Attendance at child psychiatric clinics

A study of 41 families who failed to attend their first appointment at a child psychiatric clinic is described. The study was prospective over a period of one year and the families were interviewed personally; 14.9% failed their firstappointment. Improvement of the child's symptoms during the waiting period, anxiety about seeing a psychiatrist/social worker, financial difficulties and the invitation to the family to attend were common reasons given for non-attendance. Another important factor was that families were ill-prepared by the referrers.

Attendance at child psychiatric clinics A. Ubeysekara and N. Cox A study of 41 families who failed to attend their first appointment at a child psychiatric clinic is described. The study was prospective over a period of one year and the families were interviewed personally; 14.9% failed their firstappointment. Improvement of the child's symptoms during the waiting period, anxiety about seeing a psychiatrist/social worker, financial difficulties and the invitation to the family to attend were common reasons given for non-attendance. Another important factor was that families were ill-prepared by the referrers.
Out-patient clinic non-attendance occurs across all medical and psychiatric specialities leading to available resources not being used and patients not receiving the help they need in addition to negative effects on staff morale. In Toronto, 13.6% of those offered an appointment at the Child Psychiatric Clinic did not attend (Lefebvre et al 1983). A three-month study at St George's Hospital Child Psychiatric Clinic In London showed that 15.9% failed their first appointment (Cottrell et al, 1988). At a child guidance clinic in a London borough, 26.8% of the referrals were never seen at the clinic, 15.9% failing to attend giving no warning of this (Richards, 1990). Thirty-six per cent of those offered a first appointment did not attend another National Health Service child and family psychiatric clinic (Jaffa & Griffin. 1990) while a lower rate of 11.1% was found at a local child psychiatric clinic in Ireland (Belton & O'Donovan. 1993).
Most studies were carried out retrospectively with a varying response rate from the families. A recurrent difficulty is the lack of information about the cases who do not attend (Cottrell et al, 1988). The present study, looking at the rate of non-attendance and associated factors, was Psychiatric Bulletin (1998), 22, 435-437 done prospectively and non-attending fami lies were interviewed personally to collect the information.

The setting
Mid Glamorgan Child and Family Service serves a population of 540 000 through four consul tant-led multi-disciplinary teams. The study involves referrals received by one consultant-led team serving two South Wales valleys with a population of about 150 000. The two valleys served by the clinical team have high socioeconomic problems, a significant proportion of families referred to the service having to depend on public transport to attend the clinic. The clinical team consists of a full-time consultant, two part-time doctors, two full-time social work ers, and some input from a clinical psychologist on a flexible basis. All non-urgent referrals are generally seen between one to four weeks after the case allocation and a standard appointment letter is sent to the family inviting the family to attend.

The study
The study used all the referrals received by the clinical team over a period of 12 months in 1988. The families who were offered a clinic appoint ment but failed to attend their first appointment were included in the study. Those families who contacted the clinic to cancel the appointment, and the families who referred themselves, were excluded from the study. A questionnaire was developed, to be filled in by a therapist during a semi-structured interview with the parents. If the family kept their second appointment the ques tionnaire was filled in by their respective therapists, while all the other non-attending families were visited by one of the two social workers to complete the questionnaire.

Findings
In 1988 there were 341 new referrals, of whom 92 (26.9%) failed to attend their first clinic appointment. Fifty-one (14.9%) families failed, having not contacted the clinic and were in cluded in the study. Nine families had to be excluded because they were self-referrals or had moved house, and one family refused to take part in the study. The remaining 41 'no show' families were interviewed to collect information required for the study.

Child factors
There were 29 male and 12 female children in the 'no show' group, with a mean age of eight years.
There were 12 (29%) in the 1-5 age group, 18 (44%) in the 6-11 group, and 11 (27%) in the 12-17 group, which was not different from the total referred group. Ten out of 41 children were not willing to attend the clinic but only four families gave this as the main reason for non-attendance.

Presenting symptoms
Nearly half the non-attending children had one presenting symptom while 10% had three or more symptoms at the time of the referral. The duration of the presenting symptoms varied from a few weeks in two children, to over a year in 27 (66%) children. The most common presenting symptoms were in the category of behaviour/ conduct group (31 children) while the other 10 children were referred for enuresis, encopresis, eating/sleeping difficulties, anxiety/depression or school attendance problems. In eight out of 41 children (20%) the parents reported an improve ment in the presenting symptoms during the waiting period before the first clinic appoint ment.

Family factors
There were 29 two-parent families, including 10 reconstituted families, while 12 children came from single parent families. Only 19 fathers and 10 mothers were employed at the time of the referral, and all the 26 families that we were able to categorise by social class belonged to social classes 3, 4 and 5. Sixteen families (39%) described themselves as having financial diffi culties and only 16 (39%) had the use of a car, the others (61%) having to travel by public transport. There were three or more children in 26 (63%) families, while 10 (25%) had two children and 5 (12%) had only the referred child. Most parents (78%) had faith in the helping agencies.

Referral process
The 'no show' families were referred by general practitioners, health visitors, paediatricians, so cial services departments and the education department, and there were no significant differ ences between the agencies. Two-thirds of the referrals were made at the instigation of the parents and 88% of the parents saw a need for the referral. The referrer had not explained the specific aim of the referral in 51% of cases. Similarly, nearly two-thirds of the referrers have not explained the help they may receive or that there is a family approach.

Clinic/ therapist factors
Eleven families had known about the Mid Glamorgan Child and Family Service before but only seven families have had any contact with the service. Two families (5%) said that the distance to the clinic affected their non-atten dance while seven (17%) families felt that the invitation to the family to attend may have influenced their decision not to attend. Six families felt that they had to wait too long before the clinic appointment but only one family gave this as the sole reason for their non-attendance. The fact that they were going to be seen by a child psychiatrist or a social worker had a discour aging influence on seven and five families, respectively, seven of whom gave this as the main reason for not attending the clinic.

Reasons given by the parents
Eight families (20%) did not attend as the presenting symptoms of the referred child im proved during the waiting period, while another seven families (17%) did not attend as they had to see a psychiatrist or a social worker. Child's refusal to attend caused four families (10%) not to attend the clinic. Other reasons given by the parents were family illness, appointment letter not received, father's work shifts, lack of baby sitters, lack of money for travelling, long waiting time and mother's agoraphobia.

Comment
The rates of 26.9% for total non-attendance and 14.9% for no shows at the first clinic appoint ment in two South Wales valleys appear to be similar to rates in child psychiatric clinics else where. The non-attending children, or their symptoms, were not significantly different from the total referred group. In 20% of the nonattending children an improvement was reported during the waiting period but it is difficult to know whether it was a genuine resolution of the symptoms following a crisis or whether reorgan isation of family and other factors managed to contain the symptoms to reappear later on. A shorter waiting period and/or some crisis inter vention work may be more appropriate for this group of families. As the majority of nonattending families were non-car users, and some gave financial difficulties as the main reason for non-attending, transportation needs to be in vestigated, especially if the whole family is expected to attend. The families were ill-prepared by the referrers at the time of the referral. Hence, attempts should be made to educate the referrers through clinic brochures or face to face contact about the need to explain the nature of the service, including the family approach to allay parental anxieties about clinic attendance.
We seem to underestimate the parental anxiety about having to see a psychiatrist or a social worker with their child. A leaflet/booklet ex plaining the role and the functions of the clinic, sent along with the first appointment letter, may be helpful in reassuring at least some of the families with those anxieties.