En pédopsychiatrie, le modèle classique de prise en charge, les consultations thérapeutiques, implique la continuité du suivi par le même thérapeute dès le premier entretien. Ce modèle nécessite toutefois des ressources en personnel qui ne sont souvent plus disponibles dans nos systèmes de soins. Selon le lieu, les enfants attendent plusieurs mois à plusieurs années avant d’obtenir un premier rendez-vous avec un spécialiste. À Genève, une unité pédopsychiatrique ambulatoire pour enfants d’âge préscolaire propose depuis plusieurs années une approche différente dans laquelle les familles sont d’abord vues par un pédopsychiatre expérimenté lors d’une consultation unique (CU), avec pour objectifs de réduire le temps d’attente avant le premier rendez-vous, soulager l’anxiété parentale, donner un premier conseil et/ou avis et orienter si nécessaire les familles vers un autre thérapeute au sein de la même unité ou vers une autre structure. À travers une étude observationnelle menée entre mars 2019 et février 2020 auprès de 79 familles ayant bénéficié de ce modèle, nous avons cherché à évaluer sa pertinence, son acceptation par les familles et les thérapeutes ainsi que ses avantages et inconvénients. Les données ont été collectées dans une unité de pédopsychiatrie ambulatoire pour enfants d’âge préscolaire, la Guidance infantile, qui fait partie des Hôpitaux Universitaires de Genève. Les résultats de cette étude ont montré la pertinence de ce modèle et son acceptabilité par les familles nécessitant une aide psychiatrique pour leurs enfants en âge préscolaire. La majorité des familles apprécie la rapidité de la prise en charge, plus importante à leurs yeux que la continuité des soins par le même thérapeute. Les cliniciens, qui au début émettaient des réserves quant au changement de thérapeute, sont eux aussi satisfaits par ce modèle, soulignant notamment l’apport positif de la CU à l’établissement de l’alliance thérapeutique. Ce modèle devrait cependant pouvoir être utilisé avec une certaine flexibilité. Il semble en effet opportun que le thérapeute de la CU puisse dans certains cas prévoir une deuxième séance afin d’approfondir l’évaluation initiale, et également qu’il puisse continuer lui-même le suivi s’il estime lors de la CU que la famille est à risque de rupture de soins en cas de changement de thérapeute ou de délai d’attente supplémentaire.

In child psychiatry, the classic model of care, which is the therapeutic consultations, implies a continuity of care by the same therapist from the first session. The strong emotional charge which emerges from this first consultation favours the therapeutic alliance. This model requires staff resources which are often no longer available in our care systems. Depending on the area, children have to wait several months to several years to get a first appointment with a specialist. A Geneva outpatient child psychiatric unit for preschool children has experimented a different approach in which families are first seen by an experienced child psychiatrist for a single consultation (SC) with the following objectives: to reduce the waiting time before the first appointment, to relieve parental anxiety, to give initial advice and to refer families to care with another therapist if needed, either within the same unit or to another structure.

In this article, we examine, through an observational study, the relevance of this model, its acceptance by families and therapists, as well as its advantages and limitations.

An observational study was conducted between March 2019 and February 2020 among 79 families who benefited from this model. The data were collected in an outpatient child psychiatry unit for preschool children, the Guidance infantile, which is part of the Geneva University Hospitals. Exclusion criteria were: no French speaking, the presence of a legal third party during the session (minor protection service, lawyer), or a known clinical contraindication to a change of therapist. Four questionnaires were distributed along the study. The first and second were respectively completed by the family and the therapist immediately after the SC. The third was filled out by the family by telephone two months after the SC and the fourth was completed by the second therapist in charge of the therapy after the SC, if therapy took place in the same unit.

At the end of the 79 SCs, 41 indications for continuation of care in the Guidance were made, 26 of them also including a parallel referral to an outpatient care structure. 24 patients were referred only to outpatient care, and for 14 patients no further care was indicated or desired by the parents. The SCs lasted between 60 and 90minutes. Regarding their concern about their child, 65% of families noticed a reduction of anxiety immediately after the SC and 51% two months after the SC. 75% answered that the SC helped them to better tolerate the wait before the rest of the treatment. However, this waiting time was still perceived as too long by 22% of families. Most parents (51% after the SC and also after 2 months) perceived the change of therapist as “not problematic at all”. When the patient was redirected toward a junior therapist inside the same care unit, the written report and oral transmissions facilitated the follow-up. All of the second therapists considered that the change of clinician had no negative impact on the establishment of a therapeutic alliance. On the contrary, 63% of them noted that the SC had favored the alliance.

Good clinical practice requires the development of therapeutic models that take into account their quality, effectiveness and cost effectiveness. The lack of child psychiatrists, together with the increase in needs, pushes us to think about new modes of care which take into account the particularity of child psychiatric care in which the therapeutic alliance constitutes a major stake. The results of this observational study show the relevance and acceptability of this model in a population of families seeking psychiatric help for preschool children. The families noted fare more advantages than inconveniences with this new practice. The majority of them appreciated the rapid management of care, which was more important to them than the continuity of care by the same therapist. The clinicians, who were mainly doubtful about this model, gave a positive evaluation, in particular by realizing that the therapeutic alliance was not negatively impacted by the change of therapist. However, this model should be applied with some flexibility by allowing a second session when clinically useful to improve the evaluation or the referral and by allowing the SC's therapist to continue the assessment and the treatment with families who are at risk of disruption of care if there is a change of therapist or an additional waiting period.