University of Groningen
Children's and adolescents’ enrolment in psychosocial care: determinants, expected barriers,
and outcomes
Nanninga, Marieke
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Publication date: 2018
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Nanninga, M. (2018). Children's and adolescents’ enrolment in psychosocial care: determinants, expected barriers, and outcomes. Rijksuniversiteit Groningen.
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1
General
The general aim of this thesis is to enhance understanding of children’s and adolescents’ enrolment in psychosocial care, including the association of enrolment with outcomes of this care. Such increased understanding can be applied in daily practice and policy making, but also in research and education. This chapter places the study in a broader context by providing background information on psychosocial problems of children and adolescents, on psychosocial care, and on the process of care enrolment. The chapter also introduces the academic collaborative centre in which our study took place and the longitudinal prospective cohort study that was set up for this study. This chapter ends with the research questions and an outline of the thesis.
Psychosocial problems and their impact
Psychosocial problems occur frequently in the general population, and affect an estimated 7 to 24% of children and adolescents [1-6]. Psychosocial problems can be roughly divided into behavioural, emotional and social problems. Behavioural – or externalizing – problems are outwardly visible, for example hyperactivity, aggressiveness and delinquent behaviour. However, emotional – or internalizing – problems, though not always outwardly visible, do affect the child’s emotional state; they include anxiety, depressive feelings, reservedness and psychosomatic complaints [7-9]. Social problems involve difficulties in creating and maintaining relationships with others [10, 11].
Research has consistently shown psychosocial problems to have a major impact on the daily life of children and adolescents, and their families, but also on their future adult lives if problems are not treated effectively. Children with psychosocial problems are more likely to experience less well-being in daily and social functioning, but also poor physical health and educational outcomes [4, 12-16].Given the relatively high incidence of psychosocial problems among children and adolescents and their serious impact on their current and future lives, it is essential that these children receive timely and effective treatment.
Psychosocial care for children and adolescents
Children, adolescents and their families can receive psychosocial care from various types of care providers, including as major types preventive child healthcare (PCH), child and adolescent social care (CASC), and child and adolescent mental healthcare (CAMH), see Table 1 [4, 17-20]. In PCH doctors and nurses provide care to children and families with mild child and family problems. In case of more severe problems, PCH refers children and families to specialized care, either CASC or CAMH. In CASC child (social) workers provide care for children with psychosocial problems, as well as for children with social and economic problems within the family that could impede or threaten the child’s
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development. Like CASC, CAMH provides specialized care, but primarily by psychologists and psychiatrists, to children with more severe psychosocial problems and psychiatric disorders [17, 19, 20].
In the Netherlands municipalities, local authorities, have been responsible to provide psychosocial care for children and adolescents since 2015, with the start of the new Child and Youth Act. This care emphasizes provision of preventive and light support to children and families, incorporating help from their social networks, for example via the work of so called ‘local area teams’ (in Dutch: ‘sociale wijkteams’) that work preventively within the local neighbourhood and, when necessary, facilitate access to specialized care. This Act aims to reduce the use of more specialized care, transforming the system to lead to more coherent, effective, and less expensive care for children, adolescents and their families [21, 22]. Enrolment in care is possible via local area teams but also via general practitioners and PCH.
Before 2015, responsibilities for the different care types were diffuse; municipalities were responsible for PCH, provincial governments for CASC, and health insurance companies for CAMH. This dispersion of responsibilities, combined with deficient collaboration of professionals around children and families, insufficient use of preventive and light support, excessive use of specialized care, medicalization, and over- and undertreatment were important reasons for the government to change the system [21]. Before 2015, enrolment in care took place via general practitioners and PCH, via 'youth care offices' (in Dutch: Bureaus Jeugdzorg), which referred children with more severe problems to specialized care after deciding which type of intervention was most appropriate [23].
Table 1 Main providers of psychosocial care for children and adolescents in the
Netherlands; situation at time of data collection a b
Care type Description
Preventive child healthcare (PCH)
In PCH, doctors and nurses provide care to children and families with mild problems. In case of more severe problems, PCH may refer children and families to specialized care, either CASC or CAMH.
PCH provides light psychosocial support, for example ambulatory/outpatient or home-based family support. Care is aimed to be of short duration. Children and families usually enter PCH by visiting the school doctor or nurse
employed in PCH. Enrolment via referral by their general practitioner or via the youth care office (in Dutch: ‘Bureaus Jeugdzorg’) is also possible. PCH is financed by the municipality.
