Lessons Learned from the Implementation of Youth Wellness Hubs Ontario, an Integrated Youth Services Network: Perspectives from Network Leads.

Introduction: Mental health and substance use services for youth in Canada continue to be fragmented. In response, Integrated Youth Services (IYS) has been proposed to address gaps in youth mental health services that can lead to improved youth outcomes. Youth Wellness Hubs Ontario (YWHO) was launched in 2017 as Ontario's IYS Network for youth ages 12-25, prioritizing continuous improvement through evaluation. Description: At the end of the first three years of the YWHO initiative, an evaluation was carried out to identify the barriers and facilitators to the initial implementation of YWHO and service delivery modifications resulting from the COVID-19 pandemic across ten sites. Reporting on these is the focus of this article. Key informant interviews were conducted in early 2021 with Network Leads from all ten initial YWHO sites. Reflexive thematic analysis was used to analyze all interview data. Discussion: Facilitators to the implementation of the YWHO model included diversified funding models, YWHO Provincial Office implementation supports, clear hub processes, robust community partnerships, organizational support and dedicated staff. Common barriers included certain challenges related to staffing and finances, implementation of the shared data collection platform, implementation of measurement-based care, partnerships, integrated service delivery, and branding and communications. Conclusion: Implementation of IYS is highly collaborative and quite complex. As interest in such models increase, so does the need for knowledge related to optimal implementation. Learnings have informed developments and improvements made to the YWHO model. Insights will also inform how stakeholders support youth in their communities in designing and implementing services that improve youth mental health and overall well-being.

Youth Wellness Hubs Ontario: Development and initial implementation of integrated youth services in Ontario, Canada.

AIM: The need for youth-friendly early intervention services to meet the mental health, substance use, primary care, and other social needs of adolescents and young adults is well-documented. This article describes Youth Wellness Hubs Ontario, a province-wide initiative in Ontario, Canada to build and implement a one-stop-shop model of integrated youth services. METHODS: We describe the development of Youth Wellness Hubs Ontario, in the context of global youth mental health system transformation, as well as pan-Canadian youth mental health system change. We also describe Youth Wellness Hubs Ontario's values and services. RESULTS: The demonstration phase of Youth Wellness Hubs Ontario was initiated in 2017-2018. Youth Wellness Hubs Ontario is co-created with youth for youth aged 12-25 years old across diverse community contexts. Youth Wellness Hubs Ontario centres engagement and equity, and offers developmentally-appropriate services in an integrated, community-based walk-in format. As an initiative committed to continuous learning and quality improvement, Youth Wellness Hubs Ontario offers evidence-based and evidence-generating services, and measurement-based care. Youth Wellness Hubs Ontario is supported by backbone resources with expertise in implementation science, health equity, Indigenous practices, youth and family engagement, evaluation, and knowledge translation. In 2020 Youth Wellness Hubs Ontario secured sustainable funding for the first 10 locations and scale-up began in 2021, with 10 additional locations in development. CONCLUSIONS: Youth Wellness Hubs Ontario demonstrates the feasibility of integrated mental health and substance use early intervention services, offered in the context of a broad range of health and social services.

Barriers and Facilitators to the Implementation of an Integrated Youth Services Network in Ontario.

Introduction: In response to the challenges of the traditional mental health system for youth both in Canada and abroad, models of integrated youth services (IYS) that span the integration of mental health, health, substance use, eucation, employment, peer support, and navigation into 'one-stop shops' are being established nationally and internationally. IYS models, however, need to be better described and evaluated to inform the replicability of this approach in other jurisdictions. Description: This paper describes the implementation of an IYS in a small urban city and rural county in Ontario, Canada, including insights from key informants into barriers, facilitators, and lessons learned. Discussion: This evaluation identified a number of barriers and facilitators to the implementation of the IYS model in this specific context. Implementation facilitators included youth and family engagement, network partner collaboration, leadership, governance structure, community enthusiasm and support, and collaborative funding models. Barriers to implementation included the COVID-19 pandemic and related public health restrictions, the diverse needs of youth, change management, sustainable funding, and transportation. Lessons learned: By establishing a shared vision of delivering youth services across the integrated network, and engaging youth early in the process of model development, IYS have the potential to transform the service system for youth and their families. Meeting the diverse needs and challenges of youth who live in rural or small urban communities will enhance service delivery and experience for young people.

