Position Statement on Psychiatric Services for Adolescents

Foreword

This paper is prompted for a number of reasons. For many years Child and Adult Psychiatrists alike have been concerned about the gap in Irish psychiatric services for adolescents. The different needs of adolescents have been highlighted in many areas; in adolescent medicine, the recent paper 'Get Connected' and most recently in the Health Strategy. The Division is involved in the Department of Health committee on Child and Adolescent Psychiatric Services which is most recently focusing on adolescent services specifically in the form of a sub-committee. The Division is represented by Dr C Halpin and Dr W O'Connell. The Division welcomes greatly the Minister's commitment to address this issue as outlined in the recent Health Strategy. This paper has been produced after extensive discussion and consultation with the Executive Committee of the Irish Division, the Child and Adolescent Psychiatry Section, General Adult Psychiatrists, Forensic Psychiatry, Substance Misuse and Learning Disability Sections. It is intended for guidance and initiation of process which hopefully will result in better services for our adolescent population.

Introduction

Adolescence is a time of rapid developmental change. In addition to physical, intellectual, emotional and social development, adolescents are also managing the transition from the world of the child and family to that of the independence of adulthood. Adolescents because of their developmental stage are often reluctant to approach adults with their problems. Many others simply do not know who or how to approach services for help with psychological and psychiatric problems.

Psychiatric disorders increase in incidence and prevalence during adolescent years. The incidence and prevalence of deliberate self-harm and attempted suicide also increase with increasing age throughout the adolescent phase.

Epidemiological studies show that psychological disturbances of varying intensity exist in up to 20% of adolescents. However, only 2-5% of the total adolescent population have moderate to severe disabling conditions such as major psychiatric disorders. This is the specific target group that adolescent psychiatry services should deal with. Milder psychological problems may be dealt with by a primary care type service, for example, a community care psychology service. If one considers a tiered model of service this would equate with a tier II type service while adolescent psychiatric services would equate with tier III and tier IV. However most of tier II services can be provided in primary care settings.

For these reasons it is agreed by the Irish Division of the Royal College of Psychiatrists that a dedicated adolescent psychiatric service is essential.

1. Service Principles

The services should be equitable, accessible and user friendly taking into consideration the developmental level of the age group involved.

Psychiatric services for adolescents should include the following:

1. Multidisciplinary out-patient teams headed by a Consultant Adolescent Psychiatrist. These teams should consist of a Consultant Psychiatrist, Senior Registrar, Registrar, Psychologist, Social Worker, Psychiatric Nurses, Occupational Therapist, Speech and Language Therapist and Child Care Workers.

2. Day hospital services to include a mix of occupational therapy, various treatment programmes, such as group therapy, social skills etc. and an educational focus. This day hospital service would cater for those who require more in depth assessment and a more comprehensive treatment than can be offered in the general out-patient setting, but do not require in-patient treatment. Also rehabilitation after hospital admission.

3. Assertive outreach services to provide nursing and supportive services in the home, school etc.

4. In-patient services; acute same day in-patient admission should be available to adolescents with major psychiatric disorders who require it.

5. Rehabilitation services. There should be a rehabilitative approach to the care of teenagers who present with major psychiatric disorders. In some it is necessary to provide step down services such as hostels for the recovery and early rehabilitation phases of their treatment.

6. Liaison to General Hospitals. Adolescents who overdose, attempt self-harm or have acute psychiatric illness often present to general hospitals as their first point of contact. All hospitals likely to encounter adolescents in these circumstances should have liaison adolescent psychiatric services.

2. Present service provision

(a) Child Psychiatry provides services for children up to the age of 16 years. Over the age of 16 services are provided by the adult psychiatric services.

(b) Existing adult services are not resourced to deal with adolescents because of the lack of developmental perspective and the serious lack of appropriate multidisciplinary input which would centre around family, school and social interventions. Adult services also do not have in-patient facilities that are appropriate for the admission of teenagers for various reasons. These relate to health and safety issues in addition to treatment issues. Adult out-patient clinics are generally not adolescent friendly.

