Abstract
Some authors have recently argued that youth psychiatry services should be established distinct from child psychiatry, for the following reasons:
1. Society now attaches greater importance to the phase of adolescence and youth, and demographic changes have meant that up to 20% of the population are in this life stage.
2. The treatment of psychosis and conduct disorder in adolescence had been historically neglected within traditional child and adolescent psychiatry.
3. Training in the mental health care of adolescents, especially older adolescents, needs further development within psychiatry as a whole.
4. The developing technology of prevention and early intervention provides new opportunities for preventing adult mental illness by intervening in adolescence.
5. Youth from 18 to 25 years may require a different service environment when attending mental health service as compared with traditional adult settings [1–3]. McGorry claims that his ‘new paradigm’ of a youth mental health service for 12–25-year-olds will improve service delivery, research and prevention for this group of patients, and proposes revolutionary system change [3]. Other authors argue that a separate focus on adolescence and early adulthood ignores the degree of continuity of risk factors and psychopathology from childhood into early adulthood [4, 5]. They predict that the new arrangement will create more service seams, complicate continuity of care and reduce the capacity of existing child and adolescent mental health services (CAMHS). They caution that the largest opportunities for prevention and early intervention lie in childhood and early adolescence [6–12], but agree that a preventive approach to mental health work must pervade all psychiatry [13].
This paper reviews why adolescent psychiatry should remain within the subspecialty of child and adolescent psychiatry [14], but agrees that improvement is required in the mental health care of young adults aged from 18 to 25 years. Community concern about depression and suicide in young adults [15] has been followed by the proposal that adult services should extend their traditional focus on psychosis to more actively address highprevalence disorders [16]. The high prevalence of mental health problems in young adults [17], means that their care can only be addressed through partnerships with primary health-care services (e.g. [18]). Busy area mental health services (AMHS) seem reluctant to take on this new work until new resources arrive. At the risk of being thought presumptuous, we offer some ideas on how existing AMHS can reform services for young adults, based on our local experience and partnership models already found useful within AMHS [19].
Why the child and adolescent programme should remain unified
Developmental factors
The psychosocial concept of ‘adolescence’ refers to the period between childhood and adulthood that begins with puberty and is defined as 10–19 years of age by the World Health Organization [20]. The sociological construct of ‘youth’ has since been applied to the period between 15 and 25 years of age, in recognition that the period of psychosocial immaturity extends beyond adolescence [1]. Cognitive, emotional and social development changes gradually from childhood through adolescence into adulthood without a clear transition point, and with much individual variation [21]. Information processing, affect regulation and cognitive development are further developed after adolescence, so that adult mental health clinicians need to understand developmental principles in order to understand their patients.
Personality development in children, adolescents and young adults is influenced by person–environment interactions [22, 23]. The family environment, where early socialization occurs, is especially significant. Child abuse provides a clear example of this, and is now recognized as a major factor in several axis I and axis II psychiatric disorders [22, 24]. Modern interactional models of psychiatric pathogenesis [9] emphasize the importance of understanding developmental, social and systemic factors in assessment and treatment [4] of psychotic disorders [25] and personality disorders [12]. Systemic factors influence adults as well as children. It seems more logical to establish closer links between child and adolescent psychiatry and adult psychiatry programmes, to share systemic and developmental understandings, rather than separating them with a youth programme.
While 16–18-year-olds have some capacity to consent to treatment, treatment decisions for children and adolescents will usually involve parents and guardians [26]. This legal transition to adulthood at 18 years provides the clearest demarcation between adolescent and adult status. The CAMHS programme is congruent with other service systems for under-18-year-olds, including Acute Health or Paediatrics (until 16 or 18 years), Welfare Services (until 17 years), and School Education Services (until 18 years). Stronger intersectoral links and partnerships are more possible when the structure of our mental health programmes is consistent with that of other service systems, with the divide drawn at transition to adult legal status. The arrangement is consistent with paediatrics being positioned in acute health care, which caters for developing individuals who have different illness presentations, need different treatment approaches and require parental support.
Psychopathology and care
The International classification of disease (ICD-10) [27] and the Diagnostic and statistical manual of mental disorders (DSM-IV) [28] use the same codes for children, adolescents and adults where possible, but have separate sections for child or adolescent mental disorders. This reflects developmental differences in the form or expression of psychiatric disorder before adulthood. Similarly, as personality development is consolidated in late adolescence [12], axis II disorders are not diagnosed before the age of 16 years [27, 28]. Our classification systems are informed by epidemiological studies that show that psychiatric disorders in adolescence resemble those of childhood more than adulthood [4]. In later adolescence, patterns of psychopathology merge gradually into adult forms, with a diffuse boundary due to developmental differences in the origin and expression of disorder, and the properties of our classification systems themselves [9].
