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A home for paediatricians. A voice for children and youth.

Position statement

CPS

Promoting optimal mental health outcomes for children and youth

Posted: May 4, 2023

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Principal author(s)

Wilma Arruda MD, Stacey A Bélanger MD PhD, Janice S Cohen PhD C Psych, Sophia Hrycko MD, Anne Kawamura MD, Margo Lane MD, Maria J Patriquin MD, Daphne J Korczak MD; Canadian Paediatric Society, Mental Health Task Force, with the Canadian Academy of Child and Adolescent Psychiatry, Mental Health Task Force

Paediatr Child Health 28(7): 417–425.

Abstract

While paediatric care providers are often the first point of contact for children or youth experiencing mental health challenges, they may lack the resources (e.g., access to a multidisciplinary team) or training to adequately identify or manage such problems. This joint statement describes the key roles and competencies required to assess and address child and youth mental health problems, and the factors that optimize outcomes in this age group. Evidence-informed guidance on screening for and discussing mental health concerns with young people and families is provided. Preventive and therapeutic interventions with demonstrated efficacy in community care settings are discussed. This foundational statement also focuses on the changes to medical education, health systems, and health policy that are needed to improve clinical practice and advocacy efforts in Canada, including appropriate remuneration models, stepped-care approaches, targeted government funding, and professional training and education.

Keywords: Adolescents; Assessment; Children; Diagnosis; Mental health; Psychoeducation; Psychotherapy; Outcomes; Screening; Treatment

 

Background

Mental health problems are common among children and youth in Canada. Yet less than 20 per cent of the estimated 1.2 million children and youth who are experiencing emotional, behavioural, and psychosocial problems serious enough to disrupt function and development will receive appropriate treatment[1][2]. The majority of mental health disorders reported in young adults start in childhood or adolescence, which makes early identification of mental health problems and timely intervention especially critical[3]-[5]. 

Paediatricians and other paediatric care providers (Box 1) are often the first point of contact for children, youth, and families seeking advice and support for a health concern. And while the enduring, trustful relationships they have with patients and families should enable them to promote child and youth mental health, connect young people and families in need of support with mental health services, and help ensure positive outcomes[6], significant impediments to care also exist. 

Research has shown that barriers of language or culture, insufficient access to health and social services, and fear of authority or stigmatization frequently drive immigrant, refugee, ethnoculturally distinct, or racialized individuals to seek help for a mental health problem from an emergency department rather than more mainstream care settings[7]. Further compounding marginalization are suboptimal social determinants of health, such as low income, inadequate housing, food insecurity, and lack of social supports, which are associated with, and contribute significantly to, negative physical and mental health outcomes in at-risk populations[8]-[10]. Also, paediatric care providers may encounter mental health problems or risk factors even when the presenting complaint appears unrelated, such that addressing social determinants at the patient, practice, and community levels may become part of optimal intervention[11]-[13]. Furthermore, as mental health care has been underemphasized in Canadian medical training historically, paediatric care providers may feel underequipped to assess or intervene for a mental health problem. They may also face systemic disincentives to do so, such as lack of time or inadequate remuneration mechanisms[14]. 

This position statement discusses the mental health competencies expected of paediatric care providers: to support child and youth mental health care, create a positive mental health environment, and acquire the clinical skills to provide proactive mental health care.

Box 1. Definitions

Children and youth in Canada receive care from a variety of health care professionals. In this statement, ‘paediatric care providers’ refers to family physicians, nurse practitioners, general paediatricians, and paediatric subspecialists, whose skill and comfort levels when providing mental health assessment and care may vary considerably. Certain subspecialists (for example, developmental medicine and adolescent medicine specialists) are expected to have more proficient clinical skills than those with less extensive training.

Note that when the word “parent” (singular or plural) is used, it includes any primary caregiver and every configuration of family.    

