Using program theory to develop key performance indicators for child and adolescent mental health services.

Key Performance Indicators are used increasingly by health services, but their relevance and utility may be questionable. In this article, Program Theory is used to model the irreducible stages in the system of clinical care in Child and Adolescent Mental Health Services, define the major program operations in each of these stages, and specify the intermediate outcomes of each stage and the final outcomes sought. National and State policy standards are used, with practice experience, to identify key program operations and intermediate outcomes sought. Systematic criteria are then applied to select KPIs that are measurable, reliable, valid for our program theory, utilitarian, and relevant to clinicians, clients and managers.

Children with persistent conduct problems who dropout of treatment.

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.

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.

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.

Building a learning organisation in a child and adolescent mental health service.

In recent business literature, the model of the learning organisation has been proposed as a solution to the problem of continually changing environments and increasing consumer expectations of maximum quality and value for money. The model seems highly appropriate for health services, which are staffed by educated professional staff who must become more adaptive and concerned with improving consumer outcomes. This case study describes how the principles of learning organisations have been applied to the design of a new structure and the creation of a learning culture within a mental health service for children and adolescents.

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.

Legal rights and responsibilities of adolescents and staff in Victorian Child and Adolescent Mental Health Services.

OBJECTIVES: The aim of the paper is to clarify the legal rights of adolescent patients, guardians and staff in Victorian Child and adolescent Mental Health Services (CAMHS). Victorian CAMHS have now been 'gazetted' and can admit patients on an involuntary basis under the amended Mental Health Act 1986 (MHA). The MHA applies equally to young people under the age of 18 years, which has raised some confusion about who has the right to consent to treatment. METHOD: Staff of CAMHS inpatient units have recently posed questions to the Victorian chief psychiatrist. These have included clarification of when the MHA may be appropriately used for adolescents, what is the clinician's duty of care, how to assess young people's capacity to consent to treatment, how to manage some patient groups, and what is the role of the courts in treatment decisions. The author provides a view on each of these matters, based on recent literature and confirmed by legal opinion. RESULTS: Some matters of fact are presented and advice is provided. CONCLUSIONS: Services must seek the informed consent of guardians and adolescents and, for those young people with major psychiatric disorders who require treatment and are unable to consent, the amended MHA provides clearer direction for the use of involuntary treatment. Where units offer admission to provide assessment and stabilisation, a clear explanation about the treatment goals, and the role of restraint and medication in managing behaviour is essential at the outset of the admission process.

Child Behaviour Checklist classification of behaviour disorder.

OBJECTIVE: The aim of this study was to determine the applicability of the published clinical cut-off scores of the Child Behaviour Checklist (CBCL) for the classification of behaviour disorders. METHODOLOGY: Child Behaviour Checklists were obtained for 1342 subjects newly referred to the six major mental health centres in Melbourne. The normative community sample of 1002 7-, 12- and 15-year-olds was drawn from a school-based asthma prevalence study. RESULTS: The mean total problem T-score for the children referred to mental health centres was 67 and was above the clinical range for all age groups. Using referral to psychiatric services as the gold standard, the sensitivity and specificity of the CBCL using a cut-off of > or = 60, was 77.4 and 83.2%, respectively. This compares favourably with the sensitivity of 68% and specificity of 82% for the American sample. Using a cut-off score of > or = 63, the sensitivity was 70.5% and the specificity was 88.6%. The referred and community samples differed with respect to socio-economic status, family structure and mothers' level of education. Fifty-two per cent of the clinically referred children lived with both parents, compared with 89% of the community sample. CONCLUSIONS: While there are some limitations to this study in terms of both the clinic and community sample, support is provided for the usefulness and applicability of the recommended CBCL cut-off scores in an Australian population.

Clinical evaluation of a self-rating scale for depressive disorder in childhood (Depression Self-Rating Scale).

The many conceptual and methodological difficulties involved in evaluating depression rating scales for children are discussed. A clinical validation of the Depression Self-Rating Scale for Children (DSRSC) is described. The instrument is easy to use and has a predictive value comparable with that of a psychiatric global rating of depressed appearance and history of depression obtained at interview. There was confirmation that the DSRSC can tap an internal dimension of depression and that children are able to evaluate their feeling states. An examination of misclassified children pointed to diagnostic overlap and some unreliability of diagnosis by clinicians.