Abstract
Informal communications at conferences and such reveal striking differences in CAMHS models of care between regions, states and countries. Beyond the broader ‘institutionalized’ variations there are less obvious, ‘philosophical’ differences. None of this has been examined systematically, and few of our units are resourced in such a way as to support such research. We applaud the attempt by Crocker et al. [1] to examine aspects of their service, but what are we to make of their findings, when they reveal practice so discrepant with our own?
It may be unfair to use this paper (which has a specific aim) to draw attention to broader issues, but to the extent that those other aspects are presented as unremarkable, and their publication without subsequent comment effectively normalizes them, some discussion is warranted.
The study was ‘to determine the predictors of aggression and restraint in children admitted to a child psychiatric inpatient unit in Melbourne, Australia’. The data derive from a specialist unit servicing under 12s. The major finding was, unsurprisingly, that a diagnosis of behaviour disorder was the best predictor of aggression.
Other information in the paper surprises us. Over a 12-month period 70 children were admitted, for an average length of stay of 4½ weeks. Our statewide service (<18 years) offers planned 5-day assessment admissions for under twelves, and rarely if ever admits such children acutely. An admission over 5 weeks would be unheard of in that age group. We wonder what clinical conditions would benefit from a 5-week inpatient stay.
Diagnostic groupings present another dilemma, and nosology in our field is fraught. We note the pragmatic use of the diagnoses used by the referring agencies. It seems unlikely their population included 11% with a defined (ICD or DSM) Attachment Disorder (generally deemed rare outside institutionalized cohorts) so one assumes they are using the term more broadly. As behaviour disorders are rarely free of an attachment component or a parent–child relationship component, and as they overlap substantially with attention deficit hyperactivity disorder, the validity of these groupings (admittedly done for statistical simplicity) is questionable. We make this point to highlight the shortcoming in existing classifications, and the difficulties in making useful comparisons.
Perhaps of most concern is the conceptual approach to the whole issue of aggression. With minor changes the paper could be describing an adult unit, with its emphasis on procedures, holds, staff safety and so on. It could be from a school's risk register. There is little mention of relationships (within the unit or the children's families). There is no exploration of whether aggression is instrumental (purposive) or not. There is no developmental perspective. There is, in short, no recognition that children are different from adults.
One predicts that, in the normal course of managing a behaviour-disordered child, one will occasionally get hurt: that is the nature of their pathology. We certainly shouldn't pretend it doesn't occur or doesn't matter, but a clinically sophisticated, relationally attuned response is what is called for, not a policy. This is what a good enough parent would provide were they scratched or bitten in the course of managing a squabble at home. The same parent avoids setting up a situation doomed to fail, which in our experience is often the case when you admit a behaviour-disordered child for any length of time.
These issues seem to us more relevant than the technical and procedural issues raised in the discussion and conclusions. We don't have all the answers but do think they are the important questions.