A Triage Clinic in a Child and Adolescent Mental Health Service

Measuring the Effect of the Early assessment Team (MEET) for patients referred to outpatient mental health care: a study protocol for a randomised controlled trial

BACKGROUND

Referrals to specialised mental health care (such as community mental health centres; CMHC) have increased over the last two decades. Patients often have multifaceted problems, which cannot only be solved by such care. Resources are limited, and triaging is challenging. A novel method which approaches patients early and individually upon referral to a CMHC-possibly with a brief intervention-is an Early assessment Team (EaT). In an EaT, two therapists meet the patient early in the process and seek to solve the present problem, often involving community services, primary health care, etc.; attention is paid to symptoms and functional strife, rather than diagnoses. This is in contrast to treatment as usual (TAU), where the patient (after being on a waiting list) meets one therapist, who focuses on history and situation to assign a diagnosis and eventually start a longitudinal treatment. The aim of this study is to describe and compare EaT and TAU regarding such outcomes as work and social adjustment, mental health, quality of life, use of health services, and patient satisfaction. The primary outcome is a change in perceived function from baseline to 12-month follow-up, measured by the Work and Social Adjustment Scale.

METHOD

Patients (18 years and above; n = 588) referred to outpatient health care at a CMHC are randomised to EaT or TAU. Measures (patient self-reports and clinician reports, patients' records, and register data) are collected at baseline, after the first and last meeting, and at 2, 4, 8, 12, and 24 months after inclusion. Some participants will be invited to participate in qualitative interviews.

TRIAL DESIGN

The study is a single-centre, non-blinded, RCT with two conditions involving a longitudinal and mixed design (quantitative and qualitative data).

DISCUSSION

This study will examine an intervention designed to determine early on which patients will benefit from parallel or other measures than assessment and treatment in CMHC and whether these will facilitate their recovery. Findings may potentially contribute to the development of the organisation of mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05087446. Registered on 21 October 2021.

Soliciting children's views on other-perspectives in child mental health assessments

Child mental health assessments are complex and involve the analysis of data from multiple sources to inform treatment decisions. Question sequences are central to mental health assessments; however, little research has examined the functions of questions in child mental health interactions, particularly questions that aim to elicit information from children that might be used to inform diagnosis and treatment. In this study, we utilize a large corpus of video-recorded child mental health assessments to examine the use and function of a particular kind of wh-question-circular questions-that is, questions that seek clients' views on other family members' feelings, actions, and thoughts. Using conversation analysis, we identified three "broad" functions of circular questions in child mental health assessment. Our findings provide clinicians with clinically relevant examples for using circular questions to more fully involve children in the assessment process and acquire valuable information for diagnosis.

Reflecting on what 'you said' as a way of reintroducing difficult topics in child mental health assessments

BACKGROUND

In child and adolescent mental health assessments, questions are integral to the process. There has been limited research focused on the assessment process, or on how questions are constructed within this clinical environment.

METHODS

We examined 28 naturally occurring initial assessments, with particular attention to how practitioners used questions in their communication with children and young people. We utilised conversation analysis to examine the data.

RESULTS

Analysis revealed a particular type of question preface used to reintroduce a prior topic. This was achieved through the use of 'you said x' as a foundation for asking a follow-up question and demonstrated active listening.

CONCLUSIONS

Arguably, this approach is a useful way of gathering assessment-relevant information in a child-centred way.

Agenda setting with children using the 'three wishes' technique

The National Health Service (UK) offers initial screening appointments for children referred to child and adolescent mental health services to determine clinical need and assess risk. Conversation analysis was utilized on 28 video recordings of these assessments, lasting approximately 90 minutes each with a multidisciplinary team. This article focuses on the agenda setting strategies used to establish relevant goals with children and adolescents; specifically, the technique of offering 'three wishes'. For example, ' if you had three wishes, what would you like to make happen?' In cases where children initially volunteered an assessment-relevant wish, they tended not to articulate further wishes. Non-assessment-relevant wishes (i.e. fantasy wishes, such as being 'rich') were treated as insufficient, with many approaches used to realign establishing assessment relevant goals. Where responses were not institutionally relevant, practitioners undertook considerable discursive work to realign the focus of the three wishes task to assessment relevance. In these cases, the wish responses were treated as irrelevant and tended to be dismissed, rather than explored for further detail. Such work with the children's contributions has implications for engaging children and child-centred practices.

The clinical use of Subjective Units of Distress scales (SUDs) in child mental health assessments: a thematic evaluation

Background: Despite the ubiquitous use of Subjective Units of Distress scales (SUDs) in mental health settings to establish levels of distressing emotion, there has been little empirical research in this area. SUDs are commonly used in therapy and assessments, and are a particularly useful tool for establishing current and previous levels of distress in children and young people.Aims: To explore the use of the SUD analogue rating scale in initial child mental health assessments to better understand its application in this context.Method: The data corpus consisted of 28 naturally-occurring video recordings of children and young people attending their first assessment appointment at Child and Adolescent Mental Health Services (CAMHS). A thematic analysis was utilised to explore the specific interactional use of SUDs.Results: Four themes were identified; recency, longevity, context and miscommunication. The first three themes were found to supplement the child's emotional score on the scale and were important in establishing the necessity for further therapeutic support. Miscommunication as a theme highlighted the need for clarity when using SUDs with children and young people.Conclusions: Recommendations were suggested for practitioners working with children and young people relating to the extended use of rating scales in clinical assessments.

Preventive child health care at elementary school age: The costs of routine assessments with a triage approach

BACKGROUND

Triage in Preventive Child Health Care (PCH) assessments could further the efficient use of human resources and budgets and therefore make extra care possible for children with specific needs. We assessed the costs of routine PCH assessments with and without triage for children aged 5/6 years and 10/11 years. In a triage approach, PCH assistants conduct pre-assessments to identify children requiring follow-up assessments by a physician or nurse. In the usual approach, all children are assessed by a physician and an assistant (children aged 5/6 years) or a nurse (children aged 10/11 years).

METHODS

All the direct costs of conducting routine PCH assessments with the triage and usual approach were assessed using a bottom-up micro-costing approach. In four PCH services in the Netherlands, two using triage and two the usual approach, professionals completed questionnaires about time spent on assessments, including time related to non-attendance at assessments, the referral of children and administration.

RESULTS

The projected costs for PCH professionals working on PCH assessments amounted to €5.2 million per cohort of 100,000 children aged 5/6 years in the triage approach, and €7.6 million in the usual approach. The projected costs in both approaches for children aged 10/11 years were about €4 million per 100,000 children.

CONCLUSION

The triage approach to PCH resulted in a projected cost reduction of about one-third, compared with usual practice, for routine assessments by physicians of children aged 5/6 years. There are minimal cost savings in the group of children aged 10/11 years when nurses are involved and so other considerations such as workforce shortages would be required to justify a change to a triage approach. Further research is needed to investigate the differences in costs of care after the completion of the routine assessments.

Children's claims to knowledge regarding their mental health experiences and practitioners' negotiation of the problem

OBJECTIVE

The objective was to identify how children's knowledge positions were negotiated in child mental health assessments and how this was managed by the different parties.

METHODS

The child psychiatry data consisted of 28 video-recorded assessments. A conversation analysis was undertaken to examine the interactional detail between the children, parents, and practitioners.

RESULTS

The findings indicated that claims to knowledge were managed in three ways. First, practitioners positioned children as 'experts' on their own health and this was sometimes accepted. Second, some children resisted this epistemic position, claiming not to have the relevant knowledge. Third, some children's claims to knowledge were negotiated and sometimes contested by adult parties who questioned their competence to share relevant information about their lives in accordance with the assessment agenda.

CONCLUSION

Through question design, the practitioner was able to position the child as holding relevant knowledge regarding their situation. The child was able to take up this position or resist it in various ways.

PRACTICE IMPLICATIONS

This has important implications for debates regarding children's competence to contribute to mental health interventions. Children are often treated as agents with limited knowledge, yet in the mental health assessment they are directly questioned about their own lives.

A Novel Triage Approach to Identifying Health Concerns

BACKGROUND

We investigated the detection of health problems in preventive child health care (PCH) by a novel triage approach for routine health assessments. In the triage approach, all children were preassessed by a physician's assistant, and only those in need of follow-up were assessed by a PCH physician or nurse. In the traditional approach, all children were assessed by a PCH physician or nurse.

METHODS

A prospective cohort design was used with data on routine assessments of 1897 children aged 5 to 6 and 10 to 11 years. Primary outcomes were the detection of overweight, visual disorders, and psychosocial problems, with type of approach (traditional vs triage) as independent variable. To assess the severity of health problems, BMI, Snellen, Strengths and Difficulties Questionnaire, and Child Behavior Checklist, scores were compared for both approaches in subgroups of children with overweight, visual disorders, or psychosocial problems.

RESULTS

No significant differences were found between the approaches in terms of the detection of incident cases of overweight, visual disorders, and psychosocial problems. Significantly higher Strengths and Difficulties Questionnaire scores were found in the subgroup with psychosocial problems when the triage approach was used. Marginal differences between the approaches were found for severity of overweight in the subgroup of overweight children.

CONCLUSIONS

A novel triage approach to PCH resulting in less involvement of physicians and nurses in routine assessments appears to detect health problems as effectively as the traditional approach in place. More research is needed to determine the long-term outcomes of the 2 approaches.

Identifying the interactional processes in the first assessments in child mental health

BACKGROUND

A comprehensive assessment is essential to contemporary practice in child and adolescent mental health. In addition to determining diagnosis and management, it is seen as important for clinical engagement and forming a therapeutic relationship. However, there has been little research on the processes which occur during this interaction, particularly in first assessments.

METHOD

Twenty-eight naturally occurring child mental health initial assessments were video recorded and subjected to the basic principles of the conversation analytic method.

RESULTS

Several processes were identified in a typical child and adolescent mental health assessment. These included introductions, reasons for attendance, problem presentation, decision-making and session closure.

CONCLUSIONS

Initial assessments provide a platform for all future engagement with services and an understanding of the processes occurring within this setting is important for the eventual outcomes, particularly in respect to new ways of working such as the Choice and Partnership Approach (CAPA).

A novel triage approach of child preventive health assessment: an observational study of routine registry-data

BACKGROUND

The coverage of preventive health assessments for children is pivotal to the system of preventive health screening. A novel method of triage was introduced in the Preventive Youth Health Care (PYHC) system in the Netherlands with an associated shift of tasks of professionals. Doctor's assistants carried out pre-assessments to identify children in need of follow-up assessment, whereas in the traditional approach all children would have been screened by a doctor or nurse. The accessibility and care delivery of this new PYHC system was studied.

METHODS

The new triage approach was compared to the traditional approach in 780 children undergoing PYHC assessment with the use of an observational retrospective study design. Outcomes were attendance of assessment appointments (accessibility of care) and referral of children to either extra PYHC assessment or external specialised care (delivery of preventive care). PYHC registry data were analysed. In two regions of the Netherlands, 390 children five to six years of age were randomly selected from the PYHC registries according to the socio-economic strata of the schools they attended.

RESULTS

When the triage and traditional approaches to PYHC were compared, we found similar attendance rates for assessment appointments, namely about 90%. As expected, 100% of the children in the traditional group were assessed by a PYHC doctor compared to 46% of the children in the triage group. Significantly fewer children were referred for extra PYHC assessment or for treatment by an external specialised care giver when a triage as opposed to the traditional assessment approach was used (19.6% vs. 45.9%).

CONCLUSIONS

The novel triage approach for preventive health assessment shows equal accessibility, but a different delivery of preventive care. A beneficial effect of the adoption of the triage approach is the opportunity to provide more attention from doctors and nurses to children at risk of health problems. However, lower referral rates of the triage approach may be explained by an under-identification of children with health problems. Further research is needed to document the health outcomes and the possible reduction of health care costs with a triage approach compared to traditional PYHC care.

Tackling a long waiting list in a child and adolescent mental health service

Objective: Long waiting lists have a negative impact on client satisfaction, staff moral and referrer's opinion of the service. The aim of this project was to decrease a waiting list from a maximum wait of more than one year to a wait of no more than six weeks.

Method: We introduced three simultaneous initiatives to decrease a long waiting list; (i) an individually led triage system (ii) setting-up an attention deficit hyperactivity disorder (ADHD) specialist team and (iii) division of the residual waiting list between team members. These initiatives were introduced and analysed over a ten month period. The study period ran from 1/3/2004 to 31/12/2004.

Results: The waiting time to first appointment was significantly reduced. At the beginning of the study there were 62 people waiting to be seen and each had waited an average of 122 days with a waiting time range of 0-449 days. At the end of the study, there were 19 people waiting with a mean waiting time of 19 days and a range of 0-168 days.

Conclusions: The single most powerful intervention was the triage system. The ADHD clinic allowed referrals to be streamlined in a very structured and efficient way. The division of the residual waiting list was not as onerous as it first appeared. The service saw more referrals then ever during the study period. Referrers and families appreciated being seen more quickly. By removing the burden of the waiting list from staff the potential for creative thinking around further development of the service increased.

Do triage systems in healthcare improve patient flow? A systematic review of the literature

OBJECTIVES

Triage processes are often used by Emergency Departments to sort patients according to urgency or type of service required. Triage may also be used in a broad spectrum of other health services and not just emergency departments. Triage systems may be used to ensure the most urgent patients get timely service, but do they have an effect on patient flow?

METHODS

We conducted a systematic review by searching five electronic databases (until August 2009) combining the elements 'triage' and 'patient flow', complemented by hand searching reference lists and citation tracking. We identified and assessed the quality of 25 articles that met inclusion criteria. Population, setting, design and results were extracted and a process of descriptive synthesis applied. Effect sizes for waiting time were compared for seven studies in which sufficient data could be extracted.

RESULTS AND CONCLUSION

Moderate evidence exists from a range of health services that the ability to combine triage and initial treatment in less resource intensive cases can have a positive effect on patient flow. There is conflicting evidence that triage systems that only prioritize patients, without providing any treatment, improve overall patient flow, although tailoring triage criteria more specifically to the patient population or using triage to prioritize treatable cases may be of benefit.

The Establishment of a Triage System in a Child and Adolescent Psychiatry Clinic in Hong Kong

BACKGROUND

  The problems of long waiting time and non-attendance prompted the implementation of a triage procedure in a child and adolescent psychiatry clinic in Hong Kong.

METHOD

  A two-stage triage procedure was set up, incorporating an initial screening by the Strengths and Difficulties Questionnaire, followed by a semi-structured telephone triage interview scored according to pre-set criteria. Results from the triage interview were compared with clinicians' rating of urgency.

RESULTS

  The procedure was successful in identifying cases that were in need of urgent assessment, whose waiting time was shortened substantially. The non-attendance rate also improved.

CONCLUSIONS

  The triage procedure helped to streamline the service in a grossly under-resourced clinic, but further refinement is still needed.

Reducing Waiting Times: Using an Opt-In System and Changing Prioritisation Criteria

BACKGROUND

  The Highland Clinical Psychology Service for Children and Young People, faced with excessive waiting lists, a large geographical remit, and only three psychologists, sought to change waiting list management to improve services.

METHOD

  An opt-in appointment system and outcome research were used to inform waiting list management. Referrals with the characteristics of cases where psychological interventions are helpful were prioritised over cases that had characteristics of poor outcomes.

RESULTS

  Attendance at first appointments was significantly increased and waiting times were significantly reduced.

CONCLUSIONS

  The success of the opt-in system replicated research in other CAMHS. It is also hypothesised that the new waiting list prioritisation criteria had an effect, although this needs further research. Issues associated with the change in waiting list prioritisation are discussed and it is suggested that prioritising treatable cases over complex cases is an appropriate, effective and ethical use of scarce resources.

Evaluation of a Waiting List Initiative in a Child and Adolescent Mental Health Service

BACKGROUND

  The aim of the study was to evaluate Initial Assessment (IA), a new system for managing referrals. The system is designed to: reduce waiting times, reduce 'did not attend' (DNA) rates, and improve multi-disciplinary team working and team morale, compared to the existing referral procedure.

METHOD

  A comparison was made between a child mental health service using IA and a second centre using the existing system over a 6-month period, based on administrative records, a child functioning measure, staff and user questionnaires.

RESULTS

  The Initial Assessment system was associated with a significantly shorter average waiting time for the first appointment (9 weeks) and a lower DNA rate (10%) in the intervention centre. The populations seen under the new and existing systems were similar in terms of the severity of cases. Staff reported a positive impact overall on team working and team morale, despite a reported individual increase in time pressure; users reported acceptance of the system.

CONCLUSIONS

  Findings suggest that the increase in team morale and support from colleagues associated with the new system may have mediated against any negative impact of the increased time pressure. Substantial cost savings to the NHS are indicated.

Triagem em saúde mental infantil

Este estudo foi conduzido para comparar os resultados de um procedimento grupal aberto e um procedimento individual estruturado para avaliação do comportamento da criança conforme o relato materno. Participaram deste estudo 29 mães que buscavam atendimento para seus filhos em uma unidade de saúde mental infanto-juvenil. As primeiras 15 mães que procuraram o serviço foram entrevistadas individualmente conforme um roteiro estruturado desenvolvido a partir do CBCL e depois foram entrevistadas em grupo, em formato aberto. As outras 14 mães participaram da entrevista grupal aberta e em seguida participaram da entrevista individual estruturada. Os resultados das entrevistas foram comparados tomando como referência as 67 categorias comportamentais identificadas a partir do roteiro individual e quatro variáveis contextuais relatadas nos dois procedimentos. Os resultados mostram que um número substancialmente maior de comportamentos-problema foi identificado através de entrevista individual estruturada do que através de entrevista grupal aberta realizada com os mesmos informantes. É possível que o uso de um roteiro estruturado em entrevistas grupais possa oferecer mais informações com otimização do tempo de avaliação.