Organization of services for children and adolescents with mental health problems
Miranda Wolpert
Introduction
This chapter aims to guide the thinking of practitioners who might be involved in developing services to meet the needs of children and young people with mental health difficulties. Anyone involved in this challenging but vital endeavour will need to address the following questions:
Who should the service be for?
What sort of interventions should be provided?
How should the service be structured?
Who should the staff be?
How can the service be made most accessible?
How can service quality be ensured?
This chapter will look at each of these issues in turn to explore how each might best be approached.
Who should the service be for?
Ever expanding conceptualization of mental health needs has meant that at least four groups of children are routinely referred to in the discussions about service development in this area:
1 Children and young people in difficult (and often terrible) circumstances
2 Children at risk of developing diagnosable mental health problems
3 Children with diagnosable mental health problems
4 Children with levels of impairment due to mental health issues that make it difficult for them to function within their community/culture
Lack of clarity when discussing the needs of the different groups can confuse service planning. In particular, it can result in the range of agencies that are all increasingly involved in collaborating in planning provision, talking at cross purposes. When resources are limited (as they generally are for these populations of children, even in the most economically developed countries of the world) it is likely that choices will need to be made about prioritizing between and within these groups. It is therefore vital to be clear at the outset which groups are seen as the priority for a given community and to achieve multi-agency agreement on this.
The needs of each of these groups in relation to service provision in this area is considered in turn below.
Children in difficult circumstances
Definitions of ‘difficult circumstances’ vary with national context. The estimated 14 million AIDS orphans (concentrated largely in Africa) would fall into this category as would the 12 million children in the United States living below the poverty line along with all those children who are in contexts of war, famine, or abuse.(1) This group is likely to include those children with high and complex mental health needs who are the hardest to reach and who are a policy priority in many areas. However it may also include children who do not have specific mental health needs. Services need to ensure they are accessible to these groups where they do have mental health issues but specialist mental health services are unlikely to be the main provider of care for the majority of children in such circumstances.
Children ‘at risk’
Risk factors for developing diagnosable mental health problems include some aspect of difficult circumstances (such as violent environments, lack of warm family environments) but risk is also heightened by other individual and interpersonal factors such as: brain injury, low birth weight, poor parental mental health, low IQ, irritable temperament, family dysfunction, and the lack of a key supportive relationship with an adult. For children identified as ‘at risk’ the focus for mental health provision is likely to be on how to enhance resilience. There may be key opportunities for intervention, such as when the child is born or at key transition points (such as starting school, changing school, leaving school, etc). There is an argument for targeting particular groups such as children of parents with mental health problems. However, evidence for the effectiveness of health promotion and prevention initiatives is still limited and there is some evidence that the promotion of resilience may best be achieved by agencies other than child mental health specialists, such as welfare sectors creating greater neighbourhood cohesion, perinatal services reducing risk of low birth weight and educational services implementing appropriate programmes to promote emotional well-being and support children in times of stress. It is likely that services should only put major resources into targeting ‘at risk’ children if they have sufficient resources to meet the needs of those children with existing problems.
Children with diagnosable mental health problems
Epidemiological data from Europe and the United States suggests that around 10-20 per cent of children suffer from diagnosable mental health problems (using ICD-10 or DSM-IV criteria). There are indications of differences between countries, with slightly lower rates found in India and Norway, for example, and slightly higher in Brazil, Bangladesh, and Russia. However, not all of these children need direct service provision. Some diagnosable mental health problems may get better without intervention (such as depressions in mild form). For these reasons, amongst others (in particular the fact that not all current treatments are proven to do more good than harm—as will be discussed below), it is not advised to go down the route recently suggested by the American Psychiatric Association of screening all children in schools and treating all diagnosable difficulties.(2)
Children with impairment due to mental health difficulties
It is children in this category who are likely to be the main target for specialist child mental health provision. The impact of significant and impairing mental health difficulties if not effectively treated can be substantial. Worldwide, suicide is the third leading cause of death amongst adolescents; major depressive disorder, often starting in adolescence, is associated with substantial psychosocial impairment; conduct disorders amongst children tend to persist into adult life and are reflected in later drug abuse, antisocial behaviour, and poor physical health. This group covers a wide variety of children and young people with problems ranging from bed-wetting to psychosis. It includes those with chronic and multiple difficulties and those with discrete and defined difficulties. It encompasses those with difficulties where there are known to be effective interventions and those presenting with problems where the best course of action is much less clear (as will be discussed below). It is this very mixed range of problems that child mental health services must address.
