CAMHS and Paediatricians Working Together

April
2011
Mindful – centre for training and research in developmental health
Gate 1, Building C
50 Flemington Street
Flemington Victoria 3031 Australia
t +613 9371 0200 f +613 9371 0250 w www.mindful.org.au
CAMHS & Paediatricians Working Together
Prepared and written by Dr Deeta Kimber and Dr Alessandra Radovini of Mindful, Centre for
Training and Research in Developmental Health, University of Melbourne for the Mental
Health for Child and Youth, Mental Health, Drugs and Regions Division, Department of
Health, Victoria , Australia.
April 2011
Thanks and appreciation goes to the Advisory Committee for this project:
Associate Professor Jill Sewell AM FRACP FAICD
Deputy Director, Centre for Community Child Health
The Royal Children's Hospital, Victoria
Dr Alessandra Radovini
Deputy Chief Psychiatrist - Children & Youth, Office of the Chief Psychiatrist,
Department of Health
Director Mindful, Centre for training and research in developmental health, University
of Melbourne.
Dr Jenny Proimos
Principal Medical Advisor, Child and Adolescent Health and Wellbeing Division
Office for Children and Portfolio Coordination
Department of Education and Early Childhood Development
Lesley Thornton
Manager Clinical Networks and Service Development,Department of Health ,
Victoria.
1
CAMHS & Paediatricians Working Together Table of Contents
Executive Summary and Key Ideas ............................................................................4 Key Ideas Generated ......................................................................................................................................................4 Project Brief....................................................................................................................8 Methodology .....................................................................................................................................................................8 Who we talked to ............................................................................................................................................................9 The policy and service development context ................................................................................................ 10 1 What is everybody’s main concern? -Looking after THIS child and family. .. 11 Key Idea #1 ..................................................................................................................................................................... 10 2 Being part of a “continuum of care” ..................................................................... 13 Key Idea #2 ..................................................................................................................................................................... 12 3 Negotiating the different clinical models ............................................................. 16 Paediatric Model Gains............................................................................................................................................... 16 Key Idea #3 ..................................................................................................................................................................... 14 Paediatric Model Strains ............................................................................................................................................ 16 CAMHS Model Gains................................................................................................................................................... 17 CAMHS Model Strains ................................................................................................................................................ 17 Tension of bringing the models together.......................................................................................................... 18 4 Service Strains –The structural tensions impinging on the working
relationship................................................................................................................... 19 Key Idea #4 ..................................................................................................................................................................... 18 Increasing the capacity of the Paediatrician .................................................................................................. 21 Duty of Care and Safety............................................................................................................................................. 22 5 A working relationship built on trust and respect .............................................. 23 Key Idea #5 ..................................................................................................................................................................... 23 6 Working to find a common language and understanding................................. 24 Social components of negotiating the working relationship ................................................................. 24 Key Idea # 6 .................................................................................................................................................................... 25 Procedural components of negotiating a working relationship........................................................... 25 7 Invisible tensions pulling people apart ................................................................ 27 Key Idea #7 ..................................................................................................................................................................... 27 8 Three patterns of linking to form a working relationship .................................. 29 Key Idea #8 ..................................................................................................................................................................... 29 9 Active Linking between CAMHS and Paediatricians.......................................... 29 Positive Cascade............................................................................................................................................................ 30 2 Key Idea #9 ..................................................................................................................................................................... 30 10 Passive linking between CAMHS and Paediatricians ...................................... 31 Key Idea #10................................................................................................................................................................... 32 11 Perpetual dislocation between CAMHS and Paediatricians ........................... 34 Key Idea #11................................................................................................................................................................... 34 Negative cascade........................................................................................................................................................... 34 12a Enablers ................................................................................................................. 36 General............................................................................................................................................................................. 36 Key Idea #12a ................................................................................................................................................................ 37 Moving from “Perpetually Dislocated” to “Actively Linked” ................................................................... 37 Examples of Innovation............................................................................................................................................ 38 Single session opinion linked to Intake............................................................................................................. 38 Combined Autism Training for Paediatric and Psychiatry Trainees................................................ 38 Supporting community multidisciplinary teams to perform autism assessments. .................. 39 Green Light to Paediatricians Project ................................................................................................................ 39 Buying in Psychiatric Expertise.............................................................................................................................. 40 Cross disciplinary training terms ........................................................................................................................... 40 CAMHS running an additional Tier 2 service ................................................................................................ 40 12b Barriers .................................................................................................................. 42 Key Idea #12b ................................................................................................................................................................ 42 Guiding Principles....................................................................................................... 44 Recommendations ...................................................................................................... 45 Recommendation 1: Information and Communication ............................................................................. 45 The continuum of care can be improved through the development of better information
networks by:................................................................................................................................................................... 45 Recommendation 2: Supporting the Paediatrician’s capacity and building collaboration ...... 46 Recommendation 3: Pragmatic Communication......................................................................................... 47 Recommendation 4: Common Training: Fellowship Program and CME ........................................ 48 References.................................................................................................................... 50 Appendix 1 Green Light to Paediatricians, Southern Region CAMHS ............... 51 3
Executive Summary and Key Ideas
A scoping study was conducted to look at the mental health workforce interface
between CAMHS and paediatricians who work in the community. This was in
response to paediatricians identifying that 30-40% of their caseload was
behavioural, emotional and developmental problems. A qualitative analysis
methodology was used to understand the experience of clinicians as they
negotiated this service interface to generate recommendations on how to support
paediatricians in their mental health work.
Key Ideas Generated
1. CAMHS and paediatricians’ prime concern is about providing good care to the
child and family consulting them; their care is driven by the needs of each
individual child.
2. As paediatricians look after a child and family, their capacity to care for them
may be exceeded and require transfer to another part of the mental health care
system; this may be due to the complexity, safety or the intensity of treatment
required. CAMHS and paediatricians are part of a “continuum of care”.
3. CAMHS and paediatricians have substantial areas of overlap as well as
significant areas of difference in delivery of mental health care to children and
families. The areas of difference can result in varied views regarding
understanding aetiology, diagnosis and management. These differences can
create a tension that can be misinterpreted as criticism of their professional
capacity.
4. A gap has been identified between paediatricians’ requests for assistance,
and CAMHS providing assistance or accepting referral. There are static factors
such as resource and variable factors such as understanding to whom and
where to refer. Advice and support from CAMHS can significantly increase the
paediatrician’s capacity to support the child.
4 5. Mutual trust and respect between paediatricians and CAMHS clinicians is
necessary to form a working relationship. The working relationship is the
fundamental link in the “continuum of care”. Trust is established and
strengthened via appropriate responsivity to requests for assistance.
6. Speaking a common language and having a shared understanding
between paediatricians, CAMHS and the child and family is essential when being
part of a “continuum of care”.
7. Resource limitations and different referral expectations between CAMHS and
paediatricians results in tension in the working relationship. This tension is often
erroneously interpreted as a lack of respect for the clinician and this erodes the
trust within the working relationship.
