Abstract
Childhood emotional and behavioural problems are widespread [1] and each year thousands of families seek assistance from Child and Adolescent Mental Health Services (CAMHS) around Australia. The overwhelming demand means that families often have to wait months for their first appointment [2,3]. As a result, troubled children can be denied timely help and family patterns of dysfunction can become entrenched. In South Australia, consumers and referrers have advocated change towards a more streamlined intake system. This prompted the South Australian CAMHS Program Committee to introduce Initial Consultations to triage new referrals.
Since the Initial Consultations began in June 1998, families have been offered an appointment within one to three weeks of their first telephone contact, reducing the waiting period for the first consultation by months. The Initial Consultation is a 90-minute family session for triaging new referrals according to a clinical assessment of diagnosis, problem severity and level of functioning. It enables children with serious disorders to commence immediate treatment, and those with less severe problems either to return to primary care or remain on the waiting list for follow-up. In this way access is improved for young people presenting with serious conditions such as childhood depression, eating disorders, severe attention deficit disorder and early psychosis, while children with less severe emotional and behavioural problems have the benefit of a timely consultation.
In practice about 30% of new referrals receive only the Initial Consultation and have no further specialist help. In these cases, contact is limited to the 90-minute family session. This has accelerated the trend towards shortened assessment that has been noted in South Australia [4]. The system represents a radical departure from the traditional four session model used for child psychiatry training. Other states are also trialing briefer assessments such as the two session model from the Victorian Postgraduate Child Psychiatry Training Program [4]. Relatively little is known, however, about the results of these briefer assessment approaches for children and families.
There are particular concerns when relatively complex child assessments are completed in a single session. This occurs quite frequently even when longer periods of assessment may be desirable [5,6]. Evidence from parent satisfaction studies suggests that single consultations can be useful although they fall well short of the traditional child assessment model. For instance, a survey of outpatient child and adolescent services at Rivendell [6] found that most parents (65%) were satisfied with a single consultation and most clinicians (74%) believed that the goals of assessment had been achieved. Several other Australian child and family centres have used a single session approach described by Talmon [5] to maximise the effectiveness of single consultations. Parents generally found these sessions helpful (78 to 81%) and reported subsequent improvement (68 to 78%) in the presenting problems [3].
The current study of the Initial Consultation model of assessment aimed to follow a group of children who were triaged away from further specialist care (and towards primary care). The study group is of particular interest because they had no further contact with CAMHS and clinically there was scant information about their progress. For this group, the adequacy of the initial assessment was crucial since it was a major determinant of their future contact with specialist services.
It was expected that the Initial Consultations could select a group of children who did not require ongoing specialist care. The study used standardised measures of the severity of children's mental health problems and the level of family functioning to measure these characteristics of the group. On average, children were expected to have mental health problems of moderate severity and families that were functioning reasonably well. Given these indications of relatively good prognosis, children's mental health and family functioning were likely to show some improvement in the months after assessment. The study also included a global rating of parent satisfaction to determine whether the severity of the presenting problems influenced parent satisfaction with the single session model.
METHOD
Parents of consecutive clients from one rural and two metropolitan CAMHS centres were invited to participate in the survey when they telephoned for an appointment. Questionnaires were mailed to parents preconsultation (Time 1) and 3-months post-consultation (Time 2) with two reminders for non-respondents [7]. This resulted in an overall return rate of 66% at Time 2.
At both time points, the questionnaire contained standardised measures of childhood mental health problems (the Child Behavior Checklist, CBCL) and family functioning (the general functioning subscale of the Family Assessment Device, FAD). The CBCL has 112 questions for parents about their child's behavioural and emotional problems that can be used to derive a total problem score [8]. The general functioning subscale of the FAD (12 items) gives a global rating of family dysfunction for clinical and community populations [9]. At Time 2 parents were also asked to rate their overall satisfaction with the Initial Consultation on a 4 point Likert scale. The questionnaire data was analysed with SPSS 8.0 for Windows using Student paired t-tests, Pearson correlations and Spearman correlations.
RESULTS
Ninety eight parents completed both the Time 1 and Time 2 questionnaires. Most (95%) of the respondents were mothers or stepmothers, and the remainder were fathers (3%) and other carers (2%). The children had a mean age of 9 years. Boys (54%) slightly outnumbered girls (46%).
