Development of a Scale to Assess the Attitudes of Paediatric Staff to Caring for Children with Medically Unexplained Symptoms: Implications for the Role of CAMHS in Paediatric Care

Background:  Children with medically unexplained symptoms (MUS) represent a challenge for paediatricians and typically undergo extensive in-patient investigations for symptoms such as abdominal pain. This can delay access to psychological services. This study aims to develop and evaluate a scale to assess the attitudes of paediatric staff to caring for children with MUS and to explore factors influencing those attitudes.
Method:  In this cross-sectional survey, 118 health professionals at one UK hospital with experience of caring for children with MUS completed an attitude questionnaire developed for the study.
Results:  Factor analysis identified four factors that explained significant variance in staff perceptions of care: rewarding nature of care; demanding nature of care; parental influence; children's need for skilled support. The combined subscales formed the MUS-Q.
Conclusion:  Paediatric staff found caring for children with MUS difficult and would welcome more support from CAMHS. The MUS-Q proved a reliable tool to evaluate staff attitudes.     

The Impact of Primary Mental Health Workers on Referrals to CAMHS

Background:  This paper describes the impact of a new primary mental health team within the existing child and adolescent health service on referrals and attendance rates.
Method:  100 referrals to CAMHS from prior to the PMHT and 100 referrals prior to the evaluation were examined and classified as appropriate or inappropriate for CAMHS. Information was also gathered as to whether the child and/or family attended for their appointment with CAMHS.
Results and Conclusions:  a large increase in attendance and decrease in non-attendance rates to CAMHS was seen. The referrals to CAMHS have become more appropriate for a psychiatry service. However, the service provoked a mixed response from Tier 1 professionals. Recommendations are made for the skills needed by primary mental health workers and further evaluative techniques.     

Paediatric Liaison Work by Child and Adolescent Mental Health Services

Background:  Although psychiatric morbidity is common amongst paediatric patients, little is known about the availability of CAMH paediatric liaison services.
Method:  We surveyed all Trusts with specialist CAMH services and paediatric units in Greater London, enquiring about the nature of liaison that CAMHS provide.
Results:  We found that although liaison paediatric work was common, dedicated paediatric liaison services were provided by only a minority of specialist multidisciplinary CAMHS. Their work involved most aspects of child psychopathology, and included emergencies and children with joint physical and psychiatric problems. About 2/3 of paediatricians were satisfied with CAMHS liaison services, but virtually all desired to see them developed further. There were few indications of co-ordination between specialist multidisciplinary CAMHS and other paediatric psychosocial support services.     

Social Services and CAMHS: A National Survey

Background:  Links between Social Service Departments (SSDs) and CAMHS are explored and described through a national survey and a number of site visits.
Method:  Data were collected via (1) a national questionnaire survey yielding a response rate of 75%, and (2) pre-selected site visits to seven SSDs.
Results:  Additional to existing CAMHS assessment and treatment provision to SSDs, there is increasing outreach consultation and support, some provided through primary mental health workers and dedicated clinical psychology sessions. Some SSDs have developed innovative in-house provision for Tier 2 type referrals.
Conclusions:  Outreach and core CAMHS provision to SSDs need equal investment and development.     

Providing Specialist Psychological Support to Foster Carers: A Consultation Model

Background:  The task of fostering today is a complex one and foster carers need good quality support. This paper discusses a consultation service for foster carers.
Method:  It draws upon our qualitative experiences to explore the important themes that have emerged during the provision of the consultation service.
Results:  Foster carers are highly satisfied with the consultation service, which provides them with improved levels of access to psychological advice, a different understanding of the children, and continuing support if required.
Discussion:  The reasons for this satisfaction, together with some of the difficulties we have experienced, are explored. Experimental research is needed to investigate the complex relationship between consultation, support, confidence and understanding for foster carers and to consider the long-term effects of consultation for the carer and the child.     