Recent epidemiological studies have shown increased rates of suicide and depression in some cultures, with the peak rate of youth suicide now occurring between 19 and 24 years of age [29–31]. Conversely, rates of psychosis have been fairly constant across cultures and over time [32], with 22 years being the mean age of those entering the Melbourne Early Psychosis Prevention and Intervention Centre (EPPIC) [33]. While these disorders have some similarity in onset age, their prevalence patterns, determinants and implications for prevention are different. One cannot generalize from one disorder to another and assume similar approaches to treatment are needed [4]. A range of strategies is needed for effective prevention and intervention. With high-prevalence disorders, primary health-care services will provide most of the direct care [18, 34], while for disabling, low-prevalence disorders such as first-onset psychosis, specialist providers will provide the major role in the acute phase [35].
Most high-prevalence disorders show strong continuity of symptom traits or expressed disorder from childhood through adolescence to adulthood [4, 22, 36, 37]. Neurodevelopmental vulnerabilities, cognitive deficits and developmental disorders of speech and language are risk factors for other disorders, such as schizophrenia, that emerge later [25, 38, 39]. Genetic predisposition is an important factor, but most high-prevalence disorders with impact in adulthood (e.g. conduct disorder, anxiety disorders, eating disorders and depression) have major social determinants that act through childhood into adolescence [12, 36, 40, 41]. Although the extent and limits of continuity of disorder have not yet been unravelled, and the mechanisms for vulnerability, continuity and discontinuity are not fully clarified, treatment strategies for child and adolescent disorders often target the same social determinants with similar methods. These common approaches link adolescent services logically with child services.
Prevention
The clinical implications of Mrazek and Haggerty's preventive framework [42] are still emerging [43]. Even disorders with a predominantly genetic or biological basis [25, 44] may be modified by manipulating environmental risk and protective factors [45]. Increasing knowledge of risk and vulnerability factors, and how these may be influenced, will help us target preventive strategies to particular populations, and at the most salient developmental points, to reduce the development and maintenance of specific disorders and enhance resilience [42, 46, 47]. Just as public health approaches to reducing water-borne diseases have had far greater impact on population health than medical advances, psychiatrists must appreciate that real reduction in high-prevalence disorders is likely to occur through community activity outside specialist mental health services [46].
Recent meta-analyses show that opportunities for prevention and early intervention are more extensive in childhood than adolescence, and that enhancing individual skills and building social protective factors may be as important as diminishing individual risk factors [7]. This means working with parents from early childhood to support development (e.g. [47, 48]), using general service systems such as schools or primary health services for universal preventive programmes [42, 43], and identifying high-risk groups at optimal times and applying costeffective, targeted interventions in ecological settings (e.g. [8, 49, 50]). In this context, youth psychiatry programmes cannot possibly provide best value in preventing psychiatric disorders, although it is relevant to focus on adolescents as well as children in indicated prevention and early intervention [42]. However, at this stage, although we better understand cascades of risk and how to modify pathways to disorder, we have yet to discover the optimum role for specialist mental health services in this.
Clinical competencies and professional training
Children and adolescents are not miniature adults, and Hammen et al. have recently highlighted the inadequacies of applying adult models to the treatment of depression in childhood [41]. As developmental status, social environments, risk and maintenance factors, patterns of disorder and appropriate treatment approaches for children and adolescents are different to those of adults, the training of CAMHS clinicians is also distinct. It focuses on developmental psychopathology, multidimensional assessment, interactions between biopsychological and interpersonal domains, and multimodal treatments [51]. Individualized biopsychosocial systemic interventions are tailored to diagnostic formulations, and may include psycho-education for parents, family interventions, cognitive– behaviour therapy and action-oriented psychotherapy for young people, medication and consultation– liaison with other service systems. Family system work demonstrably improves outcomes for several common disorders in childhood and adolescence [52, 53].
At this stage, the specific skills required for the specialist mental health care of 18–25-year-olds is not well articulated in the literature. The pilot youth service at EPPIC could help to define these competencies, the most appropriate curriculum and training methodologies, and the specific programmes and activities that offer best value in this age group. Early detection, comprehensive psychosocial intervention, least-restrictive care, lowdose medication and a preventive focus are said to be the principles that will be employed in the EPPIC youth service [3]. These principles are also basic to child and adolescent psychiatry. It seems likely that the existing skills of CAMHS clinicians can be more easily shared with those working in adult psychiatry if there is greater contact between CAMHS and AMHS, and new barriers do not separate them.
