Utilization review of the late adolescent patient in a mental health center: steps toward the development of criteria for the adequacy of assessment and treatment.

This study is concerned with an attempt to determine whether meaningful utilization review criteria could be productively generated by viewing a patient population from a developmental perspecitve. During a 2-year period, a multidisciplinary panel at Yale University sought to identify the sociodemographic, clinical, and administrative issues posed by late adolescents seeking treatment at the Connecticut Mental Health Center, New Haven. We sought to address the following questions: a) From what segment of the population were we drawing our adolescent patients? b) Who referred them for help? c) What kinds of problems led to referral? d) What were the diagnostic characteristics of the adolescent's evaluation? e) Under what conditions do adolescents terminate treatment? The charts of over 1222 adolescent patients were studied to help us answer these questions. Our investigation revealed that the adolescent patients seen at the Mental Health Center were sociodemographically and diagnostically heterogeneous. An increasingly large number of adolescents are referring themselves for evaluation and treatment, rather than being sent by schools, physicians, or social welfare agencies. The majority of patients seeking help come from blue collar or working class backgrounds mainly because of intrapsychic complaints of anxiety and depression. Upwardly mobile, they constitute a group who have completed their high school education, often live away from home, and are struggling with problems of defining an identity different from that of their family. Review of their charts indicated that significant sholastic, medical, and developmental information was frequently lacking or vaguely recorded. Our chart review also indicated that many clinicians did not ask their patients about symptoms relating to body functioning such as difficulties with sleeping, eating, or psychosomatic complaints. The study also discovered that it was difficult in the great majority of the charts reviewed to specify the adolescent's own perception of the difficulties which led them to seek help. Suggestions are then outlined for developing review criteria dealing with the emancipated adolescent, parental involvement in the treatment of the adolescent, treatment plans, and the termination of treatment. The comparative advantages of combining utilization review criteria from both a traditional "disease model" and a "developmental model" are discussed. The panel concluded that input from both perspectives is necessary in understanding the impact of a mental health delivery system upon adolescent patients, their family, and the community.