Mind the Gap

[Posted on 24 July, 2018 by Phil Wilson]

Non-specialists (for example general practitioners/GPs, social workers, teachers, community nurses) generally find it difficult to get a good service for children and young people with psychiatric problems. Navigating the complex landscape of specialist children’s services is a huge challenge. There are many reasons: opaque and sometimes inconsistent referral criteria; general difficulties in communication between generalists and specialists1; gaps in specialist service provision to name but a few. Some specialist services are seen by my GP colleagues as taking more pride in the children they refuse to see than the ones they do see!

Efficient and affordable health services usually have generalists as a first port of call, and referral systems to specialists2. GPs like me provide medical services across the age spectrum and typically we might see three or four children with potential mental health problems each year. Most of us will have had limited training in child mental health.

Clinical problems are usually undifferentiated when we first see the child (or parents). Let’s take a typical example. Distressed parents bring their 7-year-old child because he has just been excluded from school. He is also ‘difficult’ at home, sometimes aggressive towards his sister. He hasn’t made much progress with reading and writing at school. If the child is also disruptive in the GP consultation we may not get much more information! So where does the GP go from here? We may well know that the underlying problem (or problems) could be many and varied: ADHD, autism, conduct disorder, learning difficulties, maltreatment, dysfunctional parenting, etc. So who will offer the best service – child psychiatrist, clinical psychologist, developmental paediatrician, social worker? The GP might write a referral letter to the child psychiatrist but get a response saying that “the local child psychiatry service doesn’t deal with conduct problems, so please write to the social work department”. Or “the service doesn’t deal with developmental problems, please write to the paediatric clinic.” And, of course, vice versa. This scenario could be acted out equally easily if the parents first take their problem to a teacher or a social worker, rather than to a GP.

Of course, specialists need to offer services in their specific areas of competence but services as a whole need to provide support for all children with remediable psychiatric or behavioural problems. How can we produce a whole-system change to make this happen?

– Child mental health specialists need to spend more time with generalists, exchanging knowledge and sharing perspectives on their patients1. Simply providing more training for generalists isn’t the answer – the basic training curricula are already filled to bursting point.

– We should consider using structured diagnostic instruments at the interface between services, for example the Strengths and Difficulties Questionnaire, the ESSENCE-Q and the online Development and Wellbeing Assessment (DAWBA – currently being trialled in Scotland). This might help to direct children to the right service more quickly.

– Services need to be designed to provide a safety net for children who don’t neatly fit into a diagnostic category, and health services need to take responsibility for filling the gaps in services. This is particularly important for children who narrowly fail to meet diagnostic criteria for several disorders but who nevertheless have severe functional impairment.

[This is a blog. The purpose of the blog is to provide information and raise awareness concerning important issues. All views and opinions expressed are those of the writer and not necessarily shared by the GNC.]