AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022

Mental Health And Education – An Effective Day Program
Vicki Sykes, Mater Hospital Special School
Leanne Geppert, South Brisbane CYMHS

Introduction
Development of Model
Elements of Day Program
Patient Group
Team Structure
Program Format
Achievements
Effectiveness of the Program
Satisfaction Scores
New Hospital

Introduction:

We all know that young people with emotional and behavioural problems are not a homogeneous group and that there is no one right answer as far as intervention goes for these young people. The idea that one size fits all is either misguided idealism or cost cutting. The Day Program at the Mater Childrens Hospital is one option available which seems to provide appropriately for quite a number of these young people.

Young people we are involved with vary enormously. They may:

• Be severely antisocial, aggressive and disruptive
• Be socially rejected, isolated, withdrawn and non-responsive
• Show signs of severe anxiety or depression
• Exhibit psychotic behaviour
• Vacillate between extremes of withdrawal and aggression, and
• They nearly always have serious academic/school problems in addition to their social and emotional difficulties.

The young people we see have problems which are severe, pervasive and chronic as opposed to minor, situational or transitory.

We do not have a magic wand but try to provide a program based on characteristics which research tells us are most effective. These characteristics include:

• Systematic, data based interventions – looking at what works best for the specific problems exhibited by the individual student.
• Continuous assessment and monitoring of progress. Each student is monitored daily by both mental health staff and school staff. Students are also encouraged to become involved in monitoring their own progress.
• Treatment is matched carefully and specifically to the nature and severity of the students’ problems. Each student has his/her own individual plan.
• Multi-component treatment – the program involves a combination of services to address all aspects of the problem e.g. academic and social skills, family therapy, individual therapy, participation in groups, pharmacological intervention if required, re-entry to school assistance.

These services are not offered in a piecemeal way but as part of a coordinated program. The program provides for frequent practice of skills and opportunities to ensure skills are generalised across environments.

We try to ensure that the program is not a "one shot" intervention. The young person is not magically cured. What we do try to ensure is that follow up services continue to be provided either through us or through other agencies. We also try to ensure that support structures are set up at a local level e.g. in the school.

Resourcing is our major hurdle. I’m sure this is very familiar to all of you. Knowing what the young people need and being able to provide it are two different things and create the most frustration for the team. With health and education working together we believe we make the most effective use of the limited resources.

As with any team – whether it be interagency, multidisciplinary or transdisciplinary, members need to appreciate the context in which each person in the team is working.

Our team, like all other teams, has its ups and downs. The staff of both Child & Youth Mental Health Service and the school also belong to a number of other teams and time is always a problem. What enables us to overcome any problems that arise is the respect that team members have for each other. Central to the operation of the team is respect, cooperation and trust.

The team adopts a collaborative, problem solving approach which gives the team members equal opportunities to learn from each other. It is recognised that all members have specific, yet different but equally valued skills and knowledge to share for the benefit of the young people we work with.

All is not smooth sailing. On the odd occasion when the going is tough, team members need to regroup and think about why they came together in the first place and look at the outcomes that are being achieved because of this.

Development Of Model:

Our Day Program, which is in the process of having a name change to Partial Hospitalisation Program, did not just appear one day in its present form. It is a model that has grown, developed, had problems, gone backwards, gained momentum and continues to change. I believe that this is one of its strengths. Our day program is not something static which says this is the right way to do things and this is the way it will be done. It is a model which adapts to:

• the skills and personalities of the people involved:

Although there are similarities and differences between the worlds of health and education, if you start from the premise that the professionals involved from both worlds all want the best for the children and young people, then breaking down barriers becomes easier.

• the practical issues of staffing, funding and physical facilities:

These are the sorts of issues which are always present and can cause tensions if you let them. On the other hand if you look at resources as shared rather than yours and mine, you can make much more effective use of them.

• new research information, knowledge and experiences of others:

We are continually looking for ways to improve our service. Current research, visits to other facilities, contact with and sharing with others by fax, phone and e-mail, professional development opportunities - are all ways staff strive for continual improvement.

• the data and experience of our own staff:

We carry out case studies so that we can continually learn from what we are doing, and in turn contribute to the wider knowledge base. We hope to be able to increase our capacity for action research in the future.

• the needs of the young people and their families:

If we loose sight of this then we may as well pack up. It is the role of the team to explore all avenues to address the specific challenges being faced by each of the young people.

The history of our program dates back to when I was first appointed as Principal of the Mater School in 1986. Apparently before that there had been a psychiatric inpatient ward at the Mater Childrens Hospital. It closed in December 1985. I’m not sure of all the reasons but understand that the physical facilities were not suitable for the clientele, there were difficulties getting funding for the staff levels required and they could not get trained staff.

I had only been at the school a few weeks when I was approached by the Director of Psychiatry at the Mater Childrens Hospital. She talked about how most of the young people were receiving outpatient treatment and wanted to know if the school was willing to work with her team to put something better in place. This was the birth of the Joint Day Program between the Mater Childrens Hospital and the Mater Hospital Special School. The development of the model involved:

• a lot of meetings
• new ways of operating
• sharing of information and expertise
• team building
• opening new communication channels
• review and change
• frustration

Although the program in one form or another has been in operation since 1986 none of these things have changed – especially frustration. The program is constantly reinventing itself to better meet the needs of the young people and their families. We believe we are offering a world class service and if we are to continue to do this then continual renewal is essential.

The objective of our Day Program is to provide a tertiary-based service to young people with severe mental health problems. These young people (more often than not) also face significant educational challenges.

We offer an initial two week assessment phase for all appropriate referrals, and may go on to offer a treatment phase (involving daily attendance for a time which is suited to each individual) depending on the findings of the assessment phase.

