Transcript Loss and Grief for Children and Adolescents

Odds Ratios† Predictors Suicide Attempts
BOYS 13.5 years
DEPRESSION
2.4
5.4**
HOPELESSNESS
3.5
20.6
SUICIDE
RISK
SEXUAL
ABUSE
9.4
6.4
ANTISOCIAL
5.3
DRUG ABUSE
† adjusted for family dysfunction, significance p<.001, except ** p<.01; * p<.05
SUICIDE
ATTEMPT
The changing face of mental
health services
In the 80s
We dealt more with
Anxiety Disorders
Depression
Developmental problems
Minor behavioural problems
Drug induced psychosis and ADHD were rare
Bipolar Disorder & Asperger’s almost unknown
In the new Millennium
Serious conduct disorder and delinquency (for
which we have a limited skill set)
Self-harming behaviours (60% of our CYMHS
referrals in a recent survey)
Drug induced psychosis (where we are fighting a
losing battle)
A wide range of disorders which may have their
origins in Poor Attachment and Social Exclusion
(where social change is necessary, which may be
outside our ambit)
In the new Millennium
Family Crises (more families seem unable to
cope with normal developmental transitions)
Depression (which may itself have origins in
Poor Attachment and Social Exclusion) seems
to be at epidemic proportions, and is
overwhelming our skill set, but….
Anxiety Disorders (for which we have a rich skill
set) are now the hidden calamity (particularly
Social Phobia)
Antidepressant Use 1995
(Number)
MALE
0-14
FEMALE
15-24
0-14
Amitryptiline
1727
Dothiepin
Doxepin
15-24
2198
199
Fluoxetine
724
41
178
852
63
2134
Other
27,292
4083
4940
2845
Total
27,491
7,134
5044
7417
ABS, 1999
Medication Use (18-34 yrs)
NHS Survey 2005
704,200 used psychotropics
41,548 (5.9%) Citalopram
25,351 (3.6%) Paroxetine
51,407 (7.3%) Sertraline
= 18.5% Total SSRIs
11,972 (1.7%) Other SSRI
20,422 (2.9%) Venlafaxine
12,676 (1.8%) Tricyclics
12,676 (1.8%) Other Antidepressant
10.1% Anxiolytics
83.5% other including 69.2% Vitamins and Minerals
Table 15, page 36 Ausstats 2005
Western Australian Child Health Survey:
Children with Mental Health* Problems
Number (‘000)
30.0
23.5
Per cent
20.0
15.4
4 to 11 year olds
12 to 16 year olds
30.8
16.0
All children
53.5
Males
Females
22.7
20.6
17.7
* as determined by caregiver and teacher using the Child Behavioural Checklist
Zubrick et al 1995
Mental & Behavioural
Problems, 2005
0-14
Rate %
15-24
Rate %
19,000
0.71
Alcohol/Drug
np
Mood Disorders
30,300
0.77
144,600
5.4
Anxiety
89,700
2.3
123,600
4.6
Psychol Devel
100,600
2.57
60,800
2.26
Behavioural
116,300
2.97
34,700
1.29
Other
19,400
0.49
21,000
0.78
Symptoms/Signs
8,300
0.21
7,600
0.28
Total
263,000
6.71
267,800
9.94
Population Total
3,920,600
2,693,000
My own experience
A PERSONAL CONTEXT
London 1968-9
Analytic psychotherapy (Irving Kreeger, Gordon
Stuart Prince)
Hypnosis (Marcuse)
Behaviour Therapy (Marks and Gelder)
Canterbury 1970-74
Child Psychotherapy (Ken Munro Fraser)
Structural Family Therapy (Minuchin)
25 bed inpatient Unit
A PERSONAL CONTEXT
Adelaide 1974-82 (Children’s Hospital)
Infant Observation
Child and Adolescent Psychotherapy
Transactional Analysis (Berne)
Gestalt therapy
Group therapy
Strategic Family Therapy (Gerard, Epstein, Haley)
Systemic Family Therapy (Palazzoli et al)
Narrative Therapy (White, Epston)
A PERSONAL CONTEXT
Private Practice 1982-86
Expert Family Therapy group 2 years
Flinders Medical Centre 1986-2001
Cognitive Behavioural Therapy
Individual Therapy
Family Therapy (Screens and Teams)
Solution Focussed Therapy (de Shazer
and Insoo Kim Berg 1990)
A Note about Private Practice
Solid Clinical Work
10-12 hours per day, on the hour every hour
600 new cases in 4 years - ie about 3 new
cases per week
Some school visits
Some supervision and Teaching of registrars
Art classes one afternoon a week to preserve
sanity
If you want effectiveness and
efficiency in a service, there is no
substitute for highly skilled, well
supervised, experienced clinicians.