8. CAMHS is the organizing structure for public mental health care delivery in
Victoria. Across the state each CAMHS and their local paediatricians can be
linked in 3 broad patterns, -active, passive or dislocated. This impacts on the
“continuum of care” experience.
9. Actively linked partnerships between CAMHS and paediatricians:
•
Foster good working relationships
•
Are responsive on all levels
•
Are respectful of difference
•
Seek to build common languages and understanding.
This enables clinicians to join around the needs of the child and family, in
addition this promotes capacity building and increases access to support and
advice for future episodes of care.
This also establishes trust and respect and helps negotiate relationship repair
when referral requests cannot be met.
This creates an optimum “continuum of care” model and is considered the
“Gold Standard”.
5
10. Passively linked partnerships between CAMHS and paediatricians occur
when:
•
Services are responsive and respectful
BUT,
•
Do not actively seek to foster a good working relationship
•
Do not actively address areas of difference
•
Do not seek to build a common language and understanding.
This is less effective in jointly addressing and coordinating the needs of the
child and family, resulting in a more parallel type of care.
The absence of an established working relationship results in less capacity
building and less access to support and advice for future episodes of care.
11. Dislocated partnerships between CAMHS and paediatricians
•
Are unlikely to be able to form a working relationship
•
Are not responsive
•
Are critical and dismissive of each other’s input.
Therefore they do not perceive themselves as a “continuum of care’ resulting
in the child and families experiencing confusing, uncoordinated and
competing care.
The absence of a working relationship prevents capacity building and
prevents access to support and advice for future episodes of care.
This perpetuates the dislocation and reduces the possibility of a repair
process. The challenge for services is to restore a working relationship and
move out of this inefficient and poorly coordinated pattern.
12a. Building partnerships between CAMHS and paediatricians requires
resources such as time and work, which often goes unacknowledged and
unfunded. It relies on the goodwill of individuals and therefore is not sustainable.
12b. Structural barriers exist to forming working relationships between clinicians,
such as Triage procedures and Intake processes. Triage is designed to be a
single entry point to a service, however this is counterintuitive to referral
6 expectations and processes between paediatric specialists to medical specialists
such as a psychiatrist.
7
Project Brief
This project set out to understand the interface between Paediatricians and Child
and Adolescent Mental Health Services (CAMHS) in tending to the mental health
needs of children and youth in the state of Victoria.
In particular it aimed to develop guidelines to support effective partnerships and
shared care models that enabled paediatricians to be better included in the mental
health workforce.
This followed the identification that 30-40% of most General Paediatricians’
caseload related to emotional and developmental problems by the National Survey
of Mental Health and Well Being-Child and Adolescent component in 2000.
This study intends to generate a set of Guiding Principles of practical ways of
supporting paediatricians in their mental health work.
Methodology
This study was conducted by interviewing paediatricians and CAMHS to gain an
understanding of their shared mental health workforce interface.
A methodology from the discipline of Sociology was used called Grounded Theory.
Grounded Theory is a qualitative analysis methodology pitched at understanding
how people manage solving problems. This methodology sorts all the opinions and
experiences collected from the CAMHS and paediatricians in some manageable
way to enable a practical interpretation of what is occurring.
8 It does this by identifying a main concern shared by everyone, and then looks at
how people try to solve it and the structures that get in the way.
It generates an emergent hypothesis of what is going on that is grounded in the
data that is collected in the study.
The researcher must approach the area of enquiry theory free and follow the data as
common concerns arise. Once the focus of the study has been clarified the
researcher proceeds to conceptualize the patterns that emerge and generate a
theory that explains how the main concern is resolved.
Regular supervision from a Grounded Theory expert was obtained so that the
integrity of the data collection and generation of emergent hypotheses was ensured
as the project proceeded.
In this study we looked at how the Paediatricians and CAMHS looked after the
child and family in their care, and provided a continuum of care in the setting
of Mental Health Services in Victoria.
Who we talked to
This study was conducted in 2010 over a 6-month period and interviewed
approximately 50 paediatricians and CAMHS clinicians and managers. This broke
down to roughly 25 paediatricians, 8 of which were paediatric trainees, and 25
CAMHS clinicians, including managers, clinical directors and 9 child and adolescent
psychiatry trainees. Paediatricians and CAMHS in both metropolitan and regional
setting were interviewed in roughly equal proportions.
It was intended to be an initial scoping study to identify key themes and issues
rather than be an audit of services across the state.
What was remarkable was the high level of enthusiasm from the paediatricians to
share their experiences however; making time to do this was frequently difficult to
coordinate due to their work pressures. It was also difficult to identify the
9
paediatrician population in relation to the relevant CAMHS catchment areas due to a
lack of a readily available database.
The policy and service development context
Epidemiological surveys indicate that 50% of mental health problems have their
origins within childhood and 75% of first episode illness occurs by age 25 years. The
prevalence of mental health problems among children and young people requires
the development of a better system of mental health care that draws together the
capacity of a broad range of primary and specialist providers to respond.
Victoria’s mental health reform activities, informed by extensive consultations over
recent years with a broad range of stakeholders, have prioritised the need to
improve timely access to, and the quality of mental health care for, both children (014) and young people (12-25 years) so that continuity of care and developmentally
appropriate services are provided more seamlessly across 0-25 years. These
reforms require CAMHS and Adult MHS to work together to provide evidence-based
programs for those with the most severe and complex problems and disorders.
They are also expected to develop functional partnerships with other professionals
providing care for those with moderate to severe problems, which includes flexible
entry and exit as problems worsen and diminish. These relationships become key
to improved client care and outcomes but are known to be sustainable only where
seen to be of mutual benefit.
Paediatricians are a highly skilled specialist medical workforce providing services to
a significant number of children and young people, typically up to 18 years of age,
experiencing significant emotional and behavioural problems. As such, they play a
critical role as providers of ‘mental health care’ within communities. Positive
relationships and clear and flexible referral pathways between paediatricians and
mental health services are essential component of an effective system of mental
health care.
10 1 What is everybody’s main concern? -Looking after THIS
child and family.
Key Idea #1 CAMHS and paediatricians’ prime concern is about providing good care to the child and family consulting them; their care is driven by the needs of each individual child. When discussing their concerns about collaboration between paediatricians and
CAMHS, clinicians invariably gave examples of clinical cases and thought in terms
of individual episodes of care. Everybody wanted things to work for the child and
family in front of them.
For CAMHS it was a little more complicated as their intake criteria meant that they
had to ensure that the children referred to them reached the referral threshold. One
11
Director described this as deciding, “Which child do you love?” Nevertheless,once
accepted into care, CAMHS clinicians would also discuss episodes of care in terms
of the child in front of them. Even disorder defined services such as Autism or Eating
Disorders were managed from the point of view of the child and family in a particular
clinician’s care.
