A day clinic experience in child and adolescent psychiatry

A Day Clinic Experience in Child and Adolescent Psychiatry

Dr. Nursu ÇAKIN MEMİK,

Özlem YILDIZ OC,

Dr. Işık KARAKAYA,

Dr. Şahika GÜLEN FAT,

Dr. Belma AĞAOĞLU

Child and Adolescent

Department of Mental Health and Diseases,

Kocaeli University Faculty of Medicine,

Kocaeli

Abstract

Objective: Day clinics have been serving in the field of child and adolescent psychiatry for a short time. Interviews in day clinics are intense and various treatment methods can be used holistically. The aim of this study is to evaluate the effectiveness of the treatment applied in the Child and Adolescent Psychiatry Day Clinic, which provides a holistic treatment and was established for the first time in Turkey in the Kocaeli University Child Psychiatry Department, in increasing the functionality of the patients and reducing the symptoms.

Materials and Methods: The findings of 31 patients followed in the day clinic were evaluated with the evaluations of their therapists and their parents. This examination was carried out with a general assessment scale for children, a clinical global follow-up scale and a treatment assessment scale, taking into account gender, age group, comorbidity, and parental education level.

Results: While the mean score obtained from the general assessment scale for children was 52.59 ±9.02 at the beginning of the treatment, it was 69.07±11.01 at the end of the treatment. The mean score obtained from the clinical global follow-up scale decreased from 4.52±0.975 to 2.70±1.068. In the evaluation made with the treatment evaluation scale, it was observed that the average score obtained was 3.75±0.40 (very good). It was determined that there was no statistically significant difference in the mean scores obtained as a result of the evaluations made by considering gender, age group, comorbidity and education level of the parents.

Conclusion: As a result of the study, it was determined that the functionality of the patients treated in the day clinic increased in line with the findings obtained from the general evaluation scale for children and the clinical global follow-up scale. As a result of the evaluation made with the treatment evaluation scale, it was seen that the day clinic treatment was found beneficial by the parents. More research is needed for day clinics, which are an alternative treatment method to outpatient and inpatient treatment.

Keywords: Day clinic for children, adolescent, child

INTRODUCTION

Child and adolescent psychiatry, which is a relatively young department, was separated from psychiatry, neurology and pediatrics in 1968 and became a separate branch. 1 Child and adolescent psychiatry has realized the importance of focusing on the family rather than only the child and adolescent itself after the 1970s. When the causes of mental disorders are examined, it has been observed that disorders can occur due to many factors and the importance of family-oriented and social-psychiatric concepts has been realized. The importance of family support during the treatment of mental disorders of children and adolescents has increased the need for day clinics. 1 It is known that the first day clinic serving in the field of psychiatry in history was opened in 1930 due to the shortage of beds in a psychiatric hospital in the Soviet Union. It has been reported that there are 353 day clinics serving in the field of child and adolescent psychiatry in England in the 50s and in France in the 60s. 1 Huss et al. where you have 61 day clinics working in the field of He reported that this and these clinics mostly serve separately in one hospital, which also includes an inpatient unit, while a smaller number of day clinics serve as an independent unit or as part of an inpatient unit.5 On the other hand, in Switzerland, day clinics provide inpatient or outpatient services 1

According to the German mental health policy, in a residential area with a population of 1.5 million, an average of 80 general and 20 specialized child and adolescent mental health inpatient units, each with 12 patients There should be 4 day clinics with a capacity of 4 and outpatient treatment units working under them. Children and adolescents constitute 27 million of our country’s population of 70 million, and for this population there is only one day clinic and seven-bed unit (Uludağ University Faculty of Medicine, Dokuz Eylül University Faculty of Medicine, Bakırköy Psychiatric and Neurological Diseases Hospital, Manisa Psychiatric Hospital, Elazig Mental Health and Diseases Hospital, Adana Girls and Adolescent Residual Treatment Center, Ege University Child and Adolescent Alcohol Substance Addiction Research and Application Center). The low number of child and adolescent psychiatry specialists and personnel such as psychologists, nurses, child development specialists, occupation specialists, and teachers throughout the country can be cited as the reason for this situation. In the solution of this problem, it is thought that it is important to develop a national policy on child mental health and diseases, which has not yet been established.

