs with mental health conditions. Roles of PCPs included managing medications, "non-complex" mental health conditions, referrals, and care coordination, etc. Frequency of PCP involvement varied by AYAs; however, female, non-Black, and older AYAs, and those with severe/complex conditions appeared more likely to visit a PCP. Positive outcomes were reported for shared-care models targeting various conditions (eg, cancer, concussion, mental health). CONCLUSION: Our findings drew attention to the importance of effective collaboration among multi-disciplinary specialists, PCPs, and AYAs for overcoming multiple barriers to optimal transitional care. Highlighting the need for further study of the implementation of shared care models to design strategies for care delivery during transitions to adult care.

Recommendations for youth engagement in Canadian mental health research in the context of COVID-19.

The COVID-19 pandemic has resulted in reduced access to in-person mental health services, and a shift to virtual platforms. Youth may be uniquely impacted by physical distancing requirements during the pandemic, including limited socialization opportunities, closures of educational institutions, a lack of meaningful extracurricular activities and adverse implications on key developmental milestones. Due to the potential impact of COVID-19 on youth well-being, the need to rapidly transform services to be accessible, and the potential risks associated with this rapid transformation, it is imperative that youth continue to be engaged in research and service development. Young people's perspectives, strengths and skills need to be considered to effectively adapt the delivery of mental health services. Continuing to center youth engagement in mental health research throughout the pandemic can ensure research questions, programs, and services align with the needs and preferences of youth. In this commentary, we pose three recommendations for conducting youth-engaged mental health research during the pandemic, including adapting youth engagement strategies when rapid decisions must be made, the use of tools for virtual engagement, and suggestions for evaluating youth engagement practices. These strategies and principles may be applicable to other scenarios where rapid research or system transformation would benefit from youth engagement, such as time-limited child research by trainees (e.g., dissertations) or natural disasters.

La pandémie de la COVID-19 a entraîné un accès réduit aux services de santé mentale en personne, et une transition aux plateformes virtuelles. Les jeunes peuvent être particulièrement touchés par les consignes de distanciation physique durant la pandémie, notamment par les occasions limitées de socialisation, la fermeture des institutions éducatives, le manque d'activités parascolaires et les implications néfastes sur les principales étapes du développement. Étant donné l'impact potentiel de la COVID-19 sur le bien-être des jeunes, le besoin de transformer rapidement les services pour les rendre accessibles, et les risques potentiels associés à cette transformation rapide, il est impératif que les jeunes continuent de participer à la recherche et au développement des services. Les perspectives, les forces et les talents des jeunes gens doivent être pris en considération afin d'adapter efficacement la prestation des services de santé mentale. Continuer d'axer la participation des jeunes dans la recherche en santé mentale durant la pandémie peut faire en sorte que les questions, les programmes et les services de la recherche correspondent aux besoins et aux préférences des jeunes. Dans le présent commentaire, nous énonçons trois recommandations pour mener une recherche en santé mentale avec la participation des jeunes durant la pandémie, notamment adapter les stratégies de participation des jeunes lorsqu'il faut prendre des décisions rapidement, l'utilisation des outils de participation virtuelle, et des suggestions pour évaluer les pratiques de participation des jeunes. Ces stratégies et principes peuvent s'appliquer à d'autres scénarios quand la recherche rapide ou la transformation du système bénéficierait de la participation des jeunes, comme la recherche sur les enfants en temps limité par les stagiaires (p. ex., dissertation) ou des catastrophes naturelles.

Primary care during the transition to adult care for adolescents involved with pediatric specialty services: a scoping review protocol.

BACKGROUND: Of the 15-20% of youth in North America affected by a chronic health condition (e.g., type 1 diabetes, cystic fibrosis) and/or mental health or neurodevelopmental disorder (e.g., depression, eating disorder, Attention Deficit-Hyperactivity Disorder), many often require lifelong specialist healthcare services. Ongoing primary care during childhood and into young adulthood is recommended by best practice guidelines. To date, it is largely unknown if, how, and when primary care physicians (PCPs; such as family physicians) collaborate with specialists as AYAs leave pediatric-oriented services. The proposed scoping review will synthesize the available literature on the roles of PCPs for AYAs with chronic conditions leaving pediatric specialty care and identify potential benefits and challenges of maintaining PCP involvement during transition. METHODS: Arksey and O'Malley's original scoping review framework will be utilized with guidance from Levac and colleagues and the Joanna Briggs Institute. A search of databases including MEDLINE (OVID), EMBASE, PsycINFO, and CINAHL will be conducted following the development of a strategic search strategy. Eligible studies will (i) be published in English from January 2004 onwards, (ii) focus on AYAs (ages 12-25) with a chronic condition(s) who have received specialist services during childhood, and (iii) include relevant findings about the roles of PCPs during transition to adult services. A data extraction tool will be developed and piloted on a subset of studies. Both quantitative and qualitative data will be synthesized. DISCUSSION: Key themes about the roles of PCPs for AYAs involved with specialist services will be identified through this review. Findings will inform the development and evaluation of a primary-care based intervention to improve transition care for AYAs with chronic conditions.

