Reach Chronicles: A Community Mental Health Model For Children And Adolescents In Singapore

A Community Mental Health Model for Children and Adolescents in Singapore

D Fung, L P Ong, S L Tay, W H Sim

• Publisher: WSPC
• Year: 2012
• Print ISBN: 9789814440363
• eBook ISBN: 9789814440387
• Topic: Biological Sciences
• Subtopic: Science General
• Index: Biological Sciences

An easy read with a “how-to” intent, this book provides the insights and process of a practical and viable community mental health team. The authors of the book have produced a book which is as close an account to the reality of making the REACH team a value add to the mental wellness of students. This is the first book in Singapore that details the synergy of the various levels of decision making to enable a child and adolescent community mental health team to take shape, allowing hospital staff to reach students and service providers in primary care.

Contents:

• Introduction (Brian Poh & Cai Yiming)
• The Vision (Tay So Leng, Chan Mei Chern and Daniel Fung)
• Mental Health OutREACH: Processes and Services (Cheryl Lee)
• Supporting Schools: Strengthening the First Line of Defence for Students with Mental Halth Difficulties (Wong Hui Yi and July Lies)
• Partnership with VWOs (Estella Lim and Liew Shiang Hui)
• Partnership with General Practitioners (GPs) (Sim Wan Hua)
• Resources (July Lies)
• Taking Stock and REACHing Beyond (Delphine Koh, Jillian Boon, Daniel Fung, John Wong, Chan Mei Chern, Cheak Ching Cheng and Han Bing Ling)

Readership: Providers of services for children and their families; practitioners who are interested in program development for communities external parties who want to learn about community outreach services; REACH's partners (school counsellors, GPs, voluntary welfare organisations, etc.); mental health care professionals and school counsellors in other countries, policy makers, administrators (including those financing and supporting the operations), educators, community agency counsellors, graduate and post-graduate students who conduct research on community mental health services.

The Vision

Tay So Leng, Chan Mei Chern
and Daniel Fung

A population-based model of care

An empirically-based philosophy towards the care of the mental health of our young was the underlying strategy when the mental health blueprint was initiated. In 1995, World Health Organisation (WHO) promoted the idea of health-promoting schools which showed that schools have a vital role in health risk amelioration (WHO, 1995). There have been a number of models of care which take a school-based approach towards mental health. The most convincing was a whole-of-school approach towards social and emotional learning in Sydney called the Gatehouse project (Bond, Patton, Glover, Carlin, Butler, Thomas & Bowes, 2004). In this project, 26 schools in several districts in Sydney participated in a randomised trial which showed that for over 3200 students, a multilevel intervention programme made significant headways in improving the mental health of the school population. This was evidence that a community-based intervention was effective in mental health promotion, and that such systems are complex and require sufficient funding and cooperation for it to be successful.

Our traditional model of care for child and adolescent psychiatry is one which is largely based on outpatient services with a small inpatient residential unit to treat severe cases. It is dependent on a referral system and assumes that children and adolescents with problems would be brought forward to utilise mental healthcare services. There is a discrepancy between cases presenting to clinics and actual prevalence data on mental health conditions which is termed as a treatment gap. In Singapore, we see an average of 3000 new referrals largely from schools and doctors, yet a local prevalence study in 2004 (Woo, Ng, Fung, Chan, Lee, Koh & Cai, 2007) showed that we may have about 50,000 (12.5% of the child population) children with mental health disorders in the community. This represents the treatment gap. In fact WHO has identified that the mental health gap is one of the major challenges in the future (WHO, 1995).

Clinic-based standardised care is the mainstay for treatment as it leverages on economies of scale. As awareness of mental health increases in the population, there is a challenge to meet the needs as referrals increase. In Singapore, this exponential growth in clinic referrals led to massive expansion of our services from attending to about 150 referrals in the first year of operation in 1970 to the more than 3000 referrals that we receive annually today. To meet this increase in demand, the Department of Child and Adolescent Psychiatry of the Institute of Mental (IMH) has expanded from two psychiatrists to a staff strength of more than 150 comprising doctors and various allied health professionals. However, due to the intensity of a hospital-centric system, it became apparent that standardised clinic care and a reactive mode of care delivery of referrals are insufficient to treat mental illness and to promote the mental well-being of our youth.

Let us take an analogy from the evolution in the banking sector. In the past, consumer banking emphasised on bank branches in selected locality and human-teller interface. Now it has transformed to serving customers via a dense network of Automated Teller Machines (ATMs) and online banking through the Internet. Information and service were pushed right into the homes of the consumer or the mobile device of the consumer who is on the move. The consumer, in turn, interacts and provides inputs to the bank at the point of need for the service and receives service instantaneously. Banking service delivery has revolutionised over the past decades and successfully reached out to huge numbers of consumer banking users, serving them with more targeted service and personalised attention. The complexity of care and treatment of the mental well-being of a child or an adolescent parallels that of delivering banking service to the consumer — it requires targeted service and personalised attention.

We remain cognisant that fully automated service is not appropriate, at least not in the foreseeable future — given the general agreement that human clinical judgment remained an essential component of care and treatment. Our population-based model of care envisions that the mental well-being of a child and adolescent is not confined to the geographical premises of clinics and hospitals (except for tertiary care) but is characterised by “Service-at-the-doorstep” (much like the ATM is to the bank user) i.e. providing accessibility and convenience at the natural setting of the child/adolescent, and at a timing that optimises preventive care and early intervention for the individual.

