On reading a government document: When will we finally achieve the true organization of paediatric care in Quebec?

At the end of fall 2004, the Association of Pediatricians received a request to express its opinion on the organization of mental care as put forward by the Ministère de la Santé et des Services sociaux (MSSS). Finally! Our opinion was being asked, which had to be a first, and, in addition, it was our opinion on the organization of a very sensitive area that is affecting us more and more closely. We said to ourselves that this was real progress, even though the document was more than 60 pages long and arrived on December 22 by e-mail. We had to believe that MSSS employees did not celebrate Christmas and, obviously, did not pull extra duty during that period! However, that was incidental because, for once, someone thought that paediatricians could contribute something in this area. There was no question of missing the opportunity we were being given. Our opinion had to be produced by the end of January 2005 and presented to a committee, headed up by a psychiatrist. Because the invitation came from Dr Michel Bureau of the MSSS, we believed that our opinion would have a definite impact. So, to work! After the first read-through, we thought that perhaps we had gone a bit too quickly because there wasn't a single mention of paediatricians in the text – not one word. We read it again, and again, and then had to face the truth: the text distinguished itself by a total lack of recognition of what paediatricians do for the mental health of children in Quebec. First-line care is mentioned – detecting adjustment difficulties that can be assessed and treated by the Centres locaux de services communautaires experts. Second-line care will be the purview of general practitioners trained in psychiatry and supported by it and, finally, there is the referral to child psychiatry, which results from this second line only, to the exclusion of any other caregiver! We then learned that the government's goal was to improve the structure and supervision of psychiatric practice in Quebec. So, how did this misleading, if not patently false, title concerning the organization of mental health care in Quebec come about? Does mental health apply only to psychoses? What about all of the other needs? Does the government think its conscience will be clear and we will remain somnolent? We also learned that the MSSS wanted us to support its idea of the different levels of psychiatric care, casually dismissing our own expertise. Worse still, we discovered that no one was really interested in the overall organization of mental care needs, and certainly not those of children. It was yet another political red herring, the sole purpose being the supervision of medical practice without the least care for the future. But, what about the children in Quebec? All paediatricians, whether in outpatient or office practice, know full well that 30% to 50% of the visits they receive have a mental health component. All paediatricians in Quebec, whatever their specific area of expertise, know that there is a shameful lack of services for their patients who are in difficulty and that a two-tier system of medicine exists here, as in other sectors. The children with the greatest needs are pushed to one side. We must have a true organization of paediatric care in Quebec, with regard to both mental health and all other sectors, and the focus must be the children themselves. We must do away with organizational charts that are so complicated that you can't decipher them and discussions that have no shadow of relevance. The Association of Pediatricians fully agrees that Quebec's action on suicide, which affects our adolescent patients and young adults to a great extent, be reviewed. That is a plus, but it should also be remembered that all children with social adjustment problems, developmental deficiencies or other overwhelming developmental problems must be able to receive services from somewhere. It is vitally important that we, as child experts, be recognized as the prime interface when dealing with such children. Perhaps we should include all physically challenged children, who are also left by the wayside. The recent decision to transfer such children who are mentally challenged from children's rehabilitation centres to rehabilitation centres for the mentally challenged, with no accompanying transfer of paramedical support, is a repugnant aspect of the reorganization of child care in Quebec. These children and their families are the ones who suffer from the lack of services. Surely this forms part of mental care health organization in Quebec! And what about young people in youth centres: who will defend their needs? I hardly dare mention the problem of attention deficit hyperactivity disorder and the children who are its victims. While overmedication is severely criticized in such cases, there is a deplorable lack of access to other resources, such as psychological evaluation, psychoeducation, social services and speech therapy. The government must clearly and officially recognize our expertise, and our opinion must specifically be taken into account. It is clear that our expert knowledge is recognized at the school level by the Centres locaux de services communautaires and even the Fédération des médecins omnipraticiens du Québec. That is also the case in the field. We are recognized because we do the work and, even at the risk of being hassled by government bureaucracy, we prefer to see a few more young people at our clinics even with the meagre resources at our disposal rather than literally waste our time negotiating with a government that is totally unaware of the needs of its own children. Paediatric needs will become even more glaring with time because physicians who treat adults appear to be less and less interested in children as patients. Subspecialists with adult patients and little paediatric expertise are increasingly withdrawing from treating children, leaving paediatricians to deal with the problems. Calls for paediatricians to be present in delivery rooms during elective cesarean sections – just in case! – are becoming increasingly common, but paediatricians cannot be everywhere that care is delivered to those under 18 years of age, and referrals to a tertiary paediatric centre are not always possible because of a lack of available expertise. The shortage of medical specialists will become even more catastrophic if paediatricians have to compensate for the dearth of subspecialized expertise, especially in peripheral areas. Paediatricians are experts in child care and should be recognized by the government as being among the principal experts who can assist it in a reorganization of health care for children in Quebec. We have the expertise – we are ready. The overall prevalence of mental illness in Canadian children and youth is estimated at approximately 15% (1). The most common disorders affecting the mental health of these individuals are anxiety disorders (6.5%), conduct disorder (3.3%), attention deficit disorder (3.3%), depressive disorders (2.1%), substance abuse (0.8%), autism and other pervasive developmental disorders (0.3%). With the addition of other forms of psychosocial distress or dysfunction, secondary to related problems such as specific learning disabilities and school stress or family discord, the burden of mental illness can easily occupy 30% or more of a paediatrician's professional responsibilities. As part of the federal government's response to these alarming statistics and the lack of a national strategy for a well-coordinated network of services and supports, the Kirby commission has been holding public hearings on mental health since 2003 and will publish its recommendations by the end of 2005. The Canadian Paediatric Society has presented at these hearings and has strongly advocated for the vital role played by paediatricians, as consultants or primary care providers, in the management of mental health illness in children and youth. While it is hoped that a National Mental Health Strategy will provide the framework for provincial governments to respond to both the lack of integrated services and the excessive wait times for children and adolescents with mental illness, the current and disturbing reality is that many provinces/territories are now engaged in mental health planning without any paediatric input. With the permission of the Association des pédiatres du Québec (APQ), Paediatrics & Child Health is reprinting an article written by Dr Thérèse Côté-Boileau, APQ President, which provides an outstanding example of this glaring omission and a response that is highly appropriate. We hope that this will provide an opportunity for our provincial and territorial health ministers to have a better understanding of the unique role of paediatricians. We urge them to recognize that paediatricians are essential to the delivery of mental health care to children and youth and must be included in all program and service delivery planning. Denis Leduc, MD President, Canadian Paediatric Society

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