Strengthening Mental Health Services for Children and Youth in Canada

The majority of mental health disorders emerge before the age of 25, ¹ making early identification and effective intervention crucial defenses against disability, premature death, and suicide. Yet, the gap between youth mental health needs and available resources continues to widen. The demand for youth mental health services is at an all-time high. In Ontario, one-third of young people reported needing but not seeking mental health support in the last year, ² a longstanding trend^3,4 mirrored across Canada.^5–7 There has also been a sustained increase in mental health care use for children and youth in both the acute and ambulatory settings. ⁸

It is not just about numbers – the complex mental health needs among youth presenting for care adds strain on our limited mental health resources, particularly in terms of managing co-occurring conditions and associated functional impairment. While epidemiological studies suggest that up to 50% of youth may report symptoms meeting criteria for a mental health diagnosis, ⁹ approximately 30% require mental health services due to significant clinical impairment, ¹⁰ a number that has likely compounded post-COVID-19 (although emerging evidence suggests young females have been more adversely affected than young males).^11–15 This aligns with population-based cohort studies demonstrating that early (adolescent)-onset mental illness is associated with an elevated risk of developing additional mental health conditions over time.^16,17 While comorbidity, or evolution of clinical presentation over time, can reflect the natural course of illness over youth development, it can also be accompanied by greater impairment in cognitive, occupational and social domains, ¹⁸ thereby complicating clinical management. In tertiary care settings, preliminary data from the Toronto Adolescent and Youth (TAY) Cohort Study indicate that youth seeking mental health care meet criteria for an average of three different mental health diagnoses. Moreover, large numbers of mental health treatment-seeking youth participating in TAY report suicidal ideation, suicide-related behaviour and psychotic-like experiences, ¹⁹ an important predictor of suicide attempts in youth with psychopathology, ²⁰ further emphasizing the need to provide evidence-based care to reduce morbidity and mortality associated with mental illness in this population.

Addressing this challenge requires a multipronged and integrated approach – one that strengthens community-based mental health services for youth who can be supported in those settings, and ensures timely triage, access, and transitions to (and from) specialized services for those with more complex presentations. From studies focused on the mental health needs of youth with neurodevelopmental conditions to those with concurrent mood and substance disorders, this special issue in child and youth psychiatry underscores the need for a balanced investment in infrastructure for both primary prevention and provision of evidence-based mental health care, while fostering innovation and large-scale longitudinal research to address the current and future mental health needs of children and youth struggling with mental illness.

Starting with preschool and school-aged children, Longmore et al. ²¹ examine predictors of clinically elevated depressive symptoms, derived from parent-reported affective problems in their autistic children, finding that these symptoms are both prevalent and persistent. Leveraging the large Province of Ontario Neurodevelopmental Disorders (POND) Network (a multicentre collaborative research program including 11 sites across Ontario), this study uses data for 75 autistic youth with follow-up assessments carried out as part of the POND longitudinal substudy. The authors report that clinically elevated depressive symptoms at the first study visit (T1: average age 9.8 years) are the strongest predictor of clinically elevated depressive symptoms at the second study visit (T2), 4 years later. The authors also found that high levels of restricted/repetitive behaviours, loneliness, self-injury, suicidal ideation, psychotropic medication use, and attention deficit and hyperactivity disorder (ADHD) are all associated with an increased risk of elevated depressive symptoms at follow-up, while higher levels of social and adaptive skills are protective. The authors conclude that youth with unmet social needs may be more vulnerable to mood symptoms and that social participation could be protective. This study highlights the importance of early screening for mood symptoms, and the potential for interventions targeting social functioning and loneliness, to improve mental health outcomes in autistic youth. It also demonstrates the merit of a nuanced approach to understanding and treating co-occurring mental health conditions in neurodevelopmental and other complex conditions, the value of longitudinal data in clinical samples to evaluate risk trajectories, and the need for similar datasets.