Complementarities between CAMHS and AMHS
Australia has followed other developed countries in establishing CAMHS programmes for 0–18-year-olds and AMHS for patients between 16 and 65 years. There is flexibility of service choice between 16 and 18 years, according to developmental status and need [54]. As both CAMHS and AMHS have been preoccupied with internal reform, we believe they have had too little contact [54, 55]. Their different histories, characteristics and relative isolation help explain how misunderstandings arise between the services.
In our view, modern CAMHS emphasize the following: (i) biopsychosocial systemic conceptualizations that highlight psychosocial variables; (ii) knowledge of developmental processes and impact on cognition, emotion and behaviour; (iii) high-prevalence disorders where psychosocial factors often seem dominant; (iv) community-outpatient care emphasizing family, social and systemic therapies; (v) consultation and coordination with parents, education and welfare systems.
Compared with CAMHS, AMHS approaches emphasize (i) biopsychosocial conceptualizations that highlight biological interventions; (ii) knowledge of psychopathology and understandings of behaviour as symptoms; (iii) low-prevalence psychotic illnesses where biological factors often seem dominant; (iv) inpatient care, crisis intervention and mobile support services for the most disabled; (v) working with carers and separate disability support services.
The differences also highlight how services can complement each other and how collaboration can enhance the care of individual patients. Clinicians working in CAMHS have skills in family systems consultations and in working with families where adults and children have psychiatric disorders. Unless there is a coordinated approach to care in these situations, interactions between vulnerable individuals can exacerbate psychiatric problems in both children and adults. Regular communication and shared case planning seems to enhance treatment outcomes in these situations. Adult psychiatrists have skills in using appropriate biological interventions for patients with major depression, early psychosis and severe anxiety disorders and may usefully consult on the treatment of some adolescents. Collaboration enhances the transition of young people from CAMHS to AMHS, and enables early recognition of indications of disturbance in the children of adult patients. Table 1 outlines some of the options we have identified for strengthening linkages between CAMHS and AMHS.
Strengthening links between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS)
Improving services in child and adolescent mental health services
The per capita funding of CAMHS is much lower than that of adult services in all States, and this iniquitous situation restricts the capacity of CAMHS to address the mental health needs of children and adolescents. Despite this, Victorian CAMHS have embraced the Second National Mental Health Plan and its focus on early intervention, partnerships and service system improvement [56]. Age-specific programmes are available in most regions for distressed infants and high-risk adolescents. Disorder-specific programmes are increasingly available for autism-spectrum disorders, attention deficit hyperactivity disorder (ADHD), affective disorders, anxiety disorders, disruptive behaviour and early psychosis. These have emerged from existing resources and, in our view, three factors have restrained their development. First, many CAMHS clinicians had overapplied psychodynamic models and were slow to embrace eclectic biopsychosocial approaches to treatment. Second, the small size of CAMHS means that a comprehensive range of local specialist programmes can only occur with a critical mass of clinicians (< 20). Third, localization of services by establishing small community clinics has created obstacles to specialization and participation in cross-service clinical programmes.
Since earlier criticisms of CAMHS [2, 3, 54], several improvements have been evident in Victoria. EPPIC's guidelines have improved management of first-onset psychosis, although very few under-16-year-olds present with this diagnosis [57]. More significantly, the care of older adolescents with disruptive behaviour disorders has been demonstrably enhanced through the establishment of regional mobile adolescent teams [58]. However, the care of this population of patients remains challenging, as their psychopathology usually involves poor verbal problem-solving, impulsivity and an impressive capacity to blame others [21]. Their difficulties overlap with those of the young adult population with personality disorders, who continue to challenge AMHS. The optimal time for intervention for this population is generally thought to be in childhood, largely through other service systems [36, 37,48–50,59, 60].
Academic activity of CAMHS continues to improve in Victoria, as in other states. The Learning Organization model [61, 62], has helped our own regional service to embrace clinical research and routine outcome evaluation, and this is consistent with the experience of some AMHS in New South Wales [19]. While the volume of research may not match that of a specialist research unit, in 1999 our service staff (Maroondah Hospital CAMHS) published 14 articles in refereed journals. External feedback from consumers, other service systems and hospital reviews has been uniformly positive. Internal indicators of progress include our routine use of the Health of the Nation Outcome Scales Child and Adolescent version, and the Strengths and Difficulties Questionnaire [63, 64], to gather multiple perspectives for assessment and clinical review. Staff trained in evidence-based, cognitive–behavioural approaches, and our specialist clinical programmes are focusing research on relevant clinical problems, such as patient drop-out and disruptive behaviour disorders. Our experience is not unique, but demonstrates that modern CAMHS embrace innovation and evidence-based practice.
