Gareth Furber

Understanding Maltreating Mothers: A Synthesis of Relational Trauma, Attachment Disorganization, Structural Dissociation of the Personality, and Experiential Avoidance

Treatment options are limited for families in which the child has severe and intractable disturbances of emotion and behavior, in which there is suspected or confirmed maltreatment by the mother, and in which the mother has her own history of childhood neglect and abuse. This paper proposes a model for understanding maltreatment in mother–child dyads, drawing upon the developmental psychopathology, behavior, and trauma literatures. At the core of this model is the hypothesis that a mothers maltreating behavior arises from unconscious attempts to experientially avoid the reemergence of an attachment-related dissociative part of the personality that contains the distress arising from her own early experiences of attachment relationships. The implications of this model for therapy are considered.

The validity of the Child Health Utility instrument (CHU9D) as a routine outcome measure for use in child and adolescent mental health services.

BackgroundFew cost-utility studies of child and adolescent mental health services (CAMHS) use quality adjusted life years (a combination of utility weights and time in health state) as the outcome to enable comparison across disparate programs and modalities. Part of the solution to this problem involves embedding preference-based health-related quality of life (PBHRQOL) utility instruments, which generate utility weights, in clinical practice and research. The Child Health Utility (CHU9D) is a generic PBHRQOL instrument developed specifically for use in young people. The purpose of this study was to assess the suitability of the CHU9D as a routine outcome measure in CAMHS clinical practice.MethodsTwo hundred caregivers of children receiving community mental health services completed the CHU9D alongside a standardised child and adolescent mental health measure (the Strengths and Difficulties Questionnaire – SDQ) during a telephone interview. We investigated face validity, practicality, internal consistency, and convergent validity of the CHU9D. In addition, we compared the utility weights obtained in this group with utility weights from other studies of child and adolescent mental health populations.ResultsParticipants found the CHU9D easy and quick to complete. It demonstrated acceptable internal consistency, and correlated moderately with the SDQ. It was able to discriminate between children in the abnormal range and those in the non-clinical/borderline range as measured by the SDQ. Three CHU9D items without corollaries in the SDQ (sleep, schoolwork, daily routine) were found to be significant predictors of the SDQ total score and may be useful clinical metrics. The mean utility weight of this sample was comparable with clinical subsamples from other CHU9D studies, but was significantly higher than mean utility weights noted in other child and adolescent mental health samples.ConclusionsInitial validation suggests further investigation of the CHU9D as a routine outcome measure in CAMHS is warranted. Further investigation should explore test-retest reliability, sensitivity to change, concordance between caregiver and child-completed forms, and the calibration of the utility weights. Differences between utility weights generated by the CHU9D and other utility instruments in this population should be further examined by administering a range of PBHRQOL instruments concurrently in a mental health group.

The prevalence of psychopathology in siblings of children with mental health problems: a 20-year systematic review.

While the importance of looking at the entire family system in the context of child and adolescent mental health is well recognised, siblings of children with mental health problems (MHPs) are often overlooked. The existing literature on the mental health of these siblings needs to be reviewed. A systematic search located publications from 1990 to 2011 in four electronic databases. Thirty-nine relevant studies reported data on the prevalence of psychopathology in siblings of target children with MHPs. Siblings of target children had higher rates of at least one type of psychopathology than comparison children. Risk of psychopathology varied across the type of MHP in the target child. Other covariates included sibling age and gender and parental psychopathology. Significant variations and limitations in methodology were found in the existing literature. Methodological guidelines for future studies are outlined. Implications for clinicians, parents, and for future research are discussed.

Mapping scores from the Strengths and Difficulties Questionnaire (SDQ) to preference-based utility values

AbstractPurposeQuality of life mapping methods such as “Transfer to Utility” can be used to translate scores on disease-specific measures to utility values, when traditional utility measurement methods (e.g. standard gamble, time trade-off, preference-based multi-attribute instruments) have not been used. The aim of this study was to generate preliminary ordinary least squares (OLS) regression-based algorithms to transform scores from the Strengths and Difficulties Questionnaires (SDQ), a widely used measure of mental health in children and adolescents, to utility values obtained using the preference-based Child Health Utility (CHU9D) instrument. MethodsTwo hundred caregivers of children receiving community mental health services completed the SDQ and CHU9D during a telephone interview. Two OLS regressions were run with the CHU9D utility value as the dependent variable and SDQ subscales as predictors. Resulting algorithms were validated by comparing predicted and observed group mean utility values in randomly selected subsamples.ResultsPreliminary validation was obtained for two algorithms, utilising five and three subscales of the SDQ, respectively. Root mean square error values (.124) for both models suggested poor fit at an individual level, but both algorithms performed well in predicting mean group observed utility values.ConclusionThis research generated algorithms for translating SDQ scores to utility values and providing researchers with an additional tool for conducting health economic evaluations with child and adolescent mental health data.

