Abstract
Assessment in child and adolescent psychiatry is the key to good practice. After reviewing practice in the UK and USA, the Victorian Framework for Child and Adolescent Mental Health Service Delivery stated a general assessment and presentation of feedback to the family may generally be completed within three hours by a welltrained specialist clinician. For many years, the Victorian Postgraduate Child Psychiatry Training Program has employed a four session assessment model in its Developmental Psychiatry Course. In a recent survey, the four session assessment model was found to be the norm of practice in Metropolitan Victoria.
There are diverse views on this general model of assessment in child and adolescent psychiatry. While some maintain the four session model is well suited to the demands of a complex task others argue it is more influenced by a repetition of the model employed in the individual's training. In order to find out whether the Victorian four session norm is matched elsewhere in Australia, as compared to experience in the UK and USA, we explored whether the same number of sessions are used in a different state
METHOD
A survey used in a previous study of Melbourne services was carried out in one of the regional mental health services in Adelaide. After obtaining the permission of the management team of the service, the clinicians were invited to complete a survey on assessment. The self report questionnaire had been developed by a study group that reviewed the literature on assessment, and listed the relevant areas of data collection. Two hypothetical case vignettes were written, one for a child (Ben) and one for an adolescent (Jane) which were used to anchor the clinicians' thinking. In the information sheet provided to the clinicians, it was emphasized that the questionnaire was anonymous, and the analysis of the results of the survey would only be done on a group basis. Completion of the survey was voluntary and confidential. A reminder was sent out two weeks after the initial survey to encourage clinicians to participate.
RESULTS
121 survey forms were distributed and 33 usable forms were returned, giving a 27% return rate. The results were compared with the previously collected Victorian data (n = 123) using ANOVA in the SPSS program.
The mean number of years of experience of working in CAMHS for Adelaide was 6.6 (SD = 4.7) and for Victoria was 7.8 (SD = 7.0). Those who have received formal training in assessment for Adelaide was 82% and for Victoria 91%. The distribution of professional groups among those who returned the survey form for Adelaide were: psychiatrist, 15%; psychologist, 39%; and other, 46%; and for Victoria: psychiatrist, 22%; psychologist, 24%; and other, 54%. No statistical differences were found in the above clinician information between the two states.
The mean number of sessions of assessment for Ben for Adelaide was 1.8 (SD = 0.9) and for Victoria was 3.6 (SD = 1.1) The mean number of sessions of assessment for Jane for Adelaide was 1.9 (SD = 1.0) and for Victoria was 3.4 (SD = 1.4). The mean duration of assessment in minutes for Ben for Adelaide was 115 (SD = 47) and for Victoria was 219 (SD = 90). The mean duration of assessment in minutes for Jane for Adelaide was 132 (SD = 65) and for Victoria was 220 (SD = 101). ANOVA was used for comparison and log transformations were carried out if the variances were statistically significant differences. Differences in these four comparisons were all statistically significant at < 0.001 level: F = 75.5, 48.6, 25.1, 34.2, respectively, ‘fter log transformation.’
The approach employed in both States was similar. For Ben's vignette, 87% of the clinicians from Adelaide would use a combined approach and 96% for Victoria. The combined approach means meeting with both parents and the child present, and meeting parents and the child separately. For Jane's vignette, 90% of the clinicians from Adelaide would use a combined approach and 95% for Victoria.
Finally the estimates of time spent on each part of the assessment process was compared between Adelaide and Victoria. The analysis was exploratory and looked at the overall pattern. The result was that Adelaide workers perceived themselves as spending less time on all of the items, and this was similar for both the child and the adolescent case. In particular, four items explained the bulk of the differences in the amount of time: developmental history (8.6, SD = 4.2 vs 21.8, SD = 12.9 minutes for Ben's vignette and 7.6, SD = 5.7 vs 18.9, SD = 13.2 minutes for Jane's vignette), family history (12.3, SD = 6.6 vs 27.6, SD = 15.8 minutes for Ben's vignette and 14.6, SD = 7.1 vs 26.2, SD = 16.0 minutes for Jane's vignette), mental state of the child (14.7, SD = 11.0 vs 41.4, SD = 28.8 minutes for Ben's vignette and 23.8, SD = 22.9 vs 42.9, SD = 30.2 minutes for Jane's vignette), and feedback (15.9, SD = 17.2 vs 38.6, SD = 17.4 minutes for Ben's vignette and 16.9, SD = 17.7 vs 36.6, SD = 18.8 minutes for Jane's vignette).
DISCUSSION
This study has the obvious weakness of using a survey instrument whose validity has not been checked in relation to other methods such as keeping a diary; or employing audio/video tape recordings.
The response rate of 27% in Adelaide was lower than the 67% achieved in Victoria. However, the experience of the clinicians and the distribution of the professional groups were similar in the two samples, suggesting that the comparison of the two samples was appropriate.
The big difference in the number of sessions and duration of assessment between Adelaide and Victoria cannot be explained by the difference in the experience of the therapists or the professional groupings, both of which were found to be related to the duration of assessment in our previous study. There are a number of possible explanations. The first one is how clinicians are trained in the two States. In Victoria, a four session assessment model has been used for many years for the training of clinicians who intend to work in CAMHS. This may explain why the majority of CAMHS clinicians in Victoria use four sessions in their assessment of a child or an adolescent presenting with mental health problems. The second explanation is the different models endorsed by the services and the pressures of work within the services. The third explanation is the differences in patient or consumer expectations. At this point, we have no information about these explanations but they offer the potential for further research.
The Victorian Postgraduate Child Psychiatry Training Program has debated the issue and agreed to further examine it. We have now developed a model of assessment which requires two hours to complete and can be done in two sessions. This model will be tried in the Developmental Psychiatry Course Clinical Training Program and will be compared with the traditional four session model training program. We will evaluate the effect of this new training program on the trainees and the trainers and its impact on the practice of assessment in the long term and will report the results in the near future.
Acknowledgements
We are grateful to all the child and adolescent mental health services and staff who participated in the surveys. The support of Professor Robert Adler, Professor Margot Prior, Dr Allan Mawdsley, Dr Paul Lee, Dr Neil Coventry, Dr Robert Salo and Professor Robert Kosky, and the research assistance of Lisa Wong are much appreciated.