Since many environmental and genetic factors play a role in the etiology of mental disorders in children and adolescents, treatment should also be multifaceted. In the treatment of mental disorders in children and adolescents, the importance of considering the family and social environment as well as including the patient himself in therapy is clear.6 Success of day clinic treatment; It has been reported that the family is also involved in the treatment, the treatment environment is similar to the environment in which the patient lives, and the conditions of providing multiple treatment applications to the patient are met. This provides patients with the opportunity for direct intervention and change without moving away from conflict areas. This is the most important advantage of day clinics over inpatient treatments. In outpatient treatment, the patient and his family are evaluated and treated in a limited time and followed up at wider intervals. The fact that day clinics do not contain this limitation increases their treatment power compared to outpatient treatment.7,8

In child and adolescent psychiatry, the diagnosis and treatment of patients are often carried out on an outpatient basis. Inpatient treatment is considered for patients who are in danger of harming themselves or others, or who need to be removed from their family or social circles. It is considered appropriate to carry out the treatment of patients who are difficult to follow-up on an outpatient basis and who do not have severe disease at the level of inpatient treatment in day clinics. Although day clinics are few in number compared to outpatient treatment centers or inpatient units, they have increased rapidly over time.1

In the day clinic, parents are also heavily involved in the treatment and work together with the therapist as “co-therapists”. Families are educated about the interventions to be made to their children, problem areas and communication difficulties, and they are provided to practice. It is reported that the effectiveness of treatment increases as the support provided by the parents to the therapist during the therapy process increases.1 If the mental disorder experienced by the patient stems from his family, family therapy is recommended and family relationships are especially addressed in the treatment.1

It is difficult to conduct research on day clinics in child and adolescent psychiatry. Comparing patients with control groups in studies gives the most scientifically valuable data. However, it does not seem ethically possible to establish a control group for patients treated in day clinics. Instead, the comparison of the patient with the control group can be made by comparing the patients on the waiting list with the patients treated in the day clinic. However, outpatient treatment during the waiting period, changes in their social environment, or physical and emotional changes in the patient’s development may prevent us from obtaining healthy data. Another way to conduct research on day clinics in child and adolescent psychiatry is to compare the patient’s level of functionality before and after treatment, but this method also presents difficulties due to factors such as disease characteristics, family structure, mental and physical development and change. On the other hand, due to the fact that the evaluation tools and materials in child and adolescent psychiatry are not objective, the change in the patient can be made as a result of the subjective evaluations of many different people such as parents, physicians, teachers or the patient himself, and the possibility that positive and negative developments in the patient are caused by environmental factors. It is difficult to attribute the change to the treatment applied alone. These difficulties experienced in the field of research on child and adolescent psychiatry, which is still a relatively new field in terms of history, lead to a limited number of literature information about day clinics.1

In this article, Kocaeli University Child Psychiatry It was aimed to evaluate the sociodemographic characteristics and treatment response rates of the cases followed in the Child and Adolescent Psychiatry Day Clinic established in the Department of Health and Diseases.