Paediatric care provider roles in mental health care

Paediatric care providers can support the mental health of children and youth and improve outcomes in a consultative or primary care capacity, or both[6][15][16] by engaging in:

  1. Preventive care
  2. Screening
  3. Assessment
  4. Treatment, and
  5. Collaborative care

Sometimes the individual practitioner does this work alone, and at other times in collaboration with members of formalized health care teams. Table 1 lists specific competencies in the areas of screening, assessment, and treatment.

1. Preventive care

Most clinical guidelines recommend that mental health surveillance and screening begin with well-child visits in primary health care settings. Early engagement and timely anticipatory guidance can help prevent mental health challenges later in life. Each well-child visit is an opportunity to discuss parent concerns, counsel on development, and conduct mental health surveillance (e.g., by screening regularly for emerging mental health problems) with a view to intervening early, if needed.

Screening and addressing the social determinants of health (e.g., poor environment or housing quality, or educational inequities) is important given their known association with mental health problems[17].

Integrating mental with physical health care helps ensure earlier assessment of needs, timely access to supportive services, and optimal management pathways[18]-[23]. This type of care elicits and enlists each family’s strengths to help address the specific psychosocial, developmental, or behavioural needs of a child or youth[15][24]. Research has shown that when parents share concerns with their paediatric care provider, mental health problems are identified earlier and psychiatric diagnoses are more specific[25][26]. Children identified as being at increased risk for a mental health problem need additional screening and may require referral for individualized assessment and intervention[27][28].

2. Screening

Implementing mental health screening programs in most paediatric care settings is both practical and attainable[29]. As with chronic physical health conditions, best practice in mental health care includes administering standardized, age-appropriate screens as part of routine clinical care[16]. Reliable, validated mental health screening tools are available to download freely at the CPS website. Based on best practice and clinician, parent, or self-reporting, many of these tools can be integrated seamlessly into a practice setting or combined with those intended for standardized physical health and development surveillance (e.g., via the Rourke Baby Record, ABCDaire, or HEADDS/SSHADESS), and administered by a range of trained health professionals.

Being curious, open, and culturally sensitive when screening individuals and families can aid communication among practitioners, parents, and patients about the presence of potential problems[30][31].

While screening is not diagnostic, it can be used to:[6][32]

  • Identify children or youth at higher risk for mental health problems and those who need an immediate response
  • Assess severity of symptoms
  • Evaluate the extent to which behaviours deviate from the norm
  • Sort cases into diagnostic categories
  • Determine whether further evaluation or preliminary intervention is needed
  • Monitor treatment progress, outcome, or change in symptoms over time after interventions are initiated at a child/family or school level, and
  • Facilitate communication among clinicians and between clinicians and parents.

3. Assessment

Assessment provides a more complete, comprehensive picture of the child or youth to aid diagnosis, differential diagnosis, and treatment planning. Paediatric care providers can provide specialized assessment for children and youth with mental health challenges. They often know the child or youth and family well and can provide important contextual information that is helpful in assessing mental health challenges.

Both the assessment process and medical management of mental health conditions can be enhanced by interdisciplinary, team-based care that integrates results from screening, clinical interviews, behavioural observations, psychological tests, and collateral information[33].

Assessments and the early identification of mental health problems can help relieve family stress, limit invasive and inappropriate testing, guide prognosis and, in some cases, improve management, treatment, and outcomes[34].

4. Treatment

Evidence-based treatments such as psychotherapies, behavioural interventions, pharmacotherapy, educational accommodations, and specialized mental health services can mitigate functional impairments (e.g., difficulties in school or at work) as well as long-term disabilities. Timely, efficacious treatment modalities also decrease symptom severity, hospitalizations, and other negative health outcomes[35]-[40].

Paediatric care providers and health team members who receive focused training can effectively deliver cognitive behavioural therapy (CBT) and other psychotherapeutic interventions within a paediatric care setting, allowing families to access evidence-based care in a timely way, in a familiar setting[41][42].

5. Collaboration

Significant evidence supports the model of a paediatric “medical home”[43], a collaborative, integrated model of care to improve engagement, accessibility, and coordinated care, leading to better health outcomes[41][44]-[48]. This model also uses existing resources, allowing paediatric care providers to address a broader range of needs using an interdisciplinary approach with mental health professionals. Paediatricians who are supported by mental health teams are more likely to incorporate mental health monitoring into their practices[49].

