HOME TREATMENT FOR CHILDREN AND ADOLESCENTS SUFFERING FROM SEVERE MENTAL HEALTH
This research will identify the need for evidence based practice regarding home treatment for children and adolescents with severe mental health problems scanning the general literature in the area that may make a case for this practice. The research will then outline a critical appraisal of two specific literatures in the field as a basis for my further research on the topic. I will then identify a research question for my topic and develop a rationale and statement for the research’s aims and objectives.
The area of practice I have been working on has been in a primary care trust supporting people with severe mental health needs. It has been unfortunate in the sense that the particular ward I worked on is mainly for adults but has been supporting teenagers. I came across home treatment as a discussion at the ward among the other health practitioners and felt this may be more beneficial to the teenagers, who were kept in an adult ward because of lack of hospital bed. In the UK 30-60 per cent of people with severe and enduring mental health illness have children. Similar figures are reported in Europe and the US. (Howard et al, 2001). Recent international service development has promoted home treatment methods as an alternative to hospital treatment (Johnson et al, 2008).
According to the Daily Mail (2008), only 15 per cent of health trusts complied with the targets that all under 16s should be treated in separate units and not adult ones. The children’s commissioner, whom commissioned the investigation, said children suffering from mental illness were still being failed by the NHS. The government promised in 2006 that, by 2010, no young people under the age of 18 would inappropriately be put in adult’s ward, saying the NHS still had some way to go in achieving this. About a third of the approximate 3,000 children needing psychiatric help end up in the adult ward. The assessment followed a report by the charity Young Minds and Very Important Kids called Out of the Shadows which followed another report titled Into the Shadows, published January 2007, saying that young people with mental health problems were receiving inappropriate and inadequate care on adult wards because of a shortage of hospital beds for children under 18. The department of health stated that spending on mental health services had increased by 31 per cent or £1.2 billion in the last five years allowing the NHS to invest in the services so staff needed to transform mental health. This demonstrated the disadvantages of hospitalisation and the need for home based treatment, which from a government perspective is useful to drive down costs, and has been happening for 30 years. It was also to provide care in the least restrictive environment, and reflects the policy to provide flexible, local child and adolescent mental health services with therapeutic advantages (Khalife et al, 2009).
Approximately 2,100 are admitted to child and adolescent mental health units each year (Worall et al, 2004). While the numbers admitted each year is small, the impact of these on the young person can be severe and prolonged, and the accompanying use of resources very high, particularly for 16 / 17 year olds (Goodman, 2005). Specialist care is not always then available (DH, 2004a).
In terms of my search strategy, I reviewed a number of literatures for this research, concentrating on the most up to date and relevant material as advised by Parahoo (1997). I used mainly electronic based material, through Google and Google Scholar, as this was the quickest means of obtaining data. In order to be successful with this strategy, the key words I searched were ‘home treatment’, ‘family therapy’ and ‘severe mental health illnesses’, and ‘the efficacy of managing these’. I found that manual searching of libraries for relevant journals and texts was a highly laborious and painstaking task. Using an internet search engine was therefore necessary to manage the literature for this research.
The two major literature used were primary qualitative researches published in 2008 and 2009 in order to obtain the most up to date information in compliance with the Nursing and Midwifery Council (NMC, 2008). This should reflect current practice which has been influenced by government policies and guidelines on alternative treatments for children and adolescent people suffering severe mental health problems. Other lesser articles will be used such as in America because new solutions to hospitalisation are a global issue. The two studies I chose to be critically appraised were both pertinent to the topic question, and one used randomised control trials (RCT) and systematic reviews. Sackett et al (1996) stated that RCTs and systematic reviews are among the best forms of evidence base.
