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PLoS One
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10.1371/journal.pone.0310377
PONE-D-23-14369
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Impact of a collaborative model on community clinician confidence in child and adolescent mental health care, wellbeing, and access to child psychiatry expertise
A collaborative model to improve clinician confidence in child and adolescent mental health
D’Abaco Elise Writing – original draft 1
Khano Sonia Conceptualization Writing – original draft 2 3
Giles-Kaye Al Writing – original draft 2 4
Dhaliwal Jag Writing – original draft 5 ‡
https://orcid.org/0000-0003-3598-775X
Haslam Ric Writing – original draft 6 ‡
Prakash Chidambaram Writing – original draft 6 ‡
https://orcid.org/0000-0003-3017-2770
Hiscock Harriet Writing – original draft 1 2 3 7 *
1 Centre for Community Child Health, Royal Children’s Hospital Parkville, Melbourne, Victoria, Australia
2 Murdoch Children’s Research Institute, Health Services, Parkville, Melbourne, Victoria, Australia
3 Health Services Research Unit, Royal Children’s Hospital Parkville, Melbourne, Victoria, Australia
4 Melbourne Graduate School of Education, University of Melbourne Parkville, Melbourne, Victoria, Australia
5 North Western Melbourne Primary Health Network, Melbourne, Victoria, Australia
6 Mental Health, Royal Children’s Hospital Parkville, Melbourne, Victoria, Australia
7 Department of Paediatrics, The University of Melbourne, Parkville, Melbourne, Victoria, Australia
Moodley Saiendhra Vasudevan Editor
University of Pretoria, SOUTH AFRICA
Competing Interests: The authors have declared that no competing interests exist.

‡ These authors also contributed equally to this work.

* E-mail: harriet.hiscock@rch.org.au
23 9 2024
2024
19 9 e031037715 5 2023
29 8 2024
© 2024 D’Abaco et al
2024
D’Abaco et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Background

The COVID-19 pandemic was associated with an increase in child and adolescent mental health disorders, with subsequent worsening of patient access to specialist mental health care. Clinicians working in the community were faced with increased demands to diagnose and manage pediatric mental health disorders, without always having the confidence and knowledge to do so. We therefore developed COnnecting Mental-health PAediatric Specialists and community Services (COMPASS)—a collaborative model designed to upskill community clinicians in child and adolescent mental health care and provide them with better access to child and adolescent psychiatry expertise. COMPASS comprises (1) an online Community of Practice (CoP) with fortnightly one-hour sessions covering: anxiety; aggression and challenging behaviours; depression; self-harm and suicidality; eating disorders; and autism spectrum disorder/complex cases and (2) primary and secondary consultations for general practitioners and paediatricians with an experienced child psychiatrist. We aimed to assess the impact of COMPASS on community clinician self-reported confidence in: managing common child and adolescent mental health disorders (Objective 1, primary outcome); navigating the mental health care system (i.e. knowing how services are organised, accessed, and how to refer patients, Objective 2); diagnosing conditions (Objective 3); prescribing psychotropic medications (Objective 4) as well as the impact on, clinician practice and wellbeing (Objective 5) and outcomes of patients referred by COMPASS clinicians to the child psychiatrist (Objective 6).

Methods

We evaluated COMPASS in its first year, with COMPASS running from March to July 2021. Participating clinicians completed pre-post surveys evaluating change in Objectives 1 to 4 above, using study-designed measures. A purposive sample of clinicians was then invited to a semi-structured interview to understand their experience of COMPASS and its impacts on practice and wellbeing (Objective 5). We adopted an inductive approach to the qualitative analysis using the Framework Method. This involved selecting five random transcripts which were double coded and categorized, to generate an initial framework against which all subsequent transcripts were analysed. Themes and subthemes were generated from the data set, by reviewing the matrix and making connections within and between clinicians, codes and categories One child psychiatrist completed a 2-week logbook of the nature and outcomes of primary and secondary consultations (Objective 6).

Findings

51 (86%) clinicians attended CoP sessions and completed pre-post surveys, with 92% recommending COMPASS to peers. Clinicians reported increased confidence in the pharmacological and non-pharmacological management of all conditions, most notably for management of self-harm. They also reported increased knowledge of how to navigate the mental health system and prescribe medications. Qualitative analysis (n = 27 interviews) found that COMPASS increased clinician wellbeing and reduced feelings of professional isolation and burnout. Over the 2-week snapshot, the child psychiatrist consulted on 22 patients and referred all back to the community clinician.

Conclusions

COMPASS is associated with improved clinician confidence to manage child and adolescent mental health concerns, navigate the mental health system, improved clinician wellbeing, and reduced need for ongoing mental health care by specialists.

The author(s) received no specific funding for this work. Data AvailabilityAll relevant data are now available in a public repository with the following name and link: File name: COMPASS survey data- 22-08-24 https://figshare.com/s/a0ecdf991e56bbffa8a4.
Data Availability

All relevant data are now available in a public repository with the following name and link: File name: COMPASS survey data- 22-08-24 https://figshare.com/s/a0ecdf991e56bbffa8a4.
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pmcIntroduction

Mental disorders are a leading cause of morbidity in children and young people, worldwide [1]. One in seven 10-19-year-olds experience a mental health disorder, accounting for 13% of the global burden of disease in this age group [1]. Similarly, in Australia, 14% of children aged 4–17 years of age meet the criteria for a mental health disorder over a 12-month period [2,3]. Mental health disorders are associated with adverse impacts on child function and wellbeing, including reduced social engagement [4], school refusal [5] and educational under-achievement [6]. Left untreated, disorders can persist into adulthood [6,7]. As such, childhood provides an important opportunity for early intervention.

To provide early intervention, a healthcare system needs to have services that are accessible to children and a workforce that is suitably trained to provide pediatric mental health care and navigate access to specialist care when required. This is not the status in Australia. Two recent inquiries—the Royal Commission into Victoria’s Mental Health System and the National Mental Health Commission—identified systemic issues impacting access to mental health care for children and adolescents [8,9]. These include a lack of service capacity, inequitable access to care (including reduced access in rural areas) and limited focus on the early years, meaning that young children often miss out on the care they need [10]. Further, system access is increasingly driven by crisis, with emergency departments being used as entry points [11]. The COVID-19 pandemic has exacerbated this issue [12].

The provision of clinical care for mild to moderate child and adolescent mental health conditions in Australia sits primarily with community-based clinicians [2]. General practitioners (GPs) are the most accessed clinicians for mental health presentations (35%), followed by psychologists (23.9%), paediatricians (21%) and counsellors (20.7%) [2]. However, many community clinicians report they have inadequate training in pediatric mental health and require more professional development opportunities to improve their confidence in diagnosing and managing child and adolescent mental health conditions and to navigate the complex mental health system [13]. We previously interviewed 143 child and adolescent psychiatrists, pediatricians, child psychologists and general practitioners to understand their perspectives on problems and solutions for the Australian pediatric mental health system. Clinicians reported problems with service fragmentation, long wait times, and for GPs and pediatricians—inadequate training in child and adolescent mental health [13]. Solutions included increased access to child psychiatry expertise, mental health training, and co-located multidisciplinary services. A Community of Practice (CoP)—whereby community-based clinicians learn from an expert–could operationalise some of these proposed solutions by increasing access to child psychiatry (the expert) and providing mental health training and knowledge about how to navigate the system. CoPs are “groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly” [14]. CoPs can increase productivity, clinician connectedness and provide evidence-based practice [15–18]. Other models to improve access to child psychiatry expertise and provide mental health training include primary and secondary specialist mental health consultations to referring clinicians with the aim of providing timely assessments and advice and return of the client to the referring clinician where possible. The Massachusetts Child Psychiatry Access Program (MCPAP) is an example of such a model [19–22]. It operates at a regional level, providing access (telephone, face-to-face) to child psychiatrists for primary care pediatricians as well as education modules for common mental health conditions. It has been shown to increase primary care providers self-reported ability to meet the needs of psychiatric patients from 8% to 63% [22].