Two Years of Relationship-Focused Mentoring for First Nations, Métis, and Inuit Adolescents: Promoting Positive Mental Health.

First Nations, Métis, and Inuit (FNMI) youth are disproportionately affected by a range of negative health outcomes including poor emotional and psychosocial well-being. At the same time, there is increasing awareness of culturally-specific protective factors for these youth, such as cultural connectedness and identity. This article reports the findings of a mixed-methods, exploratory longitudinal study on the effects of a culturally-relevant school-based mentoring program for FNMI youth that focuses on promoting mental well-being and the development of cultural identity. Participants included a cohort of FNMI adolescents whom we tracked across the transition from elementary to secondary school. We utilized data from annual surveys (n = 105) and a subset of youth whom we interviewed (n = 28). Quantitative analyses compared youth who participated in 1 or 2 years of mentoring programs with those who did not participate. At Wave 3, the 2-year mentoring group demonstrated better mental health and improved cultural identity, accounting for Wave 1 functioning. These results were maintained when sex and school climate were accounted for in the models. Sex did not emerge as a significant moderator; however, post hoc analyses with simple slopes indicated that the mentoring program benefited girls more than boys for both outcomes. Interview data were coded and themed through a multi-phase process, and revealed that the mentoring program helped participants develop their intrapersonal and interpersonal skills, and enhanced their cultural and healthy relationships knowledge base. Collectively, the quantitative and qualitative components of this study identify multiple years of culturally-relevant mentoring as a promising approach for promoting well-being among FNMI youth.

Agomelatine versus other antidepressive agents for major depression.

