LETTERS TO THE EDITOR USE OF EMERGENCY SERVICES JUSTIFIED
have taken in documenting the outcome of their patients, their conclusion that the model they describe is responsible for the outcome given does not follow from the study. In particular, there is no evidence in their study that the "therapeutic family model" in any way contributes to a positive outcome. The study was not designed to test the hypothesis of whether or not the therapeutic family model determines positive outcome. The sample is too small, the number of post-discharge variables too great, and the lack of either a control group of untreated adolescents or adolescents treated using another model (which is not unethical) makes any statement about the efficacy of the treatment model not only premature but also misleading. This concern is not to criticize the very real therapeutic and clinical efforts made by this group, which sound by all descriptions quite impressive. For this they are to be congratulated. However, before one model can be held up as a "gold standard" of care, it must undergo more rigorous and evaluative scrutiny. The real challenge is now for the authors to compare this model of care to another model and use those results to argue their case for the superiority of their model.
Dear Sir: As an occasional practitioner of adolescent psychiatry at a hospital with a flourishing pediatric department, I was intrigued by the article by Drs. Cole, Turgay and Mouldey (I). After careful consideration of their concems, I realize that I find myself confronted by the same troubled teenagers as they report, but that I reach a different conclusion. The DSM-III-R places the developmental disorders central to the childhood and adolescent psychiatric illnesses. Definitive pathology is thought to mature in adulthood. Troubled adolescents who are out of control and who may be exposed to external forces such as intoxicants and various forms of social upheaval can become too much for their exhausted caregivers. Drs. Cole, Turgay and Mouldey mention that a large number of their patients are in the care of the Children's Aid Society. They appear to conclude that a number of the visits to emergency departments are unproductive. I perceive the visits of similar adolescents differently. To me, the parents or guardians are searching for a definition of the pathology by obtaining a second opinion. In an attempt to improve communication with affiliated services in geriatric psychiatry, we were told that our expert opinion is necessary at times. I have been told that the same holds true in the request for adolescent psychiatric services. In these times of cutbacks and limitations, many group homes and half way houses are understaffed, especially during evenings and weekends. Staff members who are adequately trained in all parameters are not always available. Moreover, when an impasse is reached in a crisis situation, both the patient and staff require an unbiased professional setting to deal with the situation. The suggestion that affiliated systems be made more aware of the appropriate use of emergency services appears simplistic. The responsible care plans developed by the allied professions include the use of secondary systems for support (for example, police and fire departments, repair and maintenance services). In my opinion, the emergency department can expect its share of troublesome children and adolescent psychiatry cases for various but legitimate reasons - reasons as legitimate as requests for a differential diagnosis in cases of abdominal pain or unexplained high fever.
References 1. Blackman M, Eustace J, Chowdhury T. Adolescent residential treatment: a one to three year follow-up. Can J Psychiatry 1991; 36(7): 472-479. S.P. Kutcher M.D. North York, Ontario
DR. BLACKMAN REPLIES Dear Sir: I am grateful for the chance to respond to Dr. Kutcher's letter. I must first thank Dr. Kutcher for his complimentary words about our study. The authors of the study made a point of stating that this was not a controlled study and, as such, is subject to all the problems implied in such a design. We also tried to make it clear that we were not trying to ascribe direct causal connections between the model and the outcome, although it did seem that the program design made a difference, since the majority of our patients had previously undergone intensive treatments without success. We agree that further research is needed to ascertain whether or not the "therapeutic family model" is indeed the answer. One of our senior psychologists has just completed a doctoral thesis examining curative factors of the program from the patients' perspective, and we hope that some of his findings will soon be in print and will shed new light on the situation. The paper was written to show that, contrary to popular belief, this group of adolescents can be treated and that the often negative attitudes toward residential treatment for severely dysfunctional adolescents need to be questioned. We would be most interested in pursuing comparison studies with other programs offering help to similar patient groups and would welcome the inquiries of other centres that might collaborate with us in the endeavour. M. Blackman, M.D. Edmonton, Alberta
References 1. Cole W, Turgay A, Mouldey G. Repeated use of psychiatric emergency services by children. Can J Psychiatry 199I; 36( I0): 739-742. John D. deVries, M.D. Calgary, Alberta
MORE RESEARCH NEEDED INTO THERAPEUTIC FAMILY MODEL Dear Sir: The study by Blackman et al (I), which describes a cohort of 40 teenagers in a specific multimodel program and who are followed-up with a variety of assessment measures, is very interesting. Although the authors are to be commended for the care and effort that they 455
have taken in documenting the outcome of their patients, their conclusion that the model they describe is responsible for the outcome given does not follow from the study. In particular, there is no evidence in their study that the "therapeutic family model" in any way contributes to a positive outcome. The study was not designed to test the hypothesis of whether or not the therapeutic family model determines positive outcome. The sample is too small, the number of post-discharge variables too great, and the lack of either a control group of untreated adolescents or adolescents treated using another model (which is not unethical) makes any statement about the efficacy of the treatment model not only premature but also misleading. This concern is not to criticize the very real therapeutic and clinical efforts made by this group, which sound by all descriptions quite impressive. For this they are to be congratulated. However, before one model can be held up as a "gold standard" of care, it must undergo more rigorous and evaluative scrutiny. The real challenge is now for the authors to compare this model of care to another model and use those results to argue their case for the superiority of their model.