(c) Existing Child Psychiatry services are not equipped to deal with the older adolescent age group because of the significant increase in major psychiatric illnesses which occurs in this age group. Traditionally existing Child Psychiatry services provide out-patient services only and have very limited medical and nursing back-up with no in-patient beds or day hospitals. In addition because of the changing profile of problems with age, existing child psychiatry services tend to find that the younger adolescent group, i.e., the 13-15 year olds tend to dominate the service because of their high dependency and high rate of emergency presentations with acute illness and suicide attempts etc. The need for urgent responses to this age group tends to dictate that the service deals largely with adolescents at the expense of working with younger children, thereby preventing very useful early intervention which has a huge secondary preventative value. Waiting lists for Child Psychiatry services are lengthened further by the need to respond urgently to adolescents.

(d) Both Child and Adult Psychiatrists alike are seriously concerned about the lack of dedicated adolescent psychiatric services.

3. Difficulties in planning service provision

(a) Defining a target age group. The age limits of adolescence are variable. The psychosocial stage of development is the parameter used. It may start between 12-14 years and continue up to 18-21 years. Target age groups vary greatly in both the UK and European adolescent psychiatric services. Some services target 12-17 year olds, 16 and 17 year olds only, 16-21 year olds, 18-21 year olds. This creates obvious difficulties in making recommendations for future service organisation in Ireland.

(b) Consent to Treatment. Under the Mental Health Act, 2001, adolescents under the age of 18 are not deemed capable of giving consent to treatment. Consent is implied by agreement of their parents. However the young person himself/herself may not necessarily consent or may not wish to undergo treatment. In this situation sensitive handling and understanding of the adolescent is essential. This poses yet another argument for the development of appropriate services that are acceptable to adolescents.

(c) Inappropriate referral to the psychiatric services. Difficulties with out of control children present themselves as problems for the both the child and adult psychiatric services. Essentially there is a large group of children with very severe behavioural difficulties that are not amenable to conventional psychiatric treatment. They are often inappropriately referred to psychiatric services hence producing very high dependency rates. The shortage of child care residential services has impinged on the demand for psychiatric services. National plans to develop high support units for such children will eventually alleviate some of this problem. In addition a whole range of community support services and support services to residential group homes are required. Shortage of these services tends to lead to escalation of problems thereby creating an extra demand for psychiatric services.

4. Proposals for Resolution

Following a lot of discussion, it is proposed that the target age group for a specialist adolescent service should initially be 14-17 year olds, in line with mental health and child care legislation.

We recommend that one out-patient multidisciplinary team should be provided per 100,000 population and that one in-patient team should be provided per 300,000 population.

Service Structures.

1. Out-patient clinics provided by the multidisciplinary out-patient teams.

2. Day hospital programmes.

3. In-patient services to provide 10 beds per 300,000 population to target 14-17 year old age group. An in-patient facility can be on the campus of a general psychiatric hospital or general hospital's psychiatric unit. The essential distinguishing feature is that it must be self-contained and provide a range of therapeutic and educational programmes appropriate to the youngsters it serves.

In this age group it is preferable to keep numbers of admissions to a minimum. The in-patient team should also have access to nursing staff to provide an intensive care community based treatment service in order to minimise the need for beds. There should also be a flexible system when under occupancy in the in-patient unit would allow the flexibility for the staff to work in intensive out-patient community care or the day hospital facility.

4. Rehabilitation services including a step down facility such as hostels.

It is considered that broad flexibility is required between all of the different services. While we have agreed that 14-17 year old is a reasonable target age group, there should be leeway for flexibility between child, adolescent and adult psychiatrists, whereby children or adolescents whose treatment would be more appropriately provided in a different setting could be facilitated.

Continuity of treatment across services should be made a priority for adolescents who need to transfer from adolescent to adult services. To facilitate this an overlap between adolescent and adult services should be built into/integral to the operation of the new services. Protocols should be established which practice the need for individualised, ab. initio negotiations on single cases.

A structure with input from both adolescent and adult psychiatric teams should be established in each sector whereby transitions can be smoothly negotiated and planned e.g., dedicated time to meet regularly to discuss relevant cases.

Good practice would dictate that there should be forward planning and seamless transfer of these cases both in terms of their psychosocial need and their needs n the area of physical treatments e.g., medication. This highlights the need for multi-disciplinary teams in both services.

