> Protocols
> Parents and/or child decide
> Diagnosis
Protocols
Child and adolescent psychiatrists now work according to generally recognised working methods which have been studied for efficiency. In other words, they work according to protocols.
Protocols are written out and can therefore be carried out by treatment specialists in a reliable manner. Because they are written out and always performed in the same way, their effects can also be scientifically studied and improved.
Another advantage of protocols is that they provide parents, children and other individuals involved insight into how the evaluation takes place and what can be expected from it. This facilitates the discussion of the diagnosis and treatment between the patient and treatment specialist.
Parents and/or child decide
In child and adolescent psychiatry, parents remain responsible for their child. What’s more, under normal circumstances, the parents and child themselves choose a particular treatment. Protocols make choices possible in the sense that the treatment specialist can clearly explain what evaluation and treatment entails and, with some certainty, what can be expected from evaluation and treatment.
Diagnosis
After registration, the first appointment with the child and adolescent psychiatrist will take place within a maximum of three to four weeks. During a few sessions, the child will be evaluated to determine the problem(s) and a treatment plan will be devised. The following steps are taken:
a. Prior to or during the first visit, the child and adolescent psychiatrist collects information which will be used as a basis for formulating a ‘working hypothesis’, which is an estimate of the nature and severity of the child’s problems, the possible causes and the factors that perpetuate the problems. The information can be collected from the parents/caregivers, child/adolescents and teachers. The teachers will only be approached with the foreknowledge and approval of the parents. Various questionnaires designed for the different informants are available.
b. The first meeting can be orientational in nature, with the aim of formulating a 'working hypothesis’. It is also possible for the first meeting to be more targeted when a lot of information has already been collected in advance. If the latter is the case, the meeting will already be partially oriented towards assessing the ‘working hypothesis’. The Checklist for the clinical interview will be used for this purpose. The treatment specialist also has other instruments in the form of questionnaires which can be used to screen the patient.
c. The working hypothesis is further tested during the subsequent sessions. To do so, the treatment specialist will use targeted instruments (questionnaires) or additional evaluation by different fields, such as a psychological evaluation or medical-specialist evaluation.
d. The integration and assessment of all of this information results in a conclusion in the form of a diagnosis, classification or naming of the disorder and treatment plan.
With a diagnosis, the child and adolescent psychiatrist means that he or she is familiar with the individual case and has taken into account the risks and protective factors an individual is faced with in his or her developmental context. The described behaviours are also given the name of a particular category within a classification system. In the Netherlands, the DSM-IV-TR (Diagnostic and Statistical Manual IV edition Text Revised APA 2001) is used for this. This classification system has well-defined rules. During their studies, child and adolescent psychiatrists become familiar with these rules and gain experience with them. For this reason, the reliability of a classification based on a child and adolescent psychiatrist evaluation is good in the Netherlands.
The diagnosis and classification results in an indication for a treatment according to the prevailing guidelines, which are laid down in treatment protocols.
e. The report is then written up. The diagnosis, classification and treatment plan are drawn up in a letter to the referrer: the general practitioner, referring medical specialist or the Youth Care Agency. Parents and children aged 12 and older can read the letter so that they know what will be reported to the general practitioner. Law provides for the letter to be viewed by parents and children aged 12 and older.
The letter must be written in clear and accessible language. When something is unclear to the parents and child, it can be explained during the meeting.
The letter should at least contain a summary of the referral and the evaluation. It is concluded with a carefully formulated diagnosis and treatment plan. The latter should be explicit with respect to the treatment goals, evaluation periods, drugs and who is responsible for what.