Children receiving single consultations generally had mild to moderate emotional and behavioural problems with coexisting family dysfunction. At Time 1, the mean CBCL total problem score was 45.6 (SD 22.5) which is about midway between the means for the Australian community [10] and the original clinical reference group [8]. Twenty three per cent of the children scored above 60 suggesting that their mental health problems were in the clinical range. At Time 1, the mean FAD general functioning score was 2.02 (SD 0.50) which is comparable to the mean from an earlier South Australian clinic sample [11]. Twenty five per cent scored above the ‘cut-point’ for the subscale (2.17) indicating high levels of family dysfunction. There was a modest positive Pearson correlation between family dysfunction and children's total problems (r = 0.24, P <0.05) with more severe problems being associated with poorer family functioning.
At Time 2, the mean CBCL total problem score was 35.6 (SD 26.7). A paired t-test indicated that this was a statistically significant reduction from Time 1 (t = 4.9, P < 0.01). Seventeen per cent remained high scorers indicating clinically significant problems. The mean FAD general functioning score was 1.91 (SD 0.55) at Time 2 which was significantly lower than Time 1 (t = 3.2, P < 0.01). Twenty five per cent still had high levels of family dysfunction.
The majority of parents were ‘mostly satisfied’ (34%) or ‘very satisfied’ (26%) with the Initial Consultation while the remainder were ‘indifferent or mildly dissatisfied’ (31%) or ‘very dissatisfied’ (9%). There was a significant inverse relationship between parent satisfaction and the mean CBCL total problem score at Time 2 (Spearman r = −0.30, P < 0.01) with more severe problems being associated with lower satisfaction.
DISCUSSION
A positive aspect of this study is that it investigates the routine clinical care of a relatively large group of children. While the introduction of triage interviews was greeted with positive comment by consumers and referrers, there is little systematic information about the results of the system especially for those children who are seen only once.
In the current study, most children who received a single consultation had mild to moderate mental health problems according to parent report. Family dysfunction was not extreme but was somewhat higher than expected; the mean level of dysfunction was similar to an earlier South Australian clinic sample [11]. These results suggest that single consultations were most often for children who could reasonably be referred to primary care for further treatment.
There were significant reductions in mean scores for family dysfunction and children's problems between intake and follow-up. Caution is required in interpreting these results. Parents completing questionnaires for a second time often report fewer problems. It is not possible to determine whether the current results are due to ‘regression to the mean’ in this population or measure actual mental health gains. Nevertheless these results suggest improvement rather than deterioration over the three month follow-up.
A subgroup of children were reported to have more severe and persistent problems. Over the two time points, between 17% and 23% were high scorers. Twenty five per cent also had high levels of family dysfunction. For the future, it may be useful to have routine telephone contact after the Initial Consultation. This could be done as part of the active management of CAMHS follow-up lists (of children awaiting further treatment after Initial Consultations). Telephone interviews may help identify high scoring children whose problems have not improved and these families could be encouraged to return for treatment.
Results suggest that parents of children with more severe problems were more dissatisfied with the existing Initial Consultation system. Parent satisfaction was related to the burden of children's symptoms reported at follow-up, with those reporting more problems being more dissatisfied.
Understandably a single consultation may not have adequately met the expectations of parents whose children had problems at the more severe end of the range. The correlation was only modest but warrants further exploration using more specific questions about satisfaction and reports from multiple informants (to reduce the potential bias with single informants).
The level of parent satisfaction was toward the lower end of the commonly reported range [6]. This is surprising given the positive response from consumers when the system was introduced. It is concerning that some parents may not have been satisfied because they regarded the assessment and feedback as too brief. Interestingly the Rivendell survey [6] also found relatively low parent satisfaction with single consultations and that satisfaction increased markedly when parents had received more sessions. Further study of parent satisfaction with the one, two and four session assessment models currently in use [4] could help decide which model is the most acceptable to parents. This would compliment other information from trainees, trainers and practitioners.
Acknowledgement
The authors gratefully acknowledge project funding from the South Australian Department of Human Services and administrative assistance from the Child and Adolescent Mental Health Services.