Catharina Wahlqvist, head of the BUP Mellanvård NE department Susanne Leffler, BA socialwork

1. ”Mellanvård” an intermediate level between the institutional and non institutional care and its function as a reinforcement to the child and youth psychiatry in Stockholm (BUP) Catharina Wahlqvist, head of the BUP Mellanvård NE department Susanne Leffler, BA socialwork

2. “Mellanvård” – a reinforcement within the BUP organisation • Background • “Mellanvård” , the assignment • Target group • BUP Mellanvård Nordost (NE) • Staff and the various methods of treatment offered • Case management • Case work and cooperation • Statistics • Fields of development

3. Background • 2000, the merger between the institutional and non institutional care and the formation of a joint organisation 2005 • “Sachska huset” (the house “Sachska”) – 1 clinic • 4 fields of employment • From 28 to 17 non institutional units • 4 intermediate care wards

4. Öppenvården PBU – outpatient care 1999 ÖV ÖV ÖV • Psykiska Barn - och Ungdomsvården ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV ÖV

5. Slutenvården BUP – inpatient care 1999 • Barn - och UngdomsPsykiatrin SV SV SV SV SV SV SV SV SV SV SV SV SV SV SV SV SV SV SV SV SV

6. Integration spring of 2000 • PBU

7. Integration spring of 2000 • PBU + BUP

8. PBU+BUP=BUP

9. Slutenvården BUP – inpatient care 2005 KLINIK

10. The clinic 12 Sachs Street The “Söder” Hospital Stockholm

11. One CLINIC • Reduced amount of institutional care • Specialized field of activity and the need for, in order to achieve a reasonable number of patients, widening the recruitment base to include the entire county of Stockholm.

12. 4 GEOGRAPHICAL AREAS ÖV ÖV ÖV NW NE ÖV ÖV MV ÖV MV ÖV ÖV ÖV KLINIK ÖV ÖV ÖV ÖV ÖV MV MV ÖV ÖV SW SE ÖV

14. Cooperation!

15. Outpatient care • Based on a maintained responsibility for all patients regardless of whether in “mellanvård” or institutional care • Fewer and bigger inpatient units offering the same level of competence and broad spectra of treatment to the patients irrespective of where in the county they live. • Increased degree of specialization • Special competence e.g. crisis and trauma, anxiety, compulsive disorder, phobia, development disorder / retardation, aggression, ADHD

16. Mellanvård • Forming part of the non institutional BUP within the 4 different geographical areas • Specialized activities requiring a wider recruitment base • Sufficient number of patients • Retain and develop the level of competence • Alternatives to 24 hour/day institutional care

17. “MELLANVÅRD” – THE ASSIGNMENT– a way to strengthen the BUP organisation • The “Mellanvård” forms part of the various treatment methods found within the non institutional care offered to the patients locally. Its purpose is to increase the quality of the care given by the locally based non institutional units and thus offer methods to those patients whose psychiatric problems are of such nature and depth that they otherwise could not have been dealt with by an out patients clinic alone. • Services offered are to include daytime treatment programmes at our location for children and youngsters in need of more intense and advanced care but where 24 hour/day institutional care is not yet considered to be necessary. The services are also to include access to mobile teams who are to work together with the families in their own environment

18. “MELLANVÅRD” – THE ASSIGNMENT– a way to strengthen the BUP organisation • The activities within the “Mellanvård” are to be characterized by a high degree of intensity and flexibility method wise. The “Mellanvård” is also required to offer help both for those in need of immediate care, quick but not necessarily immediate help as well as those able to await planned activities. The activities offered are to be set within a time schedule and the work with the individual patients must be performed in such a manner as to allow for new patients to be accepted without any waiting time • Patients cannot apply for help directly to the “Mellanvård”. Further, this intermediate care unit does not have the responsibility for emergency cases (as opposed to the non institutional care unit to which it belongs)

19. TARGET GROUP • Children and youngsters up to and including 17 years of age with psychiatric disorders or illness or suffering from difficulties relating to others – all presenting obstacles for individual mental growth and increased maturity • The psychiatric problems are to be of such an extent and intensity so that the various treatments available within the child and maternity wards, the primary healthcare system, the child daycare system as well as the social welfare and school systems are all considered to be inadequate

20. BUP Mellanvård NO

21. GEOGRAPHIC AREA NORTHEAST BUP Norrtälje BUP Täby Täby Österåker BUP Danderyd Danderyd Vallentuna Vaxholm Lidingö BUP Sollentuna Sollentuna Sigtuna Upplands Väsby

22. GEOGRAPHIC AREA NORTHEASTArea: 3.303 sq/km Children and youngsters 0-18: 106.000 • BUP Norrtälje • BUP TäbyTäby Österåker • BUP DanderydDanderyd Vallentuna Vaxholm Lidingö • BUP SollentunaSollentuna Sigtuna Upplands Väsby

23. STAFF • PsychologistsRegistered Nurses • Social workers / BA:s major in social work • Nurses • Specialist teachers/educators • Clerks / office staff • (Doctors, MD consulted from from local inpatient care) • A total of 25 persons

24. COMPETENCE AND AVAILABLE TREATMENT METHODS • The members of the staff have experience e.g from out patient case work, “psykologverksamhet” (daytime group activities for pregnant women and infants led by psychologists), institutional work, schools and the social welfare system • Staff members from the previous care units attached to the inpatient institution have worked with small children, teenagers and families as well as tasks connected to emergency ward duties

