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Child and adolescent epidemiologic surveys conducted in the 2 most populated provinces in Canada reveal high prevalence rates for mental disorders. These reach 18.1% in Ontario and 19.9% (according to parent report) and 15.8% (according to child report) in Quebec (1,2). In light of these findings, the priority given to youths with mental disorders in Quebec is justified (3). The limited availability of services for such youths raises major problems in each of Quebec’s social health regions (4,5). Moreover, interveners have expressed dissatisfaction with the uneven allocation of resources within the province (6). The lack of data on hospital and human resources and the lack of information regarding the functioning of child psychiatric services have made it difficult to address the problems associated with treating youths with mental disorders. This difficulty influenced the Regroupement des chefs de pédopsychiatrie du Québec (the board of heads of child psychiatry services in Quebec) to propose the present study, which has the following objectives: 1) to identify hospital resources allocated to child psychiatry services by region, 2) to determine human resources by type of service and region, and 3) to describe how services generally operate, including the request for care and the waiting period associated with these services. MethodsThe target population included all child psychiatry departments, programs, services, and teams in Quebec’s general and specialized hospitals (Figure 1). Referred to as “services” for the sake of clarity, these entities had to meet the following eligibility criteria: They had to target youths aged 0 to 17 years suffering from mental disorders, and they had to include at least 2 mental health professionals (one of whom had to be a full- or part-time child psychiatrist). They were secondary and tertiary child mental health services that were the responsibility of regional health boards in each social health region. Figure 1 Organizational chart of child mental health services in Quebec
The Questionnaire The questionnaire was reviewed by Quebec’s child psychiatry service heads in February 2001. Their comments and suggestions served in the drafting of a second version of the instrument. Teaching and research activities outside the clinical framework were excluded. Questions about hospital resources covered types of service and a description of the clientele, including age groups. The questionnaire also requested information about the number of inpatient beds and the number of places in day or evening hospitals and day or evening centres. Questions pertaining to hospital emergency services asked about the nature of the services and whether a crisis intervention team existed. Data sought on human resources included the number of full-time equivalent (FTE) child psychiatrists (1 FTE = 10 half-days) and the type and number of FTE professionals according to type of service offered. Questions on service operations covered the annual mean number of patients registered in outpatient and specialized clinics (where an evaluation was conducted by a child psychiatrist or another professional that resulted in the opening of a new file) and in day or evening centres. In addition, data were collected on the annual mean number of admissions or readmissions to inpatient units and day or evening hospitals. Other questions sought to determine the waiting period associated with an evaluation; the number of youths on waiting lists at March 31, 2001; and annual mean percentage of cross-sector cases. Additional questions sought data on the information gathered at the time of a referral and the forms used for the purpose, the existence of descriptive brochures, the methods used for medical referrals, the presence and frequency of meetings with partners, and finally, the strategies for collaboration with partners and the level of satisfaction and classification of partners according to the degree of exchange. A last series of questions focused on budget planning and management and on the degree of the child psychiatry service heads’ influence on resource allocation. Data Collection Data collection took place from May to October 2001. We sent the questionnaire to all child psychiatry service heads. We forwarded clarifications regarding the definition of certain terms a few days after the questionnaires were sent out. We did not ask child psychiatry service heads in Montreal hospitals to provide data on hospital and human resources, because this information was already available (7). We completed questionnaires by telephone for 4 services located in outlying regions. We sent 2 mail follow-ups and made follow-up phone calls to obtain questionnaires not returned. We formulated additional requests when data were missing, when responses were incomplete or ambiguous, or when outliers were found relative to the data obtained for type of service and region category. We compiled human resource data and produced organizational charts based on the responses obtained. These were forwarded to each child psychiatry service head for validation. To obtain any other missing information, we contacted the department heads by telephone. Data Analysis In 2001 there were 1 564 755 youths aged 0 to 17 years in Quebec’s 18 social health regions (Table 1). The regions were grouped into 3 categories: central, adjoining, and peripheral. The 4 central regions, which include 4 universities with faculties of medicine, were home to 606 370 youths. The 4 adjoining regions, which are characterized by their proximity to the cities of either Montreal or Quebec, accounted for 589 750 youths. The 10 peripheral regions had a population of 368 635 youths. The immensity of Quebec’s surface area explains the mean of 1 youth aged 0 to 17 years per square kilometre. Compared with the central regions, the mean density was twice as low in the adjoining regions and 80 times lower in the peripheral regions.