Paediatric care providers are often best suited to coordinate patient care within this interdisciplinary team and may work with other clinicians to provide shared care or co-management[50][51]. Co-management can be particularly helpful in complex mental health presentations, where a collaborative arrangement can also support the paediatrician’s skill development[6]. The extent of a coordinating paediatric care provider’s role will depend on a broad range of factors, including the patient’s presentation, the need for prompt intervention and supports, patient and family preferences, practitioner’s training, comfort level, and clinical skills, and access to mental health services. Having clear roles and secure access to care pathways can help the paediatric care provider organize the care process, improve communication between team members, and ensure continuity of care[48][52].

Creating an environment characterized by trusting relationships and open communication is the first step toward coordinating care[53]. Sharing information with appropriate consent can improve outcomes for children, youth, and families, and is critical to ensure continuity of care. It is important to balance privacy and confidentiality, and maintain open communication among individuals, families, and service providers. Several best practices have been developed for child and youth mental health care settings[54][55].

Creating a supportive environment

Clinical and other practice settings can help reflect the value a paediatric care provider places on mental health and be a venue for education and mental health promotion[56]. Attention to the environment—including the physical space and the attitudes and behaviours of office/clinic staff—can set the tone for clinical interactions that involve talking about mental health problems[41][57][58].

Although online platforms can be used for mental health care in remote settings, they may also pose confidentiality threats, and access to them is limited to individuals who have internet access and are able to navigate these platforms[59][60].

To promote a positive environment for mental health care, in both in-person and virtual settings, consider the following strategies:

  • When possible, use scheduling strategies that facilitate help-seeking for youth and families, such as shorter wait times and flexible scheduling (e.g., appointments after standard work or school hours).
  • Allocate specific times in the clinic day or week to schedule patients with mental health needs to ease time constraints on care[61].
  • Ensure that booking and record systems are secure[62] and that conversations among staff, families, and care providers remain confidential[54].
  • Train clinicians and staff in principles of culturally sensitive, trauma-informed care[63]-[65]. Office staff should be aware that having a history of trauma is common and that past experiences may affect how families live and respond in the present[66]-[71].
  • Learn about structural racism in health care: what it looks like and how it affects patients and families. Consider cultural safety training for all staff and paediatric care providers[67][72]-[79].

Office settings

  • Consider seating, lighting, noise levels, and auditory and visual content (e.g., softer music and news, health educational screens).
  • Create an office culture that demonstrates the inclusion of mental health as part of health by providing:
    • Educational materials and posters that are safe, affirming, and inclusive to decrease mental health stigma.
    • A diverse representation of people, languages, and family structures in written and visual materials[67][74][76]-[78][80].

Virtual settings

  • Assure confidentiality and discuss its limits when necessary[54]. Recognize that the risk of mental health conversations or therapy being overheard is greater in the virtual setting.
  • Virtual appointments may not be appropriate for individuals with severe mental illness (e.g., active psychosis, suicidality, eating disorders), or when a high degree of confidentiality is critical for disclosure (e.g., child maltreatment, domestic violence, gender identity, sexual orientation concerns, substance use disorders)[60].
  • For any virtual assessment confirm the patient’s location with an exact address, in case of emergency, and the proximity of a parent or other responsible adult. Confirm the most reliable phone numbers for patients and parents. Be sure the patient knows what do to if there are problems with technology[81].
  • Hold virtual appointments in a room with minimal background clutter[80] and minimize distractions (e.g., close the door).

Clinical skills  

Detecting and accurately assessing an emerging mental health disorder requires clinical skill, time, and appropriate remuneration. It is critical that paediatric care providers achieve and maintain knowledge and confidence in their mental health-related clinical skills (Table 1). The emergence of competency-based education in medicine provides an opportunity to enhance students’ training in mental health care.

