Characterizing mental health related service contacts in children and youth: a linkage study of health survey and administrative data

In Canada, mental health services for children and youth is delivered from a wide variety of providers who are funded both publicly and privately [1, 2]. Specifically, all necessary physician visits are covered under public funding, whereas some visits to non-physician providers, such as psychologists in private practice, requires out-of-pocket reimbursement, which may be covered by private health insurance [2]. Children and youth also receive mental health support from school settings, which are universally covered [1, 2]. Perhaps, due in part to the fractured nature of Canada’s mental health care system, Canadian evidence assessing correlates of mental health related service contact among children and youth is fragmented and disparate, arising from varying data sources (survey [1, 3], health administrative data [4, 5]), service sectors (e.g. health, education, social services) in varying geographies (local, regional, provincial). Lack of standardization in measurement and integration of service data from various sectors, including physician and non-physician-based services, has led to methodological challenges and evidence gaps. To inform the provision and organization of mental health services for children and youth, we must first characterize the children and youth being served. Moreover, to increase equitable access to mental health related services, we must identify and characterize disparities in service delivery.

Prior evidence has relied on the use of either health administrative (herein administrative) data or population-level survey data to identify correlates of mental health related service contact [1, 5‐7]. Both data sources offer differing strengths and limitations. Administrative data provides broad and continuous coverage of population contacts with physician services, as it was developed to support physician compensation in the Canadian single-payer healthcare system [8, 9]. The major limiting factor of this data source for estimating child and youth mental health related service contacts is the exclusion of non-physician based mental health professionals whose services are not captured [4, 10]. Another important limitation is that, in outpatient settings, clinicians are restricted to one billing code per visit. As such, mental health contacts may be missed when people present with multiple complaints leading to an underestimate of mental health related physician contacts. In contrast, survey data can provide information on contacts with a wider range of mental health professionals and service providers including non-physician services, and more comprehensive data on socio-demographic and clinical factors to support contextualizing the populations being serviced across these various sectors [11]. Furthermore, survey data traditionally offers standardized and culturally sensitive measurement tools [12]. However, survey data relies on self-reported mental health related service contacts, which are subject to recall bias [13‐15]. Canada is not alone in its approach to measuring mental health related service contacts among children and youth. Evidence from other nations, including the United States, United Kingdom, and Denmark also relies heavily on estimates derived from either survey or administrative/registry data with varying levels of service coverage and measurement of socio-demographic characteristics and factors related to mental health need [16‐21].

One approach to improve current methodology for contextualizing mental health related service contacts among children and youth is to use a population-based survey that has been linked with health administrative data to estimate mental health related service contacts and determine socio-demographic correlates, after adjusting for factors related to mental health need, to identify potential disparities in access to mental health related service sectors. To date, evidence using survey linked data in Canadian settings has focused on adult populations, with a gap existing for children and youth [8]. Our goal was to fill this data gap by leveraging a child and youth focused representative population-level survey and health administrative data linkage [11].

Our analytic sample includes 8991 children and youth, of which 4565 are male (50.8%) and 4426 are female (49.2%). The mean age of the sample was 10.6 (SD = 4.06) years. The 6-month prevalence of any mental health related service contact was 21.7% (n = 1952, 95% CI 19.6%, 23.4%), any physician service contact was 8.0% (n = 732, 95% CI 6.9%, 9.1%), any non-physician service contact was 18.8% (n = 1691, 95% CI 16.9%, 20.5%), and both physician and non-physician service contact was 5.2% (n = 471, 95% CI 4.3%, 6.1%) (see Fig. 1). Our findings indicate that most physician contacts were in outpatient settings (8% of the total sample) and there were few emergency department visits (0.3% of the total sample) and hospitalizations (0.1% of the total sample). The most frequent non-physician contacts were with teachers or other adults at school (13% of the total sample), followed by visits to CYMHS settings (7% of the total sample), visits to school guidance counsellors (6.2% of the total sample), visits to social workers (3.2% of the total sample), visits to psychologists (2.4% of the total sample), and visits to other type of counsellors (2.3% of the total sample) (see Additional file 4).