Prioritizing needs
The way needs are prioritized in planning service provision will be heavily influenced by the context in which services are located. In some countries independent child mental health provision and unaffordable luxury when pitted against other basic needs. The World Health Organisation(3) has suggested that where resources
are particularly limited, priority for funds for child mental health provision should be given to those children with existing difficulties which are:
are particularly limited, priority for funds for child mental health provision should be given to those children with existing difficulties which are:
occur frequently (and/or have highest cost implications)
cause a high degree of impairment
have the greatest long-term care/cost consequences
have an evidence base for treatment and (particularly in those countries with the most limited resources)
where the difficulties can be dealt with in primary care or universal services such as schools or GPs.
In countries with greater resources, child mental health professionals’ input can be conceptualized as being provided at universal, targeted, and specialist levels. This involves supporting and working alongside universal provision to promote emotional well-being whether in schools or via primary health care workers. Targeted provision aims to promote emotional well-being in those deemed either at most risk (group 2 above) or in most need (group 1 above) with the groups being determined by policy imperatives. Here specialist mental health professionals will work alongside workers from other sectors who take a lead in relation to the needs of these groups as a whole, such as social welfare workers and primary care staff. Specialist provision aims to intervene primarily with those with existing impairment due to mental health difficulties (group 4 above) and can be provided at a local community level, though for more rare and specialized resources may be provided at a regional ore even at a national level.
Weighing mental health promotion initiatives against interventions for those with existing impairments requires particularly careful thought. Whilst there is evidence that promotion programmes may sometimes promote emotional well-being, research to date has not proved that this will reduce levels of significant disturbance and thus impact on specialist services, nor that such programmes are necessarily the most effective approach. It therefore does not seem warranted at this stage to assume that investment in prevention can be done at the expense of investment in services for those with existing impairing mental health difficulties.
In planning response to ‘need’, it is also important to consider the potential negative and even harmful impact of increased specialist mental health services. Mental health professionals are frequently in danger of assuming that more specialist mental health provision is unquestionably an unalloyed good. The need for more provision must be set in the context of other (sometimes competing) ‘needs’, such as: the primary need of children to be nourished, sheltered, and protected; their need not to be stigmatized or miss education; and their need not to receive inappropriate, ineffective, or harmful treatment. At times an inappropriate mental health focus can be an unhelpful drain on resources. One documented example is when well-meaning voluntary groups entered a country following a disaster to provide ‘interventions for PTSD’ that were not linked to other relief efforts and actually interfered with and undermined key initiatives.(1) Whilst the costs of not providing effective specialist mental health inputs can be high, it is important to remember there are also costs to providing unhelpful services.
What sort of interventions should be provided?
As yet, few services have been developed on the basis of considered evidence. Systems of care in CAMHS (as for many areas in health care) have historically been developed on the basis of beliefs, assertion, and innovation within the limits of given structures but with little reference to the slowly and tentatively emerging evidence base. The arguments for trying to promote evidence-based service development are compelling. Natural biases in reasoning mean that people tend to make decisions based more on things that fit their assumptive world view than those that challenge it and are more influenced by the charisma of those promoting a particular approach than by evidence for its effectiveness. When the evidence base is not used as the basis for service development, it makes it more likely that seemingly plausible but ineffective and/or harmful interventions may be introduced or continued and that new interventions that have been shown to do more good than harm may never be introduced.(4)
The evidence base in relation to child mental health interventions, whilst growing, is still limited both in extent and quality. Shortcomings include the sheer paucity of studies, the fact that most research is conducted in United States and there is lack of agreement over appropriate outcome measures. Even where interventions have been found to work in academic studies they are generally not as effective when applied in ‘real life’ settings. This difference may be due to differences in the populations of children seen, types of interventions made, and/or outcomes assessed. There is increasing evidence of the necessity of carefully implementing all aspects of a particular intervention if it is to be as helpful, and that lack of ‘fidelity to model’ may account for the lack of generalizability of some of the interventions. On the other hand, the role of non-specific factors such as therapeutic engagement, expectations of change and therapist warmth may need to be taken into account.(5)
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