The current contextcan we learn from it

Experiment, research, and debate continue about service organization for children at country, regional, or local level in developed and developing countries.

Australian researchers have reported strategies that helped to organize services. Birleson (4) described the adoption of learning organization principles, which involved staff, in reorganizing a community child and adolescent service which included outpatient and inpatient facilities. Sawyer and Kosky (5) described an organizational model with core support from a tertiary hospital setting which was helpful in providing a comprehensive continuum of care in South Australia.

The Fort Bragg Experiment in the United States(6) is a well-funded and well-evaluated experiment in which a planned and well-resourced case-management model of providing mental health care, tailored to individual needs and using the full continuum of community-based services, was developed. This model was compared with two community services for child mental health. One of the most important findings of this study is the positive impact of the good communication links between professionals and agencies that were developed for the model.

In the United Kingdom there has been considerable emphasis in the last few years on organization of services to meet needs. A thematic review (7) proposed tiers of services (primary, secondary, and tertiary care with a first tier comprising community and family) and assigned provision from health, social services, and education. The importance of promoting and empowering the family and the community, and using their resources, is rightly emphasized. This has led to pilot projects in which mental health services have been located within primary care.

On the other hand there are examples of service organization for communities with high needs and few resources. Following the WHO case study exercise referred to above, India incorporated child mental health into national plans for mental health with short-, medium-, and long-term targets. In addition to developing centres of excellence in tertiary settings, initiatives to promote coverage in a very large country with a predominantly rural population included service delivery models in which rural clinics were provided from a tertiary centre. In addition, social policies to promote healthy development were introduced, such as an early intervention programme for preschool children in very deprived areas—the Integrated Child Development Service. (8) It is recognized that it will not be possible to provide a comprehensive system of care in the foreseeable future, and hence different initiatives have been adopted to provide help at different levels within the community to meet a proportion of the need.

Experiences from the various models of existing care enable the identification of some basic steps in service organization in a country or community.

1. Establish the level of policy commitment for children by looking at the services already provided and the legislation existing for the protection of children's rights.

2. Examine available data from epidemiological research or clinical prevalence data on childhood disorders.

3. Assess from existing information the population distribution, cultural attitudes to children, child-rearing habits, and pressures on children.

4. Formulate a service plan for child mental health and development on the basis of the existing structure, identifying resource and training needs for implementation.

A constructive use of epidemiological data is required to highlight not only overall need but different levels of need in relation to specific service inputs. The following structure for needs analysis proposed for the United Kingdom (9) provides a useful way of looking at needs in relation to service organization.

frequency encountered in the population potential severity presence of risk factors

• Identify risk factors:

in the child in the family from life events in the environment at school

• Obtain information on current multi-agency provision, legislation for children, and resource availability.

The authors advised that decisions on resource allocation should be made in terms of location, the specific activity to be undertaken, and the range of therapeutic activities (assessment, direct treatment, consultation-liaison). Defined quality standards for care and a system for monitoring and evaluating both process and outcome are essential.

These considerations lead to the definition of a model of preventive or primarily therapeutic (preventive at a secondary or tertiary level) care:

1. development within available resources of appropriate service inputs, levels of skill, and therapies;

2. administrative support;

3. collection of appropriate data;

4. indicators for monitoring and evaluating process and outcome;

5. mechanism for feeding the results from monitoring and evaluation back into the service;

6. effective communication between different components and levels of the service.

A commitment to these services from policy-makers and planners

It is essential that policy-makers and administrators are committed to these services. The importance of advocacy by professionals to maintain this commitment cannot be overemphasized, particularly because of the range of services that are required not only to initiate but to maintain a comprehensive child mental health service. A detailed discussion of the strategies that clinicians could adopt, including the value of multidisciplinary and multisectoral support, is beyond the scope of this chapter.

Aims and objectives of the service

Clearly, this issue is central for any service. In this case, the aim of is to work towards providing a comprehensive and co-ordinated service for child mental health. Estimate of need—perceived and actual

The knowledge base on the epidemiology of disorder, causal mechanisms, protective and risk factors, and effectiveness of specific treatment approaches has increased greatly in recent years and is discussed in more detail in Ch§pter,9;!.! , Ch§ple.L9.:.!.2, and Cha.pteL.!..3.

Research over the years has confirmed that child psychiatric disorders are not limited to any one country or culture. However, when estimating need account must be taken of the location and cultural context of the proposed service, as these factors influence prevalence and consultation patterns. The classic epidemiological studies carried out by Rutter et al.(1°,I!> comparing the Isle of Wight (a semi-urban/rural community) with inner-city populations in South London clearly illustrated the increased prevalence of disorder related to sociocultural deprivation, and many subsequent studies have confirmed these findings. There may be differing rates of incidence and prevalence, particularly where the disorder is culture specific, such as eating disorder, or where there is a relatively higher incidence of particular risk factors, such as for mental retardation secondary to brain damage in the perinatal period or as a consequence of TB meningitis. Clinical prevalence data may be influenced by resource factors as well as differences in consultation patterns. For example, in countries such as the United Kingdom, where there is a multiplicity of resources and/or increased specialization, children with mental retardation may not always be seen by child and adolescent psychiatry services, even where there are associated behaviour problems, and children with epilepsy are referred to a paediatric neurologist. However, in many developing countries the majority of children seen will be mentally retarded or have epilepsy, and child psychiatric services will include these children in their definition of case load. A further example is the difference in consultation patterns with regard to conduct disorder in Southeast Asia and the United Kingdom. Conduct problems have a high clinical prevalence in the United Kingdom, but not in Southeast Asia where they are perceived as being a disciplinary rather than a therapeutic matter. (!2)

Data on need may be available for a particular country or region, or need may have to be estimated from clinical prevalence and the evidence from epidemiological data obtained elsewhere. Available data can then be organized in the format for needs analysis referred to earlier. (9) An example is given below.

• A sleep problem in a young child with no associated risk factors is a common problem which is low risk.

• A conduct disorder is a problem which need not be severe but could become so, depending on associated risk factors and the severity of the problem.

• Symptoms and a clinical picture indicative of a psychotic illness, pervasive hyperactivity, autism, self-harm/attempted suicide indicate a potentially severe disorder.

• Potentially severe disorders include pervasive developmental disorders and mental health disorders meeting the criteria of adult disorders (e.g. eating disorders, schizophrenia, depression or bipolar illness).

Examples of risk factors are as follows.

• The child: acute or chronic illness, specific or general learning difficulties, language and other developmental disorder.

• The family: parental/intrafamilial discord, parental mental illness, neglect, child abuse, criminality, economic circumstances.

• The environment: very deprived environment, poor living conditions including overcrowding, homelessness, discrimination, displacement into refugee camps.

• Life events: parental separation, family disruption, bereavement, direct exposure to organized violence, disasters, involvement in war as child combatant.

• The school: bullying, inadequate help for a child impeded by limited language, inadequate help for specific developmental difficulties relating to academic skills.

• The child in other contexts: involvement in war as child combatant, street child, child labourer, lack of education and learning opportunities appropriate to age. Models of care

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