Innovations in Practice: Effectiveness of ... - Wiley Online Library

Child and Adolescent Mental Health 18, No. 2, 2013, pp. 116–119

doi:10.1111/j.1475-3588.2012.00654.x

Innovations in Practice: Effectiveness of specialist adolescent outreach service for at-risk adolescents Andrew Chia1, Ben Assan1, Erin Finch2, Robyn Stargatt1, Peter Burchell1, Hayden Jones1 & Jane Heywood-Smith1 1

Austin Health, Marian Drummond Annex, PO Box 5555, Heidelberg, VIC 3084, Australia. E-mail: andrew.chia@austin. org.au 2 Northern Area Mental Health Services, 131 Wood Street, Preston, VIC 3072, Australia

Background: Outcomes are reported for an assertive outreach team for adolescents that combines flexible service delivery (e.g. outreach) and broad-ranging interventions. Method: A retrospective evaluation over a 2-year period from 30 June 2006 to 30 June 2008 examined rates of hospitalisation, engagement with education and scores on the Child Global Assessment Scale (CGAS). Results: The sample showed statistically significant decreases in hospitalisation rates (from 47% to 17%) and increases in engagement with education (full-time attendance from 23% to 56%). There was a mean increase of 7.4 points on the CGAS. Conclusion: An intensive, flexible and broad-ranging approach can be applied to adolescents who display at-risk behaviours and/or have high risk factors for poor long-term outcome.

Key Practitioner Message: ● An intensive, flexible and broad-ranging approach can be applied to adolescents who display at-risk behav-

iours and/or who have high risk factors for poor long-term outcome ● Beneficial outcomes include reduced use of hospitalisation and improved social function as measured by

participation in education/vocation and improvement in Child Global Assessment Scale (CGAS) scores

Keywords: Assertive outreach; outcomes; adolescence; at-risk

Introduction Most intensive mental health case management services work with adults, often using assertive outreach. Their effectiveness tends to be reported in terms of engagement (Meaden, Nithsdale, Rose, Smith, & Jones, 2004) and reduction in admission rates (e.g., Holloway & Carson, 1998). Previous research has almost exclusively been in the field of Assertive Community Teams (ACT) with adults with mental health problems. These are teams where adults with mental health disorders who are not able to benefit from treatment in clinic settings are tracked and have their mental state monitored by an outreach team with options for facilitating hospitalisation when required. By contrast, in this article we review the outcome of a group of adolescents referred to the Adolescent Intensive Management (AIM) Team, which operates out of Austin Child and Adolescent Mental Health Service (CAMHS). Austin CAMHS is a tertiary service, meaning that the client base has mental health difficulties that are so severe that they cannot be managed at a general practice level. The catchment area is a large quadrant of metropolitan Melbourne and includes the spectrum of socioeconomic and culturally and linguistically diverse status. AIM seeks to deliver mental health interventions for adolescents who have been assessed as being at-risk and/or difficult to engage. Their at-risk status could arise from acute risk through behaviours such as selfharm and suicidal behaviours as well as placing selves at

risk of serious injury, assault (including sexual assault). Or, they may be at risk of poor long-term outcome in their mental health or overall functioning through pervasive and chronic difficulties in engaging with major developmental tasks and milestones. Individuals and their families are referred to AIM when standard outpatient case management is not able to adequately address concerns and more intensive and sustained mental health input is required. Such individuals often have multi-problem presentations with resistance to treatment. The AIM model of care incorporates developmental, psychodynamic, systemic and neurobiological theories of mental illness and aims to address all three areas depending on individual needs. The flexible service delivery means that there is no prototypical treatment; however, they generally focus on engaging young people and their families in more genuine dialogue with services, returning the young person on their developmental pathway (including issues of individuation and differentiation), optimising family functioning and advising welfare agencies to co-ordinate around these goals. Interventions can include any combination of individual therapy, crisis management, systemic therapy, supervision and debriefing, secondary consultation and training for other services around individual client needs. Unlike standard outpatient treatment, contact can be as frequent as several times a week around these tasks. Interventions are delivered in optimal settings for clients, generally naturalistic settings, so as to maximise

