Peter Birleson

Children with persistent conduct problems who dropout of treatment.

Abstract Dropout of treatment is one of the key issues in outcome in a child and adolescent mental health service. We report two studies focusing on the treatment process and the dropout rate of children with persistent conduct problems presenting to a community mental health service, using a prospective design. The first study included 32 children and used a randomised controlled treatment design comparing a CBT approach with conjoint family therapy and an eclectic approach. The overall dropout rate was 36%. Dropout occurred significantly less frequently in the CBT group. The dropout group was associated with mothers who were younger and less educated, a poorer rating by the clinicians at the last meeting, parental dissatisfaction with the treatment service and perception that the treatment was less organised and having less behavioural tasks. In the second study we used a naturalistic follow-up design. Forty-six children were included. The overall dropout rate was 48%. Again, the children who defaulted were rated by clinicians as less likely to have improved and dropout was also significantly associated with parental perception of a less organised treatment. In both studies dropout usually occurred after assessment and at the early phase of treatment.

Learning organisations : a suitable model for improving mental health services ?

Objective: The aim of this paper was to describe an organisational model that has created interest in recent business management literature as supporting learning, adaptation and continuous improvement. Method: Some key features of the literature on learning organisations are outlined, including the values and processes involved, together with a structural and cultural template that has been applied to a community child and adolescent mental health service. Some blocks to learning and the leadership skills required to develop adaptive services are described. Results: The experience of applying the model has led to a change in mental health service organisational structure and culture towards greater support for research, quality improvement, experimentation and adaptation. Conclusions: The learning organisation model offers a more comprehensive framework for designing adaptive mental health services and supporting quality management practices than any other recent organisational form.

Turning child and adolescent mental-health services into learning organizations

In the past few years, the business management literature has seen an exponential rise in articles on the concept of the Learning Organization. This organizational form is said to encourage innovation and creativity, improve adaptation and capacity for change, and enhance the commitment of staff. The model has been applied in a Child and Adolescent Mental-Health Service with some promising indications that it does indeed support experimentation, eclecticism and openness to change. This article provides an introduction to recent management literature on organizational design, and outlines some of the theory and practice of building structures and cultures which support ongoing evaluation and continuous quality improvement.

Developing the ‘Youth Model’ in Mental Health Services

Objective: The aim of this paper was to review the basis of the ‘youth model’ and new ‘headspace’ service delivery structures, proposed as a solution to the problem of high rates of psychiatric disorder in the youth period of life. Several issues were examined through asking key questions and answering these from the perspective of two academically oriented child and adolescent psychiatrists. Conclusions: As half of all mental disorders appear during childhood and early adolescence, more research into the origin and emergence of these problems should focus on this early period of life. Prevention research should also focus largely on children and adolescents, with interventions targeted through sequential assessment at pivotal stages. The current problem of access to mental health care for youth in the adult mental health service system could be improved with additional funding and culture change – it is not necessary to create a new service system. Indeed, there are dangers in establishing new services for 12–25-year-olds, as the 12–17-year-old population has different needs from 18–25-year-olds. In particular, the younger group are at risk of ‘adultification’ by being grouped together with young adults, and this risk needs to be actively managed. Health service planning must pay attention to developmental differences. Several suggestions are proposed for addressing the mental health needs of young adults.

Better Mental Health Services for Young People: Responsibility, Partnerships and Projects

Objective: This paper argues that adolescent psychiatry is best linked with child psychiatry and opposes separate youth mental health programmes for 12–25-year-olds. It reports on the current status of services and considers how adult mental health services (AMHS) can improve services for young adults (18–25-year-olds). Method: Factors in development, psychopathology, prevention, training and service systems are reviewed to suggest that current child and adolescent mental health service systems (CAMHS) are appropriate for 0–17-year-olds. Improvements in CAMHS are described from a Victorian perspective, including the model of specialist clinical programmes or teams for specific patient populations. Mechanisms are outlined for AMHS to better assist young adults from 18 to 25 years of age. Results: The model of clinical projects or clinical programme teams, developed in partnership with primary health and others, is a suitable vehicle to help AMHS to improve clinical services to their young adult populations. These may be funded from a variety of sources, including re-engineering existing service resources. Conclusions: Such developments complement the work of specialist research units and build local competencies. More programme development and evaluation is needed, which will require the support of the College and State and Commonwealth Mental Health Branches.