Services were divided into 2 categories: hospital and ambulatory. Hospital services included inpatient and emergency units. Ambulatory services included outpatient clinics, specialized clinics, day or evening hospitals, day or evening centres, and hospital and community consultations. Hospital emergency services, outpatient clinics, and hospital and community consultations were considered secondary services, whereas inpatient units, specialized clinics, day or evening hospitals, and day or evening centres were considered tertiary services (8). Specialized clinics served a homogeneous clientele in terms of psychopathology or treatment. Hospital consultations were provided primarily in pediatric hospitals. Community consultations were for the benefit of care providers in the area of health and social services, education, and justice. Inpatient units were for the admission of children and adolescents for short stays (fewer than 45 days). Medium-stay beds (45 to 90 days) were available only at Rivière-des-Prairies Hospital (61 beds). ResultsThe response rate for the study was 100%. The Nord du Québec, Nunavik, and Terres-Cries-de-la-Baie-James regions, which were home to only 13 625 youths (0.9%), had special agreements with hospitals in Quebec, Ontario, and New Brunswick; consequently, we excluded them from the study. We identified 35 child psychiatry services in the other 15 regions: 13 in the central regions, 9 in the adjoining regions, and 13 in the peripheral regions. All were under the responsibility of a hospital. In the central regions, 11 of the 13 (85%) services were affiliated with a university, compared with 2 of the 9 (22%) in the adjoining regions and 6 of the 13 (46%) in the peripheral regions. Seven services, of which 6 were in the peripheral regions, were staffed by a travelling child psychiatrist. Hospital Resources All child psychiatry services had outpatient clinics. At 8 hospitals (5 of which were located in the central regions), child psychiatrists provided emergency consultations, that is, a response within 24 hours) (Table 2). There were 5 functional crisis teams. Thirteen hospitals, most of which were in the central regions, had inpatient beds (a total of 18 units). Also in the central regions, 12 specialized clinics were operating within 6 hospitals. Thirteen hospitals had day or evening places (a total of 34 units). Six hospitals offered spaces in day or evening centres (a total of 7 units).
Overall, 177 short-stay beds, of which 60% were located in the central regions, were allocated for child psychiatry hospitalization (Table 3). The number of youths per bed stood at 5667 in the central regions, 16 850 in the adjoining regions, and 10 532 in the peripheral regions. There were 476 places in day or evening hospitals in Quebec, of which 77% were in the central regions. Child psychiatry services had 113 places in day or evening centres.
Human Resources At the time of our study, Quebec had 138.2 FTE child psychiatrists, of whom 69.8% worked in central regions (Table 4). Overall, the number of youths per FTE child psychiatrist reached 11 322. This number ranged from 6284 in the central regions to 23 780 in the adjoining regions and 21 813 in the peripheral regions. Services also counted on 706 FTE professionals, of whom 62.8% were located in the central regions. Overall, there were 2216 youths per FTE professional.
When only outpatient clinics were considered, there were 18 153 youths per FTE child psychiatrist (11 229, 31 039, and 27 927, respectively, by region category) and 5878 youths per FTE professional (4686, 7948, and 5889, respectively, by region category). There were 5.1 FTE professionals per FTE child psychiatrist (4.6, 6.0, and 6.8, respectively, by region category). One out of 2 child psychiatrists in the central regions, and 3 out of 4 in the adjoining and peripheral regions, worked in outpatient clinics. Child psychiatrists devoted only 1% of their time to community consultations and only 3.6% of their time to specialized clinics. The need for nursing care in inpatient units was such that 1 out of 3 FTE professionals were allocated to this type of service, compared with 1 out of 10 child psychiatrists. As was the case with child psychiatrists, professionals dedicated minimal time to community consultations and specialized clinics. One FTE child psychiatrist covered a mean of 16.5 beds, 33.3 places in day or evening hospitals, and 37.7 places in day or evening centres. One FTE professional covered a mean of 1 bed, 3.7 places in day or evening hospitals, and 2.1 places in day or evening centres. General Operating Mode There was an annual mean of 1341 hospitalizations (or rehospitalizations) in Quebec (Table 5). Most of these occurred in the central regions. The mean annual number of patients registered (or reregistered) in outpatient clinics was 12 430 and, in specialized clinics, 620. There were 740 patients admitted (or readmitted) to day or evening hospitals, compared with 101 patients registered (or reregistered) in day or evening centres.
At March 31, 2001, the number of youths on waiting lists for all services remained at 4285 (Table 6). This figure can be broken down according to region category as follows: 2112 in the central regions, 1089 in the adjoining regions, and 1084 in the peripheral regions. Most of these youths (3767) were waiting to be assessed in an outpatient clinic.
In outpatient clinics, the number of youths on waiting lists per FTE child psychiatrist remained at 44 for Quebec as a whole. The figure jumped from 31 in the central regions to 55 and 77, respectively, in the adjoining and peripheral regions. The mean waiting period was 5.7 months in outpatient clinics (3.3 months in the central regions and more than 7 months in the 2 other regions), 4.8 months in specialized clinics, and a little more than 8 weeks in day or evening hospitals and day or evening centres. In 28 of the 35 child psychiatry services, a medical referral was required for outpatient clinics. A medical referral was more frequently required in the adjoining regions (8 out of 9) and the peripheral regions (12 out of 13). Most of the outpatient clinic directors participated in meetings with partners (85%, 78%, and 69%, respectively, by region category). Nearly 1 out of 2 outpatient clinics (16 out of 35) had published brochures describing their services. Outpatient clinics ranked their collaborators according to the frequency of their contacts (these follow in order of importance, with the most important partners listed first): schools, Youth Centres–Directorate of Youth Protection Services (CJ-DPJ), local community services centres (CLSCs), and doctors’ offices. Schools were first in the central regions and CJ-DPJs in the other region categories. Three out of 4 child psychiatry service heads were aware of the budget they were allocated. Responses were evenly distributed in terms of their influence (that is, strong, moderate, and weak) on budget planning and management. DiscussionLimitations This study did not encompass the characteristics of those who made referrals, the reasons for consulting, the history of consultations, sex, or the nature and frequency of diagnoses and treatment. Collecting these data would have required a great deal of time on the part of the respondents. Moreover, the data would have been difficult to analyze and summarize, owing to the variation in collection methods within services. Data on collaboration methods with partner organizations (for example, joint care and return after assessment) were judged to be too complex to be retained for analysis. The information on hospital and human resources that service heads validated took the form of organizational charts and data compilations. Data on the number of patients admitted and registered, the number of youths on waiting lists, and the length of waiting periods were validated only when we judged responses to be outliers. Certain responses were consequently confirmed by administrative reports, but others remained estimates. It is important to point out that, 2 years after the data were gathered for this study, the situation regarding child psychiatry in Quebec, including government policy, remained essentially the same. Two hospitals in adjoining regions stopped providing psychiatric services to youths because the child psychiatrists in these hospitals resigned and replacements could not be found. A few child psychiatrists retired, and few new psychiatrists began to practise in the field. We observed no significant increase in the number of professionals. A Minority of Hospitals Offering Psychiatric Services Cater to Youths At the time of our study, only 35 of the 86 hospitals in Quebec (41%) offering psychiatric services provided services to youths (9), even though these services should be provided everywhere, given that child psychiatry is not classified as a medical specialty in the province. That said, the data reflect an even more critical situation. As a result of the heavy workload treating adult patients, most psychiatrists refuse to treat youths. Moreover, budget planning by the Quebec Ministry of Health and Social Services (MSSS) limits itself to the all-encompassing category of “psychiatry.” As a result, child psychiatry must compete with adult psychiatry. Nevertheless, the health and social services system functions as though child psychiatry is a medical specialty with organization and service delivery independent of adult psychiatry. This situation prevails in the other Canadian provinces as well. As a result, the Canadian Academy of Child Psychiatry has asked the Royal College of Physicians and Surgeons of Canada to recognize child psychiatry as a medical specialty (10). A Minimal Range of Services to be Met In 2000–2001, most hospitals offering adult psychiatric services (69%) had inpatient beds designated for this purpose (11). However, only 13 of the 35 hospitals offering child psychiatry services had inpatient beds reserved for this clientele, and 4 of the hospitals that were able to provide beds could not admit children under age 12 years The demand for inpatient beds is strong throughout Quebec. The Montreal and Quebec City regions meet part of the needs of the adjoining and peripheral regions. In Montreal hospitals, 30% of the 626 hospitalizations in 2000–2001 involved youths from regions outside Montreal and Laval. There are no norms available for the number of beds that should be assigned to child psychiatry. In adult psychiatry, the norm is 1 short-stay bed per 4000 persons (3). If we extrapolate for children and adolescents and bring the norm to 1 bed per 6000 youths to take into account the lower need for hospitalization in youths under age 6 years, there is a shortage of 84 beds in Quebec. Some regions use adult psychiatry beds, and others fall back on pediatric beds when it is necessary to hospitalize youths with mental disorders. In these cases, however, the patients lack the benefit of child psychiatrists’ specialized training for the evaluation and treatment which their disorganized state requires. The adjoining and peripheral regions need tertiary line resources. Each region should have access, either intraregionally or via an interregional agreement, to a minimal range of child psychiatry services that include outpatient clinics, short-stay hospitalization, and emergency services. To this end, each social health region should be endowed with its own development plan. However, such a plan will take several years to complete. Consequently, it is necessary in the meantime to define intra- and interregional agreements to ensure that Quebec youths have access to basic child psychiatry services, even if the protocols developed are not perfect. In addition, the adjoining and peripheral regions’ ability to attract and retain child psychiatrists is closely associated with local access to a minimal range of the services needed to allow them to adequately assume their clinical responsibilities. Child Psychiatrists and Professionals Also in Short Supply in Central Regions In 2001, according to the Association des médecins psychiatres du Québec (AMPQ), 181 Quebec psychiatrists provided services to youths aged 0 to 17 years. For 104 psychiatrists, these youths represented 100% of their practice; for 27, 80%; and for 50, less than 80%. Their mean age (51 years) corresponds to the trend observed for medical specialists as a whole. Only 22% of these psychiatrists were under age 40 years, and 17% were over age 60 years—which means we can expect some major attrition in the years to come (12). The 181 psychiatrists active in the field of child psychiatry represented 18% of the 979 psychiatrists who, in 2000, received compensation from the Régie d’assurance maladie du Québec (RAMQ), Quebec’s public health insurance board. They provided child psychiatry services in 35 hospitals, which made for an average of just over 5 psychiatrists per hospital. The average was more than twice as high for psychiatrists in the adult sector (875 psychiatrists for 86 hospitals). Consequently, the existing child psychiatrists cannot meet the needs of hospitals that do not offer child psychiatry services. In 2001, there were 138.2 FTE child psychiatrists in Quebec, including those who tended to medico-administrative duties, teaching, and research related to the delivery of clinical services. The norm proposed by the Canadian Academy of Child Psychiatry to cover all child psychiatry services is 1 FTE child psychiatrist per 4000 youths (10). By contrast, we found a ratio in Quebec of 1 FTE child psychiatrist per 11 322 youths. In the US, the number of youths per child psychiatrist is 6300. In the 1999 report on mental health, the Surgeon General underscored the shortage of child psychiatrists in the country (13). At the time of our study, 253 more FTE child psychiatrists were needed in Quebec to reach a total of 391.2 FTE and thus meet the norm of 1 child psychiatrist per 4000 youths. A shortage of child psychiatrists has also been reported in the other Canadian provinces (14). The shortage in Quebec is such that it affects each of the 3 region categories. Indeed, 55.1 of the needed 253 FTE child psychiatrists are needed in the central regions. Regarding ambulatory services (that is, outpatient clinics, specialized clinics, day or evening hospitals, day or evening centres, and hospital and community consultations), the MSSS recommends 1 child psychiatrist per multidisciplinary team per 10 000 youths (8). In 2001, there were 120.1 FTE child psychiatrists in these services and 1 FTE child psychiatrist per 13 029 youths (data not presented). In other words, if we applied the ministerial norm, 36.4 more FTE child psychiatrists were needed in ambulatory services. In short, there existed a shortage of child psychiatrists across all services, including ambulatory services, regardless of the norm used. There is a general shortage of medical specialists in Quebec. Nevertheless, the MSSS, the Fédération des médecins spécialistes du Québec, and the AMPQ should take action to recruit child psychiatrists for 2 reasons: 1) youths with mental disorders are a high-priority clientele, and 2) our survey reports evidence of a major shortage of these specialists in Quebec. Where professionals in ambulatory services are concerned, the MSSS recommends 1 professional per 2500 youths. In 2001, there were 471.4 FTE professionals in these services and 1 FTE professional per 3319 youths (data not presented). Here too, an additional 154.5 FTE professionals were required to reach a total of 625.9 FTE and thus meet the ministerial norm. More professionals tending to treatment and care would allow available child psychiatrists to spend more time evaluating patients, which would lead to shorter waiting periods. However, this scenario would also require the analysis of needs to be refined for each type of professional working in child psychiatry. Following such an analysis the MSSS, in conjunction with the various professional organizations, could develop a recruitment plan geared to meeting each region’s needs. Interregional Differences In 2001, 17 of the 35 hospitals offering child psychiatry services depended on only 2, or fewer, FTE child psychiatrists; 11 of these depended on 1, or fewer, FTEs. Thus nearly 50% of these hospitals did not meet the recommendations of the CollPge des médecins du Québec (CMQ) regarding a viable minimum number of physicians per medical service (15). In other Canadian provinces, too, child psychiatry resources tend to be concentrated in large urban centres (16). This situation can be explained by the universities’ historical role in the emergence of medical specialties. The actual delivery of specialized medical services is but a natural extension of this development. Despite being challenged in numerous forums, the unevenness of resource allocation across regions has not abated in the least over the years. Quebec universities, along with other universities in Canada, partake in the organization of health services in adjoining and peripheral regions to influence interregional dynamics—which obviously fosters the development of training experiences in rural child psychiatry for medical students and residents (17). Supply Out of Step With Demand Each year, an average of 15 232 youths are admitted to or registered in child psychiatry services. A few of these youths tend to be readmitted or reregistered within the same year. If we conservatively estimate this percentage at 10%, roughly 14 000 youths benefit each year from child psychiatry services, that is, just under 1% of Quebec youths or 1 out of 10 Quebec youths who present with mental disorders and dysfunction (1). In other words, only a minor portion of those children in need benefit from direct psychiatric services, and in Quebec, child psychiatrists devoted only 1% of their time to community consultations. These results demonstrate the relevance of fostering various forms of consultation and education experiences and developing prevention and mental health promotion programs (18–20). Primary Level Mental Health Services for Children in Need Primary level medical and psychosocial services have not developed the responses needed by youths with mental health problems (4). Care providers turn to child psychiatry for help and assistance. Quebec has 7300 general practitioners and 530 pediatricians. The province also has 3000 care providers in CLSC youth programs and 7750 care providers in direct contact with youths in CJ-DPJs, not to mention the care providers from rehabilitation centres and adaptation services in primary and secondary schools. Consequently, the province’s child psychiatrists and child psychiatry professionals are called on to respond to requests for services from potentially nearly 20 000 care providers. Unmet expectations and a sense of overload do not help the relationship and collaboration between the parties. To arrive at a functional integration of youth services, it is essential to provide a framework for practices in the primary, secondary, and tertiary lines and to determine and define limits and priorities. Determining Levels and Integrating of Services an Imperative Classifying services according to their associated level of intervention (that is, primary, secondary, and tertiary) constitutes the frame of reference that rallies all partners. Child psychiatry services are secondary and tertiary level specialized services that interact with primary level health services and secondary and tertiary level social services. Three conditions are required for this frame of reference to work. First, primary level mental health services for youths must be sufficiently developed. Second, all secondary and tertiary level services must be available and clearly identified. Third, services’ referral criteria and mode of functioning must be defined. In our study, the criteria for accepting or rejecting a request for services were generally not specified in the brochures available in child psychiatry outpatient clinics. The MSSS has confirmed the CLSCs’ mandate relative to primary level health care, while recognizing the role of medical clinics. The CLSCs are called on to complete psychosocial services by including mental health services for youths. Currently, CLSCs and physicians are not the leading partners in child psychiatry outpatient clinics. Schools and CJ-DPJs come first, and their requests for services will no doubt continue. Nevertheless, it is necessary to foster liaison with physicians and CLSCs, whose primary role was confirmed. General Practitioners: Privileged Partners The Directions régionales de médecine générale (that is, regional coucils of general practitioners) and the Groupes de médecine de famille (that is, general practitioner medical clinics with CLSC nurses and social workers) were created to develop closer ties between general practitioners and the CLSCs and other organizations in the health and social services system. General practitioners were to be helped to direct youths with mental health problems toward the CLSCs first, rather than directly to secondary and tertiary level child psychiatrists. A closer relationship between general practitioners and the CLSCs might translate into joint referrals to child psychiatry services when needed. As stipulated in a recent position paper, general practitioners are definitely called on to develop greater expertise (21). The process of medical referrals to child psychiatry clinics could thus be improved. For example, a complete medical report would be advisable for new patients. To this end, a model medical report, developed from the analysis of all the forms completed when a patient is referred for child psychiatric services, could be proposed to referring doctors. Steps in the Right Direction The CMQ has suggested that evaluation of youths in child psychiatry be conducted according to a clear ranking system known to all concerned (21). In this regard, the Practice Research Network has proposed the following waiting period for evaluation: emergency, priority, routine, and elective (22). Researchers in another ongoing initiative, the Western Canada Waiting List Project (23), have proposed a checklist for assessing the priority of child psychiatry referrals. Analyzing these 2 systems will offer a better grasp of the factors underlying the waiting period for evaluations in child psychiatry. To contribute to the integration of mental health services, child psychiatrists and professionals must focus their interventions on youths presenting with complex psychopathologies characterized by impairment, comorbidity, and resistance to earlier interventions. First-line clientele should not have direct access to child psychiatry services, provided, of course, that primary level services are sufficiently operational. Finally, indications for long-term follow-up should be defined more clearly. Funding and SupportFunding was provided by the Quebec regional health board. References1. Breton JJ, Bergeron L, Valla JP, Berthiaume C, Gaudet N, Lambert J, and others. Quebec Child Mental Health Survey: prevalence of DSM-III-R mental health disorders. J Child Psychol Psychiatry 1999;40:375–84. 