DETAILED CRITICAL REVIEWS OF TWO KEY PAPERS
Critical appraisal is the process of assessing and interpreting evidence by systematically considering its validity, results and relevance (Parkes et al, 2001 p10). Critical appraisal tools are a useful method for evaluating the quality of the study, and the methods used to lessen biases (National Health and Medical Research Council, 2000). The two studies used were Khalifeh (2009) and NIHR (2008) because in terms of the searches made these two articles were very relevant and up to date thorough empirical works that justified the rationale listed above demonstrating the need to further investigate the evidence based knowledge in the area of home based treatment for supporting young people with severe mental illnesses.
Khalifeh et al (2009) carried out a study in two heavily populated London Boroughs with high levels of deprivation and one of the highest areas of psychiatric morbidity in the UK. They used purposive sampling to recruit patients with different diagnosis, treatment histories and levels of social support. Eligible patients were sent an information sheet and consent form and contacted by phone by mental health staff. The information sheet included full explanation of the study aims and an opportunity to answer questions. The interviews included those with parents / relative as well as the children in order to triangulate the findings. Their studies were approved by the local research ethics committee.
The data collection strategy used was semi structured interviews. The interview topic guide was based on previous research in the area such as Falkov (1998). The specific aim of the study was to explore patient’s experience of home treatment, children’s experiences, treatment preferences and unmet needs. They conducted interviews with patients over a six- month period; from 2006 to 2007.The semi structured interviews explored themes.
In the data analysis, all interviews were audio taped and independently transcribed. Information indentifying the interviewees was removed. Content analysis was carried out with the support of QSR N6 software. A coding framework was developed that contained themes relevant to the aims of the study. The interview guide topics were included as themes in the coding frame at the beginning of the process of the analysis. The coding frame was then elaborated and modified as new themes and sub themes emerged in the course of the analysis. The development of the coding frame combined deductive (based on prior themes to be explored) and inductive elements (based on themes emerging directly from the data). Negative case analysis was used to refine the coding framework by searching for elements of the data that seemed to contradict emerging themes. Interviews were analysed throughout the study periods in groups of two to four interviews with findings used to refine the interview schedule and guide further analysis.
In the second research studied, the National Institute for Health Research, NIHR (2008) did a systematic review and mapping study of alternatives to inpatient care for children and adolescents with complex mental health problems. The NIHR said that it is not known if inpatient care is better than home treatment so they varied out a systemic review of effectiveness of alternatives to inpatient services. Other non home treatments involved in alternatives to inpatient care included day hospital, which is partial hospitalisation, but is a specialised intensive treatment approach; home based psychiatric treatment which is still being delivered by medical professionals except in the home rather than the hospital environment. Therapeutic foster care is a home like environment managed by foster parents who are specialist trained. Residential care provides a systematic approach for people in need of community rehabilitation. It includes behaviour management, family therapy, and medication management. The NIHR used randomised control trials and compared it with non randomised trials. There were a lot of theoretical background on multi-systemic therapy and how this is applied to family therapy. I have summarised the various concepts and terminologies in appendix one. These include the various names for family therapy such as home treatment, and the approach used by the authors, the multi-systemic therapy. The aim of the study was clearly stated, which was to identify from the literature, the different organisational structures and therapeutic approaches of inpatient mental health services for children and young people assessing the evidence of their effectiveness and cost. Then, secondly, to identify the range and prevalence of these different models.
The coverage of the literature identified by the NIHR is very thorough, though they came to the conclusion that other works on the issues of alternatives to patient care is not very well evidence based, as many studies fail to report the duration and intensity of an intervention, or the training and qualification of staff, the use of treatment manual guidelines. One of the literatures they looked at was the Rowland (2005) trial. The NIHR criticised this trial for reflecting on a limited number of therapists which resulted in difficulties with implementation. The NIHR’s research concluded that the care giver’s and teacher’s assessment showed very little improvements in behaviour of the children and young people. But the advantage of the research was that young people receiving home based MST experienced some improved functioning, they spent less days out of school and in out of home placements and significantly less alcohol consumption. Another advantage was that the caregivers and youths reported better satisfaction with the family therapy programme than with inpatient care.
