Considering children of clients in mental health services for adults

Conclusions and recommendations of the National Audit Office

The purpose of the audit was to obtain information on how the need for support and treatment among the clients’ underage children should be considered in mental health services and to give recommendations for action in this field. The auditors assessed whether the mental health services for adults are organised so that they provide an effective package when combined with the services intended for families with children. It was also examined whether the process of assessing the children’s service needs provides a basis for support for the children at the right time and whether there is effective cooperation between the parties treating the parents and the parties responsible for the services provided for the children.

In addition to expanding outpatient care, more support at home should also be provided

The emphasis in psychiatric treatment is increasingly on outpatient care. Putting the focus in mental health services on outpatient care may mean that in outpatient care, the overall situation of the family is considered, which is not the case in institutional care where the attention is often on the acute problems of the client. Placing the emphasis on outpatient care has, however, led to a situation where even patients in poor condition are now treated at home. From the perspective of families with children, more support at home should be provided or more consideration should be given to the overall situation of the families in the services that the families use. Based on the information on the cost-effectiveness of social and health care services collected for the audit, it can be assumed that providing families with early support would reduce the families’ service needs as children grow up and the overall costs arising from the families.

Hospital districts and municipalities have drawn up workable guidelines on how to consider children in mental health services for adults

The organisation of mental health services for adults under the health care plans of 20 hospital districts was reviewed in the audit. According to the audit findings, outpatient mental health services for adults are organised in a fragmented manner. Psychiatric specialised health care is provided by hospital districts and municipalities. In most of the hospital districts (12/20), outpatient mental health services are provided by the hospital district and the municipalities. The plans do not address cooperation between the mental health services for adults and the services provided for the children and the families. There are no direct connections between occupational health services and the parties providing services for the children either.

Less than half of the health care plans (7/20) reviewed in the audit stated that consideration should also be given to the children when their parents are using health care services. Hospital districts and municipalities have, however, drawn up workable guidelines on how to consider children of the clients in mental health services for adults. Most (8/10) of the adult psychiatric units whose representatives were interviewed for the audit had guidelines on how to consider children when clients are receiving treatment. Based on the audit findings, more consideration can also be given to the support and treatment required by children and to their referral to treatment if there are social work experts in the units treating adults.

Care pathways provide a good basis for agreeing on cooperation and its implementation. At the time of the audit, there were 50 care pathways in adult psychiatry. Consideration of families and supporting the next of kin are only mentioned in one of these care pathways. In the planned social and health services reform, determining the care pathways would be the responsibility of the counties. With fewer official actors involved, building care pathways could become easier in the future. The aim should be to have more unified and clearer care pathways which would also provide an overview of the situation of the children using adult services and in which the children would be referred to treatment, if necessary.

The process of assessing children’s service needs is in many respects effective

According to the audit findings, it is clearly laid down in the law that the support and treatment needs of underage children must be determined in mental health services for the adults. Adult psychiatry has also internalised the instructions on how to file child welfare notices laid down in the Health Care Act. At the same time, however, the audit findings suggest that health centres would benefit from training in how to consider children in adults’ services in a proactive manner.

Based on the audit findings, taking up the subject of children in adult psychiatry units is a rule rather than an exception. It was highlighted in the audit that even though the methods are considered workable, it is often difficult to apply them in practice as the customer service keeps the personnel busy. Staff members should be offered shorter training courses on a more frequent basis so that they can keep in touch with the methods.

It was noted in the audit that the actors need guidelines on how the details of the children should be entered into the patient documents. The decree on entries in patient documents (298/2009) is vague in this respect and leaves room for interpretation. Staff members should also be provided with training in how to motivate parents to ensure that the filing of child welfare notices will not compromise the doctor-patient/nurse-patient relationship. It was noted in the audit that the problems faced by the staff members in determining the support required by the children are connected with the unwillingness of the parents to discuss the situation of their children. The parents may be afraid that their children are taken into custody.

Providers of adult psychiatric services have plenty of experience of successful cooperation with child welfare actors

In practice, cooperation between mental health services for adults and services intended for children is cooperation between adult psychiatric units and child welfare actors. There is much less cooperation at health centres with child welfare or other services for children (such as maternity clinics).

Based on the audit findings, there have been few problems in the cooperation between mental health services for adults and the parties examining the children’s situation or the parties providing services for the children. The cooperation is more effective if the mental health services for adults and the child welfare services are physically located close to each other.

Recommendations of the National Audit Office

1. The Ministry of Social Affairs and Health should provide guidelines for social and health care personnel on how to record status investigations on children. The legal provisions on entries in patient documents are vague in this respect and leave room for interpretation.

2. The Ministry of Social Affairs and Health should obtain information on whether there is enough support at home for families where the parent is suffering from a mental disorder that deteriorates their functional capacity. After having completed this survey, the ministry should consider whether more support at home should be provided or whether the support should be redirected so that it would take into account the overall status of the family in a proactive manner. This could be done in connection with the child welfare and family services reform programme (Lapsi- ja perhepalveluiden muutosohjelma, LAPE), for example.

3. The Ministry of Social Affairs and Health should, in connection with the LAPE, for instance, encourage the counties to take into account cooperation and functional flow of information between mental health services for adults and services provided for children when planning the structures, care pathways and IT systems in connection with the social and health care services reform.