Table 1 describes specific screening, assessment, and treatment skills that will help paediatric care providers address mental health problems[6][7][31][60][82]-[89]. For paediatric residency programs developing curriculums for trainees, these competencies include CanMEDS medical expert, communicator, and collaborator roles. Table 2 describes common evidence-based, non-pharmacological therapeutic approaches for paediatric practices[6][65][89]-[98].

Table 1. Essential mental health competencies for paediatric care providers

Screening

  • Use an appropriate screening tool as part of focused history-taking and to guide assessment.
  • Identify an appropriate screening tool based on the age, developmental stage, and the informant. For example, the use of parent or teacher report alone, without child assessment, is insufficient for the determination of ADHD, mood, anxiety, or substance use disorders among older children and adolescents.
  • Make sure that the screening tool used is culturally relevant for the individual or family[31].
  • Be aware of the utility (and limitations) of self-report measures. For example, self-report measures can facilitate the disclosure of sensitive information and help identify symptoms not previously considered (e.g., anxiety symptoms in a child presenting with oppositional behaviour). However, self-report measures are not diagnostic instruments.

Assessment

  • Attend to stigmatizing views about mental health problems that may inadvertently cause feelings of embarrassment, shame, or inadequacy, and impair disclosure. Paying attention and addressing such views during assessment and management are essential components of care.
  • Ask open-ended questions and use non-judgemental interviewing techniques with children, youth, or parents to elicit and explore mental health concerns, communicate openness, and demonstrate empathy.
  • At every visit, ask about changes in sleep or eating patterns, weight gain or loss, substance use, academic performance and school or work life, and engagement in extracurricular or social activities and with peers that may indicate an underlying mental health problem.
  • Learn, train, and engage staff in patient and family-centred, culturally sensitive, trauma-informed health care. Appreciate the child and family's cultural understanding of mental health and their experience of trauma[7][82].
  • Identify family, social, and environmental protective and/or risk factors. For example, community context, the home environment, parenting styles and practices, communication patterns and conflict, sleep environment[83][84], family history of psychiatric disorders or substance use, trauma, and material deprivation, including food insecurity.
  • Consider data from screening, history-taking, physical examination, and clinical investigations to initiate appropriate non-specific mental health interventions (Table 2) and determine whether further psychiatric or psychological assessment is required.
  • Consider whether collateral information (with consent) from the child’s teacher, therapist, or other informant would be useful.
  • Recognize when a virtual assessment for symptoms of mental illness is insufficient or inappropriate[60].
  • Know the ‘red flags’ for psychiatric emergencies (e.g., active suicidal ideation, suicide risk behaviours, such as self-harm, severe or complex symptoms of mental illness) that require urgent in-person psychiatric assessment. Be ready to initiate an immediate intervention.
  • Have the knowledge of interviewing skills and diagnostic criteria to accurately diagnose common mental health disorders.
  • Evaluate symptoms of mental illness using a differential diagnosis framework – similar to how medical symptoms are assessed – to help ensure quality care and condition management.
     

Treatment

  • Provide psychoeducation (Table 2) using a biopsychosocial framework.
  • Recommend evidence-based strategies to improve symptoms of mental illness: sleep hygiene, regular and healthy dietary patterns, physical activity, pro-social relationships.
  • Initiate appropriate evidence-based psychological treatments (Table 2) for children and youth presenting with learning disabilities, anxious thoughts or behaviours, inattention, hyperactivity or impulsivity, depression, withdrawn or aggressive behaviours, or substance use, somatization, or eating disordered behaviour.
  • If pharmacological therapy is required: select, prescribe, and monitor for adverse effects of evidence-based, first-line medications for common childhood mental health disorders, such as ADHD, anxiety, and mood disorders[85]-[87].
  • Refer children for specialized psychological or psychiatric assessment and treatment in the following circumstances: atypical or complex clinical presentation including multiple comorbidities, poor response to first-line treatment, experience of significant or unexpected adverse effects, or as indicated by disorder-specific clinical practice guidelines.
  • For self-harming or aggressive behaviours, or for suicidal thoughts, develop a safety plan collaboratively with patients and family members[88].
  • Collaborate and co-manage mental health disorders with specialized mental health care providers – including psychiatrists, psychologists, nurses, nurse practitioners, and social workers – at all stages of treatment, including assuming responsibility for ongoing prescriptions, where indicated.
  • Avoid using language that could reinforce stigma.
  • Ensure that children, youth, and families have a participatory role in treatment decisions and management of a mental health disorder, including the role of community in their care.