“The paediatrician has a case management role, see yourself as the coordinator
of your person's care…” –Community Paediatrician
“I'm desperate for a secondary consultation about this case I'm really confused
and I want you to see them…”-Regional Paediatrician
“The raison d'être should be meeting the needs of the child and family…”CAMHS Manager
12 2 Being part of a “continuum of care”
Key Idea #2 As paediatricians look after a child and family, their capacity to care for
them may be exceeded and require transfer to another part of the mental
health care system; this may be due to the complexity, safety or the
intensity of treatment required. CAMHS and paediatricians are part of a
“continuum of care”. The bulk of paediatricians interviewed
worked in the community in private
practice in the various different
CAMHS catchments across the state
of Victoria. They were mostly funded
through the Medicare system, which is
under the Federal Health Care
System.
From a perspective of state health care planning, they are located in “Tier 2” of a
system of care. Tier 1 is usually the first point of contact when problems start to
show and the Tier 2 of health care compromises professionals with specific
expertise and skills in child and adolescent mental health, usually located in
community based settings. They see children and youth with moderate or severe
mental disorders with moderate to high risk of harm.
In this study paediatricians, located in Tier 2, repeatedly described their care as a
longitudinal care, following the child and young person growing up.
13
CAMHS are located in Tier 3 of the Health Care System and are set up to provide
very intense levels of care, crisis response and assertive outreach. They are multi
disciplinary specialists that include a child and adolescent psychiatrist, who work in
teams to address complex and severe mental health problems, which can include
high risk of harm.
In this study CAMHS would describe episodes of crisis care that would end with
discharge back to the referrer once the level of functioning and risk had improved.
Tier 3 services such as CAMHS have the additional role of supporting Tier 1 and
Tier 2 either with direct clinical advice or more general capacity building. Things are
organized this way to enable a flexible schema for understanding how network and
services can work together for children and adolescents with mental health
problems.
When we return to the idea of THIS child and family, however, an individual is
likely to move through the different tiers of care depending on whether or not they
are in crisis, according to the level of severity and psychosocial functioning. So, for
instance, a child with a moderate condition can attend a paediatrician in Tier 2 but
go into crisis for some reason, or deteriorate at key developmental stages, and
require the more intensive care of Tier 3, -same child, same life, same experience of
growing up, different part of the system, with different people and a different
approach. The reverse happens when things have resolved somewhat; they are
discharged back to a different part of the system.
When all the partners in the “continuum of care” are well coordinated this
theoretically delivers a care experience that meets the needs of the child and family.
When the partners across the tiers struggle to coordinate the care, the child and
family are less likely to experience a “continuum of care”.
In the following sections there will be a discussion on factors that can impinge on the
“continuum of care” experience.
14 3 Negotiating the different clinical models
Key Idea #3 CAMHS and paediatricians have substantial areas of overlap as well as
significant areas of difference in delivery of mental health care to children and
families. The areas of difference can result in varied views regarding
understanding aetiology, diagnosis and management. These differences can
create a tension that can be misinterpreted as criticism of their professional
capacity. Paediatricians and CAMHS are located in
different tiers of the mental health care
system and also have different
professional make-ups and approaches.
In the following section the relative
“gains” and “strains” of the different
models that each sector uses will be
described with a consideration of the
possible impact on the child and family as they travel through the “continuum of
care”.
We have already identified the position of the paediatricians in the community in Tier
2 of the Mental Health Care System, requiring a referral from a General Practitioner.
They are unique in the mental health care system as in addition to treating mental
health they are also a specialist of children’s health. They are a generalist and
specialist all in one.
15
Paediatric Model Gains
When describing their clinical role and engagement a picture of a powerful and
respectful engagement with the family emerged. This would be very much in the
style of joining with the parents in doing the best for the child. Practitioners often
described a very nurturing type of care with an assertive style of follow up if, for
instance, families failed to attend appointments or appeared to drop out of care.
Paediatricians would describe the clinical approach they used differently, but usually
it would have the hallmarks of a neuro-developmental approach with a behavioural
emphasis. They described their engagement as typically long term, following a child
and family as they grew up. Paediatricians were also able to identify that when
families attended them for care there seemed to be a reduction in the perception of
the stigma associated with mental illness.
Paediatric Model Strains
Some of the areas that paediatricians identified as difficult in their practice were
having the opportunity to launch into detailed parenting work. They stated that often
it seemed inappropriate or awkward to elicit detailed “family of origin” information or
episodes of trauma that had afflicted the child or family.
The kind of presentations that were more likely to require referral to CAMHS were
when there was a high level of complexity to the presentation, associated severity or
high risk that required a higher level of containment.
When episodes of past trauma were identified, many felt that the consultation time
frame and their available teaching made offering treatment for this difficult.
The other areas that paediatricians identified as sitting less comfortably within their
consultation framework, were when difficult conversations needed to be had with the
family or responsibility put back on the family.
16 CAMHS Model Gains
CAMHS, located in Tier 3 of the mental health care system was established to
handle presentations of crisis, complexity and severity.
The strength of the CAMHS clinical engagement was that it enabled a detailed
assessment that would allow a conceptualization of family and social systems,
attachment patterns and relational disturbances and transgenerational transmission
of adversity and trauma. It was set up to manage difficult to engage children, youth
and families, often with multiple and more complex needs.
Its engagement approach centred on a more contractual style, aimed at being more
empowering. The assessment team was made up of a diverse range of professional
disciplines to provide a broad perspective of clinical understandings.
CAMHS Model Strains
Some of the difficulties offered by the CAMHS style of assessment were the referral
failing to get into CAMHS, either by the family not following through with the
recommendation or the referral not reaching threshold.
Families would report to their paediatricians that they felt blamed as they proceeded
through the CAMHS assessment. The intensity of the assessment could impede the
initial engagement and the family could struggle with the different locus of
responsibility when compared with other care experiences in the health care system.
Sometimes this made the experience feel relatively uncaring and, if accustomed to a
longitudinal type of care, struggle with feelings of abandonment with an episodic
style of care.
17
Tension of bringing the models together
When a child and family moved between
paediatrician care and CAMHS there was a
significantly different experience of the two
care settings. These were usually unstated
and emerge as the process proceeded. Both
care models had something rich to contribute
and the challenge in providing a continuum of
care was to integrate both approaches to
bring together something that was enriched
rather than narrowed to one or other of the
approaches. More simply put what was best
was getting more gain and less strain when
combining the two models.
Frequently the tension created by the differences between the two models was not
seen for what it was. It was often interpreted as incompetence both ways and
worked invisibly to get in the way of a rich integration of both perspectives.
If paediatricians and CAMHS were explicitly aware of the different experience that
the two models could offer a child and family, they might be able to better prepare
them for the experience.
This happens to some extent, with paediatricians usually coaching the family on the
difficulty of getting into CAMHS and urging them to persist to activate the referral. A
better understanding might prepare the family for a different engagement
experience; warn them that the diagnosis and understanding of the presentation
might change and that there will be a different intensity to the assessment with a
broader view of the presentation pattern including a detailed family history.