© 2012 The Authors. Child and Adolescent Mental Health. © 2012 Association for Child and Adolescent Mental Health.. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA

doi:10.1111/j.1475-3588.2012.00654.x chances for engagement and to challenge an individual's avoidance strategies. There is no extended-hours service, but an after-hours telephone consultation and support service is provided by mutual agreement and after a crisis management plan has been developed. Hospitalisation is only considered when either necessary for basic safety or also by mutual consent and where it is consistent with treatment plans. (For more details of the AIM team, see Assan et al., 2008). One of the main concerns of adolescent families is the interference of mental illness in the adolescent's participation in an educational or vocational pathway and how that might interfere with the young person's trajectory into adulthood. Previous research into outcomes has targeted a number of areas including symptom control, hospitalisation and social functioning. For adolescents and their families, the outcome, however, is often about a return to some level of normalcy. This is often mainly viewed in terms of the social function of the young person. The aim of this study was to analyse outcomes in an assertive outreach team working with adolescents within a multifaceted framework, utilising outcome measures of developmental importance to and with face validity for adolescents and their families in addition to standard clinical outcome measures to provide additional clarification regarding outcomes.

Method Ethics approval was provided by Human Research and Ethics Committee at Austin Hospital, in line with National Human Research and Ethics Guidelines. Specific informed consent was not sought as only de-identified group data were analysed. We collected data on the demographic profile of the group, including their diagnosis and other risks factors. We also collected routine outcome measures such as CGAS, and the level of participation in education or vocational activities at time of referral and discharge.

Participants Summaries were made of the medical records of all clients referred to the AIM team over a 2-year period from 30June 2006 to 30June 2008 (n = 103). Outcomes were investigated in the 64 clients that had completed their treatment with the AIM team within this 2-year period. A similar sample has been described in Assan et al. (2008). The modal age was 15 with a range from 11 to 17 years of age. Sixty-eight percent of the sample was female. The mean length of involvement was 10.5 months (SD = 6.8). The length of involvement by a mental health service prior to AIM referral ranged from 0 to 105 months (mean = 25.3 months, SD = 30.2). Two-thirds of the sample exhibited at least two mental illness diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR; American Psychiatric Association, 2000). The most commonly occurring diagnoses were mood and anxiety disorders (34.9% and 22.3%, respectively), followed by psychotic disorder (13.6%). Approximately half (50.4%) were utilising one or more prescribed psychotropic medications, where the most prevalent class of medication was antidepressant (29%). Significant rates of maltreatment syndromes had been reported by the young person or significant other (sexual abuse in 31% of cases; physical abuse = 35%; emotional abuse = 55%; neglect in 34%; exposure to domestic violence = 49%) with 45% experiencing two or more forms of maltreatment. Unstable accommodation was reported in 33%. Substance use of two or more substances (including alcohol but excluding nicotine) was rated at 40.1% by their case managers with 10% formally meeting the criteria for substance use disorder. The sample demonstrated significant levels of at-risk behaviour with 47% having engaged in a suicide attempt, 59% being rated as a danger to themselves at the time of

A specialist adolescent outreach service

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referral and 46% being rated as a danger to others. There were no client deaths during the study period.

Measures Hospitalisation usage. Number of admissions was identified from the medical records.

Engagement in education/vocation. School participation was rated as full-time, part-time or not attending according to attendance data from the previous 2 months. Full-time attendance was defined by at least 80% class attendance (the state government education department requirement during final year of secondary schooling). Part-time attendance was defined as any other pattern of attendance that did not represent absenteeism. Some adolescents did not return to school but, instead, attended an alternative education setting where the emphasis was work-preparedness. This was classified as Vocational Rehabilitation. Where an adolescent obtained gainful employment, this was graded according to whether it corresponded to fulltime or part-time employment. A further education option was to continue their education through correspondence, known as Distance Education under the public state education system. Children's Global Assessment Scale. Functioning was measured with the CGAS instrument (Schaffer et al., 1983). The CGAS is a unidimensional rating scale that measures global functioning and has been adapted for children and adolescents from the Global Assessment Scale (GAS) in DSM-III (American Psychiatric Association, 1980). Clinicians rate the lowest level of functioning in the last 2 weeks on a 100-point scale. Behavioural descriptions of function are provided at 10-point intervals and serve as anchor points for scoring. Intermediary levels can be scored and low scores represent lowered functioning.