BACKGROUND: Major depressive disorder (MDD), or depression, is a syndrome characterised by a number of behavioural, cognitive and emotional features. It is most commonly associated with a sad or depressed mood, a reduced capacity to feel pleasure, feelings of hopelessness, loss of energy, altered sleep patterns, weight fluctuations, difficulty in concentrating and suicidal ideation. There is a need for more effective and better tolerated antidepressants to combat this condition. Agomelatine was recently added to the list of available antidepressant drugs; it is a novel antidepressant that works on melatonergic (MT1 and MT2), 5-HT 2B and 5-HT2C receptors. Because the mechanism of action is claimed to be novel, it may provide a useful, alternative pharmacological strategy to existing antidepressant drugs. OBJECTIVES: The objective of this review was 1) to determine the efficacy of agomelatine in alleviating acute symptoms of major depressive disorder in comparison with other antidepressants, 2) to review the acceptability of agomelatine in comparison with other antidepressant drugs, and, 3) to investigate the adverse effects of agomelatine, including the general prevalence of side effects in adults. SEARCH METHODS: We searched the Cochrane Collaboration's Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to 31 July 2013. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 onwards), MEDLINE (1950 onwards) and PsycINFO (1967 onwards). We checked reference lists of relevant studies together with reviews and regulatory agency reports. No restrictions on date, language or publication status were applied to the search. Servier Laboratories (developers of agomelatine) and other experts in the field were contacted for supplemental data. SELECTION CRITERIA: Randomised controlled trials allocating adult participants with major depression to agomelatine versus any other antidepressive agent. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and a double-entry procedure was employed. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy, acceptability and tolerability. MAIN RESULTS: A total of 13 studies (4495 participants) were included in this review. Agomelatine was compared to selective serotonin reuptake inhibitors (SSRIs), namely paroxetine, fluoxetine, sertraline, escitalopram, and to the serotonin-norepinephrine reuptake inhibitor (SNRI), venlafaxine. Participants were followed up for six to 12 weeks. Agomelatine did not show any advantage or disadvantage over the other antidepressants for our primary outcome, response to treatment (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.95 to 1.08, P value 0.75 compared to SSRIs, and RR 1.06; 95% CI 0.98 to 1.16, P value 0.16 compared to venlafaxine). Also, agomelatine showed no advantage or disadvantage over other antidepressants for remission (RR 0.83; 95% CI 0.68 to 1.01, P value 0.07 compared to SSRIs, and RR 1.08; 95% CI 0.94 to 1.24, P value 0.73 compared to venlafaxine). Overall, agomelatine appeared to be better tolerated than venlafaxine in terms of lower rates of drop outs (RR 0.40; 95% CI 0.24 to 0.67, P value 0.0005), and showed the same level of tolerability as SSRIs (RR 0.95; 95% CI 0.83 to 1.09, P value 0.44). Agomelatine induced a lower rate of dizziness than venlafaxine (RR 0.19, 95% CI 0.06 to 0.64, P value 0.007).With regard to the quality of the body of evidence, there was a moderate risk of bias for all outcomes, due to the number of included unpublished studies. There was some heterogeneity, particularly between published and unpublished studies. The included studies were conducted in inpatient and outpatient settings, thus limiting the generalisability of the results to primary care settings. With regard to precision, the efficacy outcomes were precise, but the tolerability outcomes were mostly imprecise. Publication bias was variable and depended on the outcome of the trial. Our review included unpublished studies, and we think that this reduced the impact of publication bias. The overall methodological quality of the studies was not very good. Almost all of the studies were sponsored by the pharmaceutical company that manufactures agomelatine (Servier), and some of these were unpublished. Attempts to contact the pharmaceutical company Servier for additional information on all unpublished studies were unsuccessful. AUTHORS' CONCLUSIONS: Agomelatine did not seem to provide a significant advantage in efficacy over other antidepressive agents for the acute-phase treatment of major depression. Agomelatine was better tolerated than paroxetine and venlafaxine in terms of overall side effects, and fewer participants treated with agomelatine dropped out of the trials due to side effects compared to sertraline and venlafaxine, but data were limited because the number of included studies was small. We found evidence that compared agomelatine with only a small number of other active antidepressive agents, and there were only a few trials for each comparison, which limits the generalisability of the results. Moreover, the overall methodological quality of the studies was low, and, therefore, no firm conclusions can be drawn concerning the efficacy and tolerability of agomelatine.

Observations of adolescent peer resistance skills following a classroom-based healthy relationship program: a post-intervention comparison.

This study examines peer resistance skills following a 21-lesson classroom-based intervention to build healthy relationships and decrease abusive and health-risk behaviors among adolescents. The Fourth R instructs students in positive relationship skills, such as negotiation and delay, for navigating challenging peer and dating scenarios. Observational data from 196 grade 9 students participating in a larger cluster randomized controlled trial were used to evaluate post-intervention acquisition of peer resistance skills. Pairs of students engaged in a role play paradigm with older student actors, where they were subjected to increasing pressure to comply with peer requests related to drugs and alcohol, bullying, and sexual behavior. Specific and global measures of change in peer resistance responses were obtained from two independent sets of observers, blinded to condition. Specific peer resistance responses (negotiation, delay, yielding to pressure, refusal, and compliance) were coded by research assistants; global peer resistance responses were rated by teachers from other schools (thinking / inquiry, application, communication, and perceived efficacy). Students who received the intervention were more likely to demonstrate negotiation skills and less likely to yield to negative pressure relative to controls. Intervention students were also more likely to use delay than controls; control girls were more likely to use refusal responses; the number of times students complied with peer requests did not differ. Teacher ratings demonstrated significant main effects favoring intervention youth on all measures. Program and research implications are highlighted.

Longitudinal prediction and concurrent functioning of adolescent girls demonstrating various profiles of dating violence and victimization.