MATERIAL AND METHODS

Patients followed up in Kocaeli University Child and Adolescent Psychiatry Day Clinic between 01.01.2008 and 01.01.2009 constituted the sample of the study. The multi-faceted treatment applied to the inpatients in the psychiatry wards was applied throughout the day in a similar way in our clinic. The treatment team consisted of 1 recreation specialist, 1 classroom teacher, 1 research assistant, and 2 specialist physicians. On the one hand, patients participate in activities such as sports activities, handicrafts, kitchen practices, games, group activities, on the other hand, mental treatments are arranged by the treatment team, such as cognitive behavioral therapy, psychoeducation, occupational therapy, ambient therapy (mileu therapy), pharmacotherapy, depending on the patient and the characteristics of the disorder. therapeutic methods were used. Immediately after starting the day clinic of each patient, their teachers were interviewed, information was obtained and the education of the patient was shaped by the classroom teacher working in our clinic. During the twice-weekly visits, the treatment team and the patient came together and the homework given, the difficulties experienced, the skills planned to be acquired, the effects and side effects of the drug used were discussed. The patients were interviewed every day and their families at least once a week. Apart from individual interviews, patients were constantly together and interacting.

In order to evaluate the patients, informed consent was obtained from the patients and their families. The sociodemographic characteristics of the children were collected from the file information. Response rates to treatment were evaluated using the Children’s General Rating Scale (CGI), the Clinical Global Imaging Scale (CGI), and the Treatment Rating Scale (TRS).

General Evaluation Scale for Children (CGAS): This scale, adapted from the general assessment scale for adults, is scored based on clinician observation during treatment follow-up of children. CBCL is a scale in which the general well-being and functionality of the patient are evaluated using variables such as disease symptoms, social and school functions, and coping with problems. In this scale, the patient is given a score out of 100, taking into account the characteristics mentioned above. High scores indicate good general condition and level of functioning9. This scale was adapted into Turkish in the “Interview Chart for Affective Disorders and Schizophrenia for School-Age Children-Now and Lifetime Version”.10

Clinical Global Imaging Scale (CGI): CGI was developed by Guy et al. It was developed to evaluate the course of psychiatric disorders for clinical research purposes. CGI is a three-dimensional scale and is filled in during a semi-structured interview conducted by the physician to evaluate the response of people with psychiatric disorders to treatment: I. CGI-Severity of Disease (CGI-S): It is a total seven-valued scale. The person with a psychiatric disorder is evaluated between 1 and 7 points according to the severity of the disorder at the time of filling the scale; 1 = Normal, not sick, 2 = Borderline mental illness, 3 = Mildly ill, 4 = Moderately ill, 5 = Significantly ill, 6 = Severely ill, 7 = Severely ill. II. CGI-Global Improvement (CGI-GI): It is a total seven-valued scale. It is evaluated between 1 and 7 points how much the person with a psychiatric disorder has changed according to his condition when he entered the study; 1=Very improved, 2=Very improved, 3=Minimal improvement, 4=No change, 5=Minimum worsening, 6=Very worsened, 7=Very worsened.11

Treatment Evaluation Scale (TSS) : The treatment evaluation scale has three separate forms filled by the parent, the patient, and the therapist. In our study, the short form of the treatment evaluation scale filled by the parents was used. With this scale, treatment success, treatment process and parent total satisfaction can be evaluated. 0-0.4=Poor, 0.5-1.4=Unsatisfactory, 1.5-2.4=Moderate, 2.5-3.4=Good, 3.5-4.0=Very good, it shows the success of the treatment, the treatment process and the total satisfaction of the parents.12 The validity and reliability study of this scale in our country Although it was not done, it was thought and used that it would be useful in terms of evaluating the treatment in the family’s day clinic and giving us feedback.

EVALUATION OF DATA

The data of the study were evaluated using SPSS for Windows (Statistical Package for Social Sciences) 10.0 program. Descriptive statistical methods (mean, standard deviation) were used when evaluating the study data, and the Man Whitney U test was used for comparison of paired groups. The results were evaluated at the 95% confidence interval and the significance level was p≤ 0.05.

RESULTS

31 patients were treated in our day clinic within one year. The mean age of the adolescents aged 10-17 years was 13.6±1.8 years and 10 (32.3%) were male and 21 (67.7%) were female. Sociodemographic data of the patients are shown in Table 1. In the day clinic, patients stayed between 2 and 36 weeks, with an average of 6.5±6.3 weeks of treatment. Diagnostic distribution of patients followed in the day clinic for one year by gender is shown in Table 2. It was determined that the most common diagnosis of the patients followed in the day clinic was attention deficit hyperactivity disorder, and 19 (61.3%) patients were diagnosed with more than one Axis I diagnosis. Comorbidity was observed in 7 (58.3%) of 12 patients with attention deficit hyperactivity disorder and in 8 (66.6%) of 12 patients with anxiety disorders.