Gober et al. ²² further demonstrate the importance of longitudinal data in their study on antipsychotic prescriptions in young children treated with stimulants for ADHD. Using administrative data from British Columbia, they found that stimulant use and concomitant antipsychotic prescriptions were more common in rural regions, where child and adolescent psychiatrists were scarce. In addition, children who began stimulant treatment before age 6, were at higher risk of requiring antipsychotic add-ons in adolescence, and nearly 4 times more likely to have developmental delay recorded in their medical file in close proximity to the time when the antipsychotic was added-on. Despite the limitations of administrative data, these findings may reflect reliance on medications for more severe behavioural challenges in under-resourced settings, and raise concerns about missed opportunities for early behavioural interventions, and inequities in access to care, particularly among children with more complex conditions (i.e., those with co-occurring ADHD and developmental delay). Given the limited evidence supporting antipsychotic use in ADHD,^23,24 and the risks of metabolic disturbance and polypharmacy from prolonged use, this study reinforces the pressing need for cohesive, multidisciplinary and equitably accessible services tailored to meet the needs of youth with complex conditions, and other vulnerable youth, to minimize harm, optimize functioning and improve prognosis.

Propp et al. ²⁵ report on pre/postintervention neuroimaging data in a pilot sample of school-aged (9–12 years) children with disruptive behaviour disorders that underwent an established group-based, 15-session parent and child behavioural intervention, targeting externalizing behaviours. As such interventions are less effective in children with higher callous-unemotional traits and emotional dysregulation, this study aims to explore the neurobiological overlap between these dimensions and whether neurobiological features within corticolimbic brain regions, which have been previously implicated in disruptive behaviour disorders, may be associated with psychosocial treatment response. Preliminary findings indicate that greater baseline thickness within corticolimbic regions (e.g., anterior cingulate cortex and insula) is associated with lower pretreatment callous-unemotional traits and emotional dysregulation, and that baseline brain features in this pilot sample are also associated with posttreatment conduct problem outcomes. This preliminary work provides an exemplar for embedding biological sampling within longitudinal child and youth mental health research. Increased efforts to harness this opportunity may drive innovation in biological targeting and personalization of mental health treatment, a particular need to develop novel treatment options for those who do not respond to conventional evidence-based treatment.

In their scoping review, Marshall et al. ²⁶ summarize the evidence for interventions targeting concurrent disorders in youth – a population where complexity is the norm. Historically, treatment of concurrent disorders has addressed mental health and substance use conditions in silos. Unsurprisingly, the literature remains limited in terms of the quantity, quality, and comparability of the studies. However, at least 1 randomized-controlled trial shows the positive effect of pharmacological intervention on the treatment of substance use disorders and concurrent depression, ²⁷ while several single-arm studies^28,29 demonstrate the utility of combining therapies for sustained recovery, such as a 12-step program, motivational interviewing, cognitive-behavioural therapy, and group therapy. Additionally, some studies suggest that family-based interventions improve outcomes,^30–32 despite variability in intervention and study population. Much like the need for tailored interventions for young children with ADHD, this review concludes that the most promising interventions for concurrent mental health and substance use disorders in youth require a multifaceted approach adaptable to the specific symptoms and substance use profiles contributing to impairment in a given youth, and that addresses both simultaneously. It also builds on existing evidence that family involvement, when appropriate, is important for positive treatment outcomes across adolescent mental health conditions. ³³

Hammond et al.'s ³⁴ population-representative study on adolescent self-harm disclosure and online help-seeking highlights this critical role of the family in child and youth mental health outcomes. Using data from the 2014 Ontario Child Health Study on adolescents aged 14 to 17, the study found no association between family dysfunction, positive parenting and disclosure of self-harm or suicidal ideation. However, when compared to keeping suicidal thoughts private, adolescents from more negative family environments are more likely to disclose suicidal ideation to a nonfamily member and to seek help online. By contrast, the family environment had no effect on self-harm disclosure, which the authors speculate may be due to the multiple functions of self-injurious behaviour (e.g., emotional regulation). Regardless of intent, any self-harm behaviour in youth is a strong predictor of suicide attempts, ³⁵ as is suicidal ideation^36,37; and both are markers of distress that warrant intervention. This study points to the delicate dynamics underlying family relationships and adolescent disclosure of self-harm and suicidal ideation.^38–40 While the family environment did not hinder disclosure necessarily, it also did not facilitate it, leaving potentially modifiable risk factors for suicide unaddressed, and a vital mechanism for support untapped. Furthermore, in the context of rising rates of self-harm and suicidal ideation among youth in both community ⁴¹ and acute care settings, ¹⁵ these findings expose the broader challenge of ensuring responsive and effective mental health care to reduce suicide risk and raise the potential to leverage scalable online resources for the provision of support.

