Introduction to "Guidelines to Best Practice in Child and Adolescent Mental Health Services"

Introduction

The documents in "Guidelines for Best Practice in Child and Adolescent Mental Health Services" address many of the clinical challenges that practitioners regularly face, by offering a set of qualitative standards. Developed over time based on cumulative experiences within the children's system of care and consistent with CASSP Principles, the documents address a range of tasks, issues, and topics and are intended to help agencies and practitioners achieve a high quality of care. The overriding assumption is that effective clinical practice facilitates positive outcomes. Protocols and discussion papers can create a useful framework for systematic, conscientious clinical pursuit. Ultimately, however, specific decisions within a service system that values individualization are made on an individualized, clinical basis.

There are three main sections: Assessment, Practice, and Behavioral Health Submissions. Within each of these sections, documents are organized according to specific topics. In what follows, each section will be discussed further.

Assessment:

The Assessment section first addresses psychiatric and psychological evaluations. Although the disciplines of psychiatry and psychology differ in training and expertise in some ways, in Pennsylvania both psychiatrists and psychologists can serve as "prescribers" of community-based behavioral health services. Both can also prescribe non- JCAHO residential treatment facilities (RTFs), but only psychiatrists prescribe for JCAHO RTFs. The evaluation protocol presented applies to both disciplines for use when behavioral health services are being requested. The protocol can be used, as described here, with slight modification, for both initial and continued care requests. It can also be used to request all levels of care, not just Behavioral Health Rehabilitation Services (BHRS) and RTF services. Since the Life Domain Format helps the evaluator obtain comprehensive information about the child that includes but goes beyond presenting behaviors and symptoms of concern, it can be used whether or not BHRS and RTF are being requested.

A useful evaluation cannot be part of an assembly-line process, and instead must be the considered summation of an evaluator's intense contact with a unique child and family at a critical moment in time. A useful evaluation should build on child and family experiences and include thoughtful, individualized recommendation. Therefore, it is appropriate that the key aspects of the evaluation process (interview, written report, and recommendations) are also considered here from an ethical perspective.

The Assessment section also discusses a Strengths-based Assessment Report. The inclusion of guidelines for a Strengths-based Assessment Report must not mislead practitioners into believing that the identification of the child and family strengths can be assigned to only one specific individual. Identifying and building upon strengths is the responsibility of every professional and support person who encounters the child and family. Strengths best emerge by listening to the child and family, asking questions, and engaging in unpressured discussion. The Strengths-based Assessment Report is an additional procedure that can be used to elucidate strengths and competencies, but in no way relieves each of us from doing the same.

Finally, the Assessment section considers two important special topics. Given the importance of comprehensive information when school-based services are used, this issue is addressed ("Documenting the Need for Mental Health Services in the Schools"). Given the public health concern about youth violence, as assessment tool related to this topic is included ("Child and Adolescent Readiness for Nonviolent Problem-Solving: Assessment Parameters").

Practice:

"Practice" here refers to all processes other than evaluations and assessments that involve qualitative aspects of treatment interventions with the child and family, collaboration, treatment monitoring, and the use of natural supports. Case-specific efforts at sound practice, as important as they are, cannot sustain our important behavioral health initiative unless accompanied by efforts at all levels to create a positive public sector culture. Each of us is obliged to make this effort, and to enlist the support of others in this endeavor.

It needs to be recognized that most procedures within these documents for sound practice with BHRS apply also to other services, including traditional outpatient treatment. The focus on so-called "wraparound services" emerged in recent years because these were the newest and potentially most flexible services. However, the guidelines in this packet apply to other services and levels of care. It should also be appreciated that the availability of BHRS in no way renders traditional outpatient treatment obsolete. Outpatient therapy remains the least intrusive, most normalized, behavioral health service, and should be used when clinically best suited to the child's needs.

The Practice section also delineates some aspects of strengths-based treatment and discusses the use of natural supports. Other topics include: the clinical interview; methods for achieving collaboration; specific aspects of cultural competence; the interagency team meeting; guidelines for home-based treatment (e.g., BHRS and Family-based Mental Health Services); use of Therapeutic Staff Support (TSS), when medically necessary; use of psychotropic medication; and a self-assessment document to promote the implementation of genuine biopsychosocial treatment.

Behavioral Health Submissions:

Since a funding source typically does not observe actual evaluation and clinical practice, there is reliance on documentation to determine medical necessity for initial care and continued care requests, respectively. We presume that the provider who comprehensively documents need and treatment is offering comprehensive treatment as well. While this is not always the case, the frequent association between documentation and practice should not come as no surprise. For example, comprehensive evaluations, progress notes linked to an individualized treatment plan, and evidence of frequent communication and collaboration, including team meetings convened as clinically indicated, all represent sound work efforts likely to result in positive outcomes and satisfied clients.

The Behavioral Health Submission section includes guidelines for behavioral health submissions to any funding source, and to behavioral health managed care under HealthChoices in Pennsylvania. Here again, although the identified focus may be on "wraparound services," the suggestions are clinically based and apply to a full range of service requests.

The packet closes with an original "Rap for Pennsylvania CASSP Principles" and Pennsylvania's formal description of CASSP Principles. Given the centrality of CASSP principles to our children's system, it is important that these principles be understood by as many stakeholders as possible. This rap, playful yet serious, is intended to offer another vehicle to reinforce these principles, and to promote a positive public sector culture.

Conclusion:

The Guidelines for Best Practice in Child and Adolescent Mental Health Services is a collection of documents that broadly addresses, through qualitative standards, many of the challenges facing agencies and practitioners in daily work. The scope includes Assessment, Practice, and Behavioral Health Submissions. Although often pitched to BHRS , the guidelines in fact are more generic and apply to the range of services for children and adolescents and their families.

Given the breadth of behavioral health assessment and service provision, these guidelines are not fully inclusive. Choices had to be made. The documents, however, are the end product of a series of issues identified statewide as being important to clinicians, children and families. I hope they will help you in your efforts to support children and families.

Gordon R. Hodas, M.D.
Statewide Child Psychiatric Consultant
Office of Mental Health and Substance Abuse Services
Revised April 2001

Guidelines for Best Practice in Child and Adolescent Mental Health Services