Patient-reported outcome measures (PROMs) are routinely used to inform clinicians and policymakers on clinical need and treatment efficacy. Yet despite their great value and utility, it seems that there is a low rate of outcome monitoring in Child and Adolescent Mental Health Services (CAMHS). Now, Anna Morris and colleagues have conducted the first study to examine PROM collection equality, using electronic healthcare data for a clinical cohort of >28,000 children aged 4-17 years accessing CAMHS across South London.
“As a team, we were interested in finding ways to improve routine outcome monitoring in CAMHS”, explains Morris. “Though our clinical experience alluded to a shortfall between government recommendations for the use of outcome measures in CAMHS and their actual delivery, we recognised the need to conduct a large-scale observational study to assess the magnitude of these difficulties. This approach would afford us the statistical power to explore the equitability of this practice, which is paramount given that these data are increasingly used to inform both national and service-level decisions around provisioning care.”
The researchers examined the completion rate of the caregiver Strengths and Difficulties Questionnaire (SDQ)1 — a ubiquitous PROM for CAMHS — at baseline and at 6-months follow-up. They found that the caregiver SDQ was only completed by ~40% of the sample at baseline and just 8% at follow-up. Strikingly, the pattern of SDQ completion was unequal, with biases in terms of patient gender, age, ethnicity and socioeconomic background. Males were more likely to have a baseline SDQ completed than females, whereas those of an older age, Black or Asian ethnicity, and those residing in a deprived neighbourhood were less likely to have a baseline SDQ. Similar patterns were found for the follow-up caregiver SDQ.
The study authors concede that the chosen study design was limited by several unmeasured factors that might have led to an underrepresentation of true outcome monitoring by CAMHS. Namely, the findings only reflect collection patterns for one of several outcome measures routinely used in CAMHS and specifically, only the caregiver-reported version of this measure. However, with the caregiver SDQ being a policy-recommended measure, the data reported here serve as a worrying indicator as to the potential overall uptake.
“Identifying such stark collection figures and groups of children at risk of not receiving or completing outcome measures might prompt policy-makers to revisit data collection recommendations, specifically in relation to the suitability and inclusivity of mandated questionnaires”, proposes Morris. “We hope that these risk predictors will provoke greater scrutiny around the design and accessibility of new service development initiatives to enhance data collection, such as digital health monitoring systems, to ensure that they are inclusive.”
Morris, A.C., Macdonald, A., Moghraby, O., Stringaris, A., Hayes, R.D., Simonoff, E., Ford, T. & Downs, J.M. (2020), Sociodemographic factors associated with routine outcome monitoring: a historical cohort study of 28,382 young people accessing child and adolescent mental health services. Child Adolesc. Ment. Health. doi: 10.1111/camh.12396
1Goodman, R. (1997), The Strengths and Difficulties Questionnaire: A Research Note. J. Child Psychol. Psychiatry. 38, 581-586. doi: 10.1111/j.1469-7610.1997.tb01545.x
Strengths and Difficulties Questionnaire (SDQ): The SDQ is a structured 25‐item questionnaire screening for symptoms of childhood emotional and behavioural psychopathology. Caregiver SDQs are a NICE-recommended PROM that is ubiquitous to all CAMHS services. The current clinical practice is to collect caregiver-rated SDQ for young people, either before or during the first clinical appointment.