Child and adolescent social care (CASC)
In CASC, child (social) workers and pedagogues provide specialized care to children and families. CASC treats psychosocial problems and social and economic family problems that could impede or threaten the child’s development. Compared to PCH, CASC treats more severe problems. CASC provides individual child support for trauma, experiential learning,
independent living, parenting, families and foster care. Care can be ambulatory/outpatient, home-based, day-treatment, residential or foster care. More frequently than in PCH, CASC care lasts longer than 3 months. Children and families enter CASC mainly via referral by the youth care office,
which also decides about the type of intervention needed. Referral to CASC by PCH or the general practitioner is also possible.
CASC is financed by provincial governments. Child and
adolescent mental healthcare (CAMH)
In CAMH psychologists and psychiatrists provide children and families with specialized care for psychosocial problems and psychiatric disorders. Compared to PCH, CAMH treats more severe problems.
CAMH provides support for the individual child, for trauma, for parenting and for families. Care is ambulatory/outpatient, home-based or day-treatment. More frequently than in PCH, care lasts longer than 3 months. Children and families enter CAMH mainly via referral by the general
practitioner. Referral is also possible via PCH or youth care offices. CAMH is financed by health insurance companies.
a Since the new Child and Youth Act became operational in 2015 municipalities are responsible for all three care types. b This table is based on [17, 19, 20].
Enrolment in psychosocial care
Logically, enrolment in psychosocial care takes place before the start of the treatment process. Therefore, a fluent course of enrolment of children and adolescents in care could be vital for an adequate subsequent care process, and potentially also for care outcomes. Goldberg and Huxley have described the process of enrolment in the
Pathways to Care [11, 24]. Their model, unlike other models, is more directed towards the
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and the Gateway Provider model [28],focus mainly on determinants, defined as multiple influences dynamically affecting attitudes towards and actual use of care.
Goldberg and Huxley describe enrolment in psychosocial care as a process with various stages of intensity. These stages concern various levels of care, starting with the recognition of children's needs, and ranging from community-based to inpatient care. The levels are separated by filters through which children and their families must pass in order to reach a more specialized level of care: (filter 1) the decision to consult a professional/seek help, (filter 2) the recognition of psychosocial problems by a professional, (filter 3) referral to specialized outpatient care, and (filter 4) admission to inpatient care. Based on this model we define psychosocial care enrolment as either entering the care system by passing the first filter, or moving through the care system by passing one of the subsequent filters to more specialized care. The Pathways to Care model is presented in Figure 1 of Chapter 4.
The need for more insight on children’s enrolment in psychosocial care is repeatedly underlined by the repeated finding that only a minority, an estimated 23-38%, of children and adolescents with psychosocial problems enrol in psychosocial care [9, 29-34]. Following the Pathways to Care model, our study will therefore first explore the views of children and parents in the community regarding barriers to psychosocial care. Community-based evidence on this subject is scarce, although children’s and parents’ views on barriers very likely affect seeking care and the use of care [25-27, 35].We will assess the number of barriers expected, the types of barriers most expected, and the associated child and family characteristics. Especially the latter may provide direction to improve the process of enrolment for children and adolescents. As part of this research, we will assess the psychometric properties of the scale we have developed and used to assess expectations regarding barriers to care: the Barriers to Treatment Participation Scale-Expectancies (BTPS-exp). The BTPS-exp can be used both among adolescents and parents in the community and among those at the start of psychosocial care.
We will further obtain insights into enrolment by assessing determinants of children’s and adolescents’ enrolment in and use of psychosocial care. Evidence indicates that factors other than psychosocial problems are also important determinants of enrolment, for example certain child and family background characteristics [27, 28, 32, 36]. We will perform a systematic review on this topic, because in spite of extensive available evidence on enrolment and use of care, recent literature reviews are lacking. Results of our review provide a basis to further explore the effect on psychosocial care enrolment of a child’s social environment, especially social support and parenting skills within the family.
Finally, there is but scarce evidence regarding the impact of enrolment in care, including its significance for outcomes of care. We therefore also aim to better understand the types and severity of problems present upon enrolment in psychosocial care, i.e. child, parenting and family problems, as well as assessed outcomes, i.e. care duration and problem solution, after three and twelve months. Evidence shows that psychosocial care does not solve all psychosocial problems of children and adolescents [30, 37-40]. Given the serious impact of psychosocial problems on the lives of children and families, greater insight into factors associated with effectiveness of care is urgently needed. The process of enrolment may play a crucial role in this.
Context in which the study was conducted: C4Youth and TakeCare
This study took place within the Collaborative Centre on Care for Children and Youth (C4Youth), a collaborative academic centre in the northern Netherlands aimed at care for children and adolescents with psychosocial problems. A collaborative academic centre is a knowledge-centred infrastructure involving research, practice, education and policy in long-term collaboration to enhance the quality of care. The Netherlands Organization for Health Research and Development (ZonMw) has been financing such centres since 2008. C4Youth was the first of these.
