The Integration of Health and Social Services for Young Children and Their Families

by John D. McLennan | Dec 01, 2003

Key Implications for Decision Makers

There is a variety of health and social services for young children and their families, although they were not developed in an organized or strategic way. There are now multiple attempts to integrate existing services. However, integration efforts do not often appear to be driven by an understanding of present service patterns or empirical research findings. This places integration efforts at risk of failing to have significant effects on outcomes for children and their families.

  • Services should be provided in guidance with the "integration-to-outcomes" model. The model identifies three ways to improve clinical and functional outcomes: 1) increase the extent to which services are effective; 2) increase the use of services by underserved populations; and 3) improve timing in the delivery of services.
  • Children with mental health problems who are also in the child welfare system have more trouble getting services they need. Some ways to get these children the services they need include 1) establishing multi-disciplinary teams; 2) providing educational and/or professional development opportunities to increase the awareness of mental health issues; 3) increasing advocacy efforts directed towards the ministerial levels; and 4) introducing mental health screening of children in the welfare system to improve identification of mental health needs.
  • Using service maps to track how people use the child mental health system, rather than relying on perceptions and anecdotes, will identify where parents run into problems, particularly with dead ends (that is, a professional does not refer the child, so the parent needs to find another way to a specialty centre) and service clumping (where the child receives multiple assessments by many professionals, which may contribute to waiting lists and unequal distribution of services).
  • Though potentially inefficient, multiple entry points into various services may decrease the effect of barriers to accessing services. Centralized intake efforts may address the inefficiencies, but should be rigorously evaluated to ensure that new barriers are not created.
  • Interventions should be examined to determine if they increase the number of professionals, decrease harmful and ineffective practices, and increase the use of evidence-based practices.
  • Interventions should increase access to new populations in the service system, increase outreach to new populations outside the system, increase the volume of services, and introduce or expand screening and identification of children with mental health problems.

Executive Summary

There is a variety of health and social services for young children and their families, although they were not developed in an organized or strategic way. There are now multiple attempts to integrate existing services. However, integration efforts do not often appear to be driven by an understanding of present service patterns or empirical research findings. This places integration efforts at risk of failing to have significant effects on outcomes for children and their families. The findings from this study provide information to reduce this risk.

Four health regions were selected for this study (one rural and one urban area each in Alberta and Ontario). Key approaches included individual interviews and focus groups with parents, service providers, and administrators, the construction of service use maps, document reviews, and the development and distribution of a service use survey for parents of young children with special needs.

The study developed a theoretical model that attempts to link service integration to improved child and family outcomes. Our model proposes that a service integration effort must work through at least one of the following paths in order to have an effect on child and/or family outcomes: (i) increase the extent to which services are effective; (ii) increase the use of services by under-served populations; and (iii) improve the timing of service delivery. This model may be useful for both planning and evaluating integration efforts.

Factors that influence use of mental health services by children in the child welfare system were also identified. Interaction between the child welfare and child mental health sectors was identified as one of the most common integration challenges. In particular, the difficulty in providing adequate mental health services for children in the child welfare sector was highlighted. Gross under-funding of the child welfare and mental health sectors, different mandates, and inadequate support for substantial reform efforts limit movement forward in resolving this service problem. Without substantial support at multiple levels and significant new funding, children with mental health problems in the child welfare sector will continue to be inadequately served.

The study determined that service use maps can help decision makers understand how services are organized and identify service integration problems. A group of parents with young children with special needs was interviewed in detail about services their children had received. This information was converted into pictorial displays, which provide useful depictions of the organization of services. Specific, problematic patterns were identified within the service variations experienced by families. One problem pattern was labelled the "dead-end pathway." In this pattern, a service provider did not provide a referral to specialty services so the parent took another service route. Service clumping was another pattern identified. Here some families received an "explosion" of service linkages following attendance at a tertiary care or specialty centre.

There was substantial variation in the paths families took to enter specialty services. Common paths to speciality care were family physicians, community pediatricians, and early intervention projects. Many of the participating families' experiences predated recent popular centralized intake efforts in the study regions. Though centralized intake efforts may provide more transparent paths to specialty care, the previous existence of multiple entry paths may have circumvented some of the dead-ends in the system of referrals. Centralized intake processes and other integration efforts should be rigorously evaluated to ensure that they enhance service delivery rather than create additional access barriers.

Finally, the study developed a survey to explore key service use issues and problems faced by parents of young children with special needs. More than 200 parents of children with special needs from four different specialty centres participated in the survey. Analysis of this survey data is ongoing. One section of the survey had parents identify the most problematic area of service delivery. The top five concerns were (i) having to repeat the child's story to different professionals over and over again; (ii) a lack of information about services for their child; (iii) having to navigate the health and social services systems; (iv) long wait lists for assessments; and (v) an overall lack of services for their child. Parent surveys may be useful in evaluating the service system if they include specific service questions rather than only inquire about general satisfaction.