Statistical analyses Chi square analyses were conducted given the categorical or non-normal distribution of many of the variables. Where there were empty cells in some education/vocation categories, data were collapsed together into an alternative to education category. Analyses were conducted on Microsoft Excel 2000 and SPSS (version 16).

Results There were 103 referrals over the 2-year period. Sixty-four clients completed treatment in that timeframe. Five cases where there were missing data were excluded from the analysis. Analysis is reported on the remaining 59 cases.

Reduced readmission rates There was a strong movement in young people's admission rates towards having no admissions during AIM intervention, which represents a significant difference (v2, p < .005; see Table 1).

Improved school attendance Full-time attendance at school increased from 23% prior to referral to 56% at the end of treatment. There is a corTable 1. Admission rates prior to AIM involvement compared with during AIM involvement No. of admissions

Prior (%)

During (%)

0 1 2 3 4 5 or more

53 22 10 6 3 6

83 4 3 5 2 3

AIM: Adolescent Intensive Management.

© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health..

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Child Adolesc Ment Health 2013; 18(2): 116–19

responding decrease in non-attendance (52%–19%) and part-time attendance (23%–16%). These changes in frequency were found to be highly statistically significant (v2, p < .005; see Table 2).

Improved CGAS scores The distribution of CGAS scores ranged from 20 to 61, was leptokurtic and with a small secondary mode in the low 30 s at the time of referral. Fifty-eight percent of cases had a CGAS score of 40 or more. At time of discharge, the range was from 25 to 68 with an increased mean of 50.8 (SD = 8.6). Eighty percent of cases had scores greater than or equal to 40. The mean change in score was 9.17 (SD = 7.7; see Figure 1). A paired, twotailed sample t-test (df = 58) showed that the scores had improved significantly (p < .001). Two cases exhibited a decline in CGAS scores. Individual analysis of these cases revealed that both were female, had had a significant amount of AIM involvement (15 and 14 months), both had a primary diagnosis of Reactive Attachment disorder, were abusing cannabis and alcohol and had experienced neglect. One was discharged due to exceeding age criteria for a Child and Adolescent Mental Health Service whilst the other had reduced her risk-taking behaviours and was referred back to an outpatient service.

Heterogeneity in the sample Broadly, the sample displayed three clusters that could be organised into discrete, major diagnostic groups according to the primary diagnosis. 1 Young people who presented with a primary diagnosis of either a mood, anxiety disorder or any other disturbance in conduct and behaviour, but where there was no signs to suggest an emerging personality disorder (Anxious/Depressed group). Table 2. School attendance prior to AIM involvement compared with during AIM involvement School Attendance

Prior (%)

During (%)

Not attending Full-time Part-time Vocational rehabilitation Part-time employment Distance education

52 23 23 2

19 56 16 2 2 6

2 Young people who meet the DSM-IV-TR (American Psychiatric Association, 2000) criteria of a personality disorder (Axis II group). 3 Young people who had been diagnosed with a psychotic disorder (any diagnosis belonging to the Schizophrenia and other Psychotic disorders category in DSM-IV-TR; Psychotic group). The outcomes reported were explored per diagnostic group. Reduction in readmission rates was exhibited across all groups (see Figure 2). The trend in improved educational/vocational participation was maintained across all three groups with the anxious/depressed group also exhibiting a trend towards engaging in alternative forms of education more so than the other groups (Table 3). There was also a positive trend in CGAS scores across the diagnostic groups albeit with considerable variance with each group (Table 4).

Discussion The hypothesis that assertive outreach intervention to at-risk adolescents is beneficial was supported in this study. There was a significant reduction in rates of admission in the client sample, significant increases in full-time education participation as well as improvements in clinician-rated levels of functioning. This positive trend was maintained across a heterogeneous sample of young people who had anxiety, mood, psychotic or emerging Axis II disorders as the primary diagnosis. Akin to what has been discussed in research regarding the effectiveness of ACT with adults and, particularly in young people given the developmental considerations, additional measures of functioning in combination with hospitalisation usage can provide a richer picture of outcomes following assertive outreach (cf. Burns, 2007; Gilbody, O'House, & Sheldon, 2002). Lack of school engagement can lead to higher parental conflict and a broader, poorer engagement with society that predisposes to significant functional difficulties in adulthood. Engagement with education may also represent a developmental equivalent to the concept proposed in reviewing ACT with adults around the importance of engaging other services alongside psychiatric assertive outreach as a good prognostic factor (Priebe et al., 2004). Conversely, a small portion (eight clients) exhibited either


Readmission rates per diagnostic group 80

15

70

12.5

59

60

% of group

10 Frequency

70

Prior During

7.5 5

50 40

35 29

30

20

20

2.5

11 10

0

–10

0

10 Change

20

30

Figure 1. Distribution of change to Child Global Assessment Scale scores

0

Anxious/Depressed

Axis II

Psychotic

Figure 2. Re-admission rates per diagnostic group


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Table 3. School attendance prior to AIM involvement compared with during AIM involvement in the Anxious/Depressed, Axis II and Psychotic groups Anxious/Depressed

Axis II

Psychotic

School Attendance

Prior (%)

During (%)

Prior (%)

During (%)

Prior (%)

During (%)

Not attending Full-time Part-time Vocational rehabilitation Part-time employment Distance education

38 27 32 3 0 0

14 59 14 3 3 7

64 24 12 0 0 0

18 58 18 0 0 6

80 10 10 0 0 0

40 40 20 0 0 0


Table 4. Mean change in Child Global Assessment Scale scores per diagnostic group

Mean SD

Anxious/Depressed

Axis II

Psychotic

5 7.04

8.62 9.28

6.60 8.09

nately, this was a naturalistic and retrospective study, but more sophisticated analysis with causal modelling could prove beneficial as well as utilising measures around anxiety, depression, engagement, self-efficacy and family dysfunction.

Acknowledgements no change or a drop in their functioning as rated by CGAS. This group also exhibited a very low engagement with other education/vocation services with only two clients moving towards any increased uptake. Of note, this group of individuals also exhibited higher frequencies of neglect compared with the rest of the sample (75% compared to 33%). Closer working alliances with child welfare agencies and earlier intervention may be one way of seeking a better outcome for these young people. In specific instances, reduced hospitalisation usage may be contraindicated in managing risk of suicide in adolescents. As Tyrer and Simmonds (2003) have pointed out, complicating factors in presentation, such as comorbid Axis II disorders, can mean that an ACT approach is not universally beneficial throughout psychiatric populations and can even be detrimental. The clinical aim of judiciously utilising psychiatric inpatient support, along with differences in hospitalisation policies between North America and Europe (Burns, Catty, & Wright, 2006), could also go further in explaining the lack of replication in outcome studies of ACT outside of North America. In assertive outreach in adult populations, the concept of sensitive anticipatory casework has been proposed (Weaver, Tyrer, Ritchie, & Renton, 2003) as the critical ingredient in intensive case management that leads to reduced inpatient usage through an emphasis on engagement, crisis planning and a variety of clientcentred practices. In clinical practice, this might take the form of individualised and tailored use of hospitalisation according to the client's clinical needs and context at any given point in their treatment. This may have the added benefit of conveying a sense of collaboration through actively planning for and anticipating crises. Further research is needed to investigate whether such an anticipatory approach could result in a net overall reduction in use of hospitalisation. Engaging in clientcentred practice around hospitalisation usage could possibly increase a sense of collaboration for clients rather than it becoming a potential point of difference between case manager and client. Further research is still needed to clarify what specifically in assertive outreach assists in outcomes. Unfortu-

We declare that we have no competing or potential conflicts of interest. We are indebted to Barbara Woods and Catherine Coffey for their support of the role of research and are also very grateful to Eva Booth, Austin Health Research Ethics Unit for her assistance.

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Accepted for publication: 13 December 2011 Published online: 10 March 2012