Adapted from Table 4 in reference 6

Paediatric care providers are often well situated to recommend, monitor, and evaluate first-line non-pharmacological strategies for children and youth with a mental health disorder. Table 2 provides and describes common non-pharmacological interventions that paediatric care providers should be familiar with and able to initiate or recommend as part of comprehensive management planning. When referred for a course of treatment (for example a course of CBT), patients should receive care from a health care professional who is trained in the administration of the treatment modality with children and families.

Table 2. Evidence-based non-pharmacological interventions

Therapy/Intervention

Description

Consider for

Psychoeducation

Teaches children and their parents about specific disorders: current understanding of their etiology, diagnostic definition, management strategies, and potential risk or perpetuating factors to avoid.

Can be one-on-one, or family-, group- or community-oriented.

All mental health conditions

Behavioural

Facilitates lifestyle changes (e.g., nutrition, physical activity, sleep).

Promotes relaxation techniques (e.g., meditation, yoga).

Parenting behaviour/management training programs teach strategies to establish structure, reinforce positive behaviours and consistent discipline, and strengthen the parent-child relationship through positive communication[5].

Guidance for healthier screen time exposure and use[89].

Collaborative problem-solving skills training[90][91].

Builds positive reinforcement skills (e.g., praising effort as well as outcome)[6].

Teaches effective/appropriate use of incentives and tangible rewards as well as limit-setting[6].

Mood and anxiety disorders

ADHD[92]

Disruptive or aggressive behaviours[93]

Sleep problems

Somatic symptom disorders

Motivational interviewing is a communication technique used to enhance an individual’s motivation to make positive behaviour changes over time [94].

Substance use

Eating disorders

Adherence to treatment for chronic health conditions

Enhancing motivation for help seeking

Psychotherapy

Cognitive behavioural therapy (CBT)

CBT helps children and adolescents develop awareness of inaccurate or negative thinking and effect on behaviour and feelings. CBT targets thoughts and behaviours to improve anxiety and/or mood symptoms.

Behavioural activation increases enjoyable and positive social activities[6].

Improves cognitive or coping methods (e.g., realistic thinking, goal setting, mood tracking).

Grading exposure to difficulty and intensity[6].




 

A wide range of common disorders, including:

Depression[6][95]

Anxiety disorders

Eating disorders[96]

Somatic symptom disorders
Dialectical behaviour therapy (DBT)

Teaches children and parents to identify and accept their thoughts and feelings while learning the skills and strategies to change them. Increases an individual’s ability to manage intense emotions, and parent ability to respond to their child’s intense emotions in supportive and productive ways.
Family-based treatment (FBT)

A phased treatment that initially teaches parents to employ effective strategies to eliminate eating disorder behaviours in their child, followed by a gradual handover of autonomy with eating and physical activity to the child (97).



Eating disorders

Educational interventions and accommodations

Collaborate with schools to create environments that support learning and mental health.

Optimize communication with and among school personnel.

Inform individualized learning plans (ILPs) or individualized education plans (IEPs) developed by school personnel to address specific needs (e.g., breaking tasks down into smaller pieces, providing students with extra time to complete tests and assignments).

Access to school-based resources, behavioural supports, special services (e.g., for organizational support).

 

Learning difficulties[98]

ADHD[92]

Anxiety disorders

Conclusion

Mental health is an important component of overall child and youth health, the absence of which contributes to morbidity and mortality[4][99].