Prescribing Practices of General Practitioners for Children with Mental Health Problems

Method: Fifty-two general practitioners (GPs) were surveyed to establish their prescribing practice and attitudes to the use of psychotropic medication in children and adolescents.
Results: Most GPs have no training in child psychiatry and only a quarter felt confident about their knowledge of drug treatment. Three-quarters of GPs wished to consult with a child psychiatrist before prescribing.
Conclusions: This survey has highlighted the training needs of GPs in the use of psychotropic medication for children with mental health problems. It also revealed the importance of providing accessible child psychiatry consultation to support GPs in using psychotropics appropriately and effectively.     

Use of Melatonin in Children and Adolescents: Clinicians' and Parents' Perspective

Background:  There is a paucity of research on professionals' and parents' views on melatonin use in children and adolescents with sleep problems.
Method:  A two-stage survey was employed. First stage: Child psychiatrists and community paediatricians working in a health district were surveyed. Second stage: Parents/carers of children currently on melatonin under the care of these clinicians completed questionnaires.
Results:  Eighty-seven per cent of the participating clinicians prescribed melatonin, with most of them prescribing melatonin for chronic and treatment resistant cases. Differences in prescribing practices between child psychiatrists and community paediatricians were noted. All children were prescribed either 3 mgs or 6 mgs melatonin. None of them experienced any significant side effects.
Conclusions:  This research highlights that clinicians recognise melatonin as an effective treatment of childhood insomnia and parents value its usefulness too.
Key Practitioner Message:  Two-stage survey investigating the perspective of clinicians and parents on use of melatonin to treat sleep disorders in children.

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  87% (20/23) of the clinicians who participated in the survey prescribed melatonin.
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  Only 13% (3/23) of clinicians used pharmaceuticals as their first choice of treatment. 78% (18/23) used melatonin only in chronic or treatment resistant cases.
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  Parents (12) who participated in the survey noticed an improvement in sleep pattern and none reported any serious side-effects.

     

Evaluation of a CAMHS in Primary Care Service for General Practice

Background:  Many CAMH Services have Tier 2 provision in primary care, but there has been little published evaluation. In a service aimed at general practice, this study examined: 1) the clinical activities of the primary mental health workers; 2) the effect of the service on referrals to specialist CAMHS; and 3) the utilisation and perceived usefulness of the service.
Method:  clinical activity data collection, evaluation of referral patterns, and a postal questionnaire.
Results:  Informal (unstructured) consultation-liaison was used more than formal consultation. Referrals to specialist CAMHS increased from practices using the service. The service was perceived as helpful and accessible.
Conclusions:  The service supported primary care staff in their work with child and adolescent mental health issues. Referrals to Tier 3 may increase as a result of the service.     

The Global Absence of Child and Adolescent Mental Health Policy

Background:  Few policies designed specifically to support child and adolescent mental health exist worldwide. The absence of policy is a barrier to the development of coherent systems of mental healthcare for children and adolescents.
Method:  This study collected data on existing policies from international databases, WHO headquarters in Geneva, Switzerland, and in consultation with experts in child and adolescent psychiatry from around the world. A set of criteria for ranking the adequacy of these policies was developed.
Results:  Though no single country was found to have a mental health policy strictly pertaining to children and adolescents alone, 35 countries (corresponding to 18% of countries worldwide) were found to have identifiable mental health policies, which may have some beneficial impact on children and adolescents. Though little has been achieved worldwide in this area, there has been a significant degree of movement towards policy development in the past 10 years. The policies identified vary greatly in terms of their provisions for delivering services, initiating research, training professionals, and educating the public.
Conclusions:  The development of mental health policies is feasible and would substantially aid in the expansion of service systems, the institutionalisation of culturally relevant data gathering, and the facilitation of funding.     

