What is asked, but not heard? Assessing characteristics of youth with severe and enduring mental health problems during diagnostics in child-and-adolescent psychiatry.

Abstract

Objective: Severe and enduring mental health problems (SEMHP) in youth often fall outside traditional diagnostic classifications, which may lead to insufficient assessment of these youth's characteristics in classification-based psychiatry practice. Therefore, the objective of this study is to explore how current diagnostic practices in child-and-adolescent psychiatry address specific characteristics of youth with SEMHP by mapping the diagnostic process. Moreover, we aim to identify facilitators and barriers to effective assessment of specific SEMHP-characteristics by analysing stakeholders' perspectives.

Methods: The exploration involved: 1) mapping the diagnostic processes (e.g., steps, tools) used in a CAP facility in the Netherlands by conducting semi-structured preparatory interviews with eight professionals in CAP in July-September 2023, and 2) qualitative analysis of stakeholder experiences to understand how SEMHP-characteristics are assessed, and what factors facilitate or hinder adequate assessment of these SEMHP-specific characteristics through focus groups. Separate focus groups with ten clinicians (n = 5, n = 5), eight youth (n = 5, n = 3) and five caregivers (n = 5) were conducted, using a semi-structured topic guide in December 2023 till May 2024. Data was analysed using reflexive thematic analysis to unravel barriers and facilitators in SEMHP-assessment.

Results: While all examined SEMHP-characteristics in this study were addressed in the diagnostic process, still participants reported feeling unseen or misunderstood during the assessments. Participants identified factors that hindered and facilitated the diagnostic assessment including distrust in systems, masking behaviour of youth, lack of time and generational differences in recent societal developments such as social media.

Conclusion: Our study highlights stakeholder-identified barriers, revealing a shared perception of disconnect within the diagnostic process. This disconnect refers to a mismatch between clinical assessments and the lived experiences of youth and caregivers, in which they feel unheard, share less and experience being overlooked. Overcoming barriers requires viewing diagnostics as a relational process, where, in addition to gathering information, the focus in on building a therapeutic relationship, prioritising youth's story and emphasising individual understanding.