Paediatric care providers require competencies in screening, assessment, and implementation of first-line, evidence-informed treatments for common mental health disorders affecting children and youth. Paediatric care providers who are supported by mental health teams are more likely to incorporate mental health monitoring into their practices[29]. Integrating mental health care into paediatric primary care is critical to optimizing the health of Canadian children and youth. As implementation plans may vary somewhat by province/territory and setting, support by both governments and academic institutions is required to ensure success. The importance of health systems that support efficient use of resources, shared care delivery models, and provision of evidence-based treatments delivered by trained and qualified professionals cannot be understated for the successful implementation of improved mental health care pathways.

Recommendations   

For clinicians

Paediatric care providers are encouraged to:

  • Integrate aspects of mental health care—screening, assessment, and treatment—into routine paediatric care, referring children and youth to mental health specialists when appropriate.
  • Identify personal knowledge gaps and engage in skills training related to mental health competencies through continuing medical education.
  • Create or adapt their current practice environment to provide inclusive mental health care.
  • Learn about specific barriers experienced by the families they see in practice. Providing culturally competent care can help reduce these barriers and encourage children and families from marginalized groups to seek and engage in mental health care.
  • Create regular, formalized opportunities to learn mental health competencies through collaborations with other skilled health care providers.
  • Address social determinants of health in clinical practice by fostering connections with local service providers and helping patients and families to make contact and engage with community resources.

For educators and trainees

  • Physician accreditation bodies and residency training programs should require that paediatric training programs provide sufficient training experiences in mental health care to ensure that providers are able to achieve the competencies outlined in this statement.
  • Educational competencies are needed to ensure that paediatric trainees can screen, diagnose, initiate, and monitor treatment for a broad range of mental health conditions.
  • Paediatric clinical training programs should ensure that residents are educated in acute mental health interventions, the effect of adverse childhood experiences (ACEs) on health, and trauma-informed care.
  • Continuing professional development leaders should increase opportunities for paediatric care providers to enhance their knowledge of, and skill development in, evidence-based mental health treatments.

 For government and health authorities

  • Increase funding toward providing universal access to evidence-based child-, youth- and family-centered mental health programs, services, and supports. Programs should be delivered by a wide range of trained health care professionals—including clinical psychologists—within a stepped-care, multidisciplinary, collaborative model.
  • Improve and expedite access to child psychiatrists based on a child’s mental health care needs.
  • Address physician compensation models to include fair and appropriate remuneration for mental health care (e.g., sessional payment or salary for work with multidisciplinary teams, or fee-for-service billing codes that adequately compensate time for assessment and ongoing care).
  • Strengthen the development and implementation of mental health care-related policies by committing to meaningful and ongoing consultation and engagement with paediatric mental health experts, and engagement with youth, family, and community organizations.
  • Fund and support the delivery of targeted mental health-related educational resources and training programs that increase the skills, confidence, and competencies of all those who support the health and well-being of children and youth.
  • Ensure that youth mental health treatment programs include, regularly monitor, and report on clinical and systemic indicators of youth and family mental health and well-being, such as wait-times and outcomes, using widely accepted, validated measures, and fidelity to evidence-informed treatments. Such measures would enable evaluation of program effectiveness and suggest areas for improvement.

Acknowledgements

This position statement has been reviewed by the Mental Health and Developmental Disabilities, Community Paediatrics, and Adolescent Health Committees of the Canadian Paediatric Society. It was also reviewed by the CPS Early Years Task Force and by representatives of the Canadian Academy of Child and Adolescent Psychiatry (CACAP), the Canadian Psychological Association (CPA), and the College of Family Physicians of Canada (CFPC).

CANADIAN PAEDIATRIC SOCIETY MENTAL HEALTH TASK FORCE (2021-2022)

Members: Daphne J Korczak MD (Chair), Wilma Arruda MD, Stacey A Bélanger MD PhD, Janice S. Cohen, Ph.D. C. Psych. (Canadian Psychological Association), Sophia Hrycko MD (Canadian Academy of Child and Adolescent Psychiatry), Anne Kawamura MD, Margo Lane MD, Maria J Patriquin MD (College of Family Physicians of Canada)
 

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.

Last updated: Nov 1, 2023

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