During the course of home treatment unattainable aims were dropped and newly arising acute problems are included in therapy (Gopel et al, 2000). Goals were agreed with the family and included reducing aggressive behaviour and other maladaptive behaviour, increasing pro social behaviour, control of school truancy and supervision of school tasks (Schmidt et al, 2006). The aims of the home treatment programmes are to prevent out of home placement, stabilise therapeutic success beyond the home treatment period for positive long term outcomes Gopel et al, 2000).
With regards the intervention method applied by NIHR (2008) parents were invited to address problems in their own lives (Erkholati et al, 2004), receiving training in behaviour modification techniques, and direct instructions to improve child self help, social and leisure skills, (Lay et al, 2001), reduce inappropriate behaviour, encourage child management, and promote education skills. The goal is to move the family beyond their current state of crisis towards increased competency and problem solving skills (Schmidt et al, 2006). Parents are helped to support the adolescent in new ways with the aim of returning them to school or work. This was achieved by first of all evaluating the child during home visits, with the treatment goals being determined by behavioural assessments. Different outcomes were measured using teacher reported data, the individual’s and the caregiver’s information to evaluate the effectiveness of MST.
NIHR discovered that alternative services had led to a reduction in the number of inpatient services, reduced stigma, and joint service tailored service. This meant that the study had contributed to nursing practice. The research by the NIHR was also unbiased because it gives advantages and disadvantages of the studies it mentioned.
From reading the NIHR study the participants were not subjected to harm or discomfort and steps were taken to safeguard the privacy of participants. Conducting research in this area is very difficult which may provide an explanation as to why it is hard to deliver evidence based supporting alternative modes of care. Designing a study and obtaining ethical consent to include young people with complex mental health problems is always difficult. The NIHR recommended that studies should be designed to compare home treatments with hospital treatments. In the study the evidence based is made by obtaining service user’s views on any alternative service through qualitative research. The critical appraisal of the two detailed researched works were clearly related to my area of interest, and provided a conceptual background for my future research proposal justifying the need for further empirical evidence as they identified ‘gaps’ in knowledge
EVIDENCE BASED PRACTICE
There is a criticism of evidence based given the current concerns regarding the scale and management of mental health problems in children and adolescent, a high priority should be given to improving the quality of evidence base which provides little guidance to the development of services. There is a need to collect robust data on the profiles and outcomes of users of these alternative services. The evidence based is improved by obtaining service user’s views on any alternative service through qualitative research (Khalife et al, 2009).
Evidence based practice (EBP) is the conscientious, judicious and explicit use of current best evidence in making decisions about the care of individual patients. It helps ensure fair access to effective high quality care (DH, 1997). Evidence based practice will derive from professional experience, the views and preferences of service users, and the knowledge found in any profession’s research literature (Newman et al, 2005). I found that in my placement, it is the third element of research that is absent where nurses were concerned in terms of applying research to every day practice.
This research has demonstrated to me the importance of EBP in informing policy. Where I was on placement policy documents regarding alternative treatments to hospitalisation has not been thoroughly followed. Perhaps working with nurses could be a reason to this as social workers may be more inclined to look at other community alternatives. Failure to provide evidence based care could be a breach of NMC code of professional conduct (NMC, 2008).
Effectiveness and outcomes become really important words. Effectiveness is the capacity of an intervention to deliver the outcomes, which is what social work should primarily be doing. Nurses and social workers can develop these skills by formulating a practice question, finding research evidence that can answer our question, appraising research evidence and applying the results to practice (Newman et al, 2005). The problem with social work and social care practitioners is that they concentrate more on theory and less on critical attention to the development and evaluation of effective interventions.
