Child & adolescent mental health

Since the last Child and adolescent mental health services (CAMHS) JSNA report in 2013 a transformation has occurred with the support of all agencies working with children and young people. This has included:

  • a six month programme of mapping and improving pathways across a range of agencies and for eight different conditions – anxiety and depression, self harm, autism spectrum disorder, attention deficit disorder, eating disorders, obsessive compulsive disorder, conduct disorders
  • an early detection intervention programme has been tested in three secondary schools in high risk areas and has achieved significant reductions in anxiety, depression and self harm using combined Mindfulness and cognitive behavioural therapy (CBT).
  • early help teams now work collaboratively with children and families in early years and primary school settings as part of a ‘team around the child’ or ‘team around the family’ approach
  • a multiagency hub called the Five Ways to Wellbeing hub now meets regularly to review changes in practice, learning, or to share funding and research opportunities
  • CAMHS and social care staff now review all cases before ‘stepping up’ to the common point of entry – the name for the central triage point for specialist CAMHS.
  • the Slough Services guide now contains sections on the wellbeing services available
  • resources have been developed for schools
  • a CAMHS needs assessment has been completed (see references)
  • the common point of entry to specialist CAMHS services interfaces closely with crisis response and home treatment teams
  • funding has been increased to specialist CAMHS to reduce waiting times for the pathways they are required to deliver I,e anxiety and depression, eating disorders, early intervention in psychosis, autism spectrum disorder (ASD), attention deficit disorder (ADHD), obsessive compulsive disorder.

The key themes of the local Slough CAMHS strategy (2015-19) reflect the vision which is to promote resilience and early intervention in our communities to help children, young people and their families to become resilient.

The Slough CAMHS strategy recommends that partners use effective interventions derived from a new national resource called Mental Health 4 Life (MH4L). Mental Health 4 Life National Resources

The Slough strategy is also based on the new national model of CAMH services called THRIVE. Instead of the previous four tiered model described in the 2013 JSNA, which parents and children did not understand, this contains four domains as shown below in Figure 1.

The model encourages people who work with children and families to consider what domain they are working in e.g those who offer one off support or signposting to self management are enabling parents or children to ‘cope’. When delivering evidence based goals focused programmes under 12 weeks then staff providing these interventions are ‘getting help’ for individuals or groups. Intensive programmes of over 12 weeks in duration are described as ‘getting more help’ (usually provided by specialist services).

Where the evidence is weaker and risk management is the goal the measures used pertain to those agreed by the local safeguarding board. (For example the work of social care and youth offending services, targeted youth support or any other groups working with those affected by domestic abuse, child sexual exploitation, those who are looked after or who are leavers of care).

Figure 1. The THRIVE model of CAMHS

Figure1. The THRIVE model of CAMHS

Services now record their work across the four domains and transparency of reporting has been encouraged through the CAMHS transformation work now underway based on the national report the Five Year Forward View (NHSE, 2014). This work has only just begun and is funded by NHS England.

Examples of THRIVE services in Slough

Information and signposting – this includes all universal services listed under the Slough Family Information Service guide, which includes the voluntary sector, early years, general practitioners, schools staff, social workers and others. These services provide on line or face to face information. Over 435,900 hits were received on the Slough Family Services guide in 2015 and many of these related to health and wellbeing enquiries. Examples of universal work include the PSHE programme in schools and general assemblies on topics such as bullying and child sexual exploitation.
Young people have been engaged in designing the THRIVE website which will enable them to self assess their wellbeing and access information or when needed will link them to on line counselling This site is now live at www.puffell.com/thrive.

Evidence based interventions under 12 weeks in duration. These include those individual counsellors that schools commission or those that can be contacted through the early help process that offer cognitive behaviour therapy, Mindfulness etc. These can be on line or face to face and are accessible to those in school settings. Services which offer support include the primary mental health team, the on line offer via Kooth (funded through the Transformation Fund) and the work of the educational psychology team. When the child is much younger in an early years or primary school setting then an early help approach is taken and family services and the early help advisors work with the family to create a team around the child or family.

Specialist CAMHS are commissioned to work with the most complex cases across eight pathways. GPs refer through the common point of entry and current waiting times are shown below. Evidence based interventions of 12 weeks or more are offered through this route.

Risk reduction and management – services include targeted youth support, social services, the Slough Emotional and Behavioural Difficulties Outreach Service (SEBDOS) domestic abuse services and the youth offending service. Individual care packages are put in place according to agreed pathways and local safeguarding procedures.

What do we know?

A comprehensive needs assessment has been undertaken to inform the CAMHS Transformation Plan.

