• Children at risk
• Issues arising for children in local authority care.
A more detailed discussion can be found in Chap.t§.r.9.3.3 and Chapter.9.5.6. Forensic services
• Juvenile delinquency
• Youth justice and young offender services.
A more detailed discussion can be found in Ch§piei,9.4.1. Communication links
The importance of communication is often overlooked, so that a communication network is not always included as an integral part of a service organization. However, it is essential as there are many examples of poor communication between different levels of a child mental health service, between disciplines, or between agencies. This has become a particular issue and problem in the United Kingdom. It is noteworthy that the efforts made to ensure that a good communication system was part of the continuum of care was a very significant positive outcome in the Fort Bragg experiment.(6)
The choice of therapy has tended to owe as much (or more) to the clinician's orientation and experience as to evaluated empirical evidence of effectiveness. This is changing as more treatments are evaluated in different service settings. It is desirable that therapies for use in a particular context should be selected on the basis of known effectiveness and feasibility. However, there may be tension when clinicians have become accustomed to particular psychotherapies. The issue of cost-benefit and cost-effectiveness is becoming increasingly important. A recent comprehensive review of the subject in relation to child psychiatry (18) argues strongly for clinicians to consider this dimension.
An essential step, towards which clinicians are gradually moving, is the development of guidelines and protocols based on empirical data on effectiveness in the management of specific disorders. It is important that these guidelines are formulated in relation to the service context which takes the community culture into account. These protocols are best organized at a regional or local level.
Guidelines for drug treatment in children and adolescents should also be available and should be regularly updated. These could be developed at a national level, although amendments could be made at a regional level. It may be useful for a review group to examine prescribing at local levels.
Traditionally, data collected in child and adolescent services have related to the practices of individual clinicians. However, this is changing and is under debate. Issues specific to children and adolescents are, firstly, a system that will be used by all disciplines and, secondly, a system that reflects the role of other agencies in terms of both process and outcome. For example, a child with behaviour problems secondary to specific academic difficulties will have a poor outcome if remedial help is not available within the education system. A child in the care of social services/social welfare subjected to repeated changes of placement will need stability as a therapeutic input, and psychotherapy alone will have little impact. The data collected should also provide information useful for monitoring and evaluating the service in terms of process and outcome.
Indicators need to relate to process as well as outcome. To date, clinical outcome has been the primary criterion of success regardless of cost or satisfaction of the overall needs of the community. As services reorganize on the basis of need and cost, the collection of data which can provide relevant information has become crucial. While clinical criteria of outcome may be common across many sites, specific indicators of process will need to reflect the service model being monitored, the use of therapies identified in protocols for that service, and local community characteristics. For example, in some services it is important to monitor access by ethnic minority groups as these form a significant proportion of the local population.
Monitoring the use of particular psychotherapies within a service is a relatively recent development. It has been noted (19) that this process is effective only if clinicians feel involved in the process. This comment applies to any organizational process.
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