The ADHD Clinic at Maroondah Hospital is a good example of a specialist clinical programme, and over 200 children have been referred in the last 3 years. In two appointments, a psychologist assesses the child's performance on standardized tests while a psychiatrist administers a semistructured clinical interview with parents, and then sees the child to conduct a developmental neurological examination and a semistructured clinical interview. The child completes a self-report form about symptoms and behaviour, and parents complete individual, marital and family psychopathology questionnaires. A comprehensive diagnosis and formulation is developed and intervention strategies are discussed with the referring clinician. These consultations have improved the management of ADHD in the service. Research to date has emphasized the extent of comorbidity, established a relationship between higher doses of psychostimulants and the child's report of anxiety, demonstrated executive function deficits and the positive impact of low-dose psychostimulants, and shown the effectiveness of cognitive–behavioural therapy groups for parent management.
Despite low resources compared with AMHS, while CAMHS target the most disadvantaged or disabled patients they also consult across service systems and work in partnerships to enhance primary mental health care to others [54]. The resource limitations in Victorian CAMHS have led to the development of briefer and more standardized assessments for routine patients [65], which has also occurred in other States [66]. Partnerships with consumers have strengthened and information sheets are increasingly being produced by clinical services, including our own, about programmes or specific disorders [67]. The design of our inpatient service was guided by input from adolescent inpatients, and regular focus groups with our clients and their families continue to help us to improve our programmes [62]. The Victorian Child and Adolescent Psychiatry Training Programme has increased its focus on neurosciences, developmental psychology, biological treatments, service management, research methodology, efficient evaluation, individualized service planning, multisystemic therapy and cognitive–behavioural treatment approaches, while reducing its reliance on psychodynamic theory [51].
Improving adult mental health services
Victorian AMHS have also changed much since the Framework document [55], and are currently undergoing a Ministerial Review. This will indicate whether they still provide suboptimal support to the families and children of their patients, poorly meet the needs of older adolescents [2, 3], and focus too heavily on the care of those with psychotic disorders [16, 17]. Older adolescents with severe depression and anxiety, those with comorbid substance abuse and who suffer dual disability with intellectual impairment, and patients with emergent personality disorders have not been well served by public mental health services. If Victorian CAMHS have lifted their game, can AMHS do the same for young adults?
One approach to improving services has been for State Mental Health Branches to establish specialist ‘centres of excellence’ that are supposed to spread their skills into the system. Examples include specialized services for those with eating disorders, personality disorders, firstepisode psychosis and neuropsychiatry disorders; those using languages other than English; and Kooris. These services may accept complex referrals from AMHS, conduct research on their particular target population, develop best-practice treatment and improve the competence of other services through consultation and training. The Review will examine their effectiveness in meeting these aims. Another traditional approach has been to provide new funding and programme specifications or guidelines to create new service elements in all AMHS. The Enhanced Crisis Assessment and Treatment teams provide an example for patients at high suicide risk presenting at emergency departments.
A third approach to service improvement, might be called ‘bottom up’. This is the development within a generic service of an innovative programme aimed at particular populations, by reconfiguring services to meet an identified need. An example is provided by the Maroondah Hospital AMHS Parents in Partnerships Project, now in its third year [68]. This programme for the children of parents with mental illness is the result of the service funding a project officer from existing resources to improve the performance of the service. The project now works collaboratively with welfare agencies to enhance parenting support and education, and provide group programmes to children, adolescents and parents whose parenting has been adversely affected by parental mental illness. A collaborative research project with CAMHS is now identifying the numbers of AMHS patients with children, and assessing their psychological health, to improve pathways to care for these children and families.
The Alfred Community Service for Early Psychosis Treatment (ACSEPT) Network at the Alfred Hospital is another example of improving services to a young adult population [35]. The Alfred Hospital AMHS established the ACSEPT Network to improve the treatment of 18–25-year-olds who have early psychosis or are at high risk of psychosis. It has three (full-time equivalent), CAMHS-trained staff that work with AMHS, CAMHS and others to provide developmentally sensitive and family-focused services. They aim to enhance early identification and treatment of first-onset psychosis and promote recovery through psycho-education strategies with young people and families, professional education and collaborative care through networks of recovery and support programmes, and by implementing the Clinical Guidelines of the National Early Psychosis Project [69]. This model strengthens the capacity of the existing services, and has received very positive feedback from consumers and focus groups in qualitative evaluation.