It was observed that the mean CGRS score of the patients was 52.59 ±9.02 at the beginning of the treatment and 69.07±11.01 at the end of the treatment. When evaluated statistically, it was found that the mean CGDS score increased significantly at the end of the treatment (t=-6.91, df=36, p=0.000).

The mean CGI-HS score when the patient was under treatment in the day clinic was found to be 4.52±0.975. The mean CGI-GI score at the last evaluation was 2.70±1.068. Since a score of 3 or lower according to CGI-GI is considered to have responded to treatment, it was determined that the symptoms of 77.8% (n=21) of the patients improved significantly at discharge.

According to TSS, parental satisfaction (3.38±0.47) and treatment success (3.11±0.69) were “good”, treatment course (3.75±0.40) “ very good level”. The CGDS, CGI and TDS scores according to gender, age group, and comorbidity are shown in Table 3. Parental education levels are discussed separately, and the CGDS, CGI and TDS scores according to the education level of the mother and father are shown in Table 4.

DISCUSSION

In our day clinic, the patients stayed between 2 and 36 weeks, and the mean duration of treatment was 6.5±6.3 (42.72±44.40days) weeks. Berger et al. reported the mean length of stay in day clinics as 64 days, and Mund et al. reported 9 weeks (43.2±24 days). The shorter duration of treatment in our day clinic compared to other day clinics can be explained by the fact that parents care more about school education than mental disorder, their motivation decreases after they see partial improvement in symptoms, and the treatment team directs the treatment to outpatient treatment after partial remission.

21 female (67.7%) and 10 male (32.3%) patients were treated in our day clinic within one year. In their article, Berger et al. reported their experience in day clinics, that they treated a total of 39 patients, 14 girls and 25 boys, in a 15-month period, Huss et al. They reported that the first one was female patients.2,5 It is known that most of the childhood-onset psychiatric disorders are more common in boys, and puberty-onset disorders are more common in girls.14 Compared to the literature, the higher number of female patients in our day clinic may be related to the fact that our patients are in adolescence, and this result may be related to sampling. thought to be unique.

The mean age of adolescents aged 10-17 followed in the day clinic is 13.6±1.8 years. In Germany, the mean age of patients followed in daytime clinics serving in the field of child and adolescent mental health was found to be 10.2 years. The mean age of the patients followed was found to be consistent with the results of other centers.

Looking at the work status of the parents of the patients followed up in the day clinic, it is seen that 83.9% of the fathers are working and 93.5% of the mothers are not. In a study conducted with adolescents who applied to Hacettepe University Faculty of Medicine, Department of Child and Adolescent Psychiatry for the first time, the employment status of their parents was similar. It can be said that these are the expected results.

The treatment goal of the day clinic in Germany is to achieve improvement in Axis VI (area of ​​psychosocial functioning) according to ICD-10. Since the DSM-IV classification is more widely used in our country, improvement in Axis-V, which measures the functionality of the patient, was determined as the treatment goal, and evaluations were made in this area. The functionality levels of the patients were evaluated by the physician monitoring the patient before and after the treatment. The low mean score of the general assessment scale for children at the beginning of the treatment and the high mean score of the clinical global follow-up disease severity at the beginning of the treatment is also an indicator of the severity of the deterioration in the functionality of the patients who were taken to the day clinic. Observation of a significant improvement in these mean scores at the end of the treatment suggests that the efficacy of treatment in the day clinic is high. Keeping our patients treated in our day clinic from their social relationships ensures that the conflicts of conducting the treatment in an environment similar to daily life can be better handled. The patient can transfer the gains he has gained through treatment, the new skills he has developed for the resolution of conflicts, and the new ways he has learned in interpersonal relations to his daily life without wasting time. On the other hand, patients who are treated in our day clinic can be observed in detail, and intensive treatment can be applied to both the patient and the family. The effectiveness and side effects of the drug therapy administered in the day clinic can be monitored daily by the treatment team, and the physician can intervene in the treatment without losing time in case of any negativity. All these features increase the power of the treatment applied in our day clinic and clearly reveal the reason for the significant improvement in the functionality of our patients. The fact that therapy methods such as occupational therapy (occupation therapy), psychopharmacotherapy, cognitive behavioral therapy, ambient therapy (mileu therapy) can be applied separately or simultaneously according to the patient and the disease may also contribute to the significant improvement.