18 4 Service Strains –The structural tensions impinging on
the working relationship
Key Idea #4 A gap has been identified between paediatrician’s requests for assistance,
and CAMHS providing assistance or accepting referral. There are static
factors such as resource, and variable factors such as understanding to whom
and where to refer. Advice and support from CAMHS can significantly increase
the paediatrician’s capacity to support the child. Throughout the course of the study it became increasingly clear that there was a
service gap where paediatricians self-identified their “capacity stopped” and where
they assumed “CAMHS started”. This seemed to reflect a lack of corroboration of
their assumptions between the two components of care; very rarely had there been
a consensus formed on how this operated from region to region.
19
In spite of this, the service gap was inferred rather than identified with paediatricians
repeatedly despairing that “I can’t get them into CAMHS”. They would add that
CAMHS was the only one of the few places where they could get psychological work
that was free. This was despite the Better Outcomes in Mental Health Care
(BOiMHC) program being launched to enable community access to quality primary
mental health care through Medicare. Clinicians were now observing that
practitioners were less likely to bulk bill Medicare and now charged a gap fee that
was prohibitive for many of the vulnerable families in their care.
Paediatricians wanted help on the cases that CAMHS had not yet picked up, to
prevent them escalating to the CAMHS intake threshold.
These issues were grouped as “Structural Tensions” and could be further divided
into static and dynamic factors.
Static Factors impinging on the capacity of CAMHS to respond to paediatrician’s
request started with the obvious candidates such as resource limitations and the
rationing of services. Expertise shortages also limited CAMHS ability to respond.
Dynamic structural factors that seemed to limit the capacity to provide a
continuum of care were confusion about how the mental health system was
organized.
Paediatricians would see CAMHS as the obvious port of call but alternatives to
seeking this were not so clear. In the “CAMHS in Communities” document it was a
Triage function to redirect referrals appropriately, however this was often seen as
rejection for its own sake and a lack of response to a request for help.
Generally it appeared easier for CAMHS to identify which Tier 2 service could help
them than the paediatrician being able to discern this themselves.
A repeated difficulty was being able to get in touch with each other. The sessional
nature of both the paediatrician and the CAMHS clinicians meant it took great effort
to properly confer.
20 Increasing the capacity of the Paediatrician
“You were more likely to get a secondary
consultation and would manage patients with
increased confidence and not refer everything
on…” –Regional Paediatrician
“I felt the use of medication and dependence
on the medical model reflected the lack of
availability of psychotherapy or psychiatric second option…”-Metropolitan
Paediatrician
“Get more ideas in the monthly meetings and better access i.e. easy to ring
up psychiatrist and discuss the case…”-Regional Paediatrician
In keeping with the service conventions of the general medical health care system,
paediatricians had the expectation of access to a publicly funded psychiatric opinion
to assist them in the capacity gap that exists between their care and what reaches
threshold for a CAMHS service.
Paediatricians were full of praise for the use they could make of advice from
CAMHS psychiatrists. They identified that they could much more readily hold onto a
child and continue to treat them following conferring with the psychiatrist to get
advice on management.
This could take the form of general conferring, as formal secondary consultation or
requesting a primary consultation associated with Intake. Paediatricians repeatedly
describe extracting a high level of information from the psychiatrist that greatly
assisted their capacity and increased their level of knowledge.
21
Duty of Care and Safety
Gathering clinical advice from an alternative
member of the multidisciplinary team was
counterintuitive to how they practiced and did
not feel like the responsible thing to do from a
perspective of safety and responsibility. Within
CAMHS there was an understanding of the
delegation of risk with the Clinical Director
taking the ultimate responsibility. For
paediatricians attempting to form an interface
with the service for advice on risk, best
practice and safety, this delegation was not
clear and they did not feel they had
responsibly gathered advice without a direct conversation doctor to doctor.
22 5 A working relationship built on trust and respect
Key Idea #5 Mutual trust and respect between paediatricians and CAMHS clinicians is necessary to form a working relationship. The working relationship is the fundamental link in the “continuum of care”. Trust is established and strengthened via appropriate responsivity to requests for assistance. Responsivity was a key factor in
establishing and maintaining trust with
clinical partners. Often the initial request
was for CAMHS to take over care, which
in many cases was not always feasible or
appropriate. However, if a service was
earnest in their efforts to assist the
paediatrician with their current dilemma,
either with advice on good alternative services, approaches or care pathways, they
were still considered to be responsive, and trust with CAMHS was maintained. In
this instance if a paediatrician was required to continue to care for the child despite
their request for CAMHS assistance, they would want treatment advice from the
CAMHS psychiatrist to technically enhance the care they were already offering.
If a CAMHS failed to respond to a request for help this would have a significant
impact on the trust and working relationship with CAMHS. The reason for this was
that paediatricians took a pride in their proficiency and did not ask for assistance
lightly. It put them in a difficult position of trying to fully discharge their duty of care
when they felt their clinical capacity was exceeded.
23
6 Working to find a common language and understanding
Key Idea # 6 Speaking a common language and having a shared understanding between paediatricians, CAMHS and the child and family is essential when being part of a “continuum of care”. When looking at what was involved in forming a
working relationship two distinct processes were
identified; a social process and a procedural
process. These two processes were needed to
establish trust and respect for the difficult work
of this relationship to be negotiated. The work
required was negotiating the different
understandings of the child and family and the
pressure of service gaps.
Social components of negotiating the
working relationship
The social components of the process involved
a kind of professional “courting” between
clinicians to ensure that they could indeed
provide a compatible continuum of care. As they
proceeded, behaving with good manners was
24 important, as was feeling appreciated and conversely communicating appreciation
and respect.
These social processes sound quaint and trivial but were very powerful. When a
paediatrician’s request to refer a child was not met, the paediatrician frequently felt
not respected, took the rejection as an affront and was less likely to trust or respect
a CAMHS service in return.
Procedural components of negotiating a working relationship
The procedural components of forming an
effective working relationship involved linking into
CAMHS, with feedback around the referral
outcome and a safe transfer or care.
Once accepted into CAMHS, a conversational
contact between treating clinicians would enable
them to join around the family. At this point it was
important to find a common language, diagnostic
consensus and common understanding, and then
to be able to share it with the family.
An integral part of this process included allocating jobs such as who was going to do
what or who was going be in charge of prescribing. All of this needed to operate
over the episode of care with timely and pragmatic communication.
The social and procedural elements of joining to form a working relationship
built on trust and respect was necessary to negotiate the model difference
and the services limitations in providing a continuum of care.
25
7 Invisible tensions pulling people apart
Key Idea #7 Resource limitations and different referral expectations between CAMHS and paediatricians results in tension in the working relationship. This tension is often erroneously interpreted as a lack of respect for the clinician and this erodes the trust within the working relationship.