Re-Accessing Mental Health Care After Age 18: A Longitudinal Cohort Study of Youth Involved with Community-based Child and Youth Mental Health Agencies in Ontario.

OBJECTIVE: About 20-26% of children and youth with a mental health disorder (depending on age and respondent) report receiving services from a community-based Child and Youth Mental Health (CYMH) agency. However, because agencies have an upper age limit of 18-years old, youth requiring ongoing mental health services must "transition" to adult-oriented care. General healthcare providers (e.g., family physicians) likely provide this care. The objective of this study was to compare the likelihood of receiving physician-based mental health services after age 18 between youth who had received community-based mental health services and a matched population sample. METHOD: A longitudinal matched cohort study was conducted in Ontario, Canada. A CYMH cohort that received mental health care at one of five CYMH agencies, aged 7-14 years at their first visit (N=2,822), was compared to age, sex, region-matched controls (N=8,466). RESULTS: CYMH youth were twice as likely as the comparison sample to have a physician-based mental health visit (i.e., by a family physician, pediatrician, psychiatrists) after age 18; median time to first visit was 3.3 years. Having a physician mental health visit before age 18 was associated with a greater likelihood of experiencing the outcome than community-based CYMH services alone. CONCLUSION: Most youth involved in community-based CYMH agencies will re-access services from physicians as adults. Youth receiving mental health services only within community agencies, and not from physicians, may be less likely to receive physician-based mental health services as adults. Collaboration between CYMH agencies and family physicians may be important for youth who require ongoing care into adulthood.

OBJECTIF: Environ 20 à 26 % des enfants et des adolescents souffrant d'un trouble de santé mentale (dépendant de l'âge et du répondant) déclarent recevoir des services d'un organisme communautaire de santé mentale pour enfants et adolescents (SMEA) Toutefois, puisque les organismes ont une limite d'âge supérieur de 18 ans, les jeunes nécessitant des services de santé mentale doivent faire la « transition ¼ aux soins pour adultes. Les prestataires de soins de santé généraux (p. ex., les médecins de famille) dispensent probablement ces services. La présente étude visait à comparer la probabilité de recevoir des services de santé mentale par un médecin après l'âge de 18 ans entre un jeune qui avait reçu des services de santé mentale et un échantillon apparié dans la population. MÉTHODE: Une étude de cohorte longitudinale appariée a été menée en Ontario, Canada. Une cohorte SMEA qui recevait des soins de santé mentale à l'un des cinq organismes SMEA, âgés entre 7 et 14 ans à leur première visite (N = 2,822), a été comparée pour l'âge, le sexe, les contrôles appariés par région (N = 8,466). RÉSULTATS: Les jeunes des SMEA étaient deux fois plus susceptibles que l'échantillon de comparaison d'avoir une visite de santé mentale par un médecin (c.-à-d. par un pédiatre médecin de famille, des psychiatres) après l'âge de 18 ans le temps moyen avant une première visite était 3,3 ans. Avoir une visite de santé mentale avec un médecin avant l'âge de 18 ans était associé à une plus grande probabilité de connaître le résultat que par les services SMEA communautaires à eux seuls. CONCLUSION: La plupart des jeunes impliqués dans les organismes communautaires SMEA accéderont de nouveau aux services de médecins en tant qu'adulte. Les jeunes recevant des services de santé mentale uniquement d'organismes communautaires et non de médecins peuvent être moins susceptibles de recevoir des services de santé mentale par un médecin en tant qu'adultes. La collaboration entre les organismes SMEA et les médecins de famille peut être importante pour les jeunes qui nécessitent des soins constants à l'âge adulte.

Strategies for improving primary care for adolescents and young adults transitioning from pediatric services: perspectives of Canadian primary health care professionals.