Among children ages 4–11 years, being male and living with one or no biological parents in the home was associated with significantly higher prevalence of physician, non-physician, and both service contacts. Low-income households had significantly more physician service contacts and contacts with both physician and non-physician services. Children with immigrant parent(s) had a significantly lower prevalence of non-physician service contact and of contacting both physician and non-physician services. In youth ages 12–17 years, living with one or no biological parents in the home was associated with significantly higher prevalence of physician, non-physician, and both service contacts. Youth with immigrant parent(s) had a lower prevalence of physician, non-physician, and both service contacts (see Table 1). We found the highest mean dimensional scores in children and youth receiving both physician and non-physician service contacts (see Table 1, Additional File 5).

After adjusting for total mental health symptom ratings and socio-demographic characteristics, older youth aged 12–17 years (PR: 0.84, 95% CI 0.73, 0.97) and children and youth with immigrant parent(s) (PR: 0.65, 95% CI 0.55, 0.75) were less likely to have mental health related service contacts. Children and youth with one or no biological parents in the home (PR: 1.31, 95% CI 1.10, 1.55), compared to both biological parents in the home, were more likely to have any mental health related service contacts. Positive associations between internalizing (PR: 1.31, 95% CI 1.24, 1.38) and ADHD (inattentive and hyperactivity) symptoms (PR: 1.28, 95% CI 1.21, 1.35) and any mental health related service contacts were also found. Our findings also indicate that among those with service contacts, older youth aged 12–17 years (PR: 3.02, 95% CI 1.79, 5.07) and children and youth with immigrant parent(s) (PR: 2.23, 95% CI 1.16, 4.28) were more likely to have physician service contacts alone, compared to non-physician services alone. Children and youth with increased symptoms of internalizing (PR: 0.75, 95% CI 0.59, 0.94) and externalizing disorders (PR: 0.68, 95% CI 0.53, 0.88), were less likely to have physician service contacts alone, compared to non-physician services alone. Similar trends were observed when comparing children and youth physician and non-physician service contacts alone, compared to both physician and non-physician services (see Table 2).

This work represents one of the first studies in North America to use population level survey data linked with health administrative data to estimate the correlates of mental health related service contacts among children and youth across sectors, adjusting for factors relating to mental health need. As such, our findings provide unique insight into disparities in mental health related services across sectors among children and youth, in which adjustment of factors related to mental health need is essential.

Our findings suggest that 1 in 5 children and youth had a mental health related service contact in the six-month period prior to completing the OCHS survey. Our estimate is comparable to prior work from the US, which estimated that the prevalence of any mental health related service contact was 16% [21]. We found that mental health related service contacts vary by (i) provider, (ii) by clinical factors, including symptom ratings, disorder class, and (iii) by socio-demographic characteristics including age, sex, family structure, and immigrant parent(s). Unsurprisingly, our results suggest that higher symptom ratings were associated with a higher likelihood of contacting help across providers. In particular, children and youth contacting both physician and non-physician services had higher mean symptom ratings of mental disorders across all disorder classes. Furthermore, increasing symptoms of internalizing and externalizing disorders were both negatively associated with contacting physician services alone, compared to both physician and non-physician services. While consistent with prior work [21], which suggests youth with higher symptom ratings are more likely to contact multiple sectors, this important finding highlights the increased complexity in patterns of service contacts among children and youth with the highest symptom ratings, who may have the greatest mental health service needs. As such, the coordination of care across and within sectors are critical components of mental health services for children and youth [21]. Further research is needed to better understand coordination of care across sectors and models of stepped care, where children and youth with the greatest needs receive more specialized care [31].