Evaluation of Outcome in Child and Adolescent Mental Health Services: Children with Persistent Conduct Problems

This article focuses on the evaluation of outcome in child and adolescent mental health services. We examined the outcomes of 46 children with persistent conduct problems by gathering at baseline and six months information from multiple informants on multiple domains including the functioning of the child, risk factors, and parents’ and children’s perceptions of the treatment process. A statistically significant reduction in oppositional/conduct symptoms was reported six months after the initial clinical contact. However, the majority of the group still scored within the clinical range. The various outcome measures are correlated to only a mild to moderate degree. Teachers did not notice the same degree of change at school, despite the changes noticed by parents. Symptom improvement and satisfaction with a service are two separate issues. Parents’ satisfaction was related to their perception of the therapist and the therapy offered. Their satisfaction was high if they perceived that the therapist was able to communicate well, show care and concern, and if the therapy was perceived as organized. Much can be learned from a comprehensive outcome measurement system within a mental health service.

Continuing the debate on a separate adolescent psychiatry

Objective: This paper continues the debate, started by George Patton, that a separate adolescent psychiatry is required since many psychotic illnesses begin in late adolescence, and adolescent mental health needs have not been well met by child or adult psychiatry. Method: Epidemiological studies are used to illustrate that there are many continuities, as well as discontinuities, in the natural history of psychiatric disorders throughout the life cycle. The paper comments on rational service planning, which requires data on the outcomes of different treatment approaches. It goes on to explore the implications of a separate adolescent psychiatry for service delivery, including how current service boundaries and the training of psychiatrists might need to change. Results and Conclusions: An argument is mounted that psychiatrists should take a whole life perspective, rather than further fragment the specialty. In most Australian States, recent reviews of child and adolescent mental health services are likely to result in increased funding for services to adolescents. Adult psychiatry needs to attend more to the requirements of older adolescents, and greater collaboration is recommended between psychiatry services for children and adults. The authors argue for diversity of approaches, and consider that moves towards separate adolescent mental health services may not always be appropriate.

Mental health planning for children and youth: is it developmentally appropriate?

Objectives: We aim to provide an overview of current issues facing child and adolescent mental health services and the provision of developmentally informed and appropriate care. Method: We review developmental models of mental disorder and the impact on service design. Results: Developmental issues can shape service design. Conclusions: Mental health services need to be informed and responsive to changing developmental needs and of the context of child development in terms of family and attachment relationships. Children and adolescents have specific needs in terms of service design.

Training General Practitioners in the Assessment of Childhood Mental Health Problems

Epidemiological studies have found that most children with mental health problems are not receiving appropriate help. The aim of this study was to assess an approach to train general practitioners (GPs) to detect mental health problems early, engage the families, and assist them in the access of service. Five GPs were given three hours of training on a brief assessment method. Each then interviewed parents whose children they suspected might have a mental health problem. An experienced research clinician then repeated the assessment. This information was fed back to the GP who then assisted the family in obtaining appropriate help. Twenty-nine parents were interviewed in six months. The research clinician and the GPs were in agreement for 90% of the cases for the recognition of mental health problems. GPs’ opinions on the brief assessment method were: easy to use (100%), helpful in obtaining information (100%) and helpful in engaging the parent (100%). The parents were followed up by telephone 3-4 months after the interview. Eighty-eight percent reported that the process was helpful, 67% had received help from services and 67% had improved. We conclude that with brief training, the GPs in this study were able to improve their capacity to provide early intervention for childhood mental health problems.

Early onset dysthymic disorder in children and adolescents: Clinical implications and future directions

Early onset dysthymic disorder (EODD) is a serious psychiatric disorder that is associated with impaired social and relationship functioning, comorbid psychiatric conditions, a chronic course and increased risk for adult affective disorders. Unlike major depressive disorder (MDD) in childhood, which has been the focus of ongoing research, EODD has been relatively neglected in clinical practice and research. This paper reviews and evaluates EODD research findings and outlines pertinent clinical and research implications.