25. COMPETENCE AND AVAILABLE TREATMENT METHODS • The majority of the staff members have a long clinical experience with access to a broad repertoire of different treatment methods • Included in the above mentioned are various types of therapeutic methods for the treatment of families, cognitive methods, programmes meant to support parents in their role, programmes aimed to increase the quality of the interplay between parent and child, different methods for trauma treatment plus psychological and pedagogical work dealing with investigations and assessments of psychiatric disorders

26. CASE WORK, HANDLING • The staff divided into two teams, relatively similar regarding professions, competence and gender • Each team headed by a coordinator • The teams are not formed based on geographic areas or age (regarding the patients) • In need of help from the “Mellanvården” the various non institutional care units (Öppenvården) are to address themselves to the above mentioned coordinators. • Cases with emergency status are to be distributed to staff members at “Mellanvården” available at short notice. • Remaining cases to be distributed at the weekly conference held by both teams

27. CASE WORK, COOPERATION • Request by the local out patient care unit • Meeting - normally the family / the parents meet with staff from both the Öppenvård (ÖV) and the Mellanvård (MV) - if the case appears to be more complicated – the various staff members get together for a meeting without the parents / the family present. • The meetings normally take place at ÖV • The outline of the assignment for MV is drafted in cooperation between the families and the care units.

28. CASE WORK, COOPERATION • A written agreement / a “contract” is drafted and signed by the parents and, if possible, by the patient - dealing in a concrete mannerwith the nature of the problem, type of treatment, extent of treatment, aim and date for a follow up meeting with ÖV • Primarily work within the homes of the families or their own environment. Some of the treatment may be performed at the location of MV • The various cases normally require a close cooperation with family members, schools and the people close to the patients as well as with the social welfare system, the psychiatric wards serving the adult population, the “Clinic”..

29. STATISTICSsince the start September 1st 2005 • 202 cases • 3 332 treatment occasions • 5 200 hours • 526 meetings with staff (ÖV, school, clinic etc….)

30. Distribution, sex, male/female

31. Distribution, age

32. Explanation/symptoms • Crisis and trauma • Anxiety, OCD, phobia • Acting out, ADHD • Development problems, small childrens • Autism spectrum disturbancies • Eating disorders • Self Harm • Depression/psychosis

33. Distribution with reference to most important symptom

34. Distribution with reference to most important symptom, girls, 109

35. Distribution with reference to most important symptom, boys, 93

36. Most patients have several symptomse. g. eating disorders 14, self destructive behavior 14, and anxiety, OCD, phobia 38 patients More than 90 % have psychosocial stress asrelational problems in family and with peers, sexual abuse and maltreatment, somatic problems, psychical disturbances or drug abuse in family

37. C – GAS(CHILDRENS GLOBAL ASSESSMENT SCALE) • Start: average score 38Considerable impairment of functional level in several areas and unable to function in one of them • Termination: average score 51Varying levels of functioning with occasional difficulties or symptoms in several, but not all social areas

38. Decreased inpatient care? • Our estimation • About 26 patients (14 boys, 12 girls) would earlier had a higher level of support from institutional care • 0-2 years: 7 • 7 - 12 years: 2 • 13 - 15 years: 14 • 16 - 17 years: 3 • In the above, 26 patients, 7 had shorter and planned inpatient care during the period of contact, 1 got support after inpatient treatment

39. Comparison with inpatient units • Lower average age • Some more psychosocial stress • Lower C - GAS assessment • More meetings with each patient

40. DEVELOPMENT OF METHODS

41. Environmental work with small children and babies • The method is used in families with children 0-6 years old. The children have problems with sleep, food or contact. This may be children exposed to strain/stress (prematurity, somatics, psychosomatics, disabilities) that has influenced the parent’s relation to the child. Other problems are attachments problems often expressed as parents inabilities to understand the child and problems related to becoming parents (e.g. go from 2 to 3 children.) The families need immediate help that are intensive and last for several hours on each occasion, something the outpatient unit cannot provide

42. Model of treatment for”home sitters” • This model is used for teenagers that do not attend school. They often have”turned” the clock, and use the evenings and nights in front of the computer or video. The parents have normally resigned and lost their parental authority. The school has normally unsuccessfully tried different ways of returning the youth to school. The most obvious signs from the schools point of view are a loss of self confidence in all school work (not only where there may be some difficulties) and a loss of friendship with classmates. A huge problem is that the patients normally come to intermediate care after such a long while that the problems have really taken hold. On average they have been home from school for 3,4 months.

43. ”Inpatient at home” for youth as alternative to inpatient care • An important part of the BUP reorganization has been to decrease inpatient care for the young. Often this type of care makes the young patient passive, the parents’ participation in the care less active, and a certain self-destructive behaviour may become infectious (the young learn more advanced methods from each other) and treatment is going on for a long time. It is very important to avoid long-lasting treatment because closeness to the family and the social network is essential for recovery.

44. Family work in families with children and youth with neuropsychiatric functional deviations • This method is used in families with children and youth with neuropsychiatric functional deviations such as • ADHD/DAMP • Aspergers syndrome • Tourettes syndrome • Out-acting behavioural problems • And others • These families have problems of a type or to a degree where outpatient treatment is insufficient. This may for instance be parents that have taken part in learning groups offered within the outpatient care but without being able to use the acquired competence in practice. The emphasis is on specific help rather than close contact