Henderson et al. ⁴² provide an analysis of the Integrated Youth Services (IYS) model, an innovative treatment approach to scale mental health care for youth in order to meet the aforementioned increasing youth mental health needs. The IYS is designed as a centralized hub that provides mental health, substance use, and social services in a low-barrier, youth-friendly setting. While IYS has high client satisfaction, may improve initial access, and even help reduce costs, evidence of its effectiveness is still emerging. Some research indicates that youth with moderate to severe symptoms may experience longer wait times for specialized care through the IYS model, ⁴³ and other data suggests that its impact on functional and overall improvement may be limited. ⁴⁴ The analysis supports the expansion of the IYS model in Canada but emphasizes that not all youth populations had equal representation (e.g., youth with neurodevelopmental disorders) and that data on IYS as it applies to youth experiencing homelessness, in congregate living, and rural, remote, and Indigenous contexts is not available. Thus, as Henderson et al. conclude, ongoing evaluation of IYS is essential to ensure it fulfils the return on investment and delivers in accordance with its values of equity and inclusion. Finally, future research should explore how the IYS model or links between this model and specialized mental health services can be optimized to provide both timely and sustained improvements for youth with moderate to severe mental health challenges, with seamless transitions between community, primary, and specialized mental health care settings (e.g., hospital-based outpatient and inpatient care).

A recent Lancet Psychiatry commission on youth mental health ⁴⁵ warns that we have entered a “dangerous phase” of the youth mental health crisis, citing sweeping societal changes – environmental, political, and beyond – as contributors to the current crisis, which could have detrimental global impacts. In the context of such consequential effects, it is vital to focus on what we can change. Together, the studies in this issue provide a preliminary blueprint for the approach, innovation, and research necessary to meet the mental health needs of children, youth, and families, across different stages of development and conditions in Canada. Strengthening community-based services, improving access to evidence-based as well as specialized care for those who don’t respond to lower intensity or first-line intervention, and fostering large-scale research initiatives – embedded with biological markers and ongoing evaluation and adaptation – are essential steps towards meeting this objective. Longitudinal Canadian cohort studies are key to informing primary and secondary prevention efforts and tracking outcomes to inform care planning in Canada and beyond. For example, the Canadian Youth Mental Health Insight Platform, an informatics platform that will link data from community-based integrated youth service networks across Canada aims to create the data infrastructure to match youth to available services and inform data-driven policy. ⁴⁶ At the other end of the care spectrum, the TAY Cohort Study, will follow 1500 youth (age 11–24), presenting to a tertiary (hospital-based) mental health care setting, for 5 years. This study is collecting multiple time points of clinical/behavioural, cognitive, academic, familial, social, environmental, brain and blood markers and links with health administration and health system utilization, to characterize the developmental trajectories of psychosis spectrum symptoms, functioning and suicidality, and identify their outcomes and antecedents. ¹⁹ Such work is essential to discovering risk trajectories among youth with complex mental illness, who are at greatest risk for poor longitudinal mental health and functional outcomes and informing targeted treatment innovation approaches. Combined with youth and family engagement, these are just 2 examples of how data can inform the process of refining and reconfiguring specialty child and youth mental health services to meet the growing demands.

An important caveat is that the evidence-based, efficient and scalable service delivery that is needed to address the mental health needs of children and youth must also incorporate the foundational practices that define child and adolescent psychiatry. Comprehensive assessments that include developmental and family history, collateral information to understand the impact of mental health symptoms across settings, short-term follow-up or ongoing specialized care for those who don’t respond to intervention, and transitional programs that bridge the divide between child and adult services remain essential. Equally critical is the integration of family, school, and broader advocacy efforts into treatment – recognizing that youth mental health cannot be addressed in isolation from the systems that shape their daily lives. Addressing the structural and social determinants of health – such as poverty, racism, housing instability, and barriers to education – is sine qua non for achieving equitable mental health outcomes for Canadian youth. As we evolve our models of care to meet rising demand, we must remain grounded in these first principles of child and youth well-being.