The numbers of cases needing transfer across services is likely to be significant, given the nature of psychiatric illnesses with onset in mid-late adolescence.

To facilitate this level of co-operation, we recommend that all psychiatric services should be managed under the umbrella of the one management structure, i.e., mental health services.

Certain areas need special consideration as the general adolescent psychiatric service will not be able to meet their needs. These are as follows:

(1) Conduct Disorder.

Conduct disordered or behaviourally disordered children who are not psychiatrically ill are extremely common. The problems they present generally require a multi-systemic approach with intervention at social, community, educational and early developmental levels. The scientific evidence is that there are no specific psychiatric treatments that make any significant impact in this group. Psychiatric services are increasingly pressured to provide answers for this group. This expectation is unrealistic.

We propose that the Department of Health and Children set up a forum to involve the Departments of Education/Justice and Health to address this particular issue.

(2) Forensic Services.

To date there is no forensic service in Ireland for children under the age of 18. Consideration is required to provide specialist forensic services for adolescents. The experience is that adolescents who present with criminalised behaviour are referred to the generic child and adolescent psychiatrists and adult psychiatrists who do not have the expertise or specialist service to offer. Urgent examination of this issue is required. Components of a forensic psychiatric service for adolescents would be as follows:

· Adolescent multidisciplinary teams led by a consultant adolescent psychiatrist with special expertise in forensic psychiatry to consult to all secure detention facilities for adolescents.

· Specialist forensic psychiatric team for adolescents to provide assessments on a nation-wide basis.

· Secure in-patient units for children and adolescents who are psychiatrically ill and in need of treatment in a secure setting. As a rule of thumb, about ten percent of beds for a population should be secure. This proposal suggests ten in-patient units of ten beds each. In addition, a national secure adolescent psychiatric unit should probably have 10 to 15 beds with two consultant-led teams on a single site, e.g. at the Central Mental Hospital, where there would be access to other specialist forensic assessment and treatment skills.

(3) Substance Misuse and Alcohol Abuse

Alcohol Abuse
Underage drinking nationally is increasing. So are associated problems. Presently a Task Force has been set up and will no doubt issue a variety of recommendations. It is imperative these are acted on with appropriate funding and personnel in due course.

Drug Misuse
Drug misuse in the adolescent age group is also increasing. This is evidenced by the availability particularly of Cannabis and Ecstasy (MDMA) on a more or less national basis. However, outside the EHRA it is unrealistic to suggest that there should be adolescent psychiatrists dedicated to alcohol/drug misuse. Rather it is reasonable to expect that adolescent psychiatrist would have some expertise and training in this area, which would include drug-induced psychosis or drug related dual diagnosis.

Within the EHRA

A proposed job description has been forwarded to Comhairle seeking approval for the appointment of three adolescent psychiatrists - one for each of the Health Boards within the EHRA. Approval is awaited.

(4) Learning Disability.

Adolescents with learning disability have special needs, because of their developmental level, their mental health needs are not best served by treatment in the same setting as adolescents of normal intelligence. Mental Health Services to this group vary in each Health Board area, e.g. some consultant psychiatrists have responsibility for adolescents although they are adult psychiatrists who provide a cradle to grave mental health service for persons with Learning Disability. In other areas this service is provided by consultant child psychiatrists with special interest in Learning Disability.

It is recommended, in addition to specific child psychiatrists and multi-disciplinary teams looking after the mental health needs of children and younger adolescents, community out-patient services for adolescents (14-17 years) with learning disability should be provided by multi-disciplinary teams led by adolescent psychiatrists with a special interest in learning disability. Because of their vulnerability adolescents with learning disability and psychiatric disorder would be best served by treatment where necessary in in-patient units specially designed for this group. It may be that there should be a small number nationally. Another group who require special consideration are adolescents with mild learning disability who offend. Consideration should be given to the development of national forensic adolescent services for this group. In general adolescents with learning disability are quite a complex group with complex and disparate set of problems. Close separate examination of this particular sub-group is needed to ensure that their needs are met adequately.

This paper is intended as a guideline and is not intended to be exhaustive. Further information, references etc. will be supplied on request.

Dr Colette Halpin
Chairperson
April 2002