Our core business is (a) Providing an early discharge program to inpatients of the CYMH service; (b) Assisting community based CYMHS patients who have a deteriorating mental health condition to avoid inpatient care where possible; and (c) To provide an intensive rehabilitation and reintegration service for young people with more severe illnesses.

Patient Group:

The young people accessing this program primarily present with diagnoses of Schizophrenia, Major Depression, Generalised Anxiety Disorder and other major anxiety disorders (including Separation Anxiety and Specific Phobias), Anorexia Nervosa, Bipolar Disorder and Post Traumatic Stress Disorder. Most commonly, these patients have dual diagnoses, or complex presenting problems which may not have been clearly diagnosed. Along with such presentations, may come challenges for the young person and their family such as severe behavioural disturbance, chronic self-harm, personality difficulties, school refusal, social isolation, family interactional problems and/or a general deterioration in mental state.

The age range of patients is primarily 5 years to 18 years, although we have previously offered a program to patients younger than 5 years with more of a focus on family interactions.

Team Structure:

The mental health and educational components of our team are ‘housed’ in different buildings within the Mater Hospitals Complex. Our joint team is composed of:

• Team Leader
• Psychologist
• Child Therapist
• Clinical Nurse
• 0.5 Group Facilitator
• 0.5 Occupational Therapist
• 0.1 Speech Pathology
• 0.3 VMO
• 0.5 Registrar
• 0.5 Allied Health Assistant
• School Principal
• Visiting Guidance Officer
• Liaison Teacher (as representative of Mater Hospital Special School staff)

Program Format:

Adolescent (High School) Schedule

Child (Primary School) Schedule:

• Daily start 8.30am
• Daily finish 3pm

 The children and adolescents attend on a daily basis. They participate in an individually designed program comprising of school (either the Mater Hospital Special School or their own school in the community) and individual, family or group based mental health therapies and activities.

In consideration of developmental needs, the primary school aged children typically have a higher component of education in their program than do the adolescents.

We are currently revising the parent component of our program and a parent support group will be established in April 2001. This group will be voluntary and be offered in addition to the therapy offered to families and parents.

Achievements:

Although we have been ‘in development’ since the mid-1980’s, it has only been since mid-1999 that a specific Day Program team was designated with a Team Leader, full-time Liaison Teacher and other specifically appointed staff members. This of course led to a large growth in patient numbers. In the last two years alone, our occasions of service have risen from approximately 200 per month, up to approximately 450 per month. Since January 2000, we have recorded approximately 6500 occasions of service. This demonstrates our commitment to providing a more broad-reaching service to a greater range of young people and their families.

Over the years of development, we have achieved much as a joint team. We have initiated a Community Seminar Program for both educational and mental health staff, which began last year with a seminar on the Management of Childhood Anxiety within a School Setting. This community based program supports the internal Inservice Program for our own staff, which continues to enhance the interchange of expertise, skill and knowledge between our two professional areas of mental health and education.

With the significant and talented contributions of the young people attending the Day Program, we have conducted community events such as a drama production, craft stall and art exhibition. A number of young people have also managed to shine in their contributions to Poetry competitions, winning state awards. And we contribute annually to Mental Health Week and other significant events related to education and mental health during our calendar year. These activities go a long way in developing the self-esteem, confidence and independent living skills of our young patients. Not to mention staff!

Our special interest in Early Onset Psychosis and extensive work in the assessment and treatment of young people with this illness has resulted in the invitation to contribute to relevant state policy development.

Effectiveness of the Program:

We are currently in the position of devising an empirically based assessment process to measure clinical change and patient/staff satisfaction. Measures of clinical change that we anticipate conducting pre-program, and 1 month, 3 months, 6 months and follow-up are:

• Children’s Depression Inventory
• Spence Children’s Anxiety Scale
• Strengths and Difficulties Questionnaire (Edited)
• Severity of Psychiatric Illness Scale
• Columbia Impairment Scale
• Satisfaction Survey

This battery will be supported by interview, daily observation and monitoring, therapeutic gain and any specific measures related to diagnostics.

We are presently finalising the submission for the ethics board and anticipate using the results to review outcome data of the program and publish research results in approximately 2 years.

A followup project is also currently in its planning stages within our unit. This project will involve assessing the maintenance of treatment outcomes at 12 months via written questionnaires. This will be an ongoing project conducted yearly.

In the meantime, the satisfaction and opinions of Day Patients and staff are essential to our ongoing improvement as a service. A variety of survey methods were employed to measure satisfaction levels, including parent/patient/case manager satisfaction surveys post-assessment/treatment, an annual satisfaction survey, and a ‘suggestions box’ for patients.

Overall Satisfaction Scores

Rated on a scale of 1 to 4, with 1= Unsatisfied and 4=Extremely Satisfied.

New Hospital:

In July this year, the new Mater Children’s Hospital will be fully functional and accepting its first patients. The new hospital is situated on the same complex as it is currently, but fronts on to Stanley Street (instead of Annerley Road), South Brisbane. Growth is again on the cards for the Day Program, which will be re-named the Partial Hospitalisation Program. The new name reflects an increase in illness acuity for patients accessing the program and possible changes to our core business (including the possibility that the Day Program Area and Mater Hospital Special School will be physically located further apart from each other). We anticipate assessing/treating up to 20 patients at any one time and increasing the range of services we offer. Yet again, this is a time during which we will review and enhance the current model of care between education and mental health. Our motto during this time of change:

A bend in the road is not the end of the road, unless you fail to make the turn!

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Last Modified: 27-11-2002 10:11:02