2. Offord DR, Boyle MH, Szatmari P, Rae-Grant N, Links PS, Cadman DT, and others. Ontario Child Health Study II. Six-month prevalence of disorder and rates of service utilization. Arch Gen Psychiatry 1987;44:832–6. 3. Ministère de la Santé et des Services Sociaux. Plan d’action pour la transformation des services de santé mentale, Québec (QC): MinistPre de la Santé et des Services Sociaux; 1998. 4. Ministère de la Santé et des Services Sociaux. Transformation des services de santé mentale : état d’avancement du plan d’action de décembre 1998. Québec (QC): Ministère de la Santé et des Services Sociaux; 2001. 5. Ministère de la Santé et des Services Sociaux. Accentuer la transformation des services de santé mentale: cibles prioritaires adoptées au forum sur la santé mentale de septembre 2000. Québec (QC): Ministère de la Santé et des Services Sociaux; 2001. 6. Ministère de la Santé et des Services Sociaux (rédaction par N Potvin). Bilan d’implantation de la politique de santé mentale, Québec (QC): Ministère de la Santé et des Services Sociaux; 1997. 7. Régie Régionale de Montréal-Centre (rédaction par M Perreault). Fiche des établissements, mise B jour. Services de santé mentale. Montreal (QC): Régie régionale de Montréal Centre; 2001. 8. Régie Régionale de Montréal-Centre (rédaction par M Perreault). État de situation, services de pédopsychiatrie, région de Montréal-Centre, Services de santé mentale. Montreal (QC): Régie Régionale de Montréal-Centre; 2000. 9. Gestionnaire informatisé des médecins (GIM). Base de données de la Fédération des médecins spécialistes du Québec 2002. Located at: Montréal Féderation des médecins spécialistes du Québec. 10. Parker Z, Steele M, Junek W, Morin L, Davidson S, Fleisher W, and others. Child psychiatry in Canada: physician resources. Position statement. Ottawa: Canadian Psychiatric Association; 2002. Available: http:// www.cpa-apc.org/Publications/Position_Papers/child.asp. 11. Système de données opérationnelles et financiPres informatisées (SOFI) : répertoire des volumes d’activités des établissements 2000–2001. Base de données du Ministère de la Santé et des Services Sociaux; 2001. Located at: Ministère de la santé et des services sociaux. 12. Lévesque A. Effectifs pédopsychiatriques au Québec : âge et répartition. Présentation au Congrès AMPQ; 14 juin 2001; Pointe-au-Pic (QC). 13. Crosby M. Surgeon general reports on mental health; mental illnesses spotlighted during 1999. American Academy of Child and Adolescent Psychiatry News 2000;31(2); 50,55. 14. Milne C. Catastrophes waiting to happen. Mental health help for children and teens sorely underserviced across the nation. Medical Post 2002;Sept 3:20–3. 15. Collège des médecins du Québec. Organisation des services médicaux. énoncé de position. Montreal (QC): Collège des médecins du Québec; 2000. 16. Steele MM, Wolfe VV. Child psychiatry practice patterns in Ontario. Can J Psychiatry 1999;44:788–92. 17. Leverette J, Massabki A. Training residents for rural child psychiatry: defining the objectives. Can J Psychiatry 1995;40:342–7. 18. Breton JJ. Complementary development of prevention and mental health promotion programs for Canadian children based on contemporary scientific paradigms. Can J Psychiatry 1999;44:227–34. 19. Hetchman L. A personal perspective. Can J Psychiatry 1994;39:27–32. 20. Rae-Grant N. Primary prevention: implications for the child psychiatrist. Can J Psychiatry 1988;33:433–42. 21. Collège des médecins du Québec. Accessibilité aux soins médicaux et psychiatriques pour la clientèle des adolescents: énoncé de position. Québec (QC): Collège des médecins du Québec; 1999. 22. El-Guebaly N, Atkinson MJ. Practice research network—part III: access to psychiatrists’ care. CPA Bulletin 2001;32(1):9–12. 23. WCWL Western Canada Waiting List Project. From chaos to order: making sense of waiting lists in Canada. Final report, project NA489. Ottawa: Health Canada; 2001. Author(s)Manuscript received October 2003, revised, and accepted February 2004. 1. Associate Professor, Department of Psychiatry, Université de Montréal, Montreal, Quebec; Researcher, Rivière-des-Prairies Hospital and Fernand-Seguin Research Center, Montreal, Quebec. 2. Department of Psychiatry, Université Laval, Quebec City, Quebec; Child Psychiatrist, Université Laval Hospital Center, Quebec City, Quebec. 3. Project coordinator, Research Unit, Rivière-des-Prairies Hospital, Montreal, Quebec. Address for correspondence: Dr J-J Breton, Research Unit, Rivière-des-Prairies Hospital, 7070 Perras Boulevard, Montreal, QC e-mail: jj.breton.hrdp@ssss.gouv.qc.ca
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