Education And Debate

Commentary: child mental health services are not medical empires

BMJ 1997; 314 doi: (Published 15 March 1997) Cite this as: BMJ 1997;314:814
  1. Alyson Hall, head of child mental health servicea
  1. a Tower Hamlets Healthcare Trust Emmanuel Miller Centre London E14 8HQ


    As child mental health clinics round the country develop longer and longer waiting lists it is tempting to suggest ways of helping children in other settings so that overextended specialist staff can concentrate on specific complex disorders. If additional resources were made available to local authorities so that children with conduct disorder could receive input to improve their behaviour early in childhood, professionals, parents of affected children, and society as a whole would be delighted. Specialist education staff could help teachers in managing children more effectively using behavioural programmes in mainstream classes or in small groups. Social workers might be able to provide family therapy and behaviour therapy to help parents manage behaviour effectively rather than concentrating on child protection work, accommodating children, or programmes for delinquents. This preventive rather than palliative approach is advocated by the Department of Health.1

    Loss of specialist resources

    Unless increased funds are made available, Dr Goodman proposes that mental health staff, but not child psychiatrists, should be redeployed in local authority settings. This has already happened round the country with the transfer of social workers and to a lesser extent education staff from child mental health teams into generic local authority teams.

    Unfortunately this has not led to improved treatment in these settings because it has coincided with and is related to the loss of specialist resources, especially in education, due to generalised reductions in public expenditure. In any case many specialist staff find it difficult to work in relative isolation in front line settings2 without the ongoing training, support, and ready consultation available in a multidisciplinary team.

    Exacerbated by increasing pressures on children from poverty, unemployment, single parenthood, and parental conflict, the net result has been increased demand for access to specialist child mental health services and concern about long delays for appointments even for serious urgent cases. The pressure is generally greatest for those cases which should be seen by an experienced child psychiatrist.


    Lord of the Flies: conduct disorder or a social problem needing a social solution?


    Medical empires? Child mental health services are fortunate if their funding reaches 5% of that of adult services, most likely only if there is a local inpatient service. A comparatively well resourced service such as my own has 23 whole time equivalent professional staff, including five local authority social workers, serving a multiply deprived borough which has 50 000 children and over 100 schools. Our resources are not easily shared out. Child mental health staff, apart from child psychiatrists, are no better paid than other social workers, educational or community psychologists, health visitors, or teachers unless they also have managerial responsibilities.

    Need to see a range of cases

    Child psychiatrists, especially in inner city areas, are much in demand for the assessment and management of psychosis, severe depression, complex developmental disorders, psychosomatic disorders, severe physical trauma, chronic illness, eating disorders, hyperkinetic syndrome, and child care assessments for the courts. We do see highly selected children with severe or intractable conduct disorders, and our experience and broad training are well used in integrating aspects of neglectful or abusive parenting, constitutional factors such as learning difficulties, hyperkinetic syndrome, and attachment. We may provide advice about placement and sometimes offer treatment.

    I consider severe conduct disorder an important mental health problem, and our understanding of its origins and treatment and of forensic adolescent psychiatry all require urgent development. Resources focused on young children in child psychiatry as well as in local authority services may pay dividends in reducing harm to society and the cost of imprisonment.

    Experienced non-medical staff are also fully stretched with the relentless increase in referrals of children with severe or multiple problems. Mild cases? There are a few and we are glad when the referrals come in. Otherwise how can we train junior medical staff and trainees in psychology, nursing, and social work, who will mostly work in local authority or community settings. It is essential that their training is broad so that they are familiar with the range of problems, minor and severe, and variety of treatment modalities. Some will go on to work in child mental health services, from which they will provide consultation and support for professionals in other settings, assessment and treatment for severe and complex cases, and training.


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