BACKGROUND: Family physicians and other members of the primary health care (PHC) team may be ideally positioned to provide transition care to adolescents and young adults (AYAs; aged 12-25 years) exiting pediatric specialty services. Potential solutions to well-known challenges associated with integrating PHC and specialty care need to be explored. OBJECTIVE: To identify strategies to transition care by PHC professionals for AYAs with chronic conditions transitioning from pediatric to adult-oriented care. METHODS: Participants were recruited from six Primary Care Networks in Calgary, Alberta. A total of 18 semi-structured individual interviews were completed, and transcribed verbatim. Data were analyzed using a qualitative description approach, involving thematic analysis. RESULTS: Participants offered a range of strategies for supporting AYAs with chronic conditions. Our analysis resulted in three overarching themes: (i) educating AYAs, families, and providers about the critical role of primary care; (ii) adapting existing primary care supports for AYAs and (iii) designing new tools or primary care practices for transition care. CONCLUSIONS: Ongoing and continuous primary care is important for AYAs involved with specialty pediatric services. Participants highlighted a need to educate AYAs, families and providers about the critical role of PHC. Solutions to improve collaboration between PHC and pediatric specialist providers would benefit from additional perspectives from providers, AYAs and families. These findings will inform the development of a primary care-based intervention to improve transitional care.

An implementation history of primary health care transformation: Alberta's primary care networks and the people, time and culture of change.

BACKGROUND: Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province's healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment. METHODS: Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders' perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses. RESULTS: Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another's cultures to achieve the transformation towards PHC has been central to the PCNs' survival and success. CONCLUSIONS: Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another's cultures; and how best to support the transformation of a system while delivering care locally.

Perspectives from primary health care providers on their roles for supporting adolescents and young adults transitioning from pediatric services.

BACKGROUND: Transitioning from pediatric care to adult-oriented care at age 18 (the age of transfer in most countries and jurisdictions) is a complex process for adolescents and young adults affected by chronic physical health and/or mental health conditions. The role of primary health care (PHC) providers for this population is poorly understood. Perspectives from these providers, such as family physicians and other members of the primary care team, have not been explored in depth. METHODS: A total of 18 participants (e.g., family physicians, social workers, nurses) were recruited from 6 Primary Care Networks in Calgary, Alberta, Canada. Semi-structured individual interviews were conducted, and transcribed verbatim. A qualitative description approach was used to analyze the data, and included thematic analysis. RESULTS: Five distinct, yet overlapping, roles of primary health care providers for adolescents and young adults transitioning to adult care resulted from our analysis: (1) being the "common thread" (continuous accessible care); (2) caring for the "whole patient" (comprehensive care); (3) "knowing families" (family-partnered care); (4) "empowering" adolescents and young adults to develop "personal responsibility" (developmentally-appropriate care); and (5) "quarterbacking" care (coordination of specialist and/or community-based care). Participants identified potential benefits of these roles for adolescents and young adults transitioning to adult care, and barriers in practice (e.g., lack of time, having minimal involvement in pediatric care). CONCLUSIONS: Input from family physicians, who follow their patients across the lifespan and provide the majority of primary care in Canada, are critical for informing and refining recommended transition practices. Our findings provide insights, from PHC providers themselves, to bolster the rationale for primary care involvement during transitions from pediatric specialty and community-based care for AYAs. Solutions to overcome barriers for integrating primary care and specialty care for adolescents and young adults need to be identified, and tested, with input from key stakeholders.

Pragmatic trial evaluating the effectiveness of a patient navigator to decrease emergency room utilisation in transition age youth with chronic conditions: the Transition Navigator Trial protocol.

INTRODUCTION: Transition to adult care is a challenging and complex process for youth with special healthcare needs. We aim to compare effectiveness of a patient navigator service in reducing emergency room (ER) use among adolescents with chronic health conditions transitioning to adult care. METHODS AND ANALYSIS: Pragmatic randomised controlled trial parallel group design comparing ER visit rates between patients with access to a personalised navigator intervention compared with usual care. Unit of randomisation is the patient. Treatment assignment will not be blinded. Embedded qualitative study to understand navigator's role and cost analysis attributable to the intervention will be performed. Patients aged 16-21 years, followed within a chronic disease clinic, expected to be transferred to adult care within 12 months and residing in Alberta during study period will be recruited from three tertiary care paediatric hospitals. Sample size will be 300 in each arm. Navigator intervention over 24 months is designed to assist participants in four domains: transition preparation, health system brokering, socioeconomic determinants of health and self-management. Primary outcome is ER visit rate during observation period. Secondary outcomes are ambulatory and inpatient care utilisation measures, as well as Transition Readiness Assessment Questionnaire score, and Short-Form Health Survey 12 (SF-12) score at 6 and 18 months post-randomisation. Poisson regression will compare rates of ER/urgent care visits between navigator and control participants, using intention to treat principle. Cost analysis of the intervention will be conducted. Thematic analysis will be used to identify perceptions of stakeholders regarding the role of navigators. ETHICS AND DISSEMINATION: Ethics approval was obtained from the University of Calgary Conjoint Health Research Ethics Board (REB #162561) and the University of Alberta Health Research Ethics Board (Pro00077325). Our team is composed of diverse stakeholders who are committed to improving transition of care who will assist with dissemination of results. TRIAL REGISTRATION NUMBER: NCT03342495.

