Protocol for Strategies to Improve Mental Health Care for Children and Adolescents

The protocol for the systematic evidence review, “Strategies to Improve Mental Health Care for Children and Adolescents,” is now available on the AHRQ Effective Health Care (EHC) Web site.

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Strategies to Improve Mental Health Care for Children and Adolescents

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Background and Objectives for the Systematic Review

Approximately one in five children and adolescents living in the United States has one or more mental, emotional, or behavioral health disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria in any given year.1 These disorders contribute to problems with family, peers, and academic functioning; comorbidity (including other mental and substance use disorders and chronic health conditions); and reduced quality of life; they also increase the risk of involvement with the criminal justice system and other risk-taking behaviors and suicide.2

The evidence base for pediatric mental health interventions that target mood disorders, anxiety disorders, disruptive behavior disorders, psychotic disorders, eating disorders, and substance use disorders continues to grow.3,4 Despite advances in the evidence base, outcomes for children with mental health problems remain suboptimal because of issues with access to care, failure of systems and providers to adopt interventions with proven efficacy (e.g., evidence-based practices [EBPs]), and variability in the quality of mental health care received. Studies using nationally representative data on U.S. adolescents show that only approximately one in five children with mental health problems receives services, and only one-third of treatment episodes are considered minimally adequate (at least four visits with psychotropic medication or at least eight visits without psychotropic medication).5-7 The current health care system continues to provide fragmented care to children in numerous uncoordinated systems, rendering inefficient delivery of needed services.8 Other issues include providers not having the time available or knowledge/training to identify mental health problems and treat or refer accordingly.9

Several key publications in the mid- to late-1990s suggested that usual care in children’s mental health had, at best, null11 and sometimes harmful effects.12 With the proliferation of EBPs addressing childhood mental disorders,3,13 strategies to implement or disseminate these interventions targeted a change in the organization and delivery of mental health services.14,15 These strategies sought to improve the quality of care by closing the gap between research evidence and practice.18,10

This review will focus on strategies that aim to improve the quality of mental health care rather than to determine the efficacy of interventions or quality of specific EBPs. We plan to focus on dissemination, implementation, and quality improvement (D/I/QI) strategies targeting providers, organizations, or systems that care for children and adolescents with mental health problems. Various studies have adopted the framework presented in the Institute of Medicine’s (IOM’s) landmark Crossing the Quality Chasm report10 to define a quality improvement (QI) strategy. For this review, we plan to define QI strategies as those that target providers (e.g., via education, training, and supervision) and organizations (e.g., via financial incentives, regulation, and policies) that provide mental health care to children and adolescents, with the ultimate goal of improving the quality of care.19,20

Some consider dissemination/implementation (D/I) strategies as a particular subset of QI initiatives, although the field is so new that terminology has not yet been standardized.21 Dissemination strategies can be differentiated from implementation strategies using the definition constructed by McCormack and colleagues:22dissemination is the active and targeted distribution of information and interventions to a specific public health or clinical practice audience via determined channels using planned strategies with the intent to spread knowledge and associated evidence-based interventions to enhance the adoption and the implementation of the information and/or intervention; implementation is the use of strategies to integrate evidence-based health interventions (e.g., EBPs) and change practice patterns within specific settings. Although the ultimate goal of D/I/QI strategies is to improve patient-related outcomes for children and adolescents with mental health problems, intermediate outcomes of D/I/QI strategies include changes to health care systems, organizations, and providers that provide mental health care. Recent D/I theoretical frameworks posit that effective and sustainable implementation operates through multiple nested levels.23,24 These levels typically include the macro-environment (i.e., state), organization or system (i.e., specialty mental health clinic), program (i.e., selected intervention), provider (i.e., clinicians), and patients (children and families). Outcomes across these various levels are interrelated. For instance, changes in intermediate outcomes such as provider attitudes25 or organizational climate26 may influence the successful adoption of and fidelity to EBPs, which in turn influence patient outcomes, such as behavior or quality of life.