Behavioural pediatrics and mental health programs: A case for integration?

Authors


Dr Peter Birleson, Child and Adolescent Mental Health Service Administration, Upton House, PO Box 94, Box Hill, Vic. 3128, Australia. Fax: +61 3 9895 4073; email: peter.birleson@easternhealth.org.au

This study makes an important contribution to the literature by using the Strengths and Difficulties Questionnaire (SDQ) in a paediatric clinic population to measure morbidity. It is not surprising that half the children and over 60% of adolescents attending clinics for developmental and behaviour problems were found have scores in the ‘abnormal’ range by parental rating. These patients were referred for disruptive behaviour, anxiety problems and relationship difficulties, learning difficulties, language and communication disorders, habit and sleep disorders. Many of these problems are identical with those presented to Child and Adolescent Mental Health Services (CAMHS), and we know that chronic health problems, learning problems and developmental weaknesses are potent risk factors for psychiatric disorders.1 While CAMHS clients had higher Emotional problem scores, and Behaviour Clinic clients had higher Hyperactivity scores, there was considerable overlap in total scores and impact scores, especially in older groups.

See related article by Roongpraiwan et al. on pp. 122–126.

The SDQ is a useful instrument for several reasons. It is freely available; has parent and self-rating versions; and provides a rough guide to psychopathology. It can be downloaded from several websites (http://www.sdqinfo.com/), and was chosen under the Australian National Mental Health Strategy as the consumer and parent report tool in the suite of routine outcome measures now used in publicly funded CAMHS. Around the time the SDQ was chosen, Mellor carried out a normative study in Victoria on a representative sample of 910 children aged between 7 and 17 years,2 and has published Australian population norms for the SDQ, with ranges for the top 10% of abnormal scores and 20% of borderline abnormal scores. The Australian Mental Health Outcomes and Classification Network (AMHOCN) plans to put these norms on its website, which already provides SDQ data collected at admission, review and discharge occasions from ambulatory and inpatient CAMHS.3 A Decision Support Tool can be also be downloaded for service providers to examine client’s scores to determine their significance. This has been available for the Health of the Nation Outcome Scales this year and will shortly be offered for the SDQ. In addition, the site also contains a review of all the standardised outcome measures with useful information about their psychometrics.4 The SDQ performs well as a measure of change and a screening tool in CAMHS, so Developmental Behavioural Paediatric Clinics could consider using it for these purposes.

Paediatricians have a strong interest in diagnosing and treating child and adolescent mental health problems, which they see in considerable numbers. The paper makes the reasonable claim that in a rational system of care, such as that described by Raphael, general practitioners would treat mild problems themselves and refer children with more severe and complex disorders to secondary service providers, such as paediatricians and psychologists.5 The most severe, complex and high risk cases would be referred to CAMHS and other specialised multidisciplinary (tertiary) clinics in paediatric hospitals. An effective system of mental health care would also have clear pathways of care agreed between providers, so that children could be sent quickly to the right provider for the most appropriate level of help. The SDQ could be used as a tool here to help determine problem severity and impact. Paediatric services and CAMHS everywhere need to co-ordinate their services more systematically, and could experiment with a range of collaborative models for service provision to children who present very complex problems, such as those with neuro-behavioural problems or eating disorders.

The paper also makes helpful suggestions for improving training for paediatricians. As psychological and behavioural problems are such a large part of current childhood morbidity, 6-month attachments in mental health or developmental behavioural settings seem barely adequate to equip registrars with the skills they need. Unfortunately, the small numbers of available registrar posts not occupied by psychiatry trainees limits exposure to CAMHS clinics. Acute health, community health and mental health service systems continue to operate separately when it comes to planning the training of junior doctors. It is time to change this with more integrated intersectoral planning by Health Departments. Current registrar positions only meet historical training needs, and increasing needs for service means that additional mental health training positions are required for paediatricians, along with enhanced education in the practice of psychological medicine. The National Survey findings and those of the International Review of the Second Mental Health Plan provides ample evidence that current needs are not being met, and that mental health services for children need expanding.6,7 Roongpraiwan and colleagues are optimistic that a National Action Plan on Mental Health may result in new services and better training possibilities.

There is no reason to be sanguine about this, and strong lobbying is required to advocate for the needs of children at the state level. The new Medicare funding will increase access nationally to private mental health services, but public mental health services are a state responsibility, and the lions’ share of funding here has historically gone to adults. Children’s mental health services have been funded at a quarter of the per capita rate received by adults.8 While the massive burden of disease from mental disorders and the importance of need reduction through early intervention are increasingly recognised, the focus of adult mental health services remains on schizophrenia. This distracts from the fact that mental illness burden comes largely from other disorders, which have their origins in childhood.9 US data show that 50% of all mental disorders have their onset before the age of 14 years.10 UK data show that rates of childhood mental disorders have been increasing over the past 25 years.11 However, funding bodies have not yet accepted that a serious investment in prevention means expanding primary and secondary mental health services for children to treat problems before these become entrenched. This is one area where child psychiatrists and paediatricians can speak with one voice –‘better mental health services for children means less suffering and fewer sick adults’. This paper helps us see why we must work together on this.

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