Abstract
Background
This study investigated changes in school and vocational attendance problems (SVAP) among young people receiving treatment as usual (TAU) at Child and Youth Mental Health Services (CYMHS) in Australia. Although CYMHS primarily addresses severe psychiatric disorders, SVAP frequently co-occurs in this population, impacting overall wellbeing.
Method
A random sample of 210 patients who completed treatment in the year prior to the COVID-19 pandemic was selected. SVAP was assessed using the Health of the Nations Outcome Scales for Children and Adolescents (HoNOSCA), a routinely collected measure of symptoms and functioning, with ratings recorded at Assessment, 91-day Review, and Discharge.
Results
At Assessment, 48.6% of patients presented with SVAP. This reduced to 44.8% at Review and significantly dropped to 24.3% by Discharge (p < 0.001). While no significant change was observed from Assessment to Review, a substantial reduction in SVAP was noted from both Assessment to Discharge and Review to Discharge (p < 0.001).
Conclusion
These findings suggest that CYMHS TAU, though not specifically focused on attendance issues, can positively impact SVAP in young people with complex psychiatric needs.
Plain Language Summary
Young people with mental health challenges often struggle with school or work attendance, impacting their education, social connections, and wellbeing. This study explored whether regular mental health care, provided as part of routine services, could improve attendance for young people with complex mental health needs. The research involved 210 young people treated at a Child and Youth Mental Health Service (CYMHS) in Melbourne, Australia. Their school or work attendance was assessed at three points: when treatment began, around three months later, and at discharge. At the start, almost half (49%) had serious attendance problems. After three months, this number improved only slightly. By the end of treatment, attendance problems had reduced significantly to 24%. This suggests that even though regular mental healthcare does not directly target attendance, it can have a positive impact over time. It also highlights the need for extra strategies or specialised programs for the 24% who do not respond to standard mental health care alone. This research shows that mental health services can improve young people’s participation in education and work. However, for some young people, additional support may be needed to ensure they stay engaged in school or vocational activities. The findings may help mental health professionals identify which young people might benefit from extra help earlier in their treatment.
Keywords
Introduction
School and vocational attendance problems (SVAP) significantly impact the academic, social, and mental health outcomes of young people, particularly those with severe psychiatric disorders (Lawrence et al., 2015). In Australia, nearly one-third of students miss substantial schooling annually, with SVAP linked to poor educational and vocational trajectories, family disruptions, and long-term economic and social challenges (McKay-Brown et al., 2019).
SVAP is common among those with mental health disorders and those accessing Child and Youth Mental Health Services (CYMHS) (Goodsell et al., 2017). CYMHS primary treatment focus are complex mental health disorders. Despite perceptions that CYMHS treatment as usual (TAU) may indirectly improve SVAP, a systematic literature search by the authors revealed very few studies examining the impact of TAU on SVAP.
Using longitudinal data collected at Assessment, 91-day Review, and Discharge, this study evaluated the extent of SVAP, and improvement in SVAP among CYMHS patients receiving TAU at Eastern Health CYMHS (EH CYMHS). By categorizing SVAP into clinically meaningful groups, this research sought to provide insights into the broader impact of TAU on young people with complex mental health needs.
Method
Procedure and Location
EH CYMHS, a tertiary mental health service in Melbourne Australia, treats young people up to 25 years for complex and severe presentations such as mood, anxiety, psychotic, personality, bipolar, autism spectrum, attention deficit, post-trauma and eating disorders. School and vocational issues may occur as part of presentations but are not a referral reason by themselves. TAU, in Australian CYMHS, includes comprehensive, individualised care for a broad range of severe mental health disorders. It covers biopsychosocial assessment, formulation, case management and collaboration with patients, families, and other services. The multi-disciplinary team, with its’ regular reviews facilitates individually tailored treatment planning (Wagner et al., 2017). Treatments can include evidence-based psychotherapies (e.g., cognitive, psychopharmacological, family, parenting, trauma-informed, and systemic therapies) as appropriate to the formulation. Treatment for SVAP may occur if it is germane to the impact of the specific mental health diagnosis on functioning but unlike, for example, a school refusal clinic, SVAP will not be the prime focus of treatment. The study extracted EHCYMHS routinely collected patient demographic, diagnostic and outcome data.
