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Adolescents with mental health issues

Interaction between municipal services and between municipal services and the outpatient clinic for child and adolescent psychiatry

In June 2019, HIB was notified of a 17-year old boy who had committed suicide. The boy is referred to as Jonas in this report.

On the basis of Jonas’ story, we have investigated various factors that could lead to adolescents who require healthcare not always being identified.

We have asked the following questions:

  • Why do we not always manage to reach out with the necessary healthcare to adolescents who need it?
  • What does it take for the various relief measures at municipal and central government level to work for children and adolescents?

Jonas’ story shows that we do not always manage to reach out to provide support to children and adolescents. Jonas had struggled with his schoolwork for a number of years, his absence rate was high and he was examined multiple times and was finally referred, twice, to the outpatient clinic for child and adolescent psychiatry (CAP) and was refused both times. His condition was undiagnosed. Jonas experienced significant symptom load and received no follow-up after being refused by CAP.

There is great variation in the CAP refusal rate between health trusts. National figures from the Norwegian Patient Register show that the CAP refusal rate is between 8 and 56 per cent. Such a large difference in the figures could indicate some underlying challenges in connection with the reporting itself. Despite this uncertainty, differing reporting practices alone can hardly explain the large differences. No professional justification can be found for the variation. Such an unfounded variation indicates significant inequality in services and this is considered to represent a risk in terms of patient safety.

The report will first present an account of the event and the family’s encounters with the support system. This is followed by an analysis of the patient history, compared with other available information linked to services for children and adolescents. Finally, we will present an assessment of the support system and the structures that have been established to identify and provide support to children and adolescents who are experiencing difficulties.

The investigation also covers the government’s guidelines for health services aimed at children and adolescents. HIB has taken a closer look at how the supervisory authority exercises its supervisory responsibilities, i.e. how it assesses whether the services provide healthcare in line with proper practices, patient rights and regulatory requirements.

The report considers factors relating to two main issues:

  • There are challenges associated with coordination between municipal agencies.
  • The specialist health service’s assessment of referrals to the mental health service is characterised by large, unfounded variation.

On the basis of the structures and services designed to identify and support children and adolescents who experience difficulties, we have assessed risk factors associated with municipal coordination of mental health services for children and adolescents.

The following risk factors have been identified:

  • It is unclear who is responsible for children and adolescents who experience difficulties over time.

  • Follow-up is inadequate.

  • Children and adolescents are assessed without this being followed up through systematic measures and any measures that have been initiated are not evaluated.
  • There is great variation in services between municipalities with regard to organisation, scope and expertise.
  • Refusal from CAP may, in itself, pose a risk to the individual adolescent concerned. This is especially true when there is an undiagnosed condition and when various agencies have attempted to provide support over an extended period of time.
  • Further support may be discontinued if the adolescent is not assessed by CAP.
  • The lack of overall assessment from the supervisory authorities contributes to maintaining a lack of clarity in terms of responsibilities and inadequate interaction within the service.
  • A large number of governing documents, proposed models and forms of organisation show that there is great complexity within the field of children and adolescents and reflects unclear standardisation and allocation of tasks. Many assessments are not followed up by the services.
  • Legislation and the rights of children and adolescents with mental health issues do not work as intended: This is despite the fact that both municipalities and regional health trusts have a duty of care and that the undertakings have a duty to properly organise the services.

The report is aimed at employees, managers, authorities and decision-makers responsible for health and social care services for children and adolescents. Employees at schools, the educational and psychological counselling service and others with an interest in children and adolescents may also benefit from the report.

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