Clinical Work
Central to what we do
Yet we can never be quite certain what goes
on in the consulting room
No measures, no online reporting, no audio
can really tell you what goes on
Current administrative attempts to find out are
self serving and overwhelm the clinical
process
The best Risk Management is to have good
clinicians
On Entry to Clinical Service
2 week full time Orientation Program
16 week twice a week therapy training
program in house
Option for lengthy training and supervision
with expert therapists (eg Malcolm Robinson
or Michael White for CAMHS in South
Australia) with service sharing the cost and
the time cost.
Clear Clinical Expectations
1-2 new cases a week
ie 70-75 per annum on average (range 50100)
For 30 therapists in a service you could
manage about 2200 new cases
10± clinical follow-ups a week
ie about 500 follow-up per annum
For 30 therapists about 15,000 slots per
annum
Therapist Burnout
Too little training
Too little supervision
Too little variety
Too many cases
Too much paperwork
Important to provide enrichment - special
project development, teaching, evaluation,
research, publication
Issues
You must have staff who have energy
to reach out
You must avoid the ‘Exclusive Service’
mentality:
 “we exclude everyone who does not meet
DSM4 criteria”
Every minute you take away from
a clinician doing best quality
clinical work wrecks any attempt
to provide efficiency.
Sustainable Service
Development South Australia
 Southern CAMHS (Flinders Medical Centre - 15 years)
2 teams to 6 teams
No rural service, to 3 rural teams
12 therapists to 40 therapists
No teaching, to Masters level programs
No research, to 22 programs including two longitudinal
programs
CHASP Accreditation 1994 (the first CAMHS ever)
Gold Award THEMHS 1994
Clinical Work 1985
Systematised interviewing (Eisen & Irwin)
4 sessions of assessment with an initial
interview with the family, then two
interviews with the child, then a family
feedback session.
The problem was that the mean number of
sessions attended was only 3, with a mode
of 1.
Clinical Work 1995
We reviewed 200 clients to see what
had happened to them.
50% had ‘got what they wanted’
20% felt the service had little to offer
their problem
Clinical Work 2008
Initial Consult System
Single session
Asked the patients what they wanted to
achieve by the end of the session
Listed their problems and ranked them
Discussed alternatives for change in the most
pressing problems
Psychoeducational approach
Checked at the end of the session to see
whether they had got what they wanted
Window Shopping is OK!
Registration as a Case
Genuine issue here
Do you register at the first session even if they are never going to come
back?
Or do you wait until they commit to
some specific course of therapy
Sustainable Service Development
Queensland (2001- )
 RCH & District CYMHS
 Since 2001, Service to BYDC
 CYFOS Development
 MHATODS Team
 Therapy supervision ++
 Reworking of CL Team and after hours service
 EI Strategy - KOPING strategy
 Recent ACHS Accreditation, exceeding most standards
 Publications (35 per annum - only 7-10 mine)
 Silver THEMHS award 2006
RCH & Brisbane North CYMHS
We monitor clinical and other activity,
and provide feedback to staff on a
regular basis through team leaders
We are meeting ALL of the criteria in
the National Workforce Standards
documents