Measures
HoNOSCA is a mandated clinician-rated instrument designed to assess child and adolescent mental health outcomes with good reliability and validity (Brann et al., 2001). Clinician’s rate severity and functioning difficulty in the preceding 2 weeks over 13 clinical areas, from 0 (No Problem) to 4 (Severe Problems). Scores of two or greater are considered clinically significant (Brann & Coleman, 2010). On the “Poor School Attendance” scale, scores under 2 indicate No School or Vocational Attendance Problems (NSVAP), while scores of 2 or greater indicate SVAP. For those who have left education, vocational attendance is the relevant parallel.
HoNOSCA is routinely collected for all patients at Assessment, every 91 days, and at Discharge (Burgess et al., 2015). The sample was drawn from all patients discharged from community teams in 2019 to avoid the impact of mandated home-schooling times during the COVID-19 pandemic. Of the 581 discharges, 89% had complete HoNOSCA data. 210 cases were randomly selected.
Patient Characteristics
Patient characteristics extracted included age, gender, case duration, country of birth, preferred language, housing status and diagnosis. Patient diagnoses (ICD-10) were grouped, duplicates removed and prioritised heuristically (Brann & Coleman, 2010).
Statistical Analysis
Data analysis including McNemar’s test, Cochran’s Q test, and Repeated Measures Analysis of Variance (RMANOVA) was completed using SPSS version 27. The required sample size of 210 was calculated using G*Power (Faul et al., 2007).
Ethics
Approval for the study was granted from Eastern Health Human Research Ethics Committee (LR21-022-76640).
Results
Patient Characteristics
Patients were aged between 4 and 23 years with an average age of 14.5. They were typically Australian born (94%), spoke English (99%), and 57% were female (male 42%, transgender 1%). The average case length was 10.8 months with the average treatment dose approximately 53 h (N.B. This includes all contacts recorded against that case, e.g., Patient, Family, Other services and significant others, Schools, Reviews, Supervision, Case Planning). The most prevalent diagnoses were Mood (22.4%), Eating (19%), Anxiety (15.7%), Personality (14.3%), Pervasive Developmental (11%), and Severe Stress and Adjustment Disorders (3.8%).
Changes in SVAP from Assessment to Discharge
Overall, 49% (n = 102) of patients had SVAP at Assessment compared with 24% at Discharge. Of those with SVAP at Assessment, the majority (61%, n = 62) were NSVAP at Discharge. McNemar’s test revealed a significant reduction in the number of patients with SVAP between Assessment and Discharge (Test statistic = 34.25, df = 1, p < 0.001). Of those with NSVAP at Assessment, 10% (n = 11) were SVAP by Discharge.
Cochran’s Q test revealed a significant difference in SVAP proportions between Assessment, the first Review, and Discharge (Q = 48.54, df = 2, p < 0.001). Bonferroni posthoc follow-up revealed a significant change between Assessment and Discharge (p = 0.001), between Review and Discharge (p = 0.001) but no difference between Assessment and Review (Figure 1). Percentage of Patients With SVAP Over Time
Change in Mean SVAP over Time
The RMANOVA (assumptions of sphericity not violated) revealed a significant difference in mean SVAP ratings over time (F = 32.28, df = 2, 418, p < 0.001). Mean scores at Assessment, Review and Discharge were 1.51, 1.4, and 0.79 respectively. Post-hoc Bonferroni corrected pairwise comparisons revealed a significant decrease in mean scores between Assessment and Discharge (p < 0.001), between Review and Discharge (p < 0.001) but not between Assessment and Review.
Discussion and Application to Practice
This study highlighted the high prevalence of SVAP (49%) in CYMHS patients at assessment. A significant reduction was observed from Assessment to Discharge indicating that TAU positively impacts attendance outcomes. However, this reduction did not occur by the first 91-day review.