An Exploratory Study of Children's Mental Health Providers' Perspectives on the Transition to Adult Care for Young Adolescents in the Canadian Context.

PURPOSE: Many youth who receive specialized children's mental health treatment might require additional treatment as young adults. Little is known about how to prepare these youth for transitions to adult care. DESIGN AND METHODS: This study gained perspectives from children's mental health providers (n = 10) about the process of caring for younger adolescents (aged 12-15) with mental health problems (e.g., depression, anxiety), who might require mental health services after age 18. Providers were asked about their clients' future mental health needs and the possibility of transition to adult care. RESULTS: Using Grounded Theory analysis, an over-arching theme was providers' reluctance to consider the transition process for their younger clients (<16 years old). This stemmed from uncertainty among providers about: (1) who [which youth] will need adult mental health services; (2) when this discussion would be appropriate; and (3) what adult services would be available. CONCLUSIONS AND PRACTICE IMPLICATIONS: Findings indicate a lack of treatment capacity within children's mental health to routinely monitor youth as they approach the age of transfer (18 years old). In the absence of routine monitoring (post-treatment), it may be difficult to predict who will need adult care. A comprehensive evaluation of existing follow-up practices, in children's mental health and beyond, is needed to identify strategies for ensuring adolescents with recurring conditions receive optimal transition care.

Health care stakeholder perspectives regarding the role of a patient navigator during transition to adult care.

BACKGROUND: Transition to adult care represents a vulnerable period for young people with special health care needs as they navigate multiple life transitions and developmental issues. Patient navigators are a promising intervention designed to facilitate the transfer from pediatric to adult care. However, consistent definitions, key tasks, roles and responsibilities are lacking in guiding the scope of practice and the implementation of patient navigators. METHODS: Fundamental qualitative description was utilized in this study to identify perceptions from health care providers about implementing a patient navigator service for young people with special health care needs in transition to adult care. A purposive sample of health care providers with a variety of backgrounds within pediatric and adult systems in Alberta, Canada were recruited. Semi-structured interviews with participants were analyzed using thematic analysis to inductively identify perceptions regarding the role of patient navigators. RESULTS: A total of 43 health care providers highlighted the need for a patient navigator service to encompass 4 key stages for young people with special health care needs transitioning from pediatric to adult services: (1) identification of young people with special health care needs and families requiring support, (2) preparation for transfer, (3) health system navigation and, (4) post-transfer support. CONCLUSIONS: The results of this qualitative study provide guidance for the development of patient navigator interventions for young people with special health care needs, as well as provide support for current transition services offered across Canada.

Identifying a retrospective cohort of adolescents with chronic health conditions from a paediatric hospital prior to transfer to adult care: the Calgary Transition Cohort.

PURPOSE: The Calgary Transition Cohort was created to examine health service utilisation by adolescents affected by chronic health conditions seen in a tertiary paediatric hospital in the province of Alberta, Canada. The cohort includes adolescents who received care before the implementation of a hospital-wide intervention to improve transitions to adult care. PARTICIPANTS: Using hospital records, a stepwise methodology involving a series of algorithms based on adolescents' visit frequency to a hospital ambulatory chronic care clinic (CCC) was used to identify the cohort. A visit frequency of ≥4 visits in any 24-month window, during the ages of 12-17 years old, was used to identify eligible adolescents, as agreed on by key stakeholders and chronic disease clinical providers, and reflects the usual practice at the hospital for routine care of children with chronic disease. FINDINGS TO DATE: Adolescents with ≥4 visits to the same CCC in any 2-year period (n=1344) with a median of 8.7 years of follow-up data collected (range 1.4-9.1). The median age at study entry was 14 years (range 12-17) and 22 years (range 14-24) at study exit. The cohort was linked (97% successful match proportion) to their population-level health records that allowed for examination of occurrence of chronic disease codes in health utilisation encounters (ie, physician claims, hospital admissions and emergency room visits). At least one encounter with a chronic disease code (International Classification of Diseases, 9th/10th Revisions) was observed during the entire study window in 87.9% of the cohort. FUTURE PLANS: The Calgary Transition Cohort will be used to address existing knowledge gaps about health service utilisation by adolescents, seen at a tertiary care hospital, affected by a broad group of chronic health conditions. These adolescents will require transition to adult-oriented care. Longitudinal analysis of health service use patterns over a 9-year window (2008-2016) will be conducted.