Our results indicate that the greatest disparities in mental health contacts may exist for children and youth with immigrant parent(s). After adjusting for total mental health symptom ratings and other socio-demographic characteristics, children and youth with immigrant parent(s) had lower mental health related service contacts, which may reflect disparities in service delivery, rather than variation in the clinical profile of various groups [1, 32, 33]. Furthermore, we found children and youth with immigrant parent(s) were more likely to have contacted physician services alone, compared to non-physician services alone or both physician and non-physician services. These findings build on prior evidence suggesting immigrant youth are more likely to have a first point of mental health contact be an emergency department [34]. As we were able to include non-physician contacts in our analysis, our findings highlight the need to not only reduce barriers to care in outpatient physician settings, but also in non-physician settings, which may help contribute to identifying and treating mental health problems earlier, prior to crisis [34]. Our findings also suggest there is similarly a need to reduce barriers to care for older youth ages 12 to 17 years, who experience lower mental health related service contacts, compared to children ages 4 to 11 years. This finding aligns with prior work describing an increase in barriers to mental health related services for aging adolescents and transitional aged youth [35]. Future research is needed to better describe the types of barriers to care older adolescents are experiencing in Canada.

Our findings suggest an important correlate of mental health related service contact is living with one or no biological parents. This finding reflects the importance of family context in understanding mental health related service contact, and is consistent with prior survey research, however, is missing from administrative data sources, as this information is not regularly captured [1, 36‐38]. Children and youth living with one or no biological parents may be more likely connected with the foster care system and other social services, which may facilitate mental health related service contacts. Further research is needed to better understand where and in which settings lone parent families are accessing mental health related services.

Our findings indicate comprehensive characterization of mental health related service contacts among children and youth relies on the measurement of both physician and non-physician services. Our prevalence estimates of service contacts across sectors/professionals demonstrates that non-physician service contacts are much more common. As such, our findings highlight the limitations of relying on the use of health administrative data in isolation, which is currently limited to physician contacts. The use of data linkage has increased both the breadth of mental health related service contacts and the depth in which children and youth can be characterized. As such, our findings highlight the strength of using data linkage to study the correlates of child and youth mental health related service contact across providers, compared to relying on individual data sources on their own [8]. Going forward, we believe there is a need to better understand the types of treatments children and youth are receiving from various service providers to further characterize children and youth receiving mental health related services.

Our results may not be generalizable outside of Ontario due to the provincial variation in mental health service provisions and approach to diagnostic coding [40]. Another limitation is that administrative data is a product of physician billing codes. As such, thresholds for diagnosis will vary between physicians and settings [41]. Our findings may be subject to information biases, including recall bias, telescoping bias, and potential differences among participants with, versus without, complete data. Such biases may influence the observed associations [13‐15, 42]. It is important to note that while our non-participation bias and an unwillingness to share linked data may have impacted our findings. Specifically, families of children with more severe symptoms of mental disorders may be less likely to participate in a survey and children and youth, which may not be addressed by survey weighting conducted by Statistics Canada. Furthermore, the sampling frame did not include Indigenous children living on reserve, those who are homeless, and those in the child welfare or youth justice systems, who may be at greater risk for mental health related concerns. As such, our findings may not be generalizable to children and youth with the most severe mental disorders [42]. Our approach to classifying mental health related service contacts is broad and inclusive and should not be equated with receipt of mental health treatment. Our classification reflects the data source and methodology from which they are derived and our sample distributions, which have limited our ability to differentiate between various service settings including differences between outpatient and acute care (emergency department, hospital) settings. As such, to better contextualize mental health related services that children and youth are receiving, we believe going forward, there is a need to better understand the types of treatments children and youth are receiving from various service providers. It is important to note that while we did not identify significant variation in mental health related services by rurality, evidence suggests there exists regional variation in service delivery in Ontario [10]. Furthermore, there are a number of area-level indicators we were unable to adjust for, which may have led to residual confounding; including area-level deprivation and indicators of the availability of healthcare and school related mental health services.

Our findings indicate important variation in mental health related service contacts by provider, clinical factors including symptom ratings and disorder class, and socio-demographic characteristics including age, immigrant background, and family structure. Furthermore, the coordination of care across and within sectors are critical components of mental health services for children and youth. This work suggests the greatest disparities in mental health related services may exist for children and youth with immigrant parent(s). Targeted outreach efforts to reduce barriers to care are required. This study highlights the strengths of using data linkage to study the correlates of child and youth mental health related service contacts across providers and sectors. Investment should be made to expand available population-level data linkages for children and youth, as these linkages offer strong platforms for improving our understanding of mental health service delivery.