Systems-Based Practice

Definition and Goals
Treatment of children and adolescents with psychiatric problems is undertaken in the context of multiple, complex systems. By graduation from subspecialty training, residents must acquire the knowledge, skills and attitudes to work effectively in diverse systems involved in treating children and adolescents. The resident must be capable of working in educational, social service, medical, legal and community systems of care.

Knowledge
The resident must demonstrate knowledge of:

1. Systems theory and how it is used in psychiatry. The resident should have a working knowledge of the diverse systems involved in treating children, adolescents and families and understand how to use the systems as part of a comprehensive system of care in general and as a part of a comprehensive, individualized treatment plan.
   
   
2. The Educational System including:
   
   • knowledge of the resources available both publicly and privately for the treatment of learning and developmental disorders and psychiatric/behavioral problems impacting a child or adolescent’s ability to learn
   
   • school-based mental health care
   
   • the development of Individual Educational Plans (IEPs) and the child and adolescent psychiatrist’s role in the process for determining the needs of special populations such as learning disability cases, behavioral disorders, etc.
   
   • school culture and the roles and approach of school personnel
   
   
3. The Social Service System including:
   
   • knowledge of the function of child welfare services and ability to explain the role and functioning of protective services, child welfare outreach services, adoption
   and foster care and federal and state funding mechanisms
   
   • knowledge of services for physically and developmentally disabled children and adolescents and the laws and regulations ensuring availability of the services
   
   • understanding of the role of social services in the treatment system
   
   
4. The Medical System including:
   
   • knowledge of the public and private medical resources available in the community in clinical settings
   
   • understanding of the structure and function of primary care and subspecialty pediatrics and related specialties of health care
   
   • understanding of how their patient-care practices and related actions impact component units of the health care delivery system and the total delivery system and how delivery systems impact provision of care
   
   • systems-based approaches for controlling health care costs and allocating resources and practicing cost-effective health care and resource allocation that does not compromise quality of care
   
   • advocacy for quality patient care and assisting patients in dealing with system complexities
   
   • understanding how to partner with health care managers and health care providers to assess, coordinate and improve health care and how these activities can impact system performance
   
   
5. The Legal System including:
   
   • knowledge of the workings of the juvenile justice system in assessment and rehabilitation of youth and families
   
   • understanding of how the legal system functions to provide care and protection of children and adolescents at risk
   
   
6. The Community Mental Health System including:
   
   • knowledge of the available services in the community, both public and private
   
   • understanding of the use of home, school and other community-based treatments, such as family preservation and intensive case management
   
   • knowledge of assessment for the level and intensity of care required

Skills
The resident must be able to demonstrate the following skills in the systems described above:

1. Ability to communicate effectively with multiple systems including:
   
   • eliciting information from the community systems involved in the care of a child or adolescent and using this data in the development of a treatment plan
   
   • communicating a child or adolescent’s mental health problems to other systems of care, including recommendations for the system’s role in the treatment plan
   
   
2. Providing consultation services to multiple systems
   
   
3. Using community resources effectively and focusing on community-based treatments
   
   
4. Advocating for the child and family within the multiple systems of care
   

Attitudes
The resident must develop attitudes that reflect respect for the patient, family, other caregivers and professionals in the community. Such attitudes include:

1. Expectation that care of children, adolescents and families must involve collaboration with other professionals in multiple systems in order to enhance
   a patient’s situation
   
   
2. Provision of services that remain as close to home as possible
   
   
3. Understanding that access of care is essential in all systems involved in the patient’s care
   
   
4. Understanding that an essential role of a child and adolescent psychiatrist is advocacy for the best interests of the child
   
   
5. Understanding that children and adolescents are best served in the least restrictive environment
   
   
6. Understanding that care should be cost-effective without compromising excellence