Outpatient CAMHS: Environmental characteristics and technical equipment
Overall, the region's 11 CAMHS comprised 110 outpatient Units, 43 of which were larger Units ("CNPIAs"-Centri di Neuropsichiatria dell'Infanzia e dell'Adolescenza, i.e. Child and Adolescence Neuropsychiatry Centres) and 67 of which were simple Outpatients Unit; all but one were public facilities.
All 110 participating units had a specific catchment area: most (N = 72; 65%) had a catchment area of up to 50,000 inhabitants, and 22 (20%) units were linked to a catchment area of more than 100,000 inhabitants.
The target population of 0-17 years was less than 10,000 in 80 units (72.7%), 43 of which (39.1% of the total amount) had fewer than 3,000 inhabitants in the age range examined. The remaining 30 (27%) units had a catchment area of more than 10,000 resident children and adolescents.
Approximately half of the units (for which facility history information was available) (N = 99; 90%) had been built over the last four decades (N = 41; 41.4%); 29 units (29.3%) had been built before 1950 (some had been fully refurbished). In most cases (N = 87, 79.1%), the units were hosted in a building together with other public health services. Twenty-five units (22.7%) had a separate dedicated access, and a dedicated reception area was present in 39 units (35.5%).
Forty units (36.4%) had a dedicated meeting room not used for clinical activities. Soundproofing, an important privacy feature in outpatient settings, was ensured in 74 units (67.3%).
All but 17 units had at least one dedicated room for neuropsychiatric exams; most units (101; 91.8%) had at least one room for other clinical activities (most frequently, for clinical psychologists).
In general, the participating units were equipped with games and other materials to entertain children (N = 106; 96.4%), and all had most of the technical instruments required for conducting medical exams (e.g. diaphanoscope, ophthalmoscope, etc.); these were frequently available in all rooms used for outpatient activities (N = 65; 59.1%). Most participating units (N = 79; 71.8%) had a dedicated physiotherapy and psychomotor rehabilitation room, and all had a specific room for speech and language therapy. Clinical and neuropsychological tests were available in nearly all the units (N = 107; 97.3%). An electronic clinical database was available in 94 units (85.5%), and the paper database met Italian privacy law requirements in 78 (70.9%) units. Online access to major scientific journals was available in 108 (98.2%) units.
Outpatient CAMHS Staff and Functioning
As shown in table the 110 participating units employed 769 full-time equivalent professionals i.e., 125 child psychiatrists, 147 clinical psychologists, 217 speech therapists, 13 psychomotor therapists, 125 physiotherapists and 118 educators. The CAMHS mainly employed permanent staff, and temporary contracts were quite infrequent (N = 67; 8.7%).
Full-time-equivalent (FTE) CAMHS Professionals
Staff supervision was available in 71 units (64.5%), and specific burnout prevention programmes were conducted routinely in only a few units (n = 9; 8.2%).
Most units were open Monday through Friday until 6 p.m. (N = 95; 86.4%), and 1/3 were also open on Saturday mornings (N = 32; 29.1%), with 39.35 (± 11.27) weekly mean opening hours.
All units granted direct free access, even without paediatric referral. The costs of clinical assessment (as with most clinical interventions), was fully covered by the National Health Service; a small fee was charged only by specific services, depending on the user's age and disorder.
On average, one-third of the units granted a first-visit appointment within a range of 15 days to 1 month (N = 37; 33.6%), whereas in another third, the delay was over 2 months (N = 28; 25.5%); a minority of units scheduled first visits within 7-15 days (N = 7; 6.4%).
A specific protocol for emergency 24-hr referral (priority of emergency consultation over ordinary scheduled visits) was present in 35 (31.8%) units. No CAMHS had a child psychiatrist on duty during night hours or holidays, and patients requiring treatment at these times were referred to ordinary E&A Departments.
In two third of the units (n = 74; 67.3%), first visits were conducted either by a neuropsychiatrist or psychologist, depending on staff availability, and in 18 units (16.4%) the neuropsychiatrist was the professional in charge of first visits.
Diagnoses were formulated according to the International Classification of Diseases, tenth edition [4
] and were usually based on a detailed clinical interview of the patient and his/her parents.
Most interventions included counselling, individual rehabilitation training, and meetings with school teachers (table ). Unconventional interventions, such as Pet Therapy and Music Therapy, were rarely practised (in 7 and 6 participating units, respectively).
Range of CAMHS activities and procedures (*)
All CAMHS activities were documented in clinical records and frequently followed specific protocols; only a minority of the participating units shared treatment protocols with patients' paediatricians.
Most units had at least one board-certified psychotherapist; most of these had a psychodynamic training background (78 units; 70.9%), whereas systemic family psychotherapy was practised in 33 units (30%), and cognitive-behavioural therapy in 23 units (20.9%).
Outpatient CAMHS activity data
As show Figure , the 110 units evaluated and treated the entire range of mental and behavioural disorders with onset during childhood or adolescence. Most patients contacting CAMHS for the first time during the year 2008 received a diagnosis of communication or learning disorders. It is important to note that all diagnoses recorded on the regional registry were clinical diagnoses and were not obtained via standardised assessment methods.
Distribution of all diagnoses in the target population (0-17 years). Data refer to number of patients in treatment per 100,000 inhabitants aged 0-17 years, with standard deviations.
As show Figure , The average number of target population (0-17 years), for each CAMHS, was 5,947 ± 1,239 (range: 3,915-8,254), with almost perfect symmetry of distribution (Fisher skewness = 0.017); and moderate dispersion (CV = 0.21). Overall, approximately 6% of the 0-17 year target population was in contact with CAMHS in the Emilia-Romagna Region in 2008.
Scatterplot of target population versus population in contact with CAMHS; strait line shows a linear regression curve.
As show Figure , the average number of first visits during 2008 was 1,134 (± 604.3). First visit proportions were similar across the 11 CAMHS, accounting for 30% of their total annual child psychiatric consultations.
Scatterplot of linear correlation of first visits number versus contact with CAMHS; strait line shows linear regression line.
On average, in the 11 CAMHS 3,561 ± 2,042 child or adolescent patients had at least one contact in 2008, for an average of 6,313 ± 5,435 annual visits. Each patient received on average 2 or more visits by child neuropsychiatrists at that year.
Inpatient psychiatric facilities for children and adolescents
The Emilia-Romagna Region had seven inpatient facilities (all public) for children and adolescents with neurological or behavioural problems; two were University Clinics, and one was a day-hospital.
With respect to environmental characteristics, the oldest facility was built in 1930, and all had been restructured over the previous ten years. Patients were generally hosted in double bedrooms; no single rooms were available.
Five inpatients units had dedicated rooms for clinical activities and meetings with families, and also had dedicated outdoor areas for patients (and their families).
In terms of organisational procedures, one facility admitted only patients with eating disorders; the others were generic units admitting any patients of paediatric age with mental disorders. All the facilities included a day-hospital.
Six inpatients units had inclusion/exclusion criteria for admission: three units did not admit patients with substance-related disorders, elevated suicide risk, or severe behavioural problems with aggressiveness, whereas all units treated severe MR or severe physical disabilities (e.g. blindness, paralysis...).
One inpatient unit's entrance was frequently kept locked, but all the other units had an open-door policy.
The amount of time available for family member visits was not standard: one unit permitted only two-hour family visit per day, but the other units allowed family members to stay all day.
Only two inpatient unit had a maximum hospital stay duration (30 days).
In terms of personnel, the inpatient units employed 29 child-psychiatrists, 17 (58.6%) of which were permanent staff. Treating staff included a further 68 professionals, mostly nurses, 30 of whom (44.1%) were permanently employed. The organisation of care during night shifts varied greatly by inpatient unit.
We also collected inpatient activity data for the year 2009: thirty-two (32) beds were available for the inpatient treatment of mental disorders, i.e., 5 "psychiatric beds" per 100,000 inhabitants aged 0-17 years. It should be noted, however, that these facilities can also admit patients from other regions; this proportion should therefore be interpreted with caution.
Overall, there were 624 admissions for the inpatient treatment of mental disorders in 2009, for a total of 7,822 hospital stay days. Among the 591 patients admitted in 2009, 411 (69.5%) were at their first ever admission. Moreover, a total of 1,038 patients were treated in day-hospitals in 2009 for a total of 1,046 admissions.