This community-centric personalised care model comprises five essential operating criteria:

Effectiveness: Good enough care

Mental and emotional health refers to the presence of positive characteristics in the way one thinks, feels and acts as one copes with his or her life. It also helps determine how one handles stress, relates to others and makes choices (Institute of Mental Health [IMH], 2012). Mental healthcare that is “good enough” would be reflected through addressing the multi-faceted needs of the population to maintain good mental health, identifying mental health disorders early, and establishing a comprehensive intervention programme in primary, secondary and tertiary healthcare settings (Asia Australia Mental Health, 2011). While the intervention programme should serve the population as a whole, it would not be imposing “standardised” treatment on individuals. Rather, it should involve firstly, identification — based on accurate assessment — of the multiple, systemic factors which contribute to the mental health issues of the individual and secondly, leveraging on a network of community resources, each with different specialty, to effect a personalised management and treatment programme for the individual.

Accessibility: a pull vs. push system

The typical tertiary mental healthcare setting is a Pull system. It receives referral and provides treatment as the expert, with a black-box effect, as its services are often not easily understood. The psychiatric institution, as a provider of services, is traditionally shunned by the population, till a point when problems become complex and severely impairing the individuals. Often, by this stage, some damages are irreversible, and this tends to perpetuate the stigma against approaching the institution for help earlier.

The mental healthcare service for children and adolescents should be a Push system so as to enable early preventive and intervention efforts for this group of young population. The Push model raises the accessibility of mental healthcare services by means of a mobile multidisciplinary team, which is connected to schools, family doctors and social service agencies within the community. The team would collaborate closely with these parties to deliver an integrated management and treatment programme for the child or adolescent.

Timeliness: Just in time care

In Singapore, the education system, the primary healthcare system and the social service system are the three main first-line contact for children and adolescents. It is intuitive to tap on the school personnel (e.g. counsellors, teachers) and social service providers to conduct early screening and triage, so as to identify the risks and early signs of mental health distress. This timeliness in identification would initiate early intervention to prevent aggravation and more complex and costly treatment, and ideally, enable preventive interventions to enhance the coping capacity, and in turn, the mental well-being of the children and adolescents.

Affordability: Value for money care

Through linking the family and the child or adolescent to resources that already exist in their natural environment, care and treatment could take place within the community, rather than in the tertiary setting. There is no need to tax the tertiary care system, which is costly.

Safety: Do-no-harm care

Pushing mental healthcare services to the community, instead of centralising such services at the tertiary setting, is by no means compromising the quality of service or the safety of the population. The principles of beneficence and non-maleficence must be observed.

REACH — A step towards community-centric model of care

REACH, a mobile mental health team that operates in collaboration with community agencies including schools, general practitioners, and voluntary welfare organisations was conceptualised in alignment with the population-based model. In 2007, REACH was set up as one of the four pillars of the National Mental Health Blueprint, with a target population of children and adolescents below 19 years old.

The objectives of REACH include:

i)		Improve the mental health of children in the community, with a focus on schools
ii)		Provide early intervention through the support and training of school counsellors, social service agencies and voluntary welfare organisations in managing at-risk children
iii)		Develop a mental health network in the community to support children at risk, involving voluntary welfare organisations, general practitioners and community pediatricians and schools

The mobility of REACH enables accessibility to mental health assessment and intervention, where students at risk of mental health illnesses are identified at the point of need i.e. in schools, student care service and at home. Youths-at-risk who may not be in school are identified through their engagements with restorative programmes and other assistance provided by community agencies. Collaborative interventions between REACH and help workers at these agencies would enable the youths to receive mental health assessment and treatment on-site. Combining the help worker’s knowledge of the child or adolescent, and the professional know-how of the REACH team, the child or adolescent would receive more targeted service and personalised care, thus resulting in a better outcome.

Operationalising the community-centric model of care

The community-centric model of care is operationalised through close collaboration among multiple parties — from school counsellors, educators, youth workers, social service agency case workers, to primary healthcare professionals, mental health workers, child protection officers, police officers and youth rehabilitation workers. The services and the contribution of the professionals are multi-faceted and interdependent and involve different points of entry and at varied timings. Their collaboration could be direct, where one agency or party works in tandem with another, such as the case of the school counsellor helping a student referred by his teacher, or indirect, such as a social worker at a Voluntary Welfare Organisation (VWO) running youth programmes for school-going children of low-income parents. In order that this model of care delivery is effective, it is imperative that such collaboration is multi-sectoral, multi-agency and multidisciplinary.

Collaboration across sectors: The whole-of-government approach

Mental health and mental well-being is not just a Health Ministry issue. As primary school education is mandatory, schools form the most appropriate avenue for preventive and intervention efforts. Children and adolescents who are educated in schools that support their special needs, as well as those who are out-of-school, are also target beneficiaries of the mental health serv...

Table of contents

• Front Cover
• Half Title
• Title
• Copyright
• Contents
• Foreword by Chua Hong Choon
• Preface by Daniel Fung
• Acknowledgment
• Introduction
• 1. The Vision
• 2. Mental Health OutREACH: Processes and Services
• 3. Supporting Schools: Strengthening the First Line of Defence for Students with Mental Health Difficulties
• 4. Partnership with VWOs
• 5. Partnership with General Practitioners (GPs)
• 6. Resources
• 7. Taking Stock and REACHing Beyond
• Abbreviations for Key Institutions and Organisations
• Glossary of Mental Disorders in REACH Chronicles
• Appendix A: Role descriptions of REACH team members
• Appendix B: List of Special Education Schools in Singapore
• Appendix C: List of REACH — VWO partners
• References