However, few such models exist in Australia and none, to our knowledge, have been evaluated. Further, it is unknown whether such models impact clinician wellbeing or if they are associated with a reduction in referrals to specialist services. Co-designed with community clinicians in January 2021, this study aimed to expand on previous research by implementing and evaluating a model to improve community clinicians’ confidence in the diagnosis and management of common child and adolescent mental health conditions, how to navigate the system, and increase their access child psychiatry expertise, on a background of increasing demand during the COVID-19 pandemic. The COnnecting Mental-health PAediatric Specialists and community Services (COMPASS) collaborative model consists of a multi-disciplinary online Community of Practice (CoP) and primary and secondary consultations for referring GPs and paediatricians with experienced child psychiatrists. COMPASS was developed in partnership with the regional primary care network, local clinicians, and the local child and adolescent mental health service. Now in its third year, the primary care network provides funding for the CoP administration (participant registration, conduct of the CoP sessions, emailing of resources to participants after each session), with the mental health service providing funding for the child psychiatrist.

Using clinician pre-post surveys, in-depth interviews and child psychiatrist consultation data, we aimed to determine whether COMPASS could increase clinician self-reported confidence in: managing common child and adolescent mental health disorders (Objective 1, primary outcome); navigating the mental health care system (i.e. knowing how services are organised, accessed, and how to refer patients, Objective 2); diagnosing conditions (Objective 3), prescribing psychotropic medications (Objective 4) as well as the impact on clinician practice and wellbeing (Objective 5) and outcomes of patients referred by COMPASS clinicians to the child psychiatrist (Objective 6). If effective, COMPASS could offer an acceptable way to improve capacity of community clinicians to provide pediatric mental health care, navigate the mental health system and improve their access to child psychiatry expertise. This in turn could reduce the burden on overloaded specialist mental health services and provide policy makers with scalable solutions to improve workforce capability.

Materials and methods

Recruitment of participants

Recruitment occurred through a partnership with the North Western Melbourne Primary Health Network (NWMPHN), in the state of Victoria, Australia. Local GPs, paediatricians, and Mental Health (MH) clinicians from the metropolitan area of the NWMPHN were recruited through a NWMPHN broadcast email and personal emails from the senior author (a paediatrician). Participants were eligible to take part in the COMPASS model if they were working in the NWMPHN region and providing care to paediatric patients (0–18 years) with mental health concerns. We received interest in participating from 80 clinicians, of whom 75 were eligible and formally invited to take part in COMPASS.

Co-development of the CoP

Clinicians attended up to two, one-hour co-development sessions in February 2021 to develop the content and structure of the CoP sessions. The first session focused on the key conditions clinicians wanted training in and how, with clinicians selecting common conditions that they saw in their clinical practice and opting for expert summaries on diagnosis and management followed by a case discussion. The second session focussed on how the CoP would run e.g. duration of the CoP sessions, when to conduct them (i.e. choice of during and after hours), and preferred virtual conferencing platform.

Delivery of the CoP sessions

Over a five-month period (March to July 2021), 10 fortnightly CoP sessions were delivered to participating community clinicians via an online videoconferencing platform (Zoom©). CoP sessions focused on five key areas: 1) anxiety; 2) aggressive and challenging behaviours; 3) depression, suicidal ideation and self-harm; 4) eating disorders; and 5) complex MH disorders (e.g. autism spectrum disorder). Each session included a didactic teaching lecture on the assessment and then the management of the condition(s) led by the senior child psychiatrist, followed by case-based discussions led by a general practitioner facilitator. After each session, the NWMPHN collated and shared resources with clinicians including screening and assessment tools and evidence-based treatment guidelines. Participating clinicians were encouraged to submit a case study for each session, to discuss aspects of assessment, referral, and management with the multidisciplinary group. Fifty-nine of the 75 eligible clinicians who registered to take part in the CoP attended at least one session, with 60% of clinicians attending more than 5 of 10 sessions (see S1 Appendix).

Child psychiatry consultation service

In addition to the CoP sessions, the child psychiatrist provided further support to participating clinicians through a consultation service, funded by the Royal Children’s Hospital, Melbourne. The child psychiatrist was available by phone, email, or clinic appointments to provide GPs and paediatricians with medication advice, diagnostic, assessment, management, or referral options for their patients. The service was promoted via the NWMPHN network communications including their website and newsletters.

Data collection

To assess Objectives 1 to 4, we conducted pre- (see S2 Appendix) and post-CoP (see S3 Appendix) online surveys. Clinicians who expressed interest in completing an interview in the pre-survey and attended two or more CoP sessions, were eligible for interview (see below). Interviews aimed to understand clinicians’ perceptions of COMPASS and its impact on their wellbeing (Objective 5). We chose qualitative interviews as a methodology to gain a richer, more in-depth understanding of clinician perspectives than that provided by survey data.

The child psychiatrist completed a study-designed logbook to record the nature and outcomes of their consultations over a two-week period (Objective 6).

Pre-post surveys

Clinicians were sent pre and post online surveys with two reminders through REDCap, a secure, web-based application for building and managing online surveys and databases, developed by Vanderbilt University [23,24]. All clinicians were sent the pre survey one month prior to the commencement of the CoP and the post survey one week following the last CoP session. Pre- and post-surveys included demographic items (pre-survey only) including clinician age, gender, years of practice etc (see Table 1) and confidence in pharmacological and non-pharmacological management of the specific conditions covered in the CoP (Objective 1). Surveys also asked about knowledge of how mental health services are organised and how to access and refer to them (Objective 2), overall confidence in diagnosing mental health conditions (Objective 3), and confidence (where relevant) in prescribing first line and second/third line psychotropic medications (Objective 4). For all these variables, clinicians were asked to respond separately for child versus adolescent mental health as we hypothesised that clinicians would be less familiar and confident with child versus adolescent mental health care.

10.1371/journal.pone.0310377.t001 Table 1 Demographic characteristics of clinician participants (n = 59).

Characteristic	Number, %	
Clinician gender		
    Female	50 (84.7)	
    Male	9 (15.3)	
Clinician role		
    General Practitioner	19 (32.2)	
    Psychologist	19 (32.2)	
    Paediatrician	11 (18.6)	
    Social Worker	4 (6.8)	
    Mental Health Nurse/Clinician	4 (6.8)	
    Occupational Therapist	2 (3.4)	
Duration of practice		
    Less than 6 years	18 (30.5)	
    6 to 15 years	21 (35.6)	
    More than 15 years	20 (33.9)	
Number of clinical sessions per week		
    Less than 6	16 (27.1)	
    6 to 10	32 (54.2)	
    More than 10	11 (18.7)	
Paediatric patients seen per week		
    Less than 11	28 (47.5)	
    11 to 20	18 (30.5)	
    More than 20	13 (22)	
Formal training in Paediatric Mental Health		
    Yes	18 (30.5)	
    No	41 (69.5)	

Clinicians were asked to rate their responses on a study-designed 4-point Likert scale we have previously used with GPs [23], ranging from “not at all confident”, “not very confident”, “fairly confident”, to “completely confident”. Clinicians could also nominate “not part of my role” (e.g. for psychologists who do not prescribe medications). Confidence options were then grouped into two categories: “not confident” (comprising “not at all confident” and “not very confident” responses) versus “confident” (comprising “fairly confident” and “completely confident” responses), as per our previous research [25]. The post survey also asked clinicians to rate their feedback of the model and whether they would recommend it to peers.