  • There are 42,972 children and young people aged 0-19 registered with local practices
  • The needs assessment estimates the expected numbers of children with Autism Spectrum Disorder (ASD) at 290 yet local figures show 551 are registered in local schools This represents double the estimated need but may reflect pupils being placed here from other areas.

Vulnerable groups identified as over represented in the CAMHS needs assessment include; those living in households where one or more parents have a disability, those from migrant communities, children in need, those on child protection plans, those suffering from child sexual exploitation, those affected by domestic abuse and child poverty, those who are carers

Facts, Figures and Trends

In the period 2015-16

  • 283 children were supported by the primary CAMHS team. This comprised:
    • 189 individual counselling sessions offered through the primary CAMHS team.
    • 1000 calls to signpost people to support
    • 66 social care cases and
    • 90 young people attending Pilot mindfulness and CBT sessions in two secondary schools with measurably improved anxiety and depression and Mindfulness scores.
  • Only three cases were stepped up to specialist CAMHS from primary CAMHS
  • By contrast Slough specialist CAMHS received 750 referrals from GPs in 2015.

The current waiting list shows that as of December 2015 there remained a backlog within specialist CAMHS of 289 young people mainly those awaiting a diagnosis - 143 young people on the ASD pathway, 21 on the anxiety and depression pathway, 43 on the ADHD pathway and 11 who have been accepted into the Berkshire Adolescent Unit, .

  • 425,900 hits were received by the Slough Services Guide but it is not yet known what proportion were related to health and wellbeing services
  • The Slough Emotional and Behavioural Outreach Service managed 272 cases for challenging behaviour and accepted referrals from specialist CAMHS services and schools.
  • 270 referrals were made into the Slough Youth Services and these include some of the most vulnerable young people who need care packages as part of step down care after specialist CAMHS, or following referrals from youth offending or who have been abused.
  • The Berkshire Autistic society has begun a service for parents of children who are waiting to access ASD diagnostic services locally
  • The EarlyBird programme for parents and carers of pre school children with a diagnosis of autism has helped 90 of the 246 children now registered in local primary schools The EarlyBird Plus programme for children aged 5-9years has helped 33 young people and their parents and schools locally. Work is underway to develop and test a Not So EarlyBird programme for older pupils

What is this telling us?

Local mapping of the numbers of children and young people entering CAMHS from our hotspot areas of domestic abuse indicate these areas should be a priority for partnership work to enhance resilience within the community. Any targeted work undertaken with children and young people in schools in these areas should also be aligned to mental health promotion for the wider community.

Young people trained as mental health champions, school mentors, school staff and voluntary sector services in the community have valued the mental health first aid programme used as an introduction to mental health conditions. The Youth Parliament have valued being able to design a bespoke website to promote positive mental health and challenge the stigma of mental illness.

Schools are required to promote the mental health and wellbeing of their pupils and the early intervention and detection approach using agencies who can promote an early help model has allowed 90 young people to improve their mental health in non clinical settings.

There is a significant difference between the estimated numbers of children with vulnerabilities such as autism and those diagnosed with the condition. Despite the higher rate of case finding the backlog to diagnose new cases remains high.

The total costs of specialist referrals for specialist eating disorder services in Slough is double that of neighbouring boroughs suggesting significant needs locally. A business case has been accepted by NHS England to change the way in which eating disorder and other specialist services are offered to allow young people access to a local support service rather than being sent to out of area providers.

As a result of optimising pathways for anxiety and depression and self harm the total referrals into specialist CAMHS remain the lowest in the Thames Valley and this is real and reflects a universal and targeted support system that is working effectively

The fact that 289 young people still needed to be stepped down to primary CAMHS from specialist CAMHS indicates that in these cases the referrals (the majority being from GPs) were inappropriate and the Transformation Fund has identified training for general practitioners in mental health as one of eight projects in 2015-16.

Pilot work with secondary schools has been well received and complements work in primary schools. What is not known is the extent to which schools have adopted the national guidance for commissioning psychological services. An audit is planned for 2016 and the results will inform the next steps for staff training and commissioning.

There is a real need to improve the consistency of recording outcomes in line with the THRIVE model of recording and the new national reporting system.

  • Schools and other universal services should be recording improved measures of resilience such as increased staff confidence to deliver or signpost services for children, young people and their families. PHE guidance is available at
  • Staff delivering counselling services should be able to demonstrate changes in clinical outcomes in programmes delivered on line or face to face including; reductions in anxiety and depression, increased Mindfulness scores
  • Specialist services are begging to record Children and Young Peoples Improving Access to Psychological Therapies measures as per the new mental health dataset as well as measures such as reductions in waiting times, improved client satisfaction, etc.
  • Risk reduction services are already recording reductions in domestic abuse scores such as the DASH/CAADA or CSE indicator tools but need to include a mental health measure to ensure that physical and mental health receive equal attention

What are the key inequalities?

