Components of a Modern Progressive CAMHS Service

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Components of a Modern Progressive CAMHS Service

• Jeremy Turk MD, BSc(HONS), FRCPsych, FRCPCH, DCH
• Professor of Developmental Psychiatry, Consultant
  Child Adolescent Psychiatrist Trustwide CAMHS
  Clinical Lead

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Diagnosable Psychiatric Disorder with Significant
Functional Impairment in Young People

• General population 7
• Physical Impairment 11
• Impaired brain functioning 33
• Severe learning difficulties 50
• Deprivation disadvantage doubles the percentages

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Available data, with due reference to social
demographics and urban environment, suggest the
following

• Wandsworth borough has approximately 250,000
  residents
• Of these, approximately 20 (50,000) are children
  and adolescents
• Of this 20
• 2-3 (1,500) have intellectual disability with a
  third (400) having mental health problems, 250
  of them having SLD with 50 (125) of them having
  mental health problems
• 3-5 (2,000) will have ADHD
• 0.5 (250) will have an autistic spectrum
  disorder
• 0.7 of adolescents will have anorexia nervosa
• 3 will have a conduct disorder
• 1 in 300 adolescents will develop schizophrenia
• 2-3 will have experienced obsessive-compulsive
  disorder by late adolescence
• 1-2 of children 3-5 of adolescents will
  experience clinical depression

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Trust-wide CAMHS

• Wandsworth
• St. Georges Team
• William Harvey Clinic
• Adolescent Community Team
• Child Adolescent Learning Disability Service
• Merton Child Adolescent Mental Health Service,
  Birches Grove, Cricket Green
• Cotswold House, Sutton Hospital
• Woodroffe House, Tolworth Hospital
• Richmond Royal, Kew Foot Road
• Adolescent Assertive Outreach Team Aquarius
  Unit
• Deaf Child Family Service, Inpatient
  provision
• Child Adolescent Eating Disorder Service,
  Inpatient provision
• Childrens Assertive Outreach Service

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Over-arching Principles 1

• Services that are
• Available 24/7, trust-wide, entire spectrum of
  child adolescent psychopathology,
  non-discriminatory
• Collaborative with other agencies with
  families
• Appropriate
• Client-driven
• Effective evidence-based
• Audited
• Well managed
• Socially just
• Value for money

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Over-arching Principles 2

• Most child adolescent mental health problems
  can be dealt with in primary care.
• Specialists should provide assessment, treatment
  support for other groups.
• Services should be patient centred with patient
  choice.
• Specialist services should accommodate the
  spectrum of need.
• Services should be concentrated in areas of
  greatest need. Professional isolation should be
  avoided there should be good inter-agency
  collaboration.
• Services should deliver the most cost-effective
  methods of assessment treatment as far as
  possible the choice of methods should be based on
  the best available scientific evidence.

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National Strategic Framework

• SERVICES FOR ALL

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• NOT EVERYONE NEEDS A SPECIALIST SERVICE

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Tiers of Service

• Primary
• Front line clinical services
• Secondary
• Unidisciplinary specialist services
• Tertiary
• Multidisciplinary specialist services
• Quarternary
• Highly specialised/super-regional services

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Client-Led versus Professional-Led Services

• Client/Needs led
• We go to the client (literally metaphorically).
• We listen to collaborate with the client.
• I shall need to enlist your help so that I can
  see things from your point of view.
• What are your perceptions of the assistance you
  receive?
• We need to work out together what is best.
• Interventions are symptom led fulfil clients
  needs.

• Service led
• The client comes to us (literally
  metaphorically).
• The client listens to collaborates with us.
• I shall be helping you to see things from my
  point of view.
• What are my perceptions of the assistance I offer
  to you?
• Nanny knows what is best.
• Interventions are service led fulfil
  clinicians needs.

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• COST-EFFECTIVE
• EVIDENCE-BASED INTERVENTIONS

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Main Focuses of Tertiary Work

• Intensive multi-disciplinary assessment,
  diagnosis formulation
• Evidence-based psychotherapies for emotional
  behavioural disorders, aggression, self-injury
  other challenging behaviours
• Individual, family, group consultative
  approaches
• Judicious use of paediatric psychopharmacology

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REASONABLE DATABASESPSYCHOLOGICAL

• Functional analysis, analogue ratings behaviour
  modification for challenging behaviours
• Cognitive-behavioural psychotherapies for
  depression
• Webster-Stratton group cognitive-behavioural
  approaches for conduct disorders
• Behavioural programmes for sleep disorders

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REASONABLE DATABASES PHARMACOLOGICAL

• Psychostimulants, tricyclics, atomoxetine
  clonidine for hyperactivity attentional
  deficits
• SSRIs for depression
• Anticonvulsants for cyclical ( not so cyclical)
  mood behaviour disorders
• Melatonin clonidine for sleep disturbance
• Atypical antipsychotics for challenging
  behaviours, psychoses ? social impairments