We used simple statistics (e.g. proportions, means, standard deviations) to describe clinician sample demographics. A McNemar test, with alpha set at 0.01 to allow for multi comparisons, was performed to calculate the change in dichotomised confidence scores in the relevant variables for children and adolescents separately, across pre and post time points. We considered changes with a p value of 0.05 or less to be statistically significant. Where applicable, responses to “not part of my role” were excluded from analysis. All quantitative analyses were conducted in Stata 16 (StataCorp LLC, College Station, TX, USA).

Clinician interviews

To address Objective 5, eligible clinicians were invited to take part in a qualitative interview with an independent researcher (ED). Interested clinicians were sent an email containing the participant information form (S4 Appendix) and an online link to book a telephone interview time. The researcher telephoned participants to explain the study, confirm eligibility, obtain verbal consent, and conduct the interview. Qualitative interviews were undertaken with the support of an interview guide (S5 Appendix) that allowed flexibility to explore participants experiences and perspectives. Interviews were audio recorded and transcribed verbatim by a secure online transcription service (Rev©) and cleaned by researchers ED and AG-K. Transcripts were then coded for analysis within NVivo version 15 Analysis Software (QSR International Pty Ltd., Cardigan, UK). Clinicians were offered the opportunity to review their interview transcript, however none did so.

We adopted an inductive approach to the qualitative data analysis, using the Framework Method by Gale et al. [26] which sits within the broader methodological framework of content analysis [27]. Content analysis was chosen to systematically organise data into a structured matrix, which addressed the key aims of the study. Themes and subthemes were generated from the data set by reviewing the matrix and making connections within and between participants, categories, and codes. All transcripts were coded to the framework matrix, although data saturation was reached after coding approximately half of the transcripts. E.D and A. G-K. undertook fortnightly meetings to resolve coding discrepancies and track coding decisions. They also completed journaling activities during the data collection and analysis phase to reflect on personal biases and preconceptions, as well as their relationship to participants, and how this may impact the research outcomes. Additional strategies to ensure rigor of the qualitative analysis, such as member checking and triangulation, were not able to be completed due to time constraints of the study.

Child psychiatrist logbook

To address Objective 6, the child psychiatrist maintained a logbook over a two-week period, recording the nature of the primary and secondary consultations delivered and resulting outcomes (S6 Appendix). We summarise these findings using descriptive statistics.

Ethical aspects

Ethics approval was granted by the Royal Children’s Hospital Human Research Ethics Committee (HREC 73998/ QA 73663). Due to the low-risk nature of the surveys, participants’ completion of the surveys was approved as implied consent. To ensure confidentiality, any information that connected participant contact details to their online survey was stored securely and separately on a password protected computer and only accessed by SK.

During qualitative interviews, informed consent was sought whereby participants were informed that their participation was voluntary and unpaid and verbal consent was sought over the phone by ED. Several steps were taken to ensure confidentiality of participants. Identifying details were removed from the recordings and transcripts, and participants were given an ID number. Electronic data, including interview recordings and transcripts, were stored on the network drive on a password protected computer. At the conclusion of the study, all identifying participant data was destroyed and final study data was stored in a non-identifiable format.

Results

Online community of practice (CoP)

Sample characteristics

Fifty-nine participants (19 GPs; 19 psychologists 11 paediatricians; 4 MH nurses; 4 social workers; and 2 MH occupational therapists) registered their interest to take part and attended at least one CoP session and 51 (86%) participants completed both pre and post surveys. Table 1 provides a summary of baseline sample characteristics.

Objective 1: Managing mental health conditions

Overall, clinicians reported increased confidence in non-pharmacological (Fig 1) and pharmacological (Fig 2) management of MH conditions in both children and adolescents. Increases were greatest for non-pharmacological management of self-harm (children: 35.6% to 74.5%; adolescents: 52.5% to 76.5%) and suicidal ideation (children: 32.2% to 58.8%; adolescents: 45.8 to 68.6%), respectively.

10.1371/journal.pone.0310377.g001 Fig 1 Change in clinician reported confidence in non-pharmacological management of MH conditions for children and adolescents (n = 51).

Note, * = <0.05, ** = <0.001. CH = Children; ADOL = Adolescents; AGG = Aggression/challenging behaviours; ANX = Anxiety; CD = Conduct disorder; DEP = Depression; ED = Eating disorder; OCD = Obsessive compulsive disorder; ODD = Oppositional defiant disorder; PTSD = Post-traumatic stress disorder; SELFH = Self-harm; SUI = Suicidality.

10.1371/journal.pone.0310377.g002 Fig 2 Change in clinician reported confidence in pharmacological management of MH conditions for children and adolescents (n = 31).

Note, analyses only include clinicians who reported prescribing as part of their professional role * = <0.05, ** = <0.001. CH = Children; ADOL = Adolescents; AGG = Aggression/challenging behaviours; ANX = Anxiety; CD = Conduct disorder; DEP = Depression; ED = Eating disorder; OCD = Obsessive compulsive disorder; ODD = Oppositional defiant disorder; PTSD = Post-traumatic stress disorder; SELFH = Self-harm; SUI = Suicidality.

Objectives 2, 3 and 4: Confidence in navigating the mental health system, diagnosing conditions, and prescribing psychotropic medication

For children more so than adolescents, clinicians reported improved confidence in knowing how MH services are organised, how to access services, how to diagnose problems, refer to services, and where relevant, prescribe psychotropic medication (see Table 2). However, post COMPASS, only one half to a third of clinicians felt confident in prescribing first-line (increase from 32.2% to 53%) and second/third line psychotropic medications (13.6% to 37.2%), respectively.

10.1371/journal.pone.0310377.t002 Table 2 Change in clinician confidence in knowing how to navigate mental health services, diagnose, and prescribe psychotropic medications.

Note, where applicable, responses to “not part of my role” were excluded from analysis.

	Children
	Adolescents	
	Pre
n = 59 (%)	Post
n = 51 (%)	P value	Pre
n = 59 (%)	Post
n = 51 (%)
	P value	

How mental health services are organised	
40 (67.8)	
41 (83.3)	
0.07	
50 (84.7)	
46 (90.2)	
0.36	
How to access mental health services	44 (74.6)	46 (90.2)	0.02	50 (84.7)	47 (92.2)	0.20	
How to diagnose a mental health condition	40 (67.8)	40 (78.4)	0.31	42 (71.2)	43 (84.3)	0.03	
How to refer for mental health support	41 (69.5)	46 (90.2)	0.002	50 (84.7)	46 (90.2)	0.20	
Prescribe first-line psychotropic medications	19 (32.2)	27 (45.7)	0.001	26 (44.1)	29 (49.1)	0.04	
Prescribe second and third-line psychotropic medications	8 (13.6)	19 (32.2)	0.001	11 (18.6)	20 (33.9)	0.006	

Objective 5: Understanding impact of COMPASS on clinician practice and wellbeing

Sample characteristics for qualitative interviews

Overall, 27 eligible clinicians from the 59 clinicians who attended the CoP sessions expressed interest in completing an interview of whom one declined to be involved and five failed to book an interview time despite three reminder notifications. Reasons for non-participation were not ascertained. Twenty-one interviews were completed. Interviews lasted between 12 to 48 minutes. The sample included 5 GPs, 4 paediatricians, 12 psychologists and mental health workers; most were female (n = 18). Clinicians had high rates of attendance at the CoP, (40% attending 8 or more sessions) and were clinically experienced with 42% having worked for more than 15 years.