Dear Sir: As an occasional practitioner of adolescent psychiatry at a hospital with a flourishing pediatric department, I was intrigued by the article by Drs. Cole, Turgay and Mouldey (I). After careful consideration of their concems, I realize that I find myself confronted by the same troubled teenagers as they report, but that I reach a different conclusion. The DSM-III-R places the developmental disorders central to the childhood and adolescent psychiatric illnesses. Definitive pathology is thought to mature in adulthood. Troubled adolescents who are out of control and who may be exposed to external forces such as intoxicants and various forms of social upheaval can become too much for their exhausted caregivers. Drs. Cole, Turgay and Mouldey mention that a large number of their patients are in the care of the Children's Aid Society. They appear to conclude that a number of the visits to emergency departments are unproductive. I perceive the visits of similar adolescents differently. To me, the parents or guardians are searching for a definition of the pathology by obtaining a second opinion. In an attempt to improve communication with affiliated services in geriatric psychiatry, we were told that our expert opinion is necessary at times. I have been told that the same holds true in the request for adolescent psychiatric services. In these times of cutbacks and limitations, many group homes and half way houses are understaffed, especially during evenings and weekends. Staff members who are adequately trained in all parameters are not always available. Moreover, when an impasse is reached in a crisis situation, both the patient and staff require an unbiased professional setting to deal with the situation. The suggestion that affiliated systems be made more aware of the appropriate use of emergency services appears simplistic. The responsible care plans developed by the allied professions include the use of secondary systems for support (for example, police and fire departments, repair and maintenance services). In my opinion, the emergency department can expect its share of troublesome children and adolescent psychiatry cases for various but legitimate reasons - reasons as legitimate as requests for a differential diagnosis in cases of abdominal pain or unexplained high fever.
References 1. Blackman M, Eustace J, Chowdhury T. Adolescent residential treatment: a one to three year follow-up. Can J Psychiatry 1991; 36(7): 472-479. S.P. Kutcher M.D. North York, Ontario
DR. BLACKMAN REPLIES Dear Sir: I am grateful for the chance to respond to Dr. Kutcher's letter. I must first thank Dr. Kutcher for his complimentary words about our study. The authors of the study made a point of stating that this was not a controlled study and, as such, is subject to all the problems implied in such a design. We also tried to make it clear that we were not trying to ascribe direct causal connections between the model and the outcome, although it did seem that the program design made a difference, since the majority of our patients had previously undergone intensive treatments without success. We agree that further research is needed to ascertain whether or not the "therapeutic family model" is indeed the answer. One of our senior psychologists has just completed a doctoral thesis examining curative factors of the program from the patients' perspective, and we hope that some of his findings will soon be in print and will shed new light on the situation. The paper was written to show that, contrary to popular belief, this group of adolescents can be treated and that the often negative attitudes toward residential treatment for severely dysfunctional adolescents need to be questioned. We would be most interested in pursuing comparison studies with other programs offering help to similar patient groups and would welcome the inquiries of other centres that might collaborate with us in the endeavour. M. Blackman, M.D. Edmonton, Alberta
References 1. Cole W, Turgay A, Mouldey G. Repeated use of psychiatric emergency services by children. Can J Psychiatry 199I; 36( I0): 739-742. John D. deVries, M.D. Calgary, Alberta
MORE RESEARCH NEEDED INTO THERAPEUTIC FAMILY MODEL Dear Sir: The study by Blackman et al (I), which describes a cohort of 40 teenagers in a specific multimodel program and who are followed-up with a variety of assessment measures, is very interesting. Although the authors are to be commended for the care and effort that they 455