National policy documents relevant to my study include DH (2004a) National Service Framework for children Young People and Maternity Services. They highlighted more disadvantages of hospital care which included stopping people from being dependent on hospital care and being stigmatised. Also I read the DH (2004b) Child and Adolescent Mental Health services mapping, which analysed statistical data from a variety of locations. Meusser et al (2001) discussed the deinstitutionalisation movement which led to the development of family interventions for people with schizophrenia coming home from hospital. Family members began to play an important role in care giving. In the US, the statistics for family members giving this intervention was between 30 and 60 per cent (Talbot, 1984).Why did home treatment models develop? One, because many people were not institutionalised as stated above. Two, families began to speak openly about the burden for caring for loved ones with schizophrenia and the mistreatment they often received in the hands of professionals. As a consequence of this, advocacy groups such as NAMI (National Association of the Mentally Ill) began lobbying professionals to improve the treatment of people with severe mental health illness. In the 70s and 80s these factors encouraged the development of different home treatment models. Some of these treatments are educational and supportive while others were behavioural and cognitive (Meusser, 1999). Apart from the difference in theoretical orientation, family intervention models also differ in their locus of treatment for instance clinical or home based and single family versus multiple family groups, and the duration of the treatment such as time limited and time unlimited.
Family intervention has been quite extensive since the 1980s particularly for schizophrenia. When Meusser et al (2001) carried out a study, they found out that the two programmes single family and multi family therapy were the most successful in that they were associated with fewer relapses and fewer rehospitalisation. This system will also be very popular because it can result in substantial savings particularly for patient treatment costs. (Tarrier et al, 1991) Although the work on family intervention procedures for people with schizophrenia is well established, not much research has been done on how it affects other aspects of patient functioning such as social adjustment, quality of life, work or degree of family burden. Several studies have shown that family intervention has supported improvement in patient social functioning (Allen, 1990). Yet despite the availability of family treatment manuals few patients with serious mental illness receive home treatment which may improve the outcome and access to family treatment and alleviate caregiver’s burden on relatives. (Dixon et al, 1999).
Family therapy is recommended when a family member has schizophrenia or suffers from another severe psychosis. The goal here is to help the family member understand the disorder and adjust to the psychological changes occurring in the patient (The Encyclopaedia of Mental Illness (2010). Family therapy began when patients’ symptoms rose or fell, according to the level of tension between their parents. This led to considering the family as a system. When therapists began treating the family as whole units instead of the hospitalised patient, they found that the illness improved. Problems are treated by changing the ways the system works (Campbell, 2001).
My practice role was to support patients in a hospital treating children and adolescent with mental health problems. The topic relevant to my area of practice will be to look for other alternatives to hospital treatment. While I am not currently working on other forms of treatment apart from hospitalisation I can clearly note that the young people in the hospital care are inappropriately placed, and have discussed the cost of care with other staff of the hospital which tends to be very high. The alternative I will therefore be drawing on will be home treatment or family therapy. I will assess the effectiveness of a treatment intervention that will contribute to the professional role requirement. I will systematically build the question by applying the PICO standard which refers to the population (young patients with severe mental health problems), Intervention (the home treatment), control (the hospital), the outcome of the problem (treatment for the severe mental health problem). This evidence based model is applied in Richardson et al, 2003). My research question will therefore be:
In managing children and adolescents with severe mental health problems, is treatment at home more efficient than treatment in the hospital?
RESEARCH AIMS AND OBJECTIVES
I will use NIHR’s method to critically appraise the home treatment model by first of all, classifying and describing the home treatment model and determining the effectiveness, cost and acceptability of home treatment. While NIHR (2008) looked at other models day care etc, I will focus on one of them – home treatment and its variants. The study is relevant to my research because it concentrated on children and adolescent with severe mental health problems excluding other factors. Since NIHR stated that other works on the issues of alternatives to inpatient care is not very well evidence based as many of the studies fail to report the duration and intensity of an intervention, the training and qualification of staff, the use of treatment manual guidelines I will identify this gap in the literature by ensuring that my research will cover these areas. Another gap identified in the research will be for me to ensure my questionnaire will include areas relating to the affects of mental illness to other aspects of patient functioning such as social adjustment, quality of life and work and the degree of family burden. The NIHR recommended that studies should be designed to compare home treatments with hospital treatments. In the study the evidence based is made by obtaining service user’s views on any alternative service through qualitative research. I will adopt this practice in my research.