The primary goal of C4Youth is to promote an exchange of knowledge between the realms of research, practice, education and policy [41]. Its second goal is to collect evidence on the functioning of the entire chain of care for children and adolescents, and on long-term outcomes. This is done via the longitudinal prospective cohort study called TakeCare (Tracing Achievements, Key processes and Efforts in professional care for Children and Adolescents REsearch) [20].The aim of this major cohort study is to augment evidence on children’s and adolescents’ enrolment in psychosocial care, on the various types of care offered to them, and on the outcomes of this care.
The TakeCare study covers three research themes, each comprising different aspects of the care process (Figure 1): enrolment in care, contents of care, and client-professional communication. The first theme, enrolment in care, is the main topic of this thesis, and focuses on children’s and adolescents’ enrolment in psychosocial care, its association with subsequent care, and care outcomes. The second theme focuses on the
contents of care actually provided for children and adolescents with psychosocial
problems, and their families [17]. The third theme focuses on the role of
client-professional communication: how clients perceive communication, its associations with
care outcomes, and what actually happens during client-professional encounters [42]. The database resulting from the TakeCare study provides information on the psychosocial care offered to children and adolescents as seen from the perspectives of
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parents, children (when aged 12 and over), and care professionals over the course of three years. Information is available on the enrolment, care processes and outcomes of the care sample. Information is also available on children and adolescents in a community
sample from the same region [20]. This enabled us to compare children in care with the
general population. With the data from both samples we will be able to provide empirical information on various aspects of enrolment in psychosocial care: views of parents and adolescents in the community regarding barriers to care, determinants (specifically the role of the child’s social environment) of enrolment in and use of care, and the types of problems (of the child and family) upon enrolment in different types of care, and the association of enrolment with outcomes (i.e., care duration and problem solution after three and twelve months).
Figure 1 Research themes of longitudinal prospective cohort study TakeCare Research questions
This thesis is aimed at augmenting current insights into children’s and adolescents’ enrolment in psychosocial care, and the association of enrolment with subsequent care and care outcomes. The following research questions will be addressed:
1. How many parents and adolescents in the community sample expect barriers when considering seeking psychosocial care for the child? What types of barriers are most frequently expected? And which child and family characteristics are associated with these expectations regarding barriers to care?
2. What are the psychometric properties of the Barriers to Treatment Participation Scale-Expectancies (BTPS-exp) in terms of internal consistency, scale structure, parent-adolescent agreement and validity?
3. What are determinants of children’s and adolescents’ enrolment in and use of psychosocial care as reported in the literature?
ENROLMENT CONTENTS COMMUNICATION
TAKECARE
4. Are family social support and parenting skills, two key aspects of the child’s social environment, associated with children’s and adolescents’ enrolment in psychosocial care? And, if so, what role do children’s psychosocial problems play in these associations?
5. Are the types of problems upon enrolment, i.e. child, parenting and family problems, associated with enrolment in different types of psychosocial care? And do care types differ in outcomes (of care duration and problem solution) after three and twelve months?
Figure 2 provides an overview of the research model underlying this thesis, and the connections between the various research questions.
Figure 2 Conceptual model of this thesis
Outline of the study
Our study is set up around the Pathway to Care model and starts in Chapter 2 with describing the expectations of barriers of parents and adolescents from the community sample, as well as child and family characteristics associated with these expectations. Expectations are measured with the Barriers to Treatment Participation Scale-Expectancies (BTPS-exp). In Chapter 3 we will examine the psychometric properties of this scale: internal consistency, scale structure, parent-adolescent agreement and validity. In Chapters 4 and 5 the focus lies on determinants of children’s and adolescents’
RQ 1
RQ 5a RQ 4
RQ 3 Child and family characteristics:
Sociodemographics Parenting skills Family social support Child and family problems Past use of psychosocial care
RQ 5b Expectations of barriers to
psychosocial care:
Stressors and obstacles Demands and issues Perceived irrelevance Problematic relationship with
therapist
RQ 5b Enrolment
Use of [specific types of] psychosocial care Care duration Problem solution after 3 and 12 months RQ 2
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enrolment in and use of psychosocial care. Chapter 4 will present a systematic review of this topic. In Chapter 5 we will extend the existing evidence by studying associations between elements of the child’s social environment, i.e. family social support and parenting skills, and psychosocial care enrolment. We will also examine the role of the children’s psychosocial problems in these associations. In Chapter 6 we will describe problem types, i.e. child, parenting and family problems, of children in (different types of) care compared to children not in care, and associations with outcomes (care duration and problem solution) after three and twelve months. Finally, in Chapter 7 we will draw conclusions concerning our main findings and discuss these findings in a broader context. We will discuss methodological considerations and suggest implications for practice, policy, education, and further research.
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