A Comparison Between Phone-Based Psychotherapy With and Without Text Messaging Support In Between Sessions for Crisis Patients

Background Few studies have tested whether individually tailored text messaging interventions have an effect on clinical outcomes when used to supplement traditional psychotherapy. This is despite the potential to improve outcomes through symptom monitoring, prompts for between-session activities, and psychoeducation. Objective The intent of the study was to explore the use of individually tailored between-session text messaging, or short message service (SMS), as an adjunct to telephone-based psychotherapy for consumers who present to the Emergency Department (ED) in situational and/or emotional crises. Methods Over a 4-month period, two therapists offered 68 prospective consumers of a telephone-based psychotherapy service individually tailored between-session text messaging alongside their telephone-based psychotherapy. Attendance and clinical outcomes (depression, anxiety, functional impairment) of those receiving messages were compared against a historical control group (n=157) who received telephone psychotherapy only. Results A total of 66% (45/68) of the consumers offered SMS accepted the intervention. A total of 432 messages were sent over the course of the trial, the majority involving some kind of psychoeducation or reminders to engage in therapy goals. There were no significant differences in clinical outcomes between consumers who received the SMS and those in the control group. There was a trend for participants in the intervention group to attend fewer sessions than those in the control group (mean 3.7, SD 1.9 vs mean 4.4, SD 2.3). Conclusions Both groups showed significant improvement over time. Individually tailored SMS were not found to improve clinical outcomes in consumers receiving telephone-based psychotherapy, but the study was underpowered, given the effect sizes noted and the significance level chosen. Given the ease of implementation and positive feedback from therapists and clients, individually tailored text messages should be explored further in future trials with a focus on enhancing the clinical impact of the tailored text messages, and utilizing designs with additional power to test for between-group effects.

Preventing mental illness: closing the evidence-practice gap through workforce and services planning

BackgroundMental illness is prevalent across the globe and affects multiple aspects of life. Despite advances in treatment, there is little evidence that prevalence rates of mental illness are falling. While the prevention of cardiovascular disease and cancers are common in the policy dialogue and in service delivery, the prevention of mental illness remains a neglected area. There is accumulating evidence that mental illness is at least partially preventable, with increasing recognition that its antecedents are often found in infancy, childhood, adolescence and youth, creating multiple opportunities into young adulthood for prevention. Developing valid and reproducible methods for translating the evidence base in mental illness prevention into actionable policy recommendations is a crucial step in taking the prevention agenda forward.MethodBuilding on an aetiological model of adult mental illness that emphasizes the importance of intervening during infancy, childhood, adolescence and youth, we adapted a workforce and service planning framework, originally applied to diabetes care, to the analysis of the workforce and service structures required for best-practice prevention of mental illness.ResultsThe resulting framework consists of 6 steps that include identifying priority risk factors, profiling the population in terms of these risk factors to identify at-risk groups, matching these at-risk groups to best-practice interventions, translation of these interventions to competencies, translation of competencies to workforce and service estimates, and finally, exploring the policy implications of these workforce and services estimates. The framework outlines the specific tasks involved in translating the evidence-base in prevention, to clearly actionable workforce, service delivery and funding recommendations.ConclusionsThe framework describes the means to deliver mental illness prevention that the literature indicates is achievable, and is the basis of an ongoing project to model the workforce and service structures required for mental illness prevention.

How many children in Australia are at risk of adult mental illness

Objective: To estimate the prevalence of children in the Australian population with risk factors for adult mental illness. Method: Key risk factors and risk domains were identified from a 2013 review of longitudinal studies on child and adolescent determinants of adult mental illness. Data items were identified from the Longitudinal Study of Australian Children that map onto the risk domains and were used to estimate the prevalence of these key individual risk factors and the magnitude of multiple risk in children aged 3 months to 13 years. Results: Even by infancy, risk factors for adult mental illness are highly prevalent, with 51.7% of infants having multiple risks. In 10 infants, 1 was born to mothers who consumed daily alcohol and 1 in 8 to mothers who smoked cigarettes daily during pregnancy. Also, 10.5% of infants were in families where the parents had separated, which increased to 18% in 10–11 year-olds. Psychological problems in the clinical range (based on the Strengths and Difficulties Questionnaire total problems score) ranged from 7.8% to 9.7% across the 4–13 years age range. Risks from negative parenting behaviours were highly prevalent across age groups. Two-thirds of children aged 12–13 years had parents who displayed low warmth or exhibited high hostility/anger. Across childhood, one in seven children are in families exposed to 3+ major life stressors. By age 8–9 years, more than 18% of children are exposed to ⩾5 risk factors. Conclusions: We find that modifiable risk factors for adult mental illness occur at the earliest stage in the life course and at greater prevalence than is commonly recognised. Considerable capacity will be required in child and adolescent mental health services and complementary family support programmes if risk factors for adult mental illness that are already apparent in infancy and childhood are to be addressed.