Summary of themes and subthemes

Analysis of the interview transcripts generated important themes presented below with representative quotes (Table 3). Quotes have been truncated where necessary without changing the meaning. This is represented by an ellipsis. Words which have been added to quotes by the researchers, to clarify meaning, are contained in square brackets.

10.1371/journal.pone.0310377.t003 Table 3 Quotes representing theme 1: Experience of the CoP and areas for improvement.

Sub-Theme	Experience of the CoP	Areas for Improvement	Participant Derived Solutions	Illustrative Quotes	
Program Structure, Content and Delivery	Structure
Access to psychiatry expertise and consultation liaison service	
More opportunities for reflective practice	
Use of structured teaching cases	
“… it’s good to have a child psychiatrist there because you know, often it’s really difficult to access specialists… that’s been really helpful” (Mental Health Social Worker 2)
"I think that the teaching cases would have facilitated a lot more discussion… [rather than] de novo cases… [using] two or three questions that were common across every session, that draw out the kind of critical pathways in care and management of a child and their family… using pre-prepared case studies to sort of illustrate that " (Psychologist 18)
	
Content
Lectures on eating disorders interesting and clinically relevant	
Over-emphasis on pharmacological treatment	
More content on psychological therapeutic models, referral avenues for families in crisis	
“I’m a psychologist… not a medic. . .a lot of the educational content was very geared towards medical colleagues who, you know, are in the business of deciding what and when to prescribe” (Psychologist 18)
“… it would have been nice had it been more around the combination of therapy and medication… there weren’t any new therapeutic models discussed” (Mental Health Social Worker 3)
	
Delivery
Online format convenient and enabled regular attendance
Resources provided were extremely useful	
Online format a barrier to group discussion and cohesion	
Offer virtual and in person options
Clear rules for online engagement	
“I know we are supposed to be there with our big ears on and (laughter) watching intently, but you know, at 6.30pm with three kids, it’s a bit tricky…” (General Practitioner 11)
“I’ve been doing Telehealth during lockdown, so you get a little bit desensitized and check out a little bit” (Psychologist 14)
“… the content is constantly evolving… so to get that kind of information all put together at the end of the webinars was really good… because there is some stuff that I probably wouldn’t have come across in my day-to-day work” (Paediatrician 17)	
Multi-Disciplinary Model	Enabled professional connections
Insight into skill set and knowledge base of other clinicians	Address factors impacting group dynamics (i.e., group size, professional mix, clear rules for online engagement)	Facilitation to actively manage group dynamics
Smaller online groups
Clinician specific breakout groups
	“… I’m a psychologist… so being able to hear from say paediatricians and GPs and other people who work with the same client group… but in different ways… I found that really interesting” (Psychologist 12)
“… people who already work with a lot of mental health issues, have a fairly good understanding around DSM criteria… the tricky thing was to understand where those gaps in knowledge were, especially for GP. . . being a mixed group. . .’ (Paediatrician 17)
"… so, in our session, there were a couple of very dominant voices. Um, and I just got the sense sometimes that there are people with some such expertise in that room that we weren’t hearing from. . ." (Psychologist 18)
“[It was] unclear whether to. . . put a comment in the chat room… whether it’ll be picked up there or wave your hand or, um, or just jump in. . .probably those housekeeping rules need to be mentioned each time? Like, you know. . . please put your hand up" (General Practitioner 6)	
Demand and Sustainability	High demand amongst community paediatricians	Sessions too frequent
After hours timing a barrier to attendance	Monthly rather than fortnightly
Flexible timing of sessions	"I do hope that it can continue… having that connection with other people in this field is really good for me…" (Psychologist 12)
"A lot of the paediatricians… couldn’t even get their names on the list… I know that amongst our practice of about 15 paediatricians, there was only myself and participant 10. . .and the interest in amongst our group was a lot of higher than that…” (Paediatrician 17)	

Theme 1: Experience of the CoP and areas for improvement

Subtheme: Program structure, content and delivery

The structure of sessions, including both didactic teaching and case-based discussion, was generally well received by clinicians from all professional backgrounds. Clinicians also valued access to tertiary level expertise through secondary consultation. Case presentations were found to be intellectually stimulating and generated collaborative discussion. However, some clinicians felt case presentations were under-utilized or were overly complex, which narrowed the discussion. Topics covered in the sessions were described as clinically relevant, particularly the presentation on eating disorders, which was felt to achieve a good balance between medical and psychological models of care. Teaching on psychopharmacology was interesting for those with both medical and non-medical backgrounds. However, a recurrent theme in the analysis was that the content had an over-emphasis on a medical approach to assessment and management of mental health conditions. Clinicians also requested more content on psychological therapeutic models of care, and avenues to support families in crisis.

There were differing views amongst clinicians about the delivery of the CoP via an online videoconferencing format. Many reported that virtual delivery enabled better attendance but had a negative impact on group dynamics. The after-hours timing (requested in the co-development sessions by GPs) was a significant barrier to attendance, with some citing competing commitments or fatigue at the end of the working day as key factors. Overall, clinicians requested greater flexibility regarding timing of sessions. Resources provided through the CoP, including session recordings, lecture slides, and case summaries, were universally well received. Clinicians reported that they supported self-directed learning and shared the resources with colleagues.

Subtheme: Multidisciplinary model, group dynamics and facilitation

Clinicians reported that the multi-disciplinary aspect of the CoP was felt to be extremely valuable, but also presented some challenges. Clinicians across all professional groups felt they gained important insights into the skill set, knowledge base, case load and difficulties faced by others working in the field of child mental health. Clinicians disclosed that the multi-disciplinary group also enabled them to expand their professional networks and obtain peer support. However, some clinicians thought the didactic teaching assumed gaps in knowledge, that were present for some but not for others. Possibly the multi-disciplinary nature of the model, while helpful in many respects, at times made it difficult to meet the specific learning needs of each clinician group.

Facilitation was described as an important mechanism to moderate group discussion and dynamics. Participants stated that, at times, inadequate management of the group dynamic led to unequal contributions from some individuals, or exclusion of some clinician groups. The group dynamics were also felt to be adversely impacted by technology and the absence of clear rules for online engagement. Most clinicians expressed frustration that others would contribute to discussions without introducing themselves or providing their professional background making it difficult to build group cohesion, develop connections and understand the context of comments made. Clinicians also reported that the videoconferencing format also made it difficult to perceive non-verbal communication cues and worked as a barrier to making spontaneous comments or asking questions. Some clinician suggestions included the use of smaller, online breakout groups to foster stronger group cohesion.

Subtheme: Demand and sustainability

Clinicians generally reported that their involvement in the CoP was worthwhile, and they looked forward to the sessions. Despite some challenges, many described the multi-disciplinary approach as timely, particularly for solo practitioners. A high demand for involvement was reported amongst paediatricians, who are currently the main prescribers of psychotropic medications for this patient population. Clinicians expressed a hope the CoP would continue, as it gave them a sense that teamwork was possible in the future. Many felt that monthly sessions, rather than fortnightly would support more sustained engagement.

Theme 2: Change in clinical practice

Subtheme change in knowledge, assessment and management

Table 4 summarises themes relevant to change in clinical practice. Clinicians described a broadening of clinical knowledge in several key areas of child and adolescent mental health, particularly the principles guiding pharmacological management. Discussions also challenged perceptions of prescribing psychotropic medications in younger patients. Participants provided positive feedback on the sessions which covered assessment and management of eating disorders and self-harm/suicidality. Secondary consultation was accessed outside of CoP sessions, by diverse clinician groups and was found to be associated with a significant, positive impact on patient management. Clinicians provided examples where access to psychiatry expertise expedited patient management, reduced referrals, provided additional management options, supported continuity of care and professional development.