Prior studies have found reductions in mean SVAP scores (Brann & Coleman, 2010; Manderson & McCune, 2003). The current approach employed clinically meaningful categories (SVAP vs. NSVAP) rather than numerical decreases. This approach offers meaningful insights for clinicians, patients, and families into their functional progress. TAU alone can lead to improvement, with 61% of those with SVAP shifting to NSVAP at discharge.
Patients at CYMHS have a range of severe and complex mental health disorders. No-one was accepted for treatment by EH CYMHS in the study period for management of SVAP as the only presenting problem. SVAP is co-present with major mental health diagnoses (Goodsell et al., 2017). The top five diagnoses, over 80% of this sample, required comprehensive treatment. While the majority improve, many still had SVAP after TAU. Identifying this subgroup, after 91 days treatment, may allow a targeted approach to SVAP intervention where TAU is insufficient.
This study extends previous research by using completed cases across three key time points. It also suggests that TAU will be beneficial for most CYMHS patients with SVAP. Previous studies have typically looked at specialised school-refusal programs. As noted, only two studies have looked at CYMHS TAU and SVAP (Brann & Coleman, 2010; Manderson & McCune, 2003). Combined with this study, improvement in SVAP occurs somewhere between 3 to 6 months and discharge. Future work may explore more time markers and predictors of ineffective TAU. This may also include examining whether there is an interaction between diagnostic groups and TAU impact on SVAP.
This study found that school and vocational attendance improved with TAU. This finding reflects clinicians’ perceptions based on their contact with patients, families and other services. Given that mood and anxiety disorders were the most prevalent diagnoses, it is plausible that improvements in these areas contributed to improved school and vocational attendance. This study aimed to establish the impact of TAU on SVAP. However, an expanded study is now required to examine whether improvements in specific symptom areas (e.g., emotional symptoms, hallucinations, peer relationships, self-harm) are related to decreases in SVAP. Understanding the improvement pathway could provide guidance for tailoring TAU for those whose SVAP does not improve.
This study has several limitations. TAU is likely to vary greatly between patients and between clinicians. Variation in TAU between patients is open to exploration, e.g., is there a difference between SVAP improvements related to contact with school and vocational settings.
Additional measures of SVAP, such as patient-reported outcomes or school or vocational records, were not included. They would have provided a broader lens to supplement clinician perceptions.
While there were good completion rates in routine practice, 11% of discharged cases had missing SVAP data and were excluded. This might have influenced SVAP rates in either direction.
Finally, the use of categorical data to define SVAP and NSVAP, though clinically meaningful, may overlook individual-level changes that do not meet thresholds for categorical shifts. For example, for many patients and families, a shift from Severe to Moderate Problems is very meaningful, though still SVAP.
Conclusion
This study demonstrates that TAU provided by CYMHS can significantly reduce school and vocational attendance problems in young people with complex mental health conditions despite not being the primary focus of care. Routine outcome measures, like HoNOSCA, can support tracking progress in critical symptom and functioning areas and establish baseline expectations for all future patients.
However, many did not improve, and this baseline data may assist services in identifying cases that might benefit from additional interventions. These findings also underscore the utility of routine outcome measures like the HoNOSCA, which enable mental health services to track changes in critical areas beyond primary psychiatric symptoms.
Footnotes
Acknowledgments
The authors thank all the Eastern Health Mental Health and Wellbeing participants whose data contributed to this survey.
Ethical Considerations
Approval for the study was granted from Eastern Health Human Research Ethics Committee (reference number: LR21-022-76640). The approval did not require informed consent because data was retrospective, routinely collected, anonymised and reported in aggregate.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Data is available on reasonable request and on approval from the Eastern Health HREC.
Contributorship
Yu En Chia was involved in design, writing and drafting, Peter Brann designed the study, analysed the data, wrote and reviewed drafts, Stanley Innes reviewed and edited drafts, Jeremy Couper was responsible for study design and review of drafts.