Predictors of contact with services for mental health problems among children with comorbid long-term physical health conditions: a follow-up study

We investigated the characteristics of children with pLTCs associated with contact with services in relation to their mental health. Common predictors of contact across the different services were greater impact of difficulties on child’s distress levels and everyday life and contact with the teacher. These findings suggest that services are accessed by children with the greatest mental health needs, in agreement with previous literature showing that the presence or severity of psychopathology is related to contact with different types of services in the UK [10]. In addition, these results highlight the critical role teachers and schools play in the identification of poor mental health and in linking pupils with health care professionals, as demonstrated by a previous UK population study in physically healthier school-aged children [10]. Mental health-related contact with the teacher was consistently the strongest predictor of contact with all three health care services investigated, suggesting that children/families who had been in contact with the teacher were up to nine times more likely to be in contact with a health care professional. This might be an indication of the level of parental or child concern and/or that teachers encourage help-seeking. Interestingly, the majority of participants were rated by teachers to have some or marked educational difficulties in at least one area (reading, spelling, mathematics). This is in line with previous literature showing adolescences who experience worse health to be substantially less likely to complete high school and enter post-secondary education [29]. Conversations with pupils who struggle at school (and/or their parents) may facilitate the identification of mental health symptoms by the teachers who should encourage help-seeking. Educators are, indeed, an easy-accessed, first point of communication for children/families who seek help and, therefore, schools should ensure their staff have access to high quality information so they feel confident to discuss mental health with pupils and their parents.

Predictors specific to primary health care were older age, female gender, larger family size, some or marked academic difficulties, and having parents with educational qualification(s). Adolescent girls are at increased risk of emotional problems compared to younger girls and to boys of all ages [30], while primary health care is traditionally the gate keeper for specialist health care. Ford et al. [10] found a similar interaction between age and gender in relation to mental health-related contact with primary health care professionals among the general population of children. The presence of academic difficulties increased the likelihood of reporting contact with primary health care, which might relate to distress related to struggling at school. Anecdotally, teachers often advise families and young people who are concerned to contact their General Practitioner (Fig. 1), as not all specialist mental health services accept referrals directly from schools. Ford et al. [10] found larger families to be more likely to report contact with paediatrics for mental health advice, rather than primary health care, but larger families may have more frequent contact with General Practitioners, presenting greater familiarity and also opportunities for raising concerns. Finally, parents with educational qualification(s) are likely to have greater health literacy and better access to information, hence greater perception of the need for professional help, and more time and resources to seek it [31].

Predictors specific to contact with child and adolescent mental health services were the experience of more stressful life events over the lifetime and contact with primary health care. Experiencing stressful life events is a known risk factor for poor mental health and has been previously identified as a predictor for contact with child and adolescent mental health services [10]. Contact with primary health care predicted contact with child and adolescent mental health services, replicating the findings of earlier work [10] and in line with the role of frontline services as gate keepers to specialist services. We also observed a significant age by gender interaction on the probability of reporting contact with specialist mental health services, which reflects the age and gender patterns of mental health conditions across childhood and adolescence [32]. More precisely, both younger and older boys were more likely to report contact with mental health services as compared to girls. In addition, younger boys (vs. boys in adolescence) and adolescent girls (vs. younger girls) were more likely to report contact with mental health services. Boys are more likely to develop neurodevelopmental and behaviour problems, which often present during early and mid-childhood, and which may also have a greater impact on themselves and others than emotional problems, which are more frequently seen in adolescent girls. Therefore, mental health disturbances in young boys may be considered as more severe by some parents or teachers who consequently seek specialist help. In line with our findings, a previous UK study has shown that boys in childhood are more likely than girls to be referred to child psychiatrists by general practitioners [33]. Indeed, the way in which psychiatric disorder presents may influence its perceived significance to health professionals and the likelihood of psychiatric referral. Presentations with antisocial behaviours are more likely to precipitate referral than internalising disorders such as depression [34]. Population studies suggest that even when girls meet research diagnostic criteria for neurodevelopmental disorders, they are less likely to be referred and seen by specialist services [35]. Both research, training, and guidelines should be developed that explore how neurodevelopmental conditions present differently in girls to improve their detection and access to treatment.