Throughout this study there has been a
pattern of paediatricians and CAMHS being
unified in their desire to deliver good mental
health care to the children and families they
are looking after, but frequently finding
themselves at cross purposes when trying to
participate in a continuum of care.
We have identified the factors that put
pressure on forming an effective working
relationship such as treatment model
differences, service gaps, confusion
regarding referral pathways and an unmet
need for paediatricians to have access to a
publicly funded psychiatric opinion to assist
them when their capacity is exceeded.
When treating clinicians were able to have conversational contact to discuss the
child and family they were both involved with, many of the relationships tensions
melted away and the common desire to understand the child and family were
mobilized. This interaction was very quickly and efficiently a trigger point for better
coordinated care.
26 Within CAMHS there are some formal structures that scaffold partnerships with
paediatricians. These typically exist around services such as Autism Assessment,
Eating Disorders, Somatization Disorders and Consultation Liaison Services.
These services usually have an agreed protocol and job allocation that scaffolds the
treatment model differences, finds a common language, facilitates communication
and allocates jobs. This serves to immediately reduce the tension and confusion and
everyone can focus on treating the child and family and experiencing a satisfying
episode of care.
In some services the relationships build through these collaborations can form a
more durable link that can be accessed for future assistance. Unfortunately this is
no guarantee, as often the relationship does not generalize more broadly to other
areas of CAMHS –paediatric collaboration, but remains encapsulated in the
protocol, bound to a disorder or “clinic”.
27
8 Three patterns of linking to form a working relationship
Key Idea #8 CAMHS is the organizing structure for public mental health care delivery in Victoria. Across the state CAMHS and paediatricians can be variously linked in 3 broad patterns, ‐active, passive or dislocated. This impacts on the “continuum of care” experience. Joining to form a working relationship is
central to providing a continuum of care in
meeting the long term needs of the child and
family. The working relationship runs on trust
and respect which is required to negotiate the
different understanding and the service gaps.
Paediatricians in the community work
predominantly in private practices throughout
the CAMHS catchment. The CAMHS is the organising structure for each catchment.
The pattern by which they link with their community paediatrician determines the
quality of the working relationship and the nature of the continuum of care.
The three patterns of linking are active linking, passive linking, and dislocated
services.
If the CAMHS linking pattern changes in the catchment area there will be a
matching change in the continuum of care pattern as described in the next
section.
28 9 Active Linking between CAMHS and Paediatricians
Key Idea #9 Actively linked partnerships between CAMHS and paediatricians: •
Foster good working relationships •
Are responsive on all levels •
Are respectful of difference •
Seek to build common languages and understanding. This enables clinicians to join around the needs of the child and family, in addition this promotes capacity building and increases access to support and advice for future episodes of care. This also establishes trust and respect and helps negotiate relationship repair when referral requests cannot be met. This creates an optimum “continuum of care” model and is considered the “Gold Standard”. Services that are actively linked to
their paediatricians value and seek a
working relationship. They do this by
aiming to be responsive to
paediatrician’s requests on all levels
and understand the importance of
establishing trust and respect.
This helps them negotiate the constant pressure of the different professional
understandings and service gaps. A good repair process exists to help maintain a
good enough working relationship for subsequent episodes of care.
29
Positive Cascade
Within these services there is a positive cascade of behaviours that reinforces the
relationship, these include regular expressions of appreciation both ways.
The most important factor is joining around the child and family, and the most
effective way that this occurs is via conversational contact between treating
clinicians. This is where the differences evaporate and the true common interests of
the treating clinicians gel to form an enriched, well informed and synergistic care
system. At these times there is rich and effective learning around the child through
the episode of care, which increases the capacity of all clinicians, and especially the
paediatricians.
The continuum of care benefits from optimal strengths of both treatment approaches
–an example of model “gain-gain”.
The good experience for the clinicians from this episode of care is likely to enable
better access to assistance in subsequent episodes of care due to the strengthened
working relationship with its mutual understanding of each other’s clinical capacities.
Active linking is easily overcome by the elements, namely the natural inclination for
model tension and service tensions to pull the relationship apart.
The linking is often located in the person of the linker who is usually a visionary,
outsider or a champion. The problem arises when the champion gets promoted or
burnt-out. When they go, the link goes because the environmental forces pulling the
relationship apart are far stronger.
Linking is resource dependant. It takes a lot of time and persistence, which is often
“stolen time” from other KPI’d activities.
30 10 Passive linking between CAMHS and Paediatricians
Key Idea #10 Passively linked partnerships between CAMHS and paediatricians occur when: •
Services are responsive and respectful BUT, •
Do not actively seek to foster a good working relationship •
Do not actively address areas of difference •
Do not seek to build a common language and understanding. This is less effective in jointly addressing and coordinating the needs of the child and family, resulting in a more parallel type of care. The absence of an established working relationship results in less capacity building and less access to support and advice for future episodes of care.
Services that engage in a pattern of
passive linking with the paediatricians in
their community are careful to be
responsive and respectful when
approached with request for help, but do
not actively seek a working relationship.
Once the approach has been made the respect and the responsivity of the CAMHS
allow the working relationship to be formed but relies on the persistence and
knowledge of the paediatrician. This means that the onus is on the paediatrician to
negotiate the differences and service gaps. Effectively the two components of the
continuum of care are operating as silos but are managing the interface adequately
Under these instances the paediatrician and CAMHS are more likely to deliver a
“package of care”, than be an effective member of a continuum of care.
31
The service gap tension is less reduced because there is still care pathway
confusion and little relationship beyond Intake as the CAMHS continue to “not know
what they don’t know”. They don’t negotiate model tension.
The CAMHS are still able to increase the capacity of the paediatrician and help them
manage clinical care in Tier 2 when asked, due to the responsivity that they provide.
32 11 Perpetual dislocation between CAMHS and
Paediatricians
Key Idea #11 Dislocated partnerships between CAMHS and paediatricians •
Are unlikely to be able to form a working relationship •
Are not responsive • Are critical and dismissive of each other’s input. Therefore they do not perceive themselves as a “continuum of care” resulting in the child and families experiencing confusing, uncoordinated and competing care. The absence of a working relationship prevents capacity building and prevents access to support and advice for future episodes of care. This perpetuates the dislocation and reduces the possibility of a repair process. The challenge for services is to restore a working relationship and move out of this inefficient and poorly coordinated pattern. 33
In areas of dislocated services there has been a failure to form a working
relationship. CAMHS and paediatricians have struggled to join around the needs of
the child and family.
The CAMHS service finds it difficult to be responsive to the paediatrician’s request
for assistance. Both sides became critical, defensive and dismissive of each other’s
efforts.
There is little trust or respect for each other and they frequently engage in
competing behaviour.
Some paediatricians identify actively avoiding collaborations with CAMHS as a
means of “protecting” the child and family in their care. Both CAMHS and the
paediatricians focus on all the negative components of the other’s treating model,
and see this as ultimately harmful care. When episodes of shared care do occur
there is poor communications and poor conferring in some dislocated services.