10.1371/journal.pone.0310377.t004 Table 4 Quotes representing theme 2: Change in clinical practice.

Sub-Theme	Examples	Illustrative Quote 	
Change in Knowledge Assessment and Management	Increased knowledge of
pharmacological management of child mental health conditions
Assessment of medical instability in anorexia nervosa and criteria for admission
Risk assessment of self-harm/suicidality
Lowered threshold for trial of SSRI and titration to maximal dose 	“From talking to the other member of the Community of Practice, medication seems to be much more widely used… that I thought it was” (General Practitioner 19)
“We learned a little bit more about the assessment of the severity [of anorexia nervosa]… and when you need to sort of put them in hospital… blood pressure and heart rate… how much they have lost and how quickly… those specific assessment questions were quite helpful” (Counsellor 9)
“I take shortcuts in trying to come to a formulation, and I think what these Community of Practice sessions have done is made me re-evaluate… going back and being absolutely diligent… in a really thorough history” (Paediatrician 17)
“I think following the depression series I probably have been a bit more proactive in treating younger people for depression…” (General Practitioner 11)
"… that access to Psychiatrist 1 and Psychiatrist 2 has just been immense because it’s getting an answer… what am I going do for this patient this week to make a difference? Rather than, like I said, just stringing a patient on, um, and putting them on a long wait list of somebody else to, to sort it out… [it] gave me an instant solution, so that was good" (Paediatrician 15)
	
Patient Advocacy and Communication	Promotes clinically relevant communication between clinicians
Improved communication with families	“I feel like I’ve got a better understanding… if I get a referral… I really have a good understanding of their knowledge now… it actually has helped as far as you know reporting back… what needs to go in the reports” (Psychologist 16)
"… to prepare [patients]… so that they can ask questions about the potential side effects and what the medication is for… I think lots of people feel disempowered around that… " (Psychologist 20)	

Subtheme: Patient advocacy and communication

Clinicians reported that the CoP promoted more clinically relevant communication between colleagues and that increased knowledge also translated to improvements in communication with families, patient advocacy, and care. This was often reported amongst psychologists, particularly with respect to medication management.

Theme 3: Impact on clinician wellbeing

Subtheme: Reduced feelings of isolation, stress and stigma

Table 5 summarises themes relating to clinician wellbeing. Clinicians described how the multi-disciplinary model enabled them to form peer support networks, which lessened feelings of isolation and reduced the stigma of struggling to manage challenging patient presentations. Medical practitioners working in a private practice setting expressed that this aspect of the CoP was highly valued. The CoP helped some clinicians reflect on the impact of challenging patients on their own mental health. In addition, the CoP provided solutions through increasing awareness of services available for complex case management. Participants reported that this promoted a sense of shared responsibility for patient care and helped to manage clinician stress and burnout.

10.1371/journal.pone.0310377.t005 Table 5 Quotes representing theme 3: Impact on clinician wellbeing.

Sub-Theme	Examples	Illustrative Quote 	
Reduced Feelings of Isolation, Stress and Stigma	Formation of peer support networks
Reduced stigma of struggling to manage challenging cases
Secondary consultation alleviated stress	“I think for a lot of us working in the community it can be, you know, depending on our roles, it can be a bit isolating at times, in terms of how much contact we have with other professionals. So that’s probably the part that I liked the most about it. . ." (Psychologist 8)
“…. [it’s] comforting to know that you’re not the only one that struggles with really challenging clients” (Counsellor 9)
“… knowing that there was a consultant psychiatry service that we could ring for advice… if I get really stuck again, I have got a few other options to consider…" (Paediatrician 5)
“… it really wasn’t clear to me… until I’d actually referred on… how much responsibility I was taking on… how much that was impacting me, even outside of work… just that mental space I didn’t have… I was constantly worried and thinking about this person” (Psychologist 8) 	
Increased Clinician Confidence	Increase in clinician confidence with improvement of knowledge and validation of clinical practice 	“. . . since getting to know [Psychiatrist 1] better through, um, the Community of Practice, I’ve been much more open to the idea of managing my own patients" (Paediatrician 17)
" I think it’s probably reassured me that when my complexity radar goes off, that that’s real and to trust it. Because everybody’s radar would have gone off in a similar way… " (Psychologist 18)
	

Subtheme: Increased clinician confidence

Most clinicians, across all professional groups, reported an increase in confidence associated with validation of their current clinical practices. Clinician confidence also increased with acquisition of knowledge and access to support via secondary consultation. This was noted particularly amongst paediatricians.

Secondary consultation service

Over a two-week logbook maintained by one of the child psychiatrists, 22 clinicians (5 GPs and 17 paediatricians), accessed the consultation service. Consultations included phone (n = 9), email (n = 3) and in-clinic appointments (n = 10) requesting medication (n = 12) and diagnostic advice (n = 10). All consultations resulted in the patient being referred back to the clinicians therefore avoiding potential further referrals to the tertiary Child and Adolescent Mental Health Service (CAMHS).

Discussion

We aimed to determine whether the COMPASS model was associated with increased community clinician self-reported confidence in: Managing common child and adolescent mental health disorders; navigating the mental health care system; diagnosing conditions; prescribing psychotropic medications as well as the impact on clinician practice and wellbeing and outcomes of patients referred by COMPASS clinicians to the child psychiatrist. We found increased community clinician confidence in diagnosis and management of common paediatric MH conditions, how to navigate the mental health care system, and reduced need for ongoing tertiary mental health care. Overall, benefits were greatest for non-pharmacological management of self-harm and suicidal ideation in both child and adolescent mental health conditions. These findings were reflected in the qualitative analysis, with clinicians providing numerous examples where content from the CoP sessions was used to guide patient management and care. Furthermore, the qualitative analysis found that the COMPASS model improved communication with colleagues, patient advocacy, supported clinician wellbeing and reduced feelings of professional isolation and burnout. This is likely to improve clinical care for paediatric patients.

Whilst there were many positive outcomes of COMPASS, the multi-disciplinary aspect of this model came with challenges which need to be anticipated and planned for, if the model is to function well in future iterations. The importance of effective facilitation in managing group dynamics is key, and benefits from including facilitators with clinical experience and from a variety of professional backgrounds. Groups should also have an equal representation of participants from various clinical disciplines to ensure greater cohesion. A co-design process, along with frequent feedback and structured teaching cases may ensure a more inclusive curriculum, so that the learning needs are met for all professional groups. The aims of COMPASS, as a non-hierarchical, shared learning experience should be clearly articulated, so that participants set appropriate expectations around their involvement. Effective use of the videoconferencing platforms, such as breakout rooms, the chat function, and guidelines for online engagement, may encourage greater participation across clinician groups. Future COMPASS sessions may need to be offered both in person, and online to meet clinician preferences.

To our knowledge, this is the first such evaluation of an Australian model designed to upskill community clinicians. Whilst previous models have been implemented to upskill clinicians in paediatric mental health, few have been evaluated. The MCPAP allows enrolled primary care providers to get assistance for children in their care [28] including in-person psychiatric or clinical assessment, transitional therapy, and/or facilitated linkage to community resources. The program does not directly upskill community clinicians however, a retrospective analysis of survey data from primary care clinicians utilising MCPAP over 3.5 years, found a greater proportion of clinicians were able to meet the mental health needs of their patients (from 8% to 63%), suggesting some indirect upskilling of clinicians [22].