Surprisingly, paediatric contact did not predict contact with child and adolescent mental health services. Paediatricians may not recognise or underestimate the need for referral to mental health specialists. Previous research suggests that paediatricians only identified a quarter of all cases with possible psychiatric disorder [4], in line with evidence indicating that the mental health problems associated with physical illness in young patients are commonly unrecognised and untreated [18, 36]. Introducing routine mental health screening in paediatric settings could be a beneficial tool for paediatricians to identify children with pLTCs who need specialist interventions [37]. Compared with general paediatricians, paediatric neurologists were more likely to refer children with epilepsy to specialist mental health services and were more cognizant of the benefit from mental health referrals, suggesting that improving paediatricians’ specific knowledge and awareness of the mental health comorbidities of children with pLTCs and the need for referrals is crucial [38]. Alternatively, mental health difficulties may be managed in some cases within paediatric settings because of concerns that referrals may be rejected or pessimism about long waiting lists [39]. Indeed, a recent survey in the UK showed that a sizeable proportion of community paediatricians are involved in the assessment or care of children and young people with mental health difficulties, especially neurodevelopmental conditions, mainly due to difficulty with accessing specialist mental health services [40]. Education to improve the recognition and management of child mental health difficulties should be part of paediatricians training and continued professional development.

Our study highlighted the role of impact as a universal predictor of access to services and suggested that children with mild difficulties are less likely to seek help. Given that child and adolescent specialist mental health services in the UK are under-resourced and over-stretched [41], easy-access, evidence-based interventions should be made available in children with pLTCs who face mental health difficulties. Brief and/or low-intensity (< 6 sessions) psychological interventions based on cognitive behavioural principles [42] have demonstrated the potential to benefit young people with a pLTC [43]. These interventions could be delivered at drop-in centres [44], which could be in primary or secondary health care, or at schools [45]. Our findings also revealed that some groups of children are seen in different health care settings and for different reasons. Each service should be aware of the profile of children it sees to consider which children may currently be under-served and how this situation might be addressed.

Coordination of services across sectors is also crucial. For example, implementing mental health screenings in schools and integrating them with primary health care resources or specialist mental health services could be an efficient and cost-effective way of addressing the mental health needs of CYP. Coordinated home visits by General Practitioners and mental health workers, shift of psychiatric clinics to health care centres, joint consultations and a coordinated management plan including school personnel, primary care clinicians, paediatricians, mental health specialists, and social services in the care of the child, offers the unique opportunity for patient-centred pathways to a holistic care. With the significant shortage of child and adolescent mental health specialists [41], coordinated and shared care with the wider children’s workforce becomes a viable and sustainable way of meeting child mental health needs in the community.

We excluded participants with missing data, but those with missing data were more likely to be more severely affected and to have more risk factors. Multiple imputation was deemed inappropriate in this study since data were not missing at random. Notably, some families declined consent for including teachers in the study which resulted in up to 20% teacher missing data, ultimately reducing the analytic sample size. The exclusion of participants with missing data might have introduced type 2 errors but suggests that the associations we report are likely to be robust. Secondary data analyses are always constrained by the available data. Objective data on severity of symptoms or care need were not available for analysis; future studies should seek to collect these data. We included a relatively small number of participants in the non-white group (5%), which may explain the null associations between ethnicity and service contact. As this was a population-based survey, the assessment of pLTCs was based on parental report which may involve information or recall bias; future research should corroborate these assessments with administrative medical and school data. In addition, we measured the impact of mental health difficulties on child’s distress levels and everyday life using parental report, though difficulties not expressed by the child might go unrecognised by the parent who might consequently not seek help. This suggests that some children with severe symptoms will still be untreated. Future studies need to include children’s report on the impact of mental health difficulties. This study is also limited to examining service contacts for mental health support, but there are no data on the quality of care received by each service, hence contact does not necessarily reflect appropriate problem assessment and management. The provision of care by service are likely to be heterogenous, and therefore different sets of predictors may exist for different types of interventions within services. Future research using administrative data or patient registers should explore this finer level of analysis.

In conclusion, our findings represent a first step towards identifying characteristics that may be barriers or facilitators to accessing mental health care in children with comorbid pLTCs. The role of child-, family- and service-related factors is highlighted, which could inform planning and provision of services to reduce unmet mental health needs in young patients.

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