In this setting competing silo structures tend to evolve with “bought in” expert care to
try and replace the CAMHS expertise.
Common areas of Paediatric - CAMHS collaboration, such as Consultation Liaison
services, Eating Disorders or Autism Assessment services can still continue to
function.
Negative cascade
The lack of joining to form a working relationship maintains the prevailing critical and
dismissive view of services. There are few opportunities for a repair process as
everyone is “hunkered down” in there respective defensive positions.
The lack of joining means that treatment model differences and service tensions are
not negotiated and the resultant different opinions are interpreted as evidence of
incompetence.
34 The child and family get narrow, single model care, with a strong pressure to side
with either one or other components of the continuum of care.
Regions stuck in this pattern spend a lot of time criticising the other
component of the service and defending the integrity of their own. This needs
to be understood instead as a symptom of a dislocated and stressed
catchment that is not coping with the absence of a working continuum of care
model.
In regional settings there have been examples of moving from a perpetually
dislocated pattern of linking to an actively linked pattern in less than 12 months. How
this was achieved will be discussed in the next section.
35
12a Enablers
Key Idea #12a Building partnerships between CAMHS and paediatricians requires resources such as time and work, which often goes unacknowledged and unfunded. It relies on the goodwill of individuals and therefore is not sustainable. The formation of a working relationship
has been identified as central to
paediatricians and CAMHS working
together so it follows that anything that
facilitates it or reduces the stress on it can
be considered to act as an enabler.
Examples of this around the state were:
General
Things that support relationship
building
•
•
Regular meetings.
•
Conversational contact/conferring.
•
Responsivity –secondary consult.
•
Finding a common language.
Being respectful about differing opinions e.g. un-diagnosing, or not accepting
referral.
•
Respect and appreciation in general courtesy.
•
Joining structures such as Eating Disorder, Autism, with protocols where
equal valency of input lead to mutual appreciation.
•
36 Good referrals that understand demands of the service.
Things that support capacity building
•
Providing information on latest treatments and trends such as information
sessions or supporting continuing medical education (CME)
•
Secondary consultation i.e. learning around an episode of care
•
Help with understanding systems of care, e.g. at Triage
Moving from “Perpetually Dislocated” to “Actively Linked”
All the above factors were put into play when several CAMHS wanted to move the
pattern of linking they had with their paediatricians from “Perpetually Dislocated” to
“Actively Linked”.
The Service Directors understood the importance of working with the paediatricians
in their community and respecting their contribution to mental health care in their
catchment.
They organized and attended regular monthly meetings, where shared and difficult
cases were discussed. At these meetings they would provide teaching around the
clinical cases but if the paediatricians had specific requests, would provide a more
formal summary of latest understandings and treatments. The “tea and cakes” at the
meeting provided a social setting to help heal the previous mistrust so, when the
paediatricians had a difficult case they would ring the CAMHS psychiatrist who had
made themselves available.
With all components of mental health care in the catchment under pressure, this
assisted the ongoing stress of turning down referrals or “un-diagnosing” a previous
clinical assessment but this was handled with respect and sensitivity.
The increased capacity of the paediatricians, who now felt supported by the
psychiatrist or senior CAMHS clinicians, meant that referrals that came to CAMHS
were streamlined and appropriate. There was not a “flood” of new referrals, rather a
continuation of the existing substantial pressures.
37
This work took time and a sustained effort and was only possible by increased
resourcing of the CAMHS including more funding for psychiatric time.
Examples of Innovation
Across the state different services had come
up with interesting solutions to the perpetual
problem of resource allocation and the
pressures of providing a responsive service.
Single session opinion linked to Intake.
Some CAMHS would offer single session
diagnostic assessments linked to triage for ambiguous cases with which the
paediatrician required some advice and direction. The paediatrician would be
requested to clarify their clinical dilemma so that the CAMHS could make sure they
addressed the clinical question in hand to enable the paediatrician to continue with
the ongoing care. Alternatively they could offer advice on whether referral to
CAMHS was appropriate.
Combined Autism Training for Paediatric and Psychiatry Trainees
An intensive training workshop for paediatric and psychiatry trainees was run, which
targeted conducting a streamlined, and professional assessment. This enabled
either trainee to slot into an Autism Assessment Service within CAMHS across the
state and assist in reducing the waiting list for an assessment. This simultaneously
bridged any existing clinical model differences by creating a shared language and
understanding with which to approach autism assessments. The training experience
fostered healthy and rewarding working relationships between the two disciplines.
Since this project commenced in 2009 several workshops of this nature have been
run with nearly 100 clinicians trained in this method. The make up of the workshop
continues to prioritize paediatric and psychiatry trainees, which make up the majority
38 of these numbers. Feedback from participants is consistently high in praise for
raising of clinical skill and enabling individual clinicians to perform an Autism
Spectrum Disorder Assessment that complies with the standards set out by Autism
Victoria in 2010. The workshop additionally clarifies clinical pathways into CAMHS
and goes into the pragmatics of report writing such as length and turn around times
and what to include.
Following each workshop there is a strong expression of interest for ongoing training
to further develop expertise in the field.
Supporting community multidisciplinary teams to perform autism
assessments.
A CAMHS service identified triads of speech pathologists, psychologists and
paediatricians in the community and supported them with regular professional
development in the field of autism assessments. When a request for an autism
assessment was referred to Intake they would recommended a selection of these
community triads with the advice to both the child and family or the clinical
community team to recontact the service if there was any areas of the assessment
and diagnosis with which they wanted assistance. This helped streamline the more
complex and ambiguous autism cases to the CAMHS where they had the resources
and expertise to perform a more detailed assessment. This enabled the CAMHS
waiting list to be maintained at a manageable level, build capacity in their
professional community and facilitate linked working relationships with their local
community of clinicians.
Green Light to Paediatricians Project
A large metropolitan CAMHS ran a project where they undertook to give an
automatic “green light” i.e. acceptance, to any paediatrician making a referral to
CAMHS. This was in acknowledgment of the expertise that the paediatrician brought
to mental health and that by attending a paediatrician the child had already
accessed a detailed assessment.
39
The proviso to this was that the paediatricians documented the detailed assessment
they had taken and included this with a clear statement of the treatment requests in
the referral. One-line referrals were not acceptable. (See Appendix 1)
Buying in Psychiatric Expertise
Some paediatric services working with a significant mental health caseload would
employ a psychiatrist as an “in house” expert, capacity builder and resource for
primary and secondary consultations. This reduced the strain of getting a mental
health opinion from their local CAMHS unless it was identified by the in-house
psychiatrists to be the most appropriate setting for treatment.
