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

Development of a Rural Visiting Consultant Child and Adolescent Psychiatry Service
Ms Anne Lipzker, Dr Nigel Collings, NSW Northern Rivers Area Health Service

Summary
Introduction
Consultancy Service Model
Service Evolution and Outcomes
Conclusions
References

Summary:
This Visiting Consultant Child & Adolescent Psychiatry Service - incorporating case consultations with workers, assessments of children, adolescents and their families as well as clinical development sessions - has been provided to the Northern Rivers Area of New South Wales since early 1997.

From its inception, this service has had a broad collaborative basis with involvement across the Health programs of Mental Health, Child & Family and PANOC, together with Psychiatrists, Paediatricians and General Practitioners. It has also had support, participation and some financial contribution from the School Education and Community Services sectors. Prior to this establishment, there was no locally available specialist child and adolescent psychiatric service. The Service has therefore met a considerable gap in services for children, young people and their families in the Northern Rivers. The consultancy service model builds on skills developed over past years in the absence of such a medical specialty, and is designed to respond to the varied way services are delivered across the Area, as well as to recognise the existing skills and experience of staff from a range of agencies in the Northern Rivers.
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Introduction:
The Northern Rivers Area Health Service extends from Tweed Heads in the north to Grafton in the south and west to the ranges past Tabulam and Urbenville. The Area is characterised by a higher-than-state-average proportion of young people. In a total population of approximately 260,000 people, approximately 30%, or 75 000 of these are aged under 20 years. Over three percent of these children and young people are of Aboriginal and Torres Strait Islander descent. At the 1996 Census 16.8% of families were sole parents with dependent children; unemployment is significantly higher than the state average, while income level is correspondingly low.

Health services to children, young people and their families with concerns about emotional, social or behavioral well-being are provided through Primary/Community Health Services (including 10 FTE psychologist and social work positions with a primary focus on families with children 12 years and under, and 5 FTE PANOC – Physical Abuse and Neglect of Children - counsellors) and through the Mental Health Program (13 Youth and Family Mental Health Workers with a primary 12 to 18 year focus). Other relevant services in the Health and wider network of care include Generalist Counsellors as well as Drug and Alcohol and Sexual Assault Counselling, School Support and Counselling, Accommodation Support, Disability Support and Child Protection and Substitute Care services. These networks are established to varying degrees in all major towns.

This paper describes the introduction, growth and evolution of a Child and Adolescent Psychiatry addition to the service network detailed above. As noted by Lyons [1], who was one of the main instigators of this service, managers and workers in these various agencies had been aware for many years of the lack of Child Psychiatry services to children and adolescents across this Area.
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As Lyons details in an earlier presentation, "prior to the introduction of this service, there were a number of options for children who were considered in need of a Child Psychiatry service:

1. Consultation with a Child Psychiatrist in Brisbane. This had several disadvantages including

(I) valuable information from local carers/workers was not always available/utilised

(ii) decisions re future care/treatment were made without good knowledge of local options

(iii) feedback often did not occur.

2. Consultation with a Child Psychiatrist in Sydney. All the disadvantages of Option (1) applied, with the added disadvantage of more travel and larger costs. One possible advantage was the availability of in-patient assessment, but this rarely occurred.

3. A Child Psychiatrist was paid on a one-off basis to come to Lismore to assess/consult and recommend strategies. Again there was poor knowledge of local options, no established networks and often a blatant disregard for the knowledge and skill of local workers. Additionally this option proved to be very expensive with little in the way of positive outcomes.

4. Children continued to be treated/managed by a group of workers including a Paediatrician, Psychologist, District Officer from the Department of Community Services etc. This option worked well in many cases but fell down where there were issues around ultimate responsibility. Case Conferences did not always occur as frequently as they should. There was the additional difficulty of case plans not always being ratified by magistrates. It was generally felt that a psychiatrist’s opinion would add weight to these plans, and would have the advantage of expert knowledge of medication options.

5. Some children were seen by Adult Psychiatrists in Lismore."

When new Adolescent Mental Health Services were established in the early 1990s, they included a Child and Adolescent Psychiatry capacity. However, despite repeated recruitment attempts, the capacity was never realised. The need for access to Child and Adolescent Psychiatry was again highlighted by a Regional Co-ordination Project in the Northern Rivers in 1995, and planning and negotiation for its introduction began.