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REASONABLE DATABASESEDUCATIONAL

• Structured, consistent, predictable focussed
  behavioural programmes
• Cognitive psychotherapeutic approaches
• Psychoeducation
• Mental health hygiene preventative measures

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Other Interventions Recognised As Efficacious

• Specialist speech language therapy
• Expressive language
• Comprehension
• Social use
• Augmentative communication
• Occupational Therapy
• Sensory integration

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APPROACHES LACKING IN EVIDENCE

• Individual psychodynamic psychotherapy for autism
  or ADHD
• Facilitated communication for investigation of
  alleged abuse
• Secretin for anything psychological or
  psychiatric
• Domen-Delacato patterning
• Auditory Integration Training
• Anything involving dolphins

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Service Professional Strengths

• Committed, industrious, knowledgeable
• experienced, enthusiastic, stable workforce
• providing a comprehensive, cost-effective,
  evidence-based child adolescent mental health
  service
• 24/7/365
• available accessible to all children young
  people registered to general practitioners, their
  families carers, across the five boroughs
  irrespective of age, gender, social standing,
  culture, race, religion, sexual orientation
  disability

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Jewels in the Crown

• Evidence-based, cost-effective brief
  psychotherapies
• Childhood trauma child protection PTSD, abuse
  neglect
• Socio-cultural perspectives
• Adolescent services
• Neurodevelopmental aspects
• Learning disability challenging behaviour
• Autistic spectrum disorders
• Attention deficit disorders
• 7 helpful habits of CAMHS
• Child Adolescent Psychiatry a Developmental
  Approach
• Evidence-based practice meta-analyses
• Computing IT
• Mutually beneficial collaborative links with
  medical school
• Footholds in Royal College of Psychiatrists,
  Royal Society of Medicine, Foundation for People
  with Learning Disability, National Autistic
  Society

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Recent Service Improvements

• Gathering of all relevant information from other
  agencies as part of referral process
• ? Strength length of initial face-to-face
  client meeting
• ? Duration from referral to first contact
• ? Clarity of key worker/care management role
• Robust risk assessments risk managements
  links to Care Programme Approach
• Clarification of issues surrounding consideration
  of inpatient admission
• Development of trust-wide policy for
  multidisciplinary clinical supervision, case
  discussion with colleagues being proactive in
  questioning handling of cases
• ? Standard of record keeping
• Trust-wide consistent standardised approach to
  care planning CPA
• ? Quality of documentation
• Authorship of standard textbooks toolkits

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Wandsworth CAMHS

• Progressive move towards evidence-based,
  cost-effective, increasingly community-practiced
  psychotherapies
• Ongoing review revision of specialism mix
• Premises modernisation
• Close collaborative working with
• Wandsworth Local Authority Children's Directorate
• Department of Health
• Foundation for People with Learning Disability
• Royal Society of Medicine
• Association for Child Adolescent Mental Health
• National Autistic Society

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Merton CAMHS

• Development of child adolescent mental health
  learning disability service
• Care bundles LD, ASD, ADHD, psychosis, eating
  disorders ? joint collaborative working with
  education social services
• Modernisation of evidence-based, progressive
  clinical practice
• Publicising availability of services accessing
  services
• Clarification of acceptance criteria
• Premises modernisation
• New full-time manager integrated in to clinical
  team
• CBT training
• ADHD service with seamless shared care provision

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Sutton CAMHS

• Longitudinal medication prescribing trends with
  particular emphasis on antipsychotic medication
  current best practice guidelines
• User involvement enhancement
• ADHD clinic, toolkit, group work publications
• Upgrading knowledge clinical competencies in
  key areas
• learning disability
• social communication disorders
• Cognitive-behavioural psychotherapies

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Kingston CAMHS

• Institution of CAPA ? waiting list reduction
• Seamless assessment treatment process
• Galvanising of modern, progressive evidence-based
  psychological approaches
• Staff participation in cognitive-behavioural
  psychotherapy training for CAMHS under auspices
  of Dr Bea Vickers Dr Kirsty Grieve
• Clarification of referral acceptance criteria
• Social communication disorder clinic
• Substance abuse

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Richmond CAMHS

• 7 helpful habits of CAMHS
• Royal College of Psychiatrists Child Adolescent
  Faculty
• Dr Ann York Department of Health
• Drs Ann York Morris Zwi Royal College of
  Psychiatrists, Child Adolescent Faculty

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Adolescence

• Trustwide Assertive Outreach Team
• Inpatient facility
• Substance misuse services
• Youth offending services
• Fostering adoption services
• Violence its impact on young peoples mental
  health
• Building recovery, building resilience
• Children young people are constantly
  developing
• Their goals hopes, wishes values are
  continuously changing
• They are continually developing intellectually,
  socially emotionally
• They have a legal right to a major say in their
  lives even though they remain the legal
  responsibility of their carers

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Looking to the future

• Multi-agency approach to reviewing reflