• By Kevin Mount
  • Posted on Thursday 30th October, 2008

Mental health services have too few strengths

It might be considered a fairly basic objective of any care system that children with mental health problems should get effective treatment from a well trained professional. But it remains an ideal: many western developed countries fall far short. In the UK, prominent clinicians working to correct this fundamental failure include Tamsin Ford, a senior lecturer in child psychiatry at the Peninsula Medical School in Exeter, Devon.In a recent paper she uses epidemiological data to describe how children are falling through the gaps in the mental health service provision. More importantly, she also argues that epidemiological methods can help bridge some of those gaps more effectively and get the UK system closer to achieving the ideal response.Epidemiology informs public health by providing evidence about who gets what illness, when, where, how and why. It can indicate rates of service use and explore factors likely to change the pattern. So good epidemiology will also suggest who has a problem but isn’t getting a service and point to possible reasons. All this information is part of the essential backdrop to the design and provision of new services.Simply increasing the volume of mental health services is unlikely to result in better outcomes for children, she argues. Instead professionals “need to develop strategies to increase the numbers of children seen and the effectiveness of the treatment they receive”.To take this thinking forward, researchers have transplanted some of the structured questionnaires or measures used in epidemiological studies to the practitioner’s clinic to test their effectiveness as part of assessment and outcome monitoring.For example, the ‘Strengths and Difficulties Questionnaire’ (SDQ) commonly relied upon as a measure of children’s emotional and behavioral problems is being tested in practice in London in a screening project supervised by its originator Robert Goodman. The project involves monitoring children in local authority care a few months after entry.Tamsin Ford believes that using epidemiological tools in this way to identify children at high risk of clinical disorders benefits the clinician and the children concerned. She points out that if measures such as the SDQ were to be completed by families at the time of referral to a service, they would be more likely to be offered the correct intervention and more quickly. Some might argue on the same basis that if such measures were used in studies of the general population, clinicians would have a sound baseline for their reflections on how their clients “scored”. And if the measures were used routinely, clinicians would have a basis for monitoring their own practice.With this potential in mind, it seems there can be little opposition to professionals across the country using the SDQ and other feasible, valid and reliable instruments at referral to understand the needs of their clients and match them to the most appropriate services. But here, for the moment, the trail runs out.Brief screening measures and questionnaires are used by epidemiologists to understand the needs of broad populations of people, for example all children in a school or all families living in a particular city. They give an indication of whether an individual might have a problem or meet criteria for a clinical diagnosis. But the perennial flaws associated with false positives and false negatives – when children identified as having a problem are shown to have none after fuller assessment or children who do have a problem are not identified by screening – mean brief measures cannot be relied upon at population level. So for the moment their use is likely to be confined to high risk populations. If the screening tool indicates a possible disorder, more in-depth assessment is triggered and speedier access to intervention results.Towards the end of her paper in the Journal of Child and Adolescent Psychiatry, Tamsin Ford also warns that it is “vital that clinicians do not try to amend measures to suit their local context as even small changes can make a major difference to how the scale functions”. Measures such as SDQ have been properly evaluated and tested for validity and reliability, changing questions undermines those attributes. • Summary: Ford T (2008) “Practitioner Review: How can epidemiology help us plan and deliver effective child and adolescent mental health services”, Journal of Child and Adolescent Psychiatry, 49, 9, pp 900-914

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