Risks for Mental Illness in Indigenous Australian Children: A Descriptive Study Demonstrating High Levels of Vulnerability

Policy Points: The developmental origins understanding of mental illness suggests the possibility of prevention, through addressing childhood adversities. More than 43% of Indigenous Australian children aged 6 to 10 years have 6 or more risk factors for mental illness in adulthood, and 23% are experiencing current psychological distress. Substantial risk is already present in infancy (eg, 67% exposed to 3 or more stressful family life events, and 42.5% are not living with both birth parents). An integrated service system response that can both offer high-level therapeutic services and address associated multiple adversities, from conception to late adolescence, is urgently needed to address current psychological distress in Indigenous Australian children and to reduce the future burden of mental illness. Context Mental illness is a high source of disease burden across the globe. Mental illness is now understood as largely developmental, with its genesis at least in part in adverse childhood experiences. We sought to estimate the prevalence of childhood risks for poor mental health in Indigenous Australian children, noting that Indigenous Australians by virtue of their history of traumatic colonization and dispossession, child removal, and racism are potentially at greater risk. Methods We conducted a descriptive study of the modifiable risks and adversities associated with mental illness in Australian Indigenous children (infancy to 10 years), using data from the Longitudinal Study of Indigenous Children (LSIC), a cohort of 1,671 infants enrolled in 2008 and followed up annually. Risk factors of interest were identified from a comprehensive literature review of childhood determinants of adult mental illness by Fryers and Brugha (2013). The age-category prevalence of individual risks and a multiple-risk score were computed using data extracted from 6 waves of LSIC. Findings The analytic data comprised 8,378 person-observations from the first 6 waves. Children in LSIC experience high rates of adversities. In utero, nearly 50% were exposed to smoking and 22% to alcohol. As infants, 42.5% were not living with both birth parents. Over two-thirds of survey children were in households that had experienced, in the previous 12 months, 3 or more major life events; 22% to 26% lived in households with a drug or alcohol problem; and 18% were exposed to domestic violence (41% were ever-exposed to age 10). At school, nearly 40% of children were bullied. Over 45% of children aged 6 to 10 years were exposed to 6 or more risks for mental illness. Few children (< 2%) were exposed to low parental warmth and, despite the high exposure to adversities, less than 5% of children report low self-confidence. This suggests considerable resilience. More than 1 in 4 children had conduct problems in the clinical range and more than 1 in 5 were experiencing high psychological distress. Conclusions Indigenous children in Australia face extreme levels of multiple disadvantage, exposing many to current psychological distress and high risk of developing mental illness, despite considerable resilience. For policymakers, this is a call for preventive action targeting the multiple risk factors already present in childhood. An integrated service system offering culturally appropriate, high-quality early childhood education services, linked to infant, child, adolescent, and family mental health services, and intensive family support services will be crucial in addressing this public health crisis.

The IAPT@Flinders Service: adapting the Improving Access to Psychological Therapies model to the emergency department setting in Australia.

Objective: To describe the implementation of an Improving Access to Psychological Therapies (IAPT) service at Flinders Medical Centre emergency department (IAPT@Flinders). IAPT, a population-based model of guided self-help for anxiety and depression delivered mainly by phone, was rolled-out nationally in the UK in 2010. There is a growing body of evidence demonstrating its clinical effectiveness and efficiency that can improve treatment adherence, reduce stigma, remove appointment attendance barriers and improve access for hard-to-reach populations. Conclusions: IAPT@Flinders was the test site for the first IAPT in Australia and also the first IAPT service that was integrated with an emergency department (ED). IAPT@Flinders offers rapid access, low-intensity cognitive behavioural therapy, social prescribing and signposting to clients with adjustment disorders, anxiety and/or depressive symptoms. Successful implementation within an Australian crisis setting has demonstrated that many IAPT structures and protocols are applicable to ED settings and the model can be implemented with fidelity. Adaption required consideration of positioning of the service within the Australian mental health framework; staff qualifications; the referral pathways; and exclusion criteria. It is recommended additional test sites and larger scale trials are conducted to provide further evidence of the applicability of large-scale adoption of the UK IAPT model into Australian ED settings.

Benchmarking the cost efficiency of community care in Australian child and adolescent mental health services: implications for future benchmarking

Objective: The purpose of this study was to benchmark the cost efficiency of community care across six child and adolescent mental health services (CAMHS) drawn from different Australian states. Method: Organizational, contact and outcome data from the National Mental Health Benchmarking Project (NMHBP) data-sets were used to calculate cost per “treatment hour” and cost per episode for the six participating organizations. We also explored the relationship between intake severity as measured by the Health of the Nations Outcome Scales for Children and Adolescents (HoNOSCA) and cost per episode. Results: The average cost per treatment hour was