Cross disciplinary training terms
Several CAMHS associated with paediatric teaching hospitals would offer accredited
fellowship training terms for paediatric trainees. This would give the trainee a
comprehensive teaching in the bio-psycho-social-developmental training used by
CAMHS. They would also become familiar with working as part of a multidisciplinary
team. During the rotation the paediatric trainee would need comprehensive
educational support and supervision from a psychiatrist to prevent them from feeling
overwhelmed and traumatized by the challenges of the rotation. A well-supported
rotation would enable an easy and effective working relationship with any future
contact with CAMHS as they then were able to negotiate the interface with common
language, understanding of the care model, and expertise in mental health care.
Unfortunately the converse appeared to be true such that a paediatric trainee
working in such a placement with inadequate support tended to be negatively
sensitized to the mental health clinical frame and avoidant of this kind of work.
CAMHS running an additional Tier 2 service
One metropolitan CAMHS alleviated service pressures by additionally running a
Head Space in their catchment. This is a funding model that utilizes the Medicare
system. It was able to provide a Tier 2 capacity that was coordinated with CAMHS.
This provided further options for mental health referral not deemed to meet the
CAMHS threshold.
40 12b Barriers
Key Idea #12b Structural barriers exist to forming working relationships between clinicians, such as Triage procedures and Intake processes. Triage is designed to be a single entry point to a service, however this is counterintuitive to referral expectations and processes between paediatric specialists to other medical specialists such as a Psychiatrist. There were a variety of experiences of
“Intake”, the entry point to CAMHS, and this
depended on how it was set up, where the
catchment was, and how many services the
CAMHS Intake was coordinating.
From July 2010, access to public mental health services in Victoria is being
transitioned to be via mental health Triage.
The Mental Health Drugs and Regions Division definition of triage and intake
assessment 2states that triage is provided for all potential consumers (or people
seeking assistance on behalf of a person thought to have a mental illness) and is
the first point of contact with mental health services. Triage may also be used for
assessment of current and former consumers who make unplanned contact with the
mental health service.
2
Statewide mental health triage scale: Guidelines, Department of Health, Victorian Government, May 2010.
41
Triage is a clinical function. The role of the triage clinician is to provide a positive
response to help seeking and in doing so conduct a preliminary assessment of
whether a person is likely to have a mental health problem or disorder, and the
nature and urgency of the response required.
Where a mental health triage assessment indicates that specialist mental health
services are required (or possibly required), a more comprehensive assessment is
provided through an intake assessment. The intake assessment may result in
assisted referral to another organisation or in the person being treated within the
specialist mental health service.
Note: This process and protocol for service access has not yet been operationalised
consistently across the state. In speaking with mental health managers,
psychiatrists and with paediatricians for this project, most comments in relation to
“Intake” are in reference to a direct referral contact with a CAMHS clinician rostered
to assess (triage) whether the referral is appropriate for their service.
A small regularly staffed intake, such as exists in many of the regional services
usually had better success in forming a good working relationship and had better
familiarity with the local community of referring paediatricians. This was assisted by
the fact that there were a smaller number of paediatricians to get to know.
In some regional settings the proximity and clustering around a Base Hospital made
this task even easier, thus forming a trusting and respectful working relationship
became more straightforward. Importantly, this did not guarantee it happening until
the CAMHS had committed to actively linking with their paediatric community.
One of the key success factors was the paediatrician’s ability to form a relationship
with intake, which could be built upon. Intake could serve as a vital hub of
information to help direct requests appropriately and assist in either responding to
the paediatricians needs directly or facilitating the referral to an appropriately
responsive alternative agency or practitioner.
42 In larger catchment areas or with services with a generalized intake it was difficult to
form a working relationship with a department with its rolling shift changes. Working
with a protocoled department, as opposed to an individual, meant that intake was
experienced as a significant obstacle to be overcome. Time pressed paediatricians
were finding that they had repeated, detailed and exhaustive conversations with a
succession of clinicians with a paucity of consistent or helpful information.
Paediatricians identified that the most efficient form of assistance came from a
discussion with a psychiatrist either in the form of technical advice to assist the
paediatrician to continue caring for a child, offering a formal secondary consultant or
offering a primary consultation organized around the intake department to help
clarify the clinical issues.
The challenge for CAMHS psychiatrists was to be responsive to the paediatrician’s
request for assistance without undermining the function of the Mental Health Service
Triage and Intake functions. This will require changes in the way that both specialist
areas work together.
Other barriers to forming a continuum of care between paediatricians and CAMHS
were a continual changing of “the rules” either by the CAMHS or at the State level,
or baseline lack of clarity on how care systems operated.
A lack of timely response and communication to a paediatrician’s referral to CAMHS
could leave the paediatrician and child and family in a clinical “limbo”. At times of
crisis, which is often what prompted the referral this could impact on the safety of
the child and family.
Commitments on CAMHS resources and long waiting lists impaired the continuum
of care with paediatricians identifying feeling unsupported with advice on what to do
while in a “holding pattern”. The resolution of these issues around each individual’s
care or at times of crisis is inefficient. Spending time to plan care pathways between
CAMHS and Paediatricians is clearly efficient in the longer term and benefits client
care.
43
Guiding Principles
This study has conceptualized how paediatricians and CAMHS work together.
It has come up 12 key ideas about how this occurs and what are some of the
conditions and behaviours that impinge on this relationship working in an effective
manner.
Recommendations are based on the central idea of building, supporting and
protecting effective working relationships between CAMHS and paediatricians in the
service of providing a continuum of care experience with the child and family’s
needs at its centre.
CAMHS is the organizing structure of the Child and Adolescent Mental Health
Service and need to be the leaders in developing the local partnerships with the
paediatricians in their community. The working relationship needs to be established,
build upon and protected from the environmental stressors, that put it under duress.
Understanding the factors that get in the way
such as the differences in clinical
approaches, confusion around appropriate
pathways of care and referral thresholds, are
important in developing strategies for
successful interventions between CAMHS
and paediatricians.
Future funding opportunities could facilitate some of the following recommendations.
44 Recommendations
Recommendation 1: Information and Communication
The continuum of care can be improved through the development of better
information networks by:
1.1 Establishing a paediatrician database.
1.2 Exploring the use of current and emerging communication
technology to increase the ease of communicating, while observing the
principles of confidentiality and privacy.
General information sharing and clinical case information sharing could be facilitated
by establishing a comprehensive Paediatrician Database. This currently does not
exist.
This could include up to date information on contact details and availability. This is
to assist linking a dispersed community of paediatricians to CAMHS, and beyond to
the mental health system and organizations such as Mindful, Centre for Training and
Research in Developmental Health. It would also assist CAMHS clinicians
communicating directly with referring paediatricians around shared clinical cases.
A network such as this would assist in disseminating important local and general
information about pathways of care, mental health system news and could be
accessed to promote Continuing Medical Education. A Paediatric Database would
facilitate the forming and maintaining of partnerships.
45
Recommendation 2: Supporting the Paediatrician’s capacity and
building collaboration
2.1
It is recommended that CAMHS services explore how they might better
facilitate more timely and direct interchange of clinical advice and
information between psychiatrists and paediatricians.
