Monitoring and Measurement in Child and Adolescent Mental Health: It’s about More than Just Symptoms

Routine outcome monitoring (ROM) provides information to practitioners and others providing healthcare support to demonstrate the impact of interventions and for service evaluation [...].

both adult and youth settings [22,23]. Research to date has prioritized the experiences of youth in the use of routine outcome measures, which is of paramount importance.
There are several examples of measurement-focused care worldwide e.g., [2,[24][25][26]. However, these initiatives tend to focus on symptomology tracking, as opposed to more complementary elements of change and improvement, such as functioning or empowerment. Whilst a focus on symptoms can be important, it will not be the principle area of change for all. The challenges of relying heavily on symptomology are that other important areas of outcome may be missed. For example, evidence demonstrates that widely available youth outcome measures do not capture the gamut of goals set by youth for focus in therapy, including existential areas of improvement such as understanding oneself, being independent or responsible, and increasing confidence [14]. A recent systematic review also reported that clients of all ages can experience ROM as suspicious, and limited in its ability to fully capture their needs [16]. Further, focusing solely on only one area of change, namely symptomology, runs the risk of over-or under-reporting levels of change; varied levels of improvement have been demonstrated when focused on different areas of measurement. Evidence suggests that only around 16% of youths report consistent cross-domain improvement, and one in four young people have reported significant improvements in symptoms but not in functioning. Further, one in three young people reported significant goal progress but not significant symptom improvement [27], and when goal data were added to combined analysis of symptom-based outcome analysis, an increase in the overall level of measurable improvement and a reduction in the no measurable change category was reported for youths [28].
There are also issues with the inclusiveness of self-report measures in particular. As text-based methods, these outcome measures could exclude some young people, either due to cultural or linguistic reasons, or because they have learning disabilities. Such examples include the propensity for standardized outcome measures to be developed based on experiences, behaviors, and attitudes of young White people from the Global North, which is underpinned by a general lack of research focused on young people in the Global South [29], despite 85% of the world's youth being in Global South countries [30]. Further, mental health and wellbeing measure questions have been found to not be ageappropriate [31], and young people have raised challenges associated with the readability of them [32], also highlighting the frequent disparities between chronological age and reading age. These factors render a mismatch between standardized questions and many young people's understanding and interpretation of their own experiences, as well as the understanding and interpretation of the data derived from the measures. The measurement of patients who have experienced trauma is also often excluded from exploration (e.g., [33]), or not adequately capturing relevant areas of outcome [34]. . Tying all of these studies together, the clear need for additional monitoring outside of traditional symptom tracking is required for youth mental health and wellbeing support. It has been long recommended that individualized measures, or those that seek to explore a holistic view of outcomes, are used alongside standardized symptom focused outcome measures to ensure a breadth of information is explored [35][36][37][38]. By reflecting on the monitoring and measurement in child and adolescent mental health through this wide range of methods and approaches, we hope that this Special Issue furthers learning in the field. Through this multifaceted exploration of ROM, we hope it helps to promote reflection, which is useful at all levels of service provision, from the use of measures by practitioners, to wider policy and research considerations, retaining at the heart a considered focus on young people as whole beings and with areas of important outcome measurement which reach beyond a sole focus on symptoms.
Author Contributions: Conceptualization, writing-original and subsequent draft preparation was conducted by J.J. and J.E.-C. All authors have read and agreed to the published version of the manuscript.

Funding:
The authors received no funding for this research. Edbrooke-Childs reports grants from NHS England and NHS Improvement, outside of the submitted work. Edbrooke-Childs and Jacob report grants from the Wellcome Trust outside of the submitted work.

Conflicts of Interest:
Both authors work on the Child Outcomes Research Consortium (CORC) project, based at the Anna Freud National Centre for Children and Families, which encourages the use of outcome measures amongst its members in youth mental health settings.