The aim of the research will be to identify whether the home treatment model (or family therapy) is a more effective treatment for children and adolescent suffering from severe mental health problems than hospitalisation (or inpatient care).
The objectives of the research will therefore be to:
- Develop a structured questionnaire aimed at the relevant population (family carers, family therapists, individual children and adolescent) requesting the efficacy of the home treatment models people is currently receiving.
- Statistically analyse the advantages and disadvantages of inpatient care from the literature
- Develop a questionnaire aimed at nurses, social workers and patients receiving hospital treatment about the efficacy of the treatment they are receiving based on the data collected about inpatient care.
- Compare the information gathered to ascertain why (if so) that home treatment should be the way forward for treating children and adolescents with severe mental health problems.
Anderson, c, Reiss, D and Hogarty, G (1986) Schizophrenia and the Family, New York, Guildford Press
Campbell, T (2001) “Behavioural Medicine in Family Practice: Family Systems in Family Medicine,” Clinics in Family Practice, 3(1).
Daily Mail (2008) Is the NHS failing mentally ill children placed in adult wards?
Last updated 1st October 2008
DH (1997) The New NHS Modern, Dependable, London, Department of Health
DH (2004a) National Service Framework for children, Young People and Maternity Services, London, Department of Health Publications.
DH (2004b) Child and Adolescent mental health services mapping, London, Department of Health publications.
Dixon, L, Goldman H, Hirad, A (1999) State Policy and funding of services to families of adults with serious and persistent mental illness, Psychiatry services, 50: 551-553).
Encyclopaedia of mental illness (2010) Family Therapy
Erkolahti, R, Lahtinan, E and Ilonen, T (2004) A home treatment system in child and adolescent psychiatry, clinical child psychology and psychiatry, 9(3) 427 – 436
Falkov, A (1998) Crossing bridges: Training resources for working with mentally ill parents and their children, London, Her Majesty’s Stationary Office.
Goodman, R (2005) Child and Adolescent mental health services: Reasoned advice to commissioners and providers, London, Maudsley Discussion Paper 4
Gopel, C., Scmidt, M, Blanz, B and Lay, B (2000) Clinical and medio-legal aspects of home based care by nurses as an alternative for inpatient treatment in child and adolescent psychiatry. Medical Law, 19: 327 – 334.
Henggeler, S, Rowland, M, Randall, J et al (1999) Home based multi systemic therapy as an alternative to the hospitalisation of youths in psychiatric crisis: Clinical outcomes, JAACAP, 38: 1331-1339.
Howard, L, Kumar, R, Thornicroft, G (2001) Psychosocial characteristics and needs of mothers with psychotic disorders, British Journal of Psychiatry, 178: 427 – 432).
Johnson, S., Needle, J., and Bindman, J et al eds (2008) Crisis resolution and home treatment in mental health, Cambridge, UK, Cambridge University Press.
Lay, B, Blanz, B, and Schmidt, M (2001) Effectiveness of home treatment in children and adolescent with externalising psychiatric disorders, European Child and Adolescent Psychiatry 10: 80-90.
Marley, J (2004) Family Involvement in Treating Schizophrenia: Models, Essential skills, and Processes, The Haworth clinical Practice press, London
Meusser, K and Glynn, S (1999) Behavioural Family therapy for psychiatric disorders, 2nd ed., Oakland, California, New Harbinger.
Meusser, K., Bond, G., Drake, R. (2001) Community based treatments of schizophrenia and other severe mental disorders, Medscape General Medicine, 3(1)
Miller, M (2001) How schizophrenia develops: New evidence, new ideas, Havard Mental Health Letters, 127 (8) 1-4.
National Health and Medical Research Council (2000) How to use the evidence: Assessment and Application of Scientific Evidence, Canberra, NHMRC.