Adolescent girls are involved in physical dating violence as both perpetrators and victims, and there are negative consequences associated with each of these behaviors. This article used a prospective design with 519 girls dating in grade 9 to predict profiles of dating violence in grade 11 based on relationships with families of origin (child maltreatment experiences, harsh parenting), and peers (harassment, delinquency, relational aggression). In addition, dating violence profiles were compared on numerous indices of adjustment (school connectedness, grades, self-efficacy and community connectedness) and maladjustment (suicide attempts, distress, delinquency, sexual behavior) for descriptive purposes. The most common profile was no dating violence (n = 367) followed by mutual violence (n = 81). Smaller numbers of girls reported victimization or perpetration only (ns = 39 and 32, respectively). Predicting grade 11 dating violence profile membership from grade 9 relationships was limited, although delinquency, parental rejection, and sexual harassment perpetration predicted membership to the mutually violent group, and delinquency predicted the perpetrator-only group. Compared to the non-violent group, the mutually violent girls in grade 11 had lower grades, poorer self-efficacy, and lower school connectedness and community involvement. Furthermore, they had higher rates of peer aggression and delinquency, were less likely to use condoms and were much more likely to have considered suicide. There were fewer differences among the profiles for girls involved with dating violence. In addition, the victims-only group reported higher rates of sexual intercourse, comparable to the mutually violent group and those involved in nonviolent relationships. Implications for prevention and intervention are highlighted.

Impact of sexual harassment victimization by peers on subsequent adolescent victimization and adjustment: a longitudinal study.

PURPOSE: To examine gender differences in prevalence and types of sexual harassment victimization experienced in grade 9 and how it contributes to relationship victimization and psychological adjustment 2.5 years later. METHODS: A total of 1734 students from 23 schools completed self-report surveys at entry to grade 9 and end of grade 11. Self-report data were collected on victimization experiences (sexual harassment, physical dating violence, peer violence, and relational victimization) and adjustment (emotional distress, problem substance use, self-harm, suicidal thoughts, maladaptive dieting, feeling unsafe at school, and perpetration of violent delinquency). Separate analyses by sex were prespecified. RESULTS: Sexual harassment victimization was common among boys (42.4%) and girls (44.1%) in grade 9, with girls reporting more sexual jokes, comments, and unwanted touch than among boys, and with boys reporting more homosexual slurs or receiving unwanted sexual content. For girls, sexual harassment victimization in grade 9 was associated with elevated risk of self-harm, suicidal thoughts, maladaptive dieting, early dating, substance use, and feeling unsafe at school. A similar pattern of risk was found for boys, with the exception of dieting and self-harm behaviors. Adjusted odds ratios (AOR) indicated these students were significantly more likely than nonharassed students to report victimization by peers and dating partners 2.5 years later (AOR for boys and girls, respectively; all p < .01), including sexual harassment (AOR: 2.45; 2.9), physical dating violence (AOR: 2.02; 3.73), and physical peer violence (AOR: 2.75; 2.79). Gr 9 sexual harassment also contributed significantly to emotional distress (AOR: 2.09; 2.24), problem substance use (AOR: 1.79; 2.04), and violent delinquency perpetration (AOR: 2.1; 3.34) 2.5 years later (boys and girls, respectively; all p < .01). CONCLUSIONS: Sexual harassment at the beginning of high school is a strong predictor of future victimization by peers and dating partners for both girls and boys, and warrants greater prevention and intervention efforts.

A school-based program to prevent adolescent dating violence: a cluster randomized trial.