Perspectives on Monitoring Youth with Ongoing Mental Health Problems in Primary Health Care: Family Physicians Are "Out of the Loop".

Children's mental health (CMH) problems often recur. Following specialized mental health treatment, youth may require monitoring and follow-up. For these youth, primary health care is highly relevant, as family physicians (FPs) are the only professionals who follow patients across the lifespan. The current study gained multiple perspectives about (1) the role of FPs in caring for youth with ongoing/recurring CMH problems and (2) incorporating routine mental health monitoring into primary health care. A total of 33 interviews were conducted, including 10 youth (aged 12-15) receiving CMH care, 10 parents, 10 CMH providers, and 3 FPs. Using grounded theory methodology, a theme of FPs being "out of the loop" or not involved in their patient's CMH care emerged. Families perceived a focus on the medical model by their FPs and believed FPs lacked mental health expertise. Findings indicate a need for improved collaboration between CMH providers and FPs in caring for youth with ongoing CMH problems.

"I Think He Will Have It Throughout His Whole Life": Parent and Youth Perspectives About Childhood Mental Health Problems.

Children's mental health (CMH) problems can be long-lasting. Even among children and youth who receive specialized CMH treatment, recurrence of problems is common. It is unknown whether youth and their parents view the possibility of future mental health problems. This has important implications for how CMH services should be delivered. This grounded theory study gained perspectives from youth (aged 12-15 years) who received CMH treatment ( n = 10) and their parents ( n = 10) about the expected course of CMH problems. Three disorder trajectories emerged: (a) not chronic, (b) chronic and persistent, and (c) chronic and remitting, with the majority of youth falling in the third trajectory. A gap in available services between CMH and adult care was perceived by parents, leaving them either help hopeful or help hungry about their child's future care. Improving care for youth with ongoing mental health problems is needed to minimize costs to families and the system.

Who Should Transition? Defining a Target Population of Youth with Depression and Anxiety That Will Require Adult Mental Health Care.

The process of transitioning youth from child to adult mental health services is poorly managed, and many adolescents disengage from services during transfer. The waxing and waning of symptoms over time means that some youth who are asymptomatic prior to transfer (15-17 years) will be at high risk for recurrence during the transition period. There are no clear, evidence-based guidelines about who should transfer to adult care. Objectives were to propose: (1) criteria to define anxious or depressed youth (16-21 years) that should transfer and (2) levels of service needed in young adulthood. Natural history of psychopathology and treatment response for depression and anxiety was reviewed. Risk factors for recurrence and persistence, such as initial severity, comorbidity, and family functioning, can help to identify youth requiring transfer. Few controlled treatment studies have examined predictors of long-term course. Recommendations for follow-up care and ongoing monitoring during young adulthood are discussed.

Why wait? The effect of wait-times on subsequent help-seeking among families looking for children's mental health services.

Placement on a wait-list may increase families' help-seeking efforts, leading them to contact more than one children's mental health (MH) agency/professional. Two issues were examined in the current study: 1) Does time on a wait-list for families impact the time to contact a new agency for children's MH services? 2) What are the effects of predisposing (e.g., child age), need (e.g., child psychopathology), and enabling/system-level factors (e.g., parent treatment history) on the length of time parents wait before they contact a new agency for help with their child's MH problems? A total of 273 families seeking help for their child (64% boys, M = 10.7 years old, SD = 3.3) were asked about their contact with MH agencies/professionals during the previous year. Survival analyses, modeling time from initial wait-list placement to when a new agency was contacted, were conducted separately for families who did (n = 114), and those who did not (n = 159), receive help prior to contacting a new agency. Almost half of wait-listed families contacted a new agency by the end of the study period. Longer wait-time was associated with a greater likelihood of seeking help at a second agency with 25% of families contacting a new agency within the first month of being wait-listed. Parents with previous treatment experience and families living in areas with more agencies contacted a new agency sooner. Subsequent help-seeking behaviour suggests parents' intolerance for lengthy treatment delays may result in disorganized pathways to care. These findings suggest a highly fragmented service delivery system.