Children swear because of their children

Social psychiatric care for children and adolescents: "We swear by the model"

The social psychiatry agreement for the multimodal and multiprofessional treatment of mentally ill children and adolescents has proven itself well. A practice team in Berlin provides insights.

The expertise of all specialist groups is required in the regular case conferences of the practice team. Photos: Georg J. Lopata

The green monster welcomes the visitor at the entrance of the practice for child and adolescent psychiatry on Berlin's Wittenbergplatz, directly opposite the KaDeWe in the old center west. “The children tend to be curious,” says medical assistant Tanja Izmir when asked whether small children are sometimes also afraid of the waist-high figure made of paper mache.

Behind the discreet practice sign hides a multi-disciplinary center with 14 treatment rooms on 650 square meters: three specialists for child and adolescent psychiatry and psychotherapy work together with qualified psychologists, curative educators, a social worker, an occupational therapist, a dance and movement therapist and interns in training as a child and adolescent psychotherapist. Together with the reception staff, Prof. Dr. med. Peter Greven and his team 16 employees. This is made possible by the Social Psychiatry Agreement (SPV) * according to Section 85, Paragraph 2, Clause 4 and Section 43a of the Social Code Book V, which enables child and adolescent psychiatrists as well as paediatricians, psychiatrists and neurologists with at least two years of further training in child and adolescent psychiatry to work in an interdisciplinary manner in outpatient contract medical care. There are 35 such practices in Berlin; nationwide there are 578 practices, most of them in North Rhine-Westphalia. More than half of all 774 child and youth psychiatrists use the model (KBV, as of December 31, 2009).

"The trend is increasing because it is very attractive to work in this model," says Dr. med. Christa Schaff, deputy chairwoman of the professional association for child and adolescent psychiatry, psychosomatics and psychotherapy and owner of a social psychiatric practice. The self-administration finally created a secure basis through the SPV agreement in the federal shell contracts on July 1, 2009. Regional social psychiatry contracts with the health insurance companies have existed since 1994, but these have also been terminated and the practice teams have existed in dire straits.

"We didn't want to have to laboriously obtain the expertise of other specialist groups from outside, but rather work in our own practice in a multimodal and multi-professional manner," says Greven, who ran the practice ten years ago together with Dr. med. Silvia Treuter has built. The two were used to working in a team from the Charité. "Multi-dimensional diagnostics is very important in our field," says Treuter. The impressions of others, which round off the picture of a patient, are very useful. Corinna Adamowski-Philippe joined the team a few months ago as the third specialist. New in Berlin, she had settled down as a lone fighter two years ago. "The many contacts to schools, daycare centers or the youth welfare office that are necessary in child psychiatry - that quickly exceeded my possibilities." She also missed the professional exchange in the team that she had previously at a psychiatric clinic in Saarland.

Above: A small practice center is hidden behind the inconspicuous entrance. Bottom: Developmental and Creative Therapy helps children express themselves.

"In addition to the objective diagnostic criteria, subjective impressions always have an impact in our subject - that is why it is important to have a corrective in the team," explains Greven. The whole team meets twice a week for case discussions.

Each of the three doctors takes an hour for the first presentation of a child with the family. Young people also sometimes come alone. With the help of anamnesis, neurological examination and psychiatric findings, they begin the diagnosis. Psychodiagnostic tests with one of the five employed psychologists or in-depth educational exploration with one of the five educators often follow. Occupational therapist Anne Osterhues also uses non-verbal methods, especially with small children, to do her part in a comprehensive diagnosis. Discussions with teachers, educators or child and youth welfare services, which the social workers or pedagogues of the SPV practice relieve the doctors of, complete the picture. Then one of the doctors draws up the therapy plan.

The majority of the psychologists and pedagogues are trained in behavioral therapy, while the doctors are all trained in depth psychology. "Behavior therapy is often superior in day-to-day work because it can provide concrete structures," says Greven. "We have come closer and closer to behavior therapy."

One advantage of the social psychiatric model is that it can treat significantly more patients than an individual practice can. The practice on Wittenbergplatz cares for around 1,200 to 1,300 adolescents every quarter, although not all patients meet the criteria for participation in the social psychiatry agreement. A single practice, on the other hand, has an average of around 100 to 150 patients. There are enough children and young people looking for help not only in Berlin: "The pressure is high," says Silvia Treuter: "We could have at least ten first screenings every day." The waiting times are up to two months. “Of course, we deal with emergencies immediately,” emphasizes the doctor.

Most patients choose the practice specifically because of its central location. They come from both middle-class neighborhoods such as Zehlendorf and from socio-economically poorer districts such as Wedding or Neukölln. However, it does not play such a decisive role as one might suspect. “Social or emotional neglect is more common in problem areas,” explains Treuter. But even in Zehlendorf, emotional neglect causes behavior problems in children. "The families only have more resources to hide that."

The specialists can only treat a few patients with psychotherapy themselves. "Our job is more about case management and support as well as more psychiatric-psychotherapeutic work," explains Greven. Therefore, if guideline psychotherapy is necessary, doctors often refer them to others. He describes the referral to a child and adolescent psychotherapist (KJP) as the “eye of the needle”. Getting a therapy place could take a long time. For this reason, referring physicians often switch to outpatient clinics from psychotherapeutic training institutes, where KJP in training are allowed to treat under supervision from the third year onwards. “We have had good experiences with this,” says Treuter. "The level of knowledge is high and the prospective KJP are very motivated."

In addition to the EBM numbers, a flat rate fee can be charged within the scope of the SPV, which is intended to cover the costs for employees and rooms. “You can work well with it,” says Greven. However, he feels that it is a “disadvantage” that group practices have only been able to bill the full number of SPV flat rates for one owner since 2009; each additional owner is limited to 80 percent of the cases.

Another remuneration regulation causes problems in practice: Standard benefit volumes (RLV), which are based on the specialist group average, which in turn does not differentiate between individual practice and social psychiatric practice. The specialist group average in Berlin is 200 to 300 cases. The doctors in the practice team each have more than 400 patients on average. Services that go beyond the RLV are only remunerated at a residual value: “The service rendered and remuneration are disproportionate,” criticized Greven.

The National Association of Statutory Health Insurance Physicians and the National Association of Statutory Health Insurance Funds, which negotiated the social psychiatry agreement two years ago, have committed to an evaluation. Preparations are in progress. The practice team at Wittenbergplatz no longer needs to be convinced of the benefits of the SPV: “We swear by the model,” say the three doctors in unison.

Petra Bühring

* The social psychiatry agreement on the Internet: www.kbv.de/rechtsquellen/2279.html