Pathways To Mental Health Care Among South African Adolescents: Analysis Of Referrals To An Adolescent Psychiatric Unit

Adolescence, Summer, 1998 by Raymond M. F. Berard, Justin P. B. Sennett, Nazeema Ahmed

ABSTRACT

Assessment forms of 670 adolescents referred over four years to an adolescent psychiatric unit were analyzed to establish how they entered mental health care. The first part of the study examined referral sources; the second established the appropriateness of referral. Adolescents were referred via a number of pathways, of which school sources, psychiatric services, and social agencies were prominent. Interestingly, 60.7% of the referrals were from persons not trained in mental health care. No significant difference in appropriateness of referral was found between trained and nontrained sources. Thus, the unique referral base of adolescents in need of mental health care must be recognized. Although the majority in this study were not mental health care workers, the findings show that their referrals were clinically appropriate. This suggests that by improving the mental health skills of this sector, the provision of psychiatric care to adolescents could be enhanced.

The delivery of psychiatric services to adolescents is a subject that has received closer scrutiny in recent years (Bruggen, Byng-Hall, & Pitt-Aitkens, 1973). This reflects the increased recognition accorded adolescent mental health issues. A number of studies have focused on the provision of care at individual psychiatric facilities designed for this age group (e.g., Bruggen et al., 1973; Framrose, 1975; Wells, Morris, Jones, & Allen, 1978; Steinberg, Galhenage, & Robinson, 1981; Ainsworth, 1984; Jaffa & Dezsery, 1989). Few have specifically addressed the referral of adolescents to mental health treatment (e.g., Takeuchi, Bui, & Kim, 1993; Pettle, Fyvel, & Bruggen, 1995). Thus, whereas there has been some exploration into the quality and scope of adolescent mental health care, less research has been conducted on the means of access to it. A similar trend appears in the literature on nonclinical or "normal" adolescent populations, where adolescent help-seeking has received considerably less attention than ha s coping behavior (Boldero & Fallon, 1995).

Some studies of admissions to adolescent units (Framrose, 1975; Ainsworth, 1984) have shown medical practitioners to be the source of a large proportion of referrals. In the case of Ainsworth (1984), however, the predominance of referrals by psychiatrists (62%), family practitioners (18%), and nonpsychiatric medical specialists (17%) was attributed to the unit's earlier policy of insisting upon a medical referral. In examinations of units with a more open system of referral, the primacy of medical referrals was less pronounced. Results from Framrose (1975) indicated that 25% of patients were referred by sources other than general practitioners or psychiatrists; Steinberg et al. (1981) found that 34.6% of patients were referred by family doctors, 30.4% by psychiatrists, and 22.8% by a range of nonmedical sources, including social workers, welfare and legal agencies, and school personnel. Likewise, findings from a therapeutic intervention service identified approximately equal proportions of referrals by psych iatrists, child guidance clinics, general practitioners, and social service departments (Wells et at, 1978). More recently, in a study by Jaffa and Dezsery (1989), the majority of referrals were by social workers, a pattern related to the unit's policy of accepting referrals from all professional groups involved with adolescents.

An important theme to emerge from the literature is that the more open the referral system, the broader the referral base serving adolescents. The aim of the present retrospective study was to analyze the pattern of referrals to an adolescent psychiatric day-patient facility serving the greater Cape Town (South Africa) metropolitan area. Particular emphasis was placed on determining the frequency and appropriateness of referrals. Based on clinical experience, it was hypothesized that referrals from persons not trained in mental health care would constitute a large proportion. A second hypothesis was that such referrals would be less appropriate than those from mental health personnel, who are better able to identify psychopathology in adolescents.

METHOD

The Unit

The William Slater Centre provides a psychotherapeutic milieu for adolescents with emotional and behavioral problems. It has a multidisciplinary staff trained specifically in adolescent psychiatry. Although the unit does not have codified exclusion criteria, it places emphasis on adolescents with evidence of depressive symptoms and associated comorbidity factors, such as dysthymia, adjustment disorders, externalizing behavior, eating disorders, and substance abuse.

The unit offers a 12-week day-patient program of both structured and unstructured group therapeutic interventions for as many as 22 young people. The unit accepts patients generally between the ages of 14 and 25 according to an open referral system. They undergo a detailed psychiatric interview to establish whether they are suitable for admission.

Subjects