There is evidence to support the use of CoP models to upskill community clinicians in providing mental health care for children. Project TEACH is a pediatric specific, community-based intervention that shares key components of the COMPASS model: secondary consultation from tertiary specialists and structured education [29,30]. However, this program was targeted specifically to primary care practitioners, and was not truly multi-disciplinary in nature. Project TEACH was delivered to 139 primary care clinicians in New York, and included four 3-hour evening core educational sessions, access to secondary telephone consultation and referral support [29]. Results of a qualitative study (n = 30), found that clinicians reported greater confidence communicating with families, assessing severity of mental health presentations, prescribing medication, and developing management plans [29]. Participation in Project TEACH was also reported to strengthen relationships with MH specialists, reduce barriers to seeking advice and generally helped them work with the mental health system in a more integrated manner [26]. The multi-disciplinary nature of COMPASS meant that professional connections were strengthened across several clinician groups: primary care, paediatrics, psychology and psychiatry. As such the COMPASS model is unique, in being able to amplify the benefits of inter-disciplinary learning and collaboration to support child and adolescent mental health care.

Another point of difference for our COMPASS model was that of co-design. One the major barriers to participation highlighted by participants involved in Project TEACH was the time and travel commitment involved, as sessions were longer and delivered in person. Co-design was a unique aspect of our COMPASS model, which overcame such barriers for busy clinicians who requested shorter, more frequent sessions which were scheduled outside business hours.

Like Project TEACH, BHIP comprises a structured education program and on demand psychiatry consultation for primary care clinicians [30,31]. However, in contrast to COMPASS, BHIP is a more intensive and costly program, embedded as a clinical service in the primary care practice, supported triaging of referrals and including clinicians who deliver brief psychotherapy. BHIP also provides support for practice transformation including operational sessions focusing on clinical and business workflow, crisis protocols, care pathways and linkage to speciality services. A survey of participants (n = 66, response rate 81.5%) found 95% acquired new knowledge about psychotropic medication, psychological therapies and felt they were able to provide better patient care [30]. The results of these studies align with the COMPASS evaluation.

Strengths and limitations

This mixed methods study has several strengths. Appropriate quantitative and qualitative methodologies were chosen to meet the aims of the evaluation and 86% completed pre and post surveys. Clinicians were from a range of disciplines with varying clinical experience suggesting our findings could generalise to a range of healthcare providers. However, clinicians self-selected into COMPASS and are thus likely to represent a group motivated to improve pediatric mental health care. They self-reported on confidence which may lead to response bias however, we note that not all changes in confidence were significant. As it was a pre-post design, causality cannot be assumed. Potential confounders such as clinicians accessing other MH training to improve confidence or organising their own access to a child psychiatrist cannot be ruled out. Future research could address this by conducting an adequately randomized controlled trial of COMPASS, whereby clinicians are randomly assigned to participate in COMPASS or not. However, it may prove difficult to recruit clinicians to a control group.

A purposive sample of clinicians completed qualitative interviews, including an even distribution of medical and non-medical professionals. The interview transcripts were double coded and data saturation was reached after analysing approximately half of all transcripts. Researchers undertook fortnightly meetings to resolve coding discrepancies and track coding decisions. They also completed journaling activities during the data collection and analysis phase to reflect on personal biases and preconceptions, as well as their relationship to participants, and how this may impact the research outcomes. Although we reached data saturation with our qualitative interviews, data saturation might not capture the full range of perspectives and experiences in the broader clinical community. Our sample was mostly females, who were relatively experienced clinicians. It may have been useful to hear from less experienced clinicians to better understand whether COMPASS met their needs. One child psychiatrist completed a brief snapshot of consultations and future research should aim to capture these outcomes over a longer period.

We have evaluated COMPASS in its first year of operation and from clinicians’ perspectives only. Future research could evaluate the longer-term impacts on clinicians’ confidence and wellbeing, impacts on patient outcomes, and barriers and enablers to scaling the model.

Conclusion

The COMPASS model meets several strategic policy priorities outlined in Royal Commission into Victoria’s Mental Health System Final Report and the National Children’s Mental Health and Wellbeing Strategy [8,32]. Recommendations 58 and 64 from the Royal Commission seek to “advance workforce capabilities, professional development and drive innovation in mental health-care treatment and support”[8]. COMPASS provides a novel approach to meeting these objectives and could be expanded to areas of even greater need such as rural communities [10]. Furthermore, the multi-disciplinary nature of this model, along with access to child psychiatry consultation, meets Objective 2.2 in the National Children’s Mental Health and Wellbeing Strategy which calls for better integration and coordination of services, as well as collaborative care [32]. Our evaluation of COMPASS shows this feasible and desirable. It is now in its third year of operation with the NWMPHN and is ripe for expansion nationally. It could be further scaled to other healthcare systems where there is a lack of access to child psychiatry expertise and a need to upskill community clinicians. If Australia is to meet the growing demand for paediatric mental health care, we need to upskill existing, community-based providers in a manner that is feasible and sustainable.

Supporting information

S1 Appendix Participant flowchart.

(PDF)

S2 Appendix Clinician pre survey.

(PDF)

S3 Appendix Clinician post survey.

(PDF)

S4 Appendix Participant information form.

(PDF)

S5 Appendix Qualitative interview guide.

(PDF)

S6 Appendix Secondary consultation record log.

(PDF)

The authors would like to acknowledge the North Western Melbourne Primary Health Network and The Royal Children’s Hospital Mental Health for their invaluable partnership. The authors would like to especially thank the child psychiatrists who led the Community of Practice sessions and the clinicians who dedicated their time to complete surveys and provided valuable feedback.

10.1371/journal.pone.0310377.r001
Decision Letter 0
Sacca Lea Academic Editor
© 2024 Lea Sacca
2024
Lea Sacca
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version0
7 Sep 2023

PONE-D-23-14369Impact of a collaborative model on community clinician confidence and competence in child and adolescent mental health: mixed method analysis.PLOS ONE

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Reviewer #1: Abstract

The abstract provides a concise overview of the study's objectives, methods, and anticipated results. However, there are several areas where it could be improved to enhance clarity and transparency.

1. Specificity of objectives: The objectives mentioned are quite general ("confidence, competence, and well-being of community clinicians"), and it might be beneficial to provide more specific details about what aspects of confidence, competence, and well-being are being measured. This would give reviewers a clearer understanding of the study's focus.

2. Lack of background: The abstract lacks background information about the current state of child and adolescent mental health care, the challenges faced by community clinicians, and the need for collaborative models like COMPASS. Providing a brief context would help reviewers understand the significance of the study.

3. Methods and measures: The abstract briefly mentions pre-post surveys and semi-structured interviews as methods, but it doesn't elaborate on the specific scales or tools used for assessing confidence, competence, and well-being. Including details about the measurement tools and their validity/reliability would enhance the methodological transparency.

4. Qualitative analysis approach: The description of the qualitative analysis is quite brief ("inductive approach" and "content analysis"). Elaborating on the process of qualitative data analysis, including coding strategies, inter-coder reliability, and how themes are being generated, would provide a clearer picture of the rigor in the qualitative component.

5. Outcomes of consultations: The abstract mentions a child psychiatrist's snapshot of consultations without explaining the purpose of this snapshot or how it contributes to the study's objectives. Clarifying how this data will be used and what insights it aims to provide would be beneficial.