2.2
As specialised services, CAMHS and Paediatrics (Paediatricians)
develop collaborative practice options that suit clients who may require
expertise from both sectors concurrently or sequentially eg: shared
care, consultation and advice.
Paediatricians have identified that access to specialist mental health information
with difficult cases greatly assists their own level of expertise, enriches their
treatment model and helps appropriately direct referrals and manage risk. This
expands their capacity to manage moderate to high-risk children.
The health care sector in which they operate has the expectation of being able to
discuss cases doctor to doctor. Paediatricians experience the most efficient
extraction of technical information and clinical advice from speaking with the
CAMHS psychiatrist.
Where possible this could be promoted as a means of partnership linking and
capacity building. This can occur through regular clinical meetings, calling the
CAMHS psychiatrist for advice, formal secondary consultations linked to Intake or
psychiatrist lead education sessions. Without new funding or additional resources,
this will require careful management of psychiatrist time.
In addition it is important that paediatrician’s form working relationships with nonmedical CAMHS treating clinicians and that direct consulting with the psychiatrist
does not undermine the intake process. If a clinical case does not meet CAMHS
criteria, current Triage policy and practice guidance requires that the mental health
46 service actively assist the referring agent (paediatrician) to access appropriate
alternatives.
Recommendation 3: Pragmatic Communication
It is recommended that:
3.1
Referrals from paediatricians to CAMHS provide adequate and
appropriate information ensuring that the nature of and the reason for
the referral request are clearly articulated.
3.2
CAMHS make referral forms readily available.
3.3
All CAMHS consider and refine their processes to ensure provision of
timely pragmatic feedback to referring paediatricians.
A crucial requirement of operating in a continuum of care is that all the partners
need up to date information about the current management plan and progress.
Communication needs to be timely and pragmatic.
A very efficient form of communication occurs when treating clinicians are able to
talk directly to each other at some stage during the episode of care. This is not
always possible.
Written communication needs to use concise, easy to understand language to
communicate the clinical understanding and provide clear information on treatment,
the management plan and clinical review criteria. When there is a significant status
change in the child’s clinical presentation, more frequent communication is required.
The “standard” discharge summary is often jargon heavy and relies on CAMHS
specific technical language that is not useful. It can be confusing and leaves the
practitioner unclear on what target symptoms to monitor, when to refer back or
alternatively when to cease treatment.
47
Similarly, when a paediatrician refers a child and family to CAMHS, a detailed
history accompanied with a specific request or statement of the clinician’s dilemma
will help direct the process and allow the triage and intake to be more helpful.
Specific attention to timely and direct communication around the success or failure
of a referral to CAMHS will assist the paediatrician to manage the safety of patients
at risk.
An exemplar of communication and access arrangements is the “Green light to
Paediatricians Project” – Appendix 1. For this system to work paediatricians need to
understand CAMHS criteria and the requirements of referral documentation.
.
Recommendation 4: Common Training: Fellowship Program and CME
It is recommended that:
4.1 Mindful and the Paediatric Clinical Network explore opportunities to
influence and participate in the creation of shared and cross sector
training for trainees as well as for qualified psychiatrists and
paediatricians.
4.2 In order to promote building of local working relationships, CME style
training would be most beneficial delivered locally and involving Child
and Youth mental health services.
Common training is an effective way to address many of the barriers to providing a
continuum of care.
It enables the continuum of care, and the increased capacity that results from
training, better prepares the Tier 2 clinician for support from Tier 3.
48 Training can occur at 2 levels, as a form of Continuing Medical Education (CME) for
practicing clinicians, or during the initial fellowship training of both Paediatricians
and Psychiatrists. The Autism Assessment training was an example of this.
CME style training needs to be delivered in an easily accessible way that
understands the pressure and time constraints of the paediatricians in the
community and sessional CAMHS clinician. New technologies such as online
learning and teleconferencing help bring a virtual community together.
In order to promote building of local working relationships CME style training could
be delivered at or by the local CAMHS.
Mindful, Centre for Training and Research in Developmental Health and others,
could assist with the development of appropriate training modules that could be
modified for local needs and distributed to the local CAMHS to role out.
49
References
Australian and New Zealand Journal of Psychiatry2000, Vol. 34, No. 2 : Pages 214220 The national survey of mental health and wellbeing: the child and
adolescent component. Michael G. Sawyer, Robert J. Kosky, Brian W. Graetz,
Fiona Arney, Stephen R. Zubrick, Peter Baghurst
Victoria. Dept. of Human Services. 2006 CAMHS in communities : working
together to provide mental health care for Victoria's children and young
people Department of HumanServices, Melbourne:
http://www.health.vic.gov.au/mentalhealth/camhs/camhsrep0906.pdf
50 Appendix 1 Green Light to Paediatricians, Southern
Region CAMHS
Phase I of this Project has been rolled our around the Autism Assessment Team.
Phase II is planned for role out around more general mental health presentations.
Document 1: Letter to Paediatricians introducing the project
51
Document 2: CAMHS sets out referral and Intake criteria.
Paediatrician Autism Green-light Project: Southern CAMHS
CAMHS tier 3, by definition should provide services to those children and young
people with complex and severe mental health problems who require multidisciplines team input. CAMHS referral acceptance should reflect this guiding
principle. In many instances, children and adolescents have had
assessment/treatment through tier 1 and tier 2 services.
Autism referrals, in general, can be categorised in 4 groups:
A. Preschool or primary school-aged children who have been developmentally
assessed by a paediatrician, who meet all the DSM-IV or ICD-10 criteria for
either Autism or Asperger’s Disorder. The child meets the criteria for autism
or Asperger’s Disorder, and requires no further assessments to confirm the
diagnosis.
B. Preschool or primary school-aged children who have many features
suggestive of the Autism or Asperger’s Disorder where a paediatrician is
seeking diagnostic clarification from the CAMHS multi-disciplines team.
C. Preschool or primary school-aged children who have been assessed by a
paediatrician, and meet all the DSM-IV criteria for either Autism or
Asperger’s Disorder, but require further (IQ or speech & language)
assessments. In exceptional circumstances, where a referral has been made
but assessment cannot be provided by practitioners in the private or
government sector (e.g. private psychologist and speech pathologist,
Specialist Children’s Services, Biala or a Department of Education and
Training psychologist or speech pathologist), Southern Health CAMHS will
consider and accept the referral to carry out such assessments.
52 D. The child displays significant developmental delay and/or deviancy,
associated with complex psychiatric co-morbidities. These children will be
characterised by persistent and severe affective and/or behavioural
difficulties. Referrals should be at the more severe end of the spectrum with
significant functional impairment.
In summary, those children who meet the criteria B (needing diagnostic clarification),
C (having a diagnosis of autism/Asperger’s and, require IQ or speech & language
assessment which can not be obtained by any engaging other service), or criteria D
(complex autism/Asperger’s Disorder) are considered appropriate PTS referral for
CAMHS assessment.
Children meeting criteria A are not considered appropriate CAMHS referrals.
53