Ethnic variation in service utilisation among children with intellectual disability

Background   This study examined whether service utilisation among children with intellectual disability (ID) varied by ethnic cultural group.
Method   Survey carried out in four special schools in London. Information was provided by school teachers using case files, and 242 children aged 7 to 17 years with mild and moderate ID were identified. Ethnic categories were derived from self-reported main categories. Service utilisation categorised as use of: child and adolescent mental health services (CAMHS), social services, physical health and education services.
Results   Child and adolescent mental health services uptake was lower for South Asians than for White British ( P  = 0.0487). There were statistically significant differences among ethnic groups for community-based social services uptake (being the highest for the Black groups and the lowest for South Asians, P  = 0.015) and respite care uptake (being the highest for the Black and White European groups and the lowest for South Asians, P  = 0.009). In regression analysis family structure predicted CAMHS service utilisation and social service community support. Ethnicity predicted use of respite care.
Conclusions   Significant ethnic differences in service utilisation among children with ID were found for both CAMHS and social service contact. There was particularly low service use for the South Asian group. These differences might arise because of differences in family organisation, as more South Asian children lived in two-parent families, which may have been better able to provide care than single-parent families. Other factors such as variation in parental belief systems and variation in psychopathology may be relevant. Implications are discussed.     

Survey of Atypical Antipsychotic Medication Use by Child and Adolescent Psychiatrists

Background:  Atypical antipsychotics could be replacing traditional antipsychotics in the treatment of childhood disorders.
Method:  A postal survey was conducted of Child Psychiatrists in a region of the United Kingdom to evaluate their use of atypical antipsychotics for psychotic and non-psychotic conditions.
Results:  97% of respondents reported prescribing atypical antipsychotics and at least 65% did so for non-psychotic indications although several concerns were raised. Differences in prescribing and monitoring practices between Community and Specialist services were noted.
Conclusions:  Atypical antipsychotics appear to play a significant role in current child psychiatry practice. Further discussions and research needs to occur about their use and guidelines produced.     

Parental Perceptions of the Assessment of Autistic Spectrum Disorders in a Tier Three Service

Background:  Little is known about the satisfaction of the parents of children receiving child and adolescent mental health services in general, and autistic spectrum services in particular.
Method:  This audit examined parent and carer perceptions of the Autistic Spectrum Disorder assessments undertaken by the multi-agency team in a Tier Three CAMHS in Manchester. Forty families completed a brief questionnaire.
Results:  The majority of parents and carers reported satisfaction with the service (95%), although responses highlighted areas in both the assessment process and the service facilities that needed improvement.
Conclusions:  Useful information with both local and national applications can be gathered quickly in an easily replicated manner.     

Child Mental Health is Everybody's Business: The Prevalence of Contact with Public Sector Services by Type of Disorder Among British School Children in a Three-Year Period

Method:  A third of the children from the 1999 British Child and Adolescent Mental Health Survey were followed-up over 3 years. Parents provided summary information on service contacts in relation to mental health; selected subgroups provided more detailed information by telephone interview.
Results:  Common overlaps in service use were between health services, between teachers and educational specialists, and between the latter and CAMHS or social services. Services other than primary health care saw more children with externalising disorders, while children with anxiety disorders were less likely than children with other psychiatric disorders to be in contact with any service.
Conclusions:  Child mental health is everybody's business, and professionals need to be alert(ed) to the types of disorders that children using their service may have.     

Optimizing referral of patients with neuromuscular disorders to allied health care

Background and purpose:  To report the predictive validity of the perceived limitations in activities and need questionnaire (PLAN-Q), a screening instrument to support neurologists to select patients with neuromuscular disorders (NMD) for referral for a one-off consultation by occupational therapist (OT), physical therapist (PT) and speech therapist (ST).
Methods:  In a cross-sectional validation study, 102 patients with various NMD participated. Patients received a one-off consultation by an expert OT, PT and ST and filled out the PLAN-Q. Therapists rated the appropriateness of the one-off consultations based on need, available treatment and patient's motivation. Receiver Operation Characteristic analysis and multivariate logistic regression analysis were used to obtain a PLAN-Q based prediction model for the appropriateness of the one-off consultations.
Results:  Probability for a one-off OT consultation increased from 64% to 78% (95% CI: 69–85%). Prior test probability for a one-off ST consultation increased from 44% to 61% (95% CI: 48–73%). Prior test probability for one-off PT consultation could not be increased.
Conclusion:  Screening patients with NMD using the PLAN-Q may assist neurologists in selecting the appropriate patients for a one-off consultation by OT and ST. Unlike our expectations the screening did not guide referral for a one-off consultation by PT.     

