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Autumn 2007 | Vol 11 No 1

Focus

Working together for kids

Child and youth collaborative care in action

By Terry Isomura, Tracy Lindberg, Ann Turner, Andrea Chapman and Martin Howard

Since 2005, the Child and Youth Shared Mental Health Care Program in British Columbia has linked mental health professionals and family physicians. Supported by the Fraser Health Authority and the Ministry of Children and Family Development, the shared care (SC) program features two health teams comprising psychiatrists, mental health clinicians and a psychologist that operate out of four primary care sites. The teams take referrals from six multi-physician offices in Coquitlam and New Westminster. Clinicians attend each site one-half or one full day every week; psychiatrists attend each clinic once or twice per month.

Psychoeducation and early intervention are important program objectives. Referrals range from youth with no prior mental health issues to those with extensive histories. The teams provide assessment, medication consultation, short-term psychotherapy, follow-up and liaison with mental health resources.

Communication is key to the collaborative approach: “We communicate with family practice colleagues in the usual formal way, but our informal interactions are also valuable,” says Dr. Ann Turner, one of the program’s psychiatrists. “Questions can be asked and answered and ideas shared simply by a brief exchange between appointments.”

Dr. Andrea Chapman, another SC psychiatrist, agrees: “Since we are all in the same office, we can discuss the case and treatment recommendations with the physicians, who usually know the family and child well. This adds a real depth to our assessments.”

Stigma-busting is another benefit: “We have engaged clients who were reluctant to accept other mental health services because of stigma,” says Dr. Tracy Lindberg, the SC psychologist. “Parents and children appear to find it more comfortable and convenient to come to their doctor’s office.”

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Drawing from experience in the clinics, the following case illustrates what collaborative care with youth might look like.

Sixteen-year-old Amanda* was referred to the SC program by her family physician after her adoptive mother, Sharon,* consulted her about Amanda’s suspected drug use and declining school performance. The doctor scheduled a meeting for Amanda and Sharon with the SC clinician to take place in her office within five days of the referral. The clinician gave explained the program to Amanda and her mother and scheduled a multidisciplinary assessment with the SC psychiatrist and psychologist for two weeks later.

During the assessment, Amanda reported increasing family conflict and a decline in functioning. She had become involved with a group that used alcohol, marijuana and cocaine and had run away from home for one month. Sharon had persuaded Amanda to return home but Amanda had refused counselling. Sharon described Amanda’s increased irritability, lack of interest in school and disrespect for house rules. Amanda reported a low and irritable mood, decreased interest in activities, social withdrawal and disrupted sleep and appetite. She was self-critical and anxious. She also reported impulsive behaviour and difficulty with attention, concentration and school work.

At the end of the assessment, a case formulation and treatment recommendations were shared with Amanda and Sharon. The family doctor received a consultation report. She persuaded Amanada to start counselling.

In regular meetings with the psychiatrist and psychologist, Amanda and Sharon received psycho-education about mental illness and learned how substance use affects judgment, mood and behaviour. They also attended joint sessions to monitor symptoms and address family conflict. Amanda and the psychologist used a cognitive-behavioural approach to identify and change maladaptive behaviour patterns and to learn better strategies for managing mood.

Psychoeducational testing found that Amanda’s cognitive skills and attention abilities were intact, but that she struggled with a mathematics learning disorder. A report was sent to Amanda’s school, allowing her to receive coursework adaptations. The psychologist reviewed compensatory strategies with Amanda and her mother that could help Amanda with school. The psychiatrist started Amanda on anti-depressant medication to address her depressive symptoms. Throughout counselling, Amanda’s doctor received informal updates and copies of all formal reports, and shared responsibility for following up on symptoms and medication issues.

Amanda reported improvement in her symptoms. Meetings with the SC team were tapered off as Amanda’s doctor took over medication management. However, over the next year, Amanda continued to display impulsivity and lack of regard for consequences, which affected her relationships and functioning. She had a substance use relapse and visited the emergency room several times. During this period, Amanda’s doctor consulted with the SC team to review diagnostic issues and coordinate treatment. The team gave her information and resources about counselling strategies to use with Amanda and ways to support Sharon. Amanda was referred to a local substance abuse program and returned briefly with her mother to psychotherapy with the SC psychologist to review strategies for managing her behaviour and mood.

Amanda terminated her substance use, disengaged from some of the detrimental factors in her social environment and established structure in school and at home that supported better functioning. Her mood issues stabilized. Amanda’s care is currently managed by her family physician. The SC team remains available for formal and informal consultations on medication issues, counselling strategies and local resources.

The benefits of collaborative care are clear. For Dr. Kathleen Ross, a family physician in Coquitlam, “This coordination has decreased the morbidity associated with mental illness in this age group, helped to relieve the uncertainties and stress facing families and improved the long-term outcome for our patients.”

*names have been changed

The authors are members of the Child and Youth Shared Mental Health Care Program in British Columbia.