This initial planning and funding collaboration was extraordinary, and has been a likely key factor in the on-going successful outcomes of the service. Funding contributions were originally obtained from four separate sources, ie Mental Health, Primary Health Care, Department of Community Services and Department of School Education, and in mid 1996 recruitment was initiated.

Although Child and Adolescent Psychiatry Services in the Northern Rivers are now fully integrated, planned and funded within the Mental Health Program, the benefits of that strong initial ‘partnership’ philosophy continue to be felt.

Funding was very limited however and translated into approximately two days per month of a child and adolescent psychiatrist’s time. The challenge then became how to provide the best possible spread of this valuable service across a large geographical area, to a large number of children with diverse issues, and to a range of professionals from private practice and non-government services as well as to the agencies of three government departments. Because of the diversity within the Area, each child was also likely to have a unique combination of professionals involved in their care.
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Development of the Consultancy Service Model:
The Service is primarily based on consultancy and clinical service development. The intention and direct effect of this service model has been to successfully ration and maximise the very limited child and adolescent psychiatry resource available. However, the other indirect effects on the clinical service network have been equally significant. The model:-

* recognises and gives due focus to the professional skill and client knowledge within the service network

* builds on the premise that a young person child with significant emotional difficulties needs the services of a team of professionals across the major domains of his/her life.

* allows the awareness of gaps in clinical knowledge or service development which arise out of collaborative case consultations to prompt clinical development activities or further service planning, eg School Link initiatives.

* effectively draws in other medical practitioners – particularly paediatricians, psychiatrists and general practitioners -to full participation in the service network

The model includes Full Case Consultations where workers providing the primary services to a child or young person about whom there are mental health diagnostic, therapeutic or management concerns, have the opportunity for a group inter-sectoral consultation with the Child & Adolescent Psychiatrist. Because of the scarce nature of this resource, the service is targeted for children with complex or severe problems whose needs are not sufficiently met through existing services, or where there are diagnostic and/or treatment issues.

In order to access the service, a worker must go through the following process:

• Obtain informed consent from the family/care giver via a signed consent form.
• Liaise with an appropriate health worker to act as case manager throughout the process

They must also collect detailed and up-to -date information on the following:

• developmental history for the child or adolescent and a detailed family history
• details of the child’s current situation, both home and educational placement, including current supports at home and at school
• details of any involvement with the Department of Community Services, including placement history if applicable
• medical history, including current medication and any previous history of relevant medical intervention
• details of any cognitive, emotional, language and motor assessments to date
• A possible management plan
• And, importantly, the questions or dilemmas to be presented for the consultation
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Having collected the above information, the worker arranges a consultation time, ensures that all appropriate staff are invited to attend and arranges for the information to be available to the psychiatrist prior to the consultation. The outcome of the consultation is then documented and distributed.

Where the outcome of the full case consultation is that a psychiatric assessment is necessary, a Direct Child Psychiatric Consultation Service to the child/adolescent and family is also provided and documented. Both this component of the model and the full case consultations are lengthy and time-consuming but they have been able to demonstrate efficient, effective and valued outcomes.

Follow-up Consultation to the case management team, which is a typically shorter component than those described above is always provided subsequent to a direct assessment and frequently also as the case management process develops for each client family.

Shorter Case Process Consultations are also provided, often on referral to a Health Service of a complex or unusual presentation or on the development within a case management process of a new, sometimes crisis, element. This type of consultation has the benefit of efficiently clarifying for one or two workers, the purpose and method of the assessment and formulation or re-evaluation phase of service provision.