It is known that disruptive behavior disorders and mood disorders are frequently discussed in daytime clinics due to common disorders in childhood and adolescence, but it is not recommended to treat patients with suicidal thoughts and the possibility of harming themselves and others.1 Risk assessment should be addressed for each patient. should be taken into consideration, and the possibility of harming itself and the environment should be evaluated in detail. In patients above a certain risk value, it is appropriate to consider high-security inpatient units and to delay the treatment to be applied in the day clinic.16 In line with the literature, attention deficit hyperactivity disorder was determined as the most common diagnosis in this sample. Berger et al. also reported that attention deficit hyperactivity disorder is observed with a high rate in daytime clinics.2 In a study evaluating all day clinics working in the field of child and adolescent psychiatry in Germany in 2000, hyperkinetic disorders and behavioral disorders (20.2%) were the most frequently observed diagnoses.5 This finding can be explained by the high prevalence of attention deficit hyperactivity disorder in children.17,18,19,20

It is a remarkable result that attention deficit hyperactivity disorder was observed at a higher rate in female patients in our day clinic. As it is known, attention deficit hyperactivity disorder is seen at a higher rate in males.18,21 However, in females, attention deficit hyperactivity disorder symptoms contradict with calm, calm and reserved behaviors attributed to girls and reinforced by positive feedback. Families may complain about the symptoms of attention deficit hyperactivity disorder in girls. Perceiving these attitudes as a deficiency and negative feature by the society may lead to a greater awareness of the problem in girls. In this case, the family’s desire for treatment and the physician’s expectation for treatment may be higher than for boys. On the other hand, it can be thought that attention deficit hyperactivity disorder impairs the functionality of girls more and as a result, the search for treatment is more intense. The fact that the number of female patients in the sample was twice that of male patients may explain the higher rate of attention deficit hyperactivity disorder observed in female patients in the sample.

It is known that the rate of comorbidities is high in many mental disorders.22,23,24 Similarly, 61.3% of the patients who were followed up in our clinic during the daytime were diagnosed with a second Axis I. It was observed that comorbidity was 58.3% in attention deficit hyperactivity disorder and 66.6% in anxiety disorders. When the literature was reviewed, it was determined that the comorbidity rates were 70% in attention deficit hyperactivity disorder and 28.8% in anxiety disorders. , high comorbidity rates were thought to be an expected finding. However, when the disorders are considered individually, the decrease in the number of patients makes it difficult to make comments and general inferences about the findings.

In a study in which 15 of 30 patients with disruptive behavior disorder were treated in the day clinic and the others were treated as an outpatient, it was shown that recovery rates were higher in patients treated in the day clinic and their well-being continued after six months.27 In another study conducted with patients with serious behavioral problems, day clinic treatment was found to be more effective in reducing behavioral problems and depressive symptoms, increasing social skills, and improving family functionality compared to outpatient treatment. In this study, it was reported that well-being lasted for a long time.6 In our study, patients’ functionality levels and parental satisfaction were evaluated. However, the follow-up findings of the patients after the treatment were not evaluated and comparisons with the outpatient treatment method were not made. Despite this limitation, the significant improvement in the functionality levels of the patients supports the short-term effectiveness of day clinic treatment.