Would I Attend Child and Adolescent Mental Health Services (CAMHS)? Fourteen to Sixteen Year Olds Decide

Background:  Research indicates minors over 14-years have capacity, yet, in England and Wales, only over-16s are legally presumed able to consent. This study compared 14/15- and 16-year-olds' decision-making about attending CAMHS.
Method:  Questionnaire-based study of 1129 14–16-year-olds.
Results:  Fewer 16-year-olds think parents contribute to decision-making. There were no significant differences between 14/15- and 16-year-olds in relation to thinking they have the final say, voluntariness or information preferences. Four-fifths wanted a range of information and thought it should be provided to all young people, not just those referred.
Conclusions:  14/15-year-olds are as likely as 16-year-olds to be able to consent to attending CAMHS.     

Consultation frequency and perceived consultation time in a Japanese psychiatric clinic: their relationship with patient consultation satisfaction and depression and anxiety

Aim:  To examine the relationship of the consultation frequency and the perceived consultation time of psychiatric clinic attenders with their satisfaction towards the consultation and depression and anxiety (measured by the Hospital Anxiety and Depression Scale).
Methods:  Questionnaires were distributed to 186 outpatients attending a psychiatric clinic.
Results:  In a path analytic model, a longer session with shorter interval ('dense' session) predicted lowered depression and anxiety level of the patientsthrough the perceived satisfaction of the patients, and it was also predicted by the higher anxiety level. The dense session was also influenced by shorter duration of clinic attendance.
Conclusion:  Dense psychiatric sessions in busy Japanese outpatient clinics may benefit patients.     

The Efficacy of a Relational Treatment for Maltreated Children and their Families

Background:  The objective of this study was to assess the effects of participation in a relational intervention program on child abuse potential, parenting stress and child behaviour in maltreated children and their foster parents.
Methods:  A convenience sample of participants ( N  = 53) were randomly assigned to an immediate treatment or a wait-list control condition and completed pre and post test measures.
Results:  Participant's mean pretest scores were equivalent between groups. Post-intervention, treatment participants had significantly lower scores on total child abuse potential, parenting stress, and child internalising and externalising behaviour than control subjects. Engagement in treatment was a significant predictor of positive change in reported child behaviour.
Conclusions:  This intervention was effective in decreasing symptoms in respondents who were at high-risk for placement disruption.     

Duration of Untreated Psychosis, Referral Route, and Age of Onset in an Early Intervention in Psychosis Service and a Local CAMHS

Background:  The aim of this study was to investigate associations between demographic and clinical variables and duration of untreated psychosis (DUP) in a sample of cases of psychosis across an adult early intervention in psychosis service and a child and adolescent community team.
Method:  Cross-sectional baseline data for cases of psychosis across the two teams on the caseload at a given time point were collected, including age of onset, gender, ethnicity, referral route, and DUP.
Results:  The median DUP across the entire sample was 91 days, while those patients with initial treatment for psychosis from the child and adolescent team had a median DUP of 69 days. Using multiple linear regression, there were two variables that showed a significant association with DUP: referral route ( p  < .001), and age of onset, with earlier age of onset associated with shorter DUP ( p  = .015).
Conclusion:  These findings are discussed in relation to possible explanatory factors, with particular focus on service-level variables and pathways to care. It is suggested that the involvement of child and adolescent teams is vital to the work of early intervention in psychosis services.