Also, Clinical Development Activities are scheduled from time to time with the Child Psychiatrist presenting a summary update on the diagnostic and treatment issues of the selected topic and workers bringing along case fragments and questions related to that topic. Workers in rural areas do not have ready access to concise staff development activities, such as the lunchtime lectures offered in many cities, and so are thirsty for clinical discussion and development.
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Service Evolution and Outcomes:
Review of the profile of cases referred for consultation shows that amongst the wide range of referral questions, a significant proportion have an intersection of child protection issues, disruptive school behaviour and diagnostic dilemmas with implications for health treatment and management. The other prominent cluster of consultation referrals concern the odd, bizarre and withdrawn behaviours, which prompt difficult differential diagnosis questions involving autistic spectrum, psychotic processes, obsessive compulsive issues etc.. In other words, this Visiting Child Psychiatry Consultancy Service has effectively targeted those very referrals which are, by their nature, inter-sectoral and cannot be catered for without a specialist child psychiatric contribution, which is informed by and coordinated with the contributions from all the other sectors involved.

Outcomes of the consultations in general were characterized by greater articulation and coordination of the elements of the case plan – specifically there were medication recommendations, specific psychotherapeutic and psycho-educational recommendations and specialist referral recommendations. Once these achievable goals are understood and accepted, the result is more effective social, emotional and educational participation by the client child/adolescent and family.

The goal of the project was to provide an efficient and accessible child psychiatry consultation service to the residents of Northern Rivers Area Health service. As only a small number of children will be seen individually by the psychiatrist, and the project aims to enhance other workers’ skills in diagnosis, treatment and management of children with serious emotional and behavioural difficulties, the target group in most cases is the multidisciplinary, interagency "team" who work with the child/adolescent and family.

So, workers from all three major agencies and the three local paediatricians were consulted during the establishment phase of the project and subsequently by evaluation survey at key service development points. On each occasion, the evaluation demonstrated a strong demand, very high usage across the sectors, high levels of both satisfaction and efficiency and good outcomes in terms of comphrensivness of client management. Workers report that the service has informed and enhanced their case practice, made an essential contribution to coordinated case planning across the sectors and decreased their sense of operating in an isolated vacuum. From the 1999 evaluation – "the service has been especially highly valued in the light of the increasing level of more complex presentations which workers have been seeing in recent times", and from the paediatricians – "the service has taught us a great deal about how to approach Child and Adolescent Mental Health in general and a number of our patients in particular"
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A key ingredient for the planned and effective use of the service has been the development of the role of Local Clinical Convenor. This person, a locally based clinician, answers process queries, reassures, discusses and collects referrals and sometimes suggests additional steps, schedules the consultations and convenes the clinical development activities.

Initially the service operated from a centrally located Lismore Health Facility and visits occurred on a fortnightly basis, with workers from other locations travelling from around the Area for consultations. In order to increase the participation and equity, from 1998 the location of the service was rotated around the different Community Health sites.

In 1999 the service was increased to weekly and continued its rotation around the four Clusters of the Area. During this same period, the Telepsychiatry Service, providing four hours a week of Child and Adolescent Psychiatry Services via videoconference from The Children’s Hospital at Westmead, was introduced and also rotated around the Area. Over the next two years, the two services continued their development in complement with each other.

From February 2001, in order to increase equity to the more remote locations of the Northern Rivers and to increase the frequency of consultations at each location, an additional four hours per week of the Visiting Service was provided. Combining the Child and Adolescent Telepsychiatry Service and the now expanded Visiting Child and Adolescent Service provides a weekly half-day service to each of the four Clusters of the Area. There will be more capacity for direct client consultations and for consultative involvement in more urgent crisis presentations. Development of professional relationships, referral networks and collaborations will be enhanced by the more regular contact.
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Conclusions:
Regular evaluation of this innovative rural service over its four years of operation have demonstrated its effectiveness in providing not only the necessary Child and Adolescent Psychiatry component of the Mental Health Network but also the facilitation of clinical service development, professional support and effective client-focused collaboration. Features of this model which distinguish it from the traditional Child Psychiatry Service model, and which have contributed to its success, include the key role of the Local Clinical Convenor in guiding referral and consultation processes and identifying clinical service development needs. Importantly, the model also involves a shift to seeing the workers of the service network as the ‘client’ and this is accompanied by a strong respect and understanding of the framework in which they operate.

References:
[1] Lyons, R. "As Thin As Prosciutto" in Proceedings of the 1998 NSW Rural Mental Health Conference, pp 225-228

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Last Modified: 27-11-2002 10:11:40