OBJECTIVE: To determine whether an interactive curriculum that integrates dating violence prevention with lessons on healthy relationships, sexual health, and substance use reduces physical dating violence (PDV). DESIGN: Cluster randomized trial with 2.5-year follow-up; prespecified subgroup analyses by sex. SETTING: Grade 9 health classes. PARTICIPANTS: A total of 1722 students aged 14-15 from 20 public schools (52.8% girls). Intervention A 21-lesson curriculum delivered during 28 hours by teachers with additional training in the dynamics of dating violence and healthy relationships. Dating violence prevention was integrated with core lessons about healthy relationships, sexual health, and substance use prevention using interactive exercises. Relationship skills to promote safer decision making with peers and dating partners were emphasized. Control schools targeted similar objectives without training or materials. MAIN OUTCOME MEASURES: The primary outcome at 2.5 years was self-reported PDV during the previous year. Secondary outcomes were physical peer violence, substance use, and condom use. Analysis was by intention-to-treat. RESULTS: The PDV was greater in control vs intervention students (9.8% vs 7.4%; adjusted odds ratio, 2.42; 95% confidence interval, 1.00-6.02; P = .05). A significant group x sex interaction effect indicated that the intervention effect was greater in boys (PDV: 7.1% in controls vs 2.7% in intervention students) than in girls (12.1% vs 11.9%). Main effects for secondary outcomes were not statistically significant; however, sex x group analyses showed a significant difference in condom use in sexually active boys who received the intervention (114 of 168; 67.9%) vs controls (65 of 111 [58.6%]) (P < .01). The cost of training and materials averaged CA$16 per student. CONCLUSION: The teaching of youths about healthy relationships as part of their required health curriculum reduced PDV and increased condom use 2.5 years later at a low per-student cost.

The relationship of child neglect and physical maltreatment to placement outcomes and behavioral adjustment in children in foster care: a Canadian perspective.

Dramatic increases in child welfare rates in Canada over recent years have been largely driven by an increased reporting of neglect cases (Trocmé, Fallon, MacLaurin, & Neves, 2005). To a large extent, exploring the importance of neglect separate from physical maltreatment has been ignored in the child maltreatment literature. This study examined the differential effects of foster care in the child welfare system with children who presented as either experiencing physical maltreatment or neglect prior to their admission to care. Findings from this study are important to child welfare decision making about the differential needs of these two groups of children. The files of a sample of 110 children (79 neglected children and 31 physically maltreated children) were examined for differences in their adjustment while in foster care and on discharge. Some distinct differences in presentation were noted between the children experiencing the two types of maltreatment. Children experiencing neglect were younger, were more likely to have caregivers diagnosed with a substance abuse disorder, and had higher rates of exposure to spousal violence than maltreated children. Physically maltreated children displayed greater difficulty during their foster care adjustment. Once discharged from care, neglected children were more likely to be returned to the care of the agency. This study draws attention to the differential needs of children who experience neglect prior to their admission to a child welfare agency. Longer-term outcome studies are necessary to more completely understand how these two types of maltreatment influence the outcomes of children who are provided care within the child welfare system.

Understanding the link between childhood maltreatment and violent delinquency: what do schools have to add?

Child maltreatment constitutes significant risk for adolescent delinquency. Although an ecological model has been proposed to explain this relationship, most studies focus on individual risk factors. Prospective data from 1,788 students attending 23 schools were used to examine the additive influence of childhood maltreatment, individual-level risk factors, and school-level variables assessed at the beginning of Grade 9 on delinquency 4 to 6 months later. Individual-level results indicated that being male, experiencing childhood maltreatment, and poor parental nurturing were predictors of violent delinquency. School climate also played a significant role: Given the same individual risk profile, a student attending a school that was perceived by students as safe was less likely to engage in violent delinquency than was a student attending a school perceived to be unsafe. Moreover, the impact of childhood maltreatment on risk for engaging in violent delinquency was somewhat mitigated by schools' participation in a comprehensive violence prevention program.

The empirical basis of risk assessment in child welfare: the accuracy of risk assessment and clinical judgment.

The importance of risk assessment is juxtaposed with the lack of empirical support regarding the validity of risk inventories. This study compared risk ratings of one risk assessment tool to decisions made by case managers. The researchers sampled 450 children and compared predictive utility of risk assessment to child protection decisions. Risk assessment was consistent with clinical judgment in 74% to 81% of cases, more than previously reported in studies of risk assessment validity. Further analyses identified discriminate functions at the instrument's category and individual-item levels. The results have implications for the validity of the instrument and its utility in child welfare.