National Institute for Health Research (2008), Alternates to Impatient Care for Children and Adolescents with complex Mental Health Needs, NIHR, UK
Newman, T., Moseley, A., Tierney, S et al (2005) Evidence based social work: A guide for the perplexed, Lyme Regis, Russell House Publishing.
Nursing and Midwifery Council (2008) Codes of Professional Conduct, London, NMC
Parahoo, K (1997) Nursing Research Principles, Process and Issues, Great Britain, Palgrave
Parkes, J., Hyde, C., Deekes, J et al (200) Teaching critical Appraisal skills in health care settings, The Cochrane Database of Systematic Reviews, Issue 3
Richardson, W, Wilson, M., Nishikawa, J et al (1995) The Well Built Clinical Question: A key to evidence based decisions, ACP Journal club, 123 (3) A12-A13.
Rowland, M, Halliday-Boykins, C., Henggeler, S (2005) A Randomised trial of Multi-systemic therapy with Hawaii’s Felix class youth, Journal of Emotional and behavioural disorders 13: 13-23.
Sackett, D, Rosenberg, W and Gray, M (1996) Evidence Based Medicine: What it is and What it isn’t, British Medical Journal, 312, p71-72
Schmidt, M, Lay, B, Gopel, C (2006) Home treatment for children and adolescents with psychiatric disorders, European child and Adolescent Psychiatry 15: 265-276.
Talbot, A, (1984) The chronic mental patient, The Chronic Mental Patient: In Mirabi, M (ed) The Chronically Mentally Ill, Research and Services, New York, NY, Spectrum Publications), 1984, 3-32.
Tarrier, N, Lowson, K and Barroclough, C (1991) Some aspects of Family intervention in Schizophrenia, British Journal of Psychiatry, 167: 473 – 479. )
Worall, A, O’Herlihy, A, Jaffa, T et al (2004) Inappropriate admission of young people to adult psychiatric wards and paediatric wards: Cross sectional study of six months activity, British Medical Journal, April 10, 328 (7444): 867
GLOSSARY OF TERMINOLOGY
Family therapy – This is a form of psychotherapy that involves all the members of a nuclear or extended family, and may be conducted by a pair of therapists. Some types of family therapy are based on behavioural or psychodynamic principles, and the most widespread form is based on family systems theory. Family therapy is an approach that regards the entire family as the unit of treatment and emphasises such factors as relationships and communication factors rather than traits or symptoms of individual members. The purpose of family therapy is to identify and treat family problems that cause dysfunction Encyclopaedia of mental Illness (2010).
Multi-systemic therapy – Follows a standard procedure and is family centred, targeting the individual, family and environmental factors of psychopathology in the community (Henggeler et al, 1999 and Rowland et al, 2005).
Multi-systemic intervention – Is an intensive short term ecological orientated therapeutic approach that targets individual, family and community factors contributing to youth psychopathology.
Comprehensive crisis plans – Are developed jointly by the therapists and the child psychiatrists and focus on mobilising the problem solving skills within the family and the community. The families participate in both the assessment and family therapy. In this model family factors that contribute to psychopathology are also addressed as part of the intervention.
The Multi systemic therapist – Work with three families each to design interventions that emphasised family empowerment and use family strength as levers for change. MST practitioners work with these people in identifying the determinants of the youth’s problems and develop behavioural management techniques. They are also involved in mobilising the problem solving skills of the youth and their family to prevent relapse. MST therapists are masters’ level clinicians who are supervised by child psychiatrists, who receive training in MST methods.
The home treatment approach – It uses a child and family centred approach with importance placed on addressing difficulties with the psychosocial environment (Schmidt et al, 2006) and alleviating individual psychiatric treatment. Home treatment is based on ecological theories from family systems using systemic development models of symptomatic behaviour, together with family centred problem solving approaches (Erkolhati et al, 2004). Home treatment is used when family factors are a significant one.