The functionality levels of the patients were measured twice, on the first day of treatment in the day clinic and on the day they were discharged, with the help of a general assessment scale for children and a clinical global assessment scale. The determination of whether the parents were satisfied with the treatment in the day clinic was made on the day of the patient’s discharge using the treatment evaluation scale. When the scale scores were evaluated according to gender, age group and education level of the parents, it was found that there was no difference in the functionality levels between male and female patients, between early or middle adolescents, and between the children of parents with primary and high school/high school education levels, according to the evaluations made both before treatment and at discharge. seen. Since the patient’s functionality level was taken into consideration rather than age, gender and parental education level, it was an expected result that there was no difference between the functionality levels before the treatment when deciding to treat the patient in the day clinic. In addition, the absence of a significant difference between the functionality levels of patients with and without comorbidity before treatment can be attributed to the admission of patients whose functionality is significantly affected to the day clinic, even if the patient does not have comorbidity.

Although there are differences in patients in terms of gender, age, parental education level and co-morbidity in the day clinic, the patient and disease-specific formulation of the treatment methods may be the reason why patients receive similar benefits, and there is no difference in parental satisfaction and functionality levels between groups.

SINIRLILIKLAR

İzlenen hastaların sayıca az olması araştırma sonuçlarını genelleştirmemizi engellemektedir. Tedavi etkinliğinin hekimin ve ebeveynlerin öznel değerlenmesi sonucu yapıldığı, hastaların öz bildirimlerinin değerlendirilmemiş olması bulgularımızın gücünü azaltmaktadır. Gündüz kliniği tedavisinin ayaktan ya da yataklı birimde tedavi gören hastalarla, diğer tedavi modellerinin etkinliği ile karşılaştırılmaması, hastalar taburcu olduktan sonra iyilik hallerinin sürekliliğine yönelik bir değerlendirmenin yapılmamış olması, tedavi sonunda tedavinin etkinliğini değerlendiren hekimin hastalara kör olmaması çalışmamızın sınırlılıklarındandır. Gelecekte yapılacak çalışmalarda belirtilmiş olan kısıtlılıkların göz önüne alınması ve hastanın hastalığa özgü ve genel ölçüm araç ve geri bildirimleri ile tedavi düzeylerinin belirlenmesi önerilmektedir.

Sonuç

Gündüz kliniği tedavi uygulamaları Almanya’da 20. yüzyılın başlarında, Avusturya’da ise son yıllarda gelişmeye başlamıştır.2 Amerika ve Avrupa’daki hızlı gelişime karşın gündüz klinikleri ile ilgili sınırlı sayıda bilimsel yayın bulunmaktadır.2 Yapılmış olan sınırlı sayıdaki çalışmalarda gündüz kliniği tedavi modelinin hızlı düzelmeye yol açtığı, sosyal işlevselliği artırdığı, aile yükünü hafiflettiği ve tekrarlama oranlarını azalttığı bildirilmiştir.28,29,30,31 Gündüz kliniklerinde izlenen hastalarda ortaya çıkan davranış değişikliğinin yoğun olması, tedavinin hem çocuk hem de aileye uygulanıyor olması nedeniyle tekrarların azaldığı bildirilmekte ve gündüz kliniği tedavi yaklaşımının etkili bir tedavi yaklaşımı olduğu kabul edilmektedir.6,8,17 Batılı ülkelerde çocuk ve ergen ruh sağlığı alanında gündüz kliniği uygulamaları uzun yıllardan beri kullanılmakta olmasına rağmen ülkemiz için yeni bir kavramdır. Ayaktan tedavinin yetersiz kaldığı hastalarda gündüz kliniğinin etkili bir tedavi yöntemi olduğu, çocuk ve ergen psikiyatrisinde kullanımının yaygınlaştırılması gerektiği söylenebilir.

Tablo 1: Sosyodemografik özellikler

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