Improving services for young people: a call to arms
These examples lead us to believe that regional AMHS can strengthen their performance through supporting specific projects for young people within their services, rather than by establishing specialist units that can draw resources from regional AMHS, or by adopting the revolutionary, but unproven, model proposed by McGorry [3]. While a balance of specialist centres and regional approaches may be optimal for some disorders, within- AMHS projects are a logical vehicle for improving clinical care to young people with high-prevalence disorders. Specialization can focus on any problem, and by collecting experience on large numbers of clients with a particular clinical problem, research and teaching is supported [14]. Generic service providers refer to specialists if they, and their patients, believe they will receive added value. Specialist teams within AMHS can enhance local services, increase the validity of assessments, improve the value of consultations and raise efficiency by maximizing treatment efficacy. They also build local competencies.
We challenge area AMHS to establish more specialist clinics or programmes for older adolescents and young adults with high-prevalence disorders. These could simply focus on under-25-year-olds, or be developed for specific clinical populations, such as those with anxiety disorders, depression, emergent personality disorder and comorbidity with substance abuse, depending upon local needs and interests. Programmes could focus on 16–25- year-olds and be run jointly by AMHS and CAMHS staff. They might emphasize clinical services [18, 35], professional education [70], or partnerships with other services (e.g. [71, 72]), or all of these concurrently. Although academic linkages are essential, specialist clinics do not depend upon the presence of academics. Useful starting points might be consultation about major needs, determining the programme focus, defining potential models of practice and evaluation methodologies and identifying logical partners. As seed grants from regional offices, State Government Mental Health Branches or other parties can be difficult to obtain, academic partners may identify alternate funding sources or facilitate postgraduate student involvement. Alternatively, management consultants may create resources by work process re-engineering [73, 74] and redeploying current staff to work full-time or sessionally.
We believe the Royal Australian and New Zealand College of Psychiatrists should encourage links between CAMHS and AMHS, and be more active in improving mental health services to young adults. The College could audit and report on current arrangements, encourage research on the mental health needs of young adults, review international best practice and provide guidance to AMHS. Young adults are identified as a distinct cohort in the Second National Mental Health Plan [56], for which the National Action Plan for Mental Health Promotion and Prevention raises research questions and proposes national strategies [75]. The College could lobby Mental Health Branches to support experimentation and research into programmes that improve access to mental health care for young people with high-prevalence disorders. This means giving greater urgency to the work now occurring with the Royal Australian College of General Practitioners to strengthen links with primary health, and facilitating links between Psychiatry and Drug Treatment Services at a Commonwealth and State level.
Conclusion
This paper comments upon mental health services and agrees with other critics that the mental health care is deficient for the young adult population. As children and adolescents are different from adults in their development, patterns of psychopathology, opportunities for prevention, service requirements, and the linkages with other service systems, we conclude there is no need for radical change to current service arrangements. Instead of revolutionary change by developing new youth psychiatry programmes to stand between CAMHS and AMHS, it seems more realistic for CAMHS to continue being responsible for clients who have not reached adult legal status and to reform AMHS to more actively take responsibility for all those between 18 and 65 years. This means that AMHS must increase their understanding of their younger population and develop their services and methods of service delivery for these clients. Stronger links between AMHS and CAMHS will be likely to improve clinical care, and also facilitate service development for 16–25-year-olds.
The paper acknowledges some positive changes that have occurred within Victorian CAMHS through having a clearer framework [54], by improving service funding and through the model of specialist clinical programmes described here. Just as some CAMHS staff work mainly with adolescents while remaining a part of the broader programme, we encourage some AMHS staff to develop specialist expertise with 16–25-year-olds. Regional AMHS should utilize the model of project teams to establish new clinical services for this population, especially aimed at depression and anxiety, comorbidity with substance abuse and dual disability. Service improvement is also required for the children of adults whose parenting is adversely affected by mental illness. We believe this is likely to be best organized through local partnerships with consumers, academics, CAMHS, drug treatment services, welfare organizations and others. The leaders of area mental health services must take responsibility for closing these service gaps, and the College and Commonwealth and State Mental Health Branches must actively support them with guidance, encouragement and funding.
Footnotes
Acknowledgements
The assistance of Alasdair Vance is gratefully acknowledged in the preparation of this manuscript, and in providing the description of the Attention Deficit Hyperactivity Clinic at Maroondah Hospital, in which he is the principal consultant psychiatrist and researcher.