As well a strong focus on the social and emotional wellbeing of the wider children and young person population, it is well evidenced that certain population groups are more likely to suffer from poor wellbeing and have mental health problems and there is a call to focus efforts on improving outcomes for these groups.
Particular groups who may be at an increased risk of having poor mental health have been identified as including those who:

  • Children and young people who have a long term physical illness or disability are twice as likely to suffer from emotional problems and disrupted behaviours
  • Those who have a learning disability are 4 times more likely to have an emotional disorder and 1.7 times more likely to have a depressive episode
  • Of those who have an Autistic Spectrum Disorder (ASD), 70% have a least one mental health problem
  • Looked After Child (LAC) are 4 times more likely to have a mental health problem
  • A third of children and young people with mental health problems have suffered from abuse or neglect
  • Those who are in contact with the criminal justice system are three times as likely to have mental health problems
  • Half of parents with a child with an emotional disorder also have an emotional disorder themselve

 
Other groups who may be at increased risk include those who have a parent with substance or alcohol misuse problem, those who have a parent in prison, those from low income households, those who are refugees or asylum seekers, those who are from a traveller community, those who are Lesbian, Gay, Bi-sexual or Transgender (LGBT)

Another group whose needs are often not taken into account when CAMHS are commissioned are those children of an age where they are transitioning between services. In particular:

  • One in three 16 to 17 year olds faces five or more risk factors including risky behaviours and poverty
  • Young people aged 16 to 17 are particularly vulnerable to sexual abuse, exploitation, and trafficking
  • In 2014 11% of forced marriage victims were age 16 to 17
  • 22% of looked after children aged 16 to 17 were living in arrangements other than residential homes or foster care

What are the unmet needs/ service gaps?

The CAMHS transformation plan sets out the unmet needs under the four headings that follow taken from the Five Year Forward View (NHSE 2014)

Promoting resilience, prevention and early intervention
Work is required to tackle the stigma of mental ill health. An anti stigma campaign is required and will be run in 2016 in our local schools.An audit is needed of local schools to investigate the range of the use of evidence based resources in PSHE and within school support services to build children’s and young people’s resilience

Early years and voluntary sector settings need further support for parents and carers in regard to recognising and responding appropriately to a range of mental health problems which if not addressed early can develop into disorders e.g. anxiety and depression and eating disorders.

Improving access to effective support – a system without Tiers

  • The THRIVE website enables the young person to self assess their wellbeing on a regular basis and if if anxiety or depression or self-harm scores remain high over an extended period then they will be directed to on line services in the first instance.
  • Assessment will then encourage referral to local face to face services if required.
  • Training and supervision from specialist CAMHS is required for all referring GPs to enable them to make appropriate referrals and to understand their role in information provision and the locally agreed pathways.
  • Shared data entry systems are required to ensure smooth transitions between agencies.
  • A common set of KPIs is required for all school commissioned counselling services.
  • The primary mental health service which responds to the common point of entry (CPE) and social care is not visible to young people and needs a dedicated page describing its coordination role in the Slough Services guide.
  • The secondary school pilot in reach team has demonstrated the need to embed early detection skills in schools yet capacity at targeted level is limited.
  • The lack of an agreed trauma pathway requires additional national funding as does the provision of perinatal mental health services – see links at the end of the section

Care for the most vulnerable
There is an urgent need to ensure there is better, co-ordinated post-diagnosis support, particularly for children with Autistic Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD).

Other more vulnerable young people e.g. looked after and care leavers, those with a learning disability and victims of Child Sexual Exploitation need to be prioritised for help to address their emotional health and wellbeing concerns at the appropriate level. A local project will offer evidence based cognitive therapy to those who have been identified as suffering from child sexual exploitation.

Developing the Workforce
The ongoing training needs of GPs, school staff and community volunteers has been identified in the CAMHS transformation plan

Recommendations for consideration by other key organisations:

The Health & Social Care Act 2012 gives CCGs the power to commission certain health services under Section 3A NHS Act 2006. Each CCG has the power to arrange for the provision of such services or facilities as it considers appropriate for the purposes of the health service that relate to securing improvement in –
(a) the physical and mental health of persons for whom it has responsibility; or
(b) the prevention, diagnosis and treatment of illness in those persons.

A CCG may not arrange for the provision of a service or facility if the Board has a duty to arrange for its provision under sections 3B or 4.

The CCG will need to expand perinatal mental health provision within Secondary Care Mental Health teams, including improved access to psychological treatment and medication management as well as post traumatic birth support and support to mothers suffering from depression who do not attend Increasing Access to Psychological Services

See also