Attrition in Psychiatric Clinics for Children

THE PAST DECADE has seen an increase in the number of outpatient psychiatric clinics for children, yet facilities are not and may never be adequate to meet the need. Even if the necessary funds were available, recruitment of trained personnel would be difficult. Moreover, the increasing demand for psychiatric services as the public becomes more aware of their value may far outstrip future expansion of clinic facilities. Without in any way minimizing the need for more psychiatric facilities, it may be well to ask whether present clinics are now being fully used in giving direct psychiatric services to children. There appears to be a large proportion of patients or parents acting for them who terminate contact with the clinic before service is completed. Karpe (1) reports an overall attrition rate (patient and parent termination of clinic contact) of 26 percent, and Anderson and Dean (2), of 31 percent. Simon (3) mentions a considerably higher rate, 53 percent, which is broken down into rate of termination at intake (21 peircent) and during treatment (32 percent). Golden (4) reports 14 percent attrition at intake, and Gray (5) states that one third of the patients did not return after intake. Witmer (6) does not give an overall rate but mentions that more than half of the cases in treatment withdrew before service was completed. With the exception of Anderson and Dean, these and other investigators (7-9), using case history data or telephone f ollowup contact, have concerned themselves with reasons for termination or with factors associated with attrition. The factors studied have included sex, age, occupation of father, number of siblings, and distance from the clinic, as well as more subjective items such as parental attitudes toward the child or toward treatment and the ability of the parent to express anxiety. These studies of attrition and the factors associated with it, although useful in pointing up an important problem, have certain limitations. In general, the phase of the clinic process at which attrition occurred, whether intake, diagnostic evaluation, or treatment, is not indicated. Without such a breakdown of the data, it would be difficult for clinics to focus their efforts toward remedying the situation. Moreover, factors associated with attrition may vary from phase to phase. The rationale for inclusion or exclusion of cases in computing attrition rates is not always clear nor are the samples clearly defined. For the most part, the data are based on small samples of less than 100 cases. In the studies concerned with factors associated with attrition, it is difficult to interpret the findings since the data generally have not been subjected to statistical test. The purposes of this study, designed to avoid the limitations mentioned above, are to estimate attrition rates at each phase of the clinic process and to investigate the relationship between attrition at each phase and a number of personal and social factors. The study was conducted by the division of mental health, Philadelphia Department of Public Health, in cooperation with the health division of the Philadelphia Health and Welfare Council. Dr. Tuckman is chief, section on psychological services, education, and standards, division of mental health, Philadelphia Department of Public Health, and associate in psychology in psychiatry, School of Medicine, University of Pennsylvania. Miss Lavell is a statistician w'ith the division.