Introduction

The introduction provided seems to address the research topic of child and adolescent mental health and the need for improved support for community-based clinicians. However, from a peer-review perspective, there are several limitations and areas for improvement that should be considered before publication:

1. Clarity and focus: While the introduction covers a wide range of relevant information, it could benefit from greater focus. The introduction should clearly state the research problem, objectives, and research questions. The reader should be able to understand the main purpose of the study from the introduction alone.

2. Citation usage: The introduction relies heavily on citations, which is good for providing evidence but can become overwhelming. It's important to strike a balance between providing evidence and maintaining a coherent narrative. Some information might be better summarized instead of directly quoting from sources.

3. Transition and flow: The introduction lacks smooth transitions between the different sections. Each paragraph should naturally lead to the next, guiding the reader through the argument. Consider using transitional phrases to connect ideas and improve the overall flow.

4. Research gap: While the introduction mentions the lack of evaluated models in Australia, it could further emphasize the research gap in the existing literature. What specific aspects of the current knowledge are insufficient? How will the proposed study address these gaps?

5. Theoretical framework: It would be beneficial to include a brief overview of the theoretical framework that underpins the study. What theoretical perspectives are guiding the research? This will help readers understand the context within which the study is situated.

6. Hypotheses/research questions: The introduction should clearly present the hypotheses or research questions that the study aims to address. This provides readers with a clear roadmap for what the study intends to investigate.

7. Significance and implications: Highlight the significance of the study in addressing the identified gaps. What are the potential implications of the study's findings for the field of child and adolescent mental health, clinical practice, and policy development?

8. Methodology preview: While the introduction does briefly mention the study's implementation and evaluation of the COMPASS model, a clearer preview of the research methodology would be valuable. This could include a brief overview of the study design, data collection methods, and analytical approaches.

9. Engagement with existing literature: While the introduction references a few statistics and the lack of evaluated models, it could engage more deeply with the existing literature on community-based mental health care and the challenges faced by clinicians. This will help position the study within the broader academic discourse.

10. Conciseness: Some sections of the introduction could be condensed without losing the essential information. This will help maintain reader engagement and prevent information overload.

Methods/materials

The provided Methods section outlines the implementation of the COMPASS model and the research methods used to assess its impact. However, there are areas within this section that could be improved from a peer-review perspective:

1. Clarity of procedures: While the description of the COMPASS model and its implementation is quite detailed, there could be clearer organization and separation of the different stages or components. The description could be broken down into subsections, such as "Recruitment of Participants," "Co-Development of CoP," "Delivery of CoP Sessions," "Qualitative Interviews," etc., to enhance readability and structure.

2. Rationale for method selection: Provide more justification for the chosen methods. Why were CoP sessions and qualitative interviews selected as the main approaches to evaluate the COMPASS model's impact? How do these methods align with the study's objectives and research questions?

3. Sampling and recruitment details: Provide more information about the size and characteristics of the participant pool. How many clinicians were initially approached, and how many participated in the CoP sessions and surveys? How were participants selected for interviews? Including this information provides context for the representativeness of the sample.

4. CoP content and structure: While the content of the CoP sessions is mentioned, there could be more detail about the development process, how the topics were selected, and the rationale behind choosing those specific areas. This could help readers understand the design and intent of the CoP sessions better.

5. Ethical considerations and informed consent: While the ethics approval is mentioned, it would be beneficial to elaborate on the ethical considerations taken into account during the study. Describe the steps taken to ensure participant confidentiality and how informed consent was obtained, particularly for both surveys and interviews.

6. Data collection and analysis: Elaborate on the process of data collection, management, and analysis. How were surveys administered? How were survey responses coded and analyzed? Similarly, how were qualitative interviews conducted, transcribed, and analyzed?

7. Validity and reliability: Discuss steps taken to ensure the validity and reliability of both the quantitative and qualitative data. This could include measures to ensure consistent administration of surveys, inter-rater reliability for coding qualitative data, and methods to enhance data triangulation.

8. Limitations and potential biases: Address potential limitations and biases in the study design and methods. For instance, what are the limitations of relying on self-reported measures of confidence? How might the use of a single child psychiatrist influence the consultation service's outcomes? These can also be included in the Discussion.

9. Alignment with research objectives: Continuously relate the methods back to the research objectives and questions. Ensure that each method's purpose is clear and directly connected to the study's overall aims.

10. Appendices: References to appendices are made without providing the content of the appendices. While they should be provided separately, consider adding a brief description of what each appendix contains to guide readers.

Results

The Results section of the study appears to provide a comprehensive overview of the findings and outcomes of the COMPASS Online CoP intervention. However, there are a few areas where improvements could be made:

1. Clarity and structure: While the section is well-organized and divided into themes and subthemes, some of the subthemes could benefit from clearer headings or labels. This would help readers quickly understand the main points of each subtheme and how they relate to the overall theme.

2. Data representation: The use of tables and figures to present quantitative data is helpful, but ensure that the data are clearly labeled and explained in the text. For instance, in Table 1, it would be helpful to include a brief description of each characteristic being presented, especially for readers who may not be familiar with the field.

3. Quotation usage: The use of quotations from participants to support themes is valuable, but consider providing more context for each quote. Briefly explain who the participant is (e.g., GP, psychologist) and their role, which would add credibility to the qualitative findings.

4. Statistical significance and effect size: When presenting quantitative data, it's important to indicate whether any observed changes are statistically significant and, when possible, provide effect size information. This helps readers understand the magnitude of the changes and their significance.

Discussion and conclusion

While the content of the discussion covers relevant aspects and findings of the study, there are some limitations and areas that could be improved before publication. Here are some suggestions and potential limitations to consider:

1. Clear linkage to research objectives and findings: The discussion should start by explicitly linking back to the research objectives or hypotheses stated in the introduction. This helps readers understand how the study addressed the research questions and what the key findings were.

2. Causality and study design: It's important to emphasize that the study used a pre-post design, which allows for examining changes within the same group over time but doesn't establish causality. This limitation should be acknowledged, and potential confounding factors discussed. Additionally, the discussion could highlight how future research could incorporate control groups or more rigorous study designs to strengthen causal inferences.

3. Comparative analysis with other models: While the discussion mentions other models like Project TEACH and BHIP, it could provide a more detailed comparative analysis of COMPASS with these models in terms of outcomes, implementation, and potential advantages and disadvantages. This would help readers understand how COMPASS contributes uniquely to the field.

4. Challenges and lessons learned: Beyond facilitation and group dynamics, other challenges that emerged during the implementation of the COMPASS model should be discussed. This could include issues related to participant engagement, technology, or any unforeseen barriers that affected the model's effectiveness.

5. Generalizability and external validity: Discuss the generalizability of the findings. How representative is the sample of the broader clinician population? Are there potential biases in the sample that could affect the applicability of the findings to other settings or regions?

6. Implications for policy and practice: In addition to addressing the strategic policy priorities mentioned, discuss how the findings of this study could inform decision-making at both policy and practice levels. How could the COMPASS model be adapted or replicated in other regions or healthcare systems?

7. Limitations of qualitative analysis: The qualitative analysis reached data saturation after analyzing about half of the transcripts. While this is common in qualitative research, acknowledge that data saturation might not capture the full range of perspectives and experiences. Discuss potential areas that might have been missed due to this limitation.

8. Future Directions: Provide concrete suggestions for future research directions. This could include exploring the long-term sustainability of the COMPASS model, evaluating its impact on patient outcomes, or investigating the barriers to wider implementation.

9. Language and style: Ensure that the language in the discussion is precise and concise. Avoid overly technical jargon, and explain complex concepts or findings in a clear and accessible manner.

Reviewer #2: General Comments:

1. The manuscript presents both quantitative and qualitative evaluation of the COMPASS model (mixed method analysis), on a highly relevant topic.

2. The title suggests the idea of different methods of analysis, yet the statistical analysis is not clear and lacks innovation

3. The main objective of the study should be clearly defined. It was confusing to understand precisely what the study aimed to evaluate.

4. The description of the study's methodology and the statistical analysis should be improved.

5. The methodology and results sections need restructuring.

6. It's not clear whether the COMPASS model is an approach created by the study or an existing program.

Title: Impact of a collaborative model on community clinician confidence and competence in child and adolescent mental health: mixed method analysis

- Why the expression "confidence and competence"? Maybe describe it better in the methodology, or adjust it, as it becomes confusing when reading the title.

- I'm not sure if "mixed method analysis" is the best to use, because in terms of statistical methods, the study is limited. It's a study where I work with qualitative and quantitative data

Abstract:

- Objectives are extensive. Determine a primary objective.

- Results: Present the outcome of the association mentioned in the conclusion.

Introduction:

- It's extensive and still doesn't clarify well how the Community of Practice functions. Is it a government program, an initiative by someone, funded by someone? Does it still exist, or was it an emergency response during the pandemic? Is COMPASS an example of a Community of Practice? It all appears somewhat confusing.

- The study's objective is mixed with the COMPASS objective. Adjust it.

Methods:

- Who facilitated the sessions, a trained researcher, a clinical member?

- What were the development sessions like?

- Please include the ethical approval at the end of the methodology.

- Regarding ethical considerations, shouldn't a consent form have been signed? Additionally, for data collected from children and adolescents, shouldn't their guardians have been informed and given consent to participate? If it's secondary data, wouldn't there need to be a specific protocol for secondary data?

- Are the data from children and adolescents sourced from a database, medical record collection, or patients treated by the recruited clinicians?

- Reorganize the methodology (Design and Sample, Data Collection, Ethical Aspects...)

- Page 10, line 156: "Clinician pre and post surveys included demographic items (pre-survey only)." What data?

- Was a sample calculation performed? Is the sample size sufficient to make any claims?

- The methodology needs to be rewritten and reorganized. It requires information regarding the study design, the data used, and how they were analyzed (including specific statistical tests). I understand that COMPASS is an approach created by the study, so the objective and details of COMPASS should be included in the methodology.

-I suggest using a flowchart to describe participant recruitment and attrition.

Results:

- Page 12, lines 204-211: This belongs in the methodology.

- Tables: Describe all acronyms and symbols used in the captions, even if they are obvious (such as n).

- Use lowercase n for sample size. This applies to all figures and tables.

- Table 3: Describe statistical significance (*) in the caption.

- In the main text, focus more on describing what was statistically significant or not, rather than presenting only descriptive data.

- Figures 1 and 2: Remove the underlining from the figure titles.

- Pages 19-20, lines 269-281: This is methodology.

- Are the 27 eligible clinicians from the quantitative data among the 59 participants from the quantitative part of the CoP session data, or do you have two different samples?

Discussion:

- Page 415: "As per our aims, the COMPASS model was associated with increased community clinician knowledge of services, confidence in diagnosis and management of common paediatric MH conditions, and reduced referrals to CAMHS." Where is this data in the results?

- Describe the study's limitations more comprehensively.

Conclusion:

- Much of the conclusion comprises final considerations that should be in the discussion. The conclusion, in general, should be concise and address the objective and title.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: Yes: Amanuel Abajobir

Reviewer #2: No

**********

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10.1371/journal.pone.0310377.r002
Author response to Decision Letter 0
Submission Version1
24 Oct 2023

10th October 2023

Lea Sacca

Academic editor

PLOS ONE

Dear Lea

Re: PONE-D-23-1439

Many thanks for the opportunity to revise our paper which we believe is considerably improved thanks to reviewer comments.

We have now clearly stated our key aims (6 aims in all) for this paper and ensured that our aims align with the methodology and results. In doing this, we have deleted a small section of the original paper that focused on clinician self-reported factors that may affect their decision to refer a patient (summarized in the original table 2). We felt that these 4 factors were not particularly informative and lead to unnecessary lengthening of the paper, but we would be happy to re-instate them if you wish.

Kind regards,

Professor Harriet Hiscock MB BS, FRACP, MD, FAAHMS, GAICD

On behalf of the co-authors

Please see "PONE-D-23-1439- Response to Reviewers.docx" for full response to reviewers comments.

Attachment Submitted filename: PONE-D-23-1439- Response to Reviewers.docx

10.1371/journal.pone.0310377.r003
Decision Letter 1
Moodley Saiendhra Vasudevan Academic Editor
© 2024 Saiendhra Vasudevan Moodley
2024
Saiendhra Vasudevan Moodley
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
16 Aug 2024

PONE-D-23-14369R1Impact of a collaborative model on community clinician confidence in child and adolescent mental health care, wellbeing, and access to child psychiatry expertise.PLOS ONE

Dear Dr. Hiscock,

 This paper was allocated to me as Academic Editor on 24 July 2024. My sincere apologies for the lengthy delay prior to this and I am not clear on the reasons for this. I am satisfied that your revisions have addressed the concerns of the previous reviewers. In addition, a third reviewer has also indicated that the revised paper can be accepted. I would, however, like a couple of minor revisions (see below) before I can recommend acceptance.  We invite you to submit a revised version of the manuscript that addresses the points below as soon as possible. 

ACADEMIC EDITOR:1. In your abstract, please replace your first heading "Objectives" with "Background".

2. The overall aim of your paper is to 'determine the impact of a collaborative model on community clinician confidence in child and adolescent mental health care' but what you are describing as Aims 1-6 are actually objectives within this broad aim. Please replace all the references to Aims 1-6 throughout the paper and replace these with Objectives 1-6.

Please submit your revised manuscript by Sep 30 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Saiendhra Vasudevan Moodley, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: I think at present the paper is good to go. However there are some typos of capitatization etc which need to be corrected

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

10.1371/journal.pone.0310377.r004
Author response to Decision Letter 1
Submission Version2
27 Aug 2024

Dear Dr Moodley,

Re: PONE-D-23-14369R1

Impact of a collaborative model on community clinician confidence in child and adolescent mental health care, wellbeing, and access to child psychiatry expertise.

I have made your requested changes to our revised manuscript i.e. to:

1. In abstract, please replace your first heading "Objectives" with "Background".

2. Replace all the references to Aims 1-6 throughout the paper and replace these with Objectives 1-6.

Thank you for finally moving this paper on!

Kind regards,

Professor Harriet Hiscock

Attachment Submitted filename: Response to Reviewers_PLOS ONE.docx

10.1371/journal.pone.0310377.r005
Decision Letter 2
Moodley Saiendhra Vasudevan Academic Editor
© 2024 Saiendhra Vasudevan Moodley
2024
Saiendhra Vasudevan Moodley
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version2
30 Aug 2024

Impact of a collaborative model on community clinician confidence in child and adolescent mental health care, wellbeing, and access to child psychiatry expertise.

PONE-D-23-14369R2

Dear Dr. Hiscock

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Saiendhra Vasudevan Moodley, PhD

Academic Editor

PLOS ONE

10.1371/journal.pone.0310377.r006
Acceptance letter
Moodley Saiendhra Vasudevan Academic Editor
© 2024 Saiendhra Vasudevan Moodley
2024
Saiendhra Vasudevan Moodley
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
13 Sep 2024

PONE-D-23-14369R2

PLOS ONE

Dear Dr. Hiscock,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Saiendhra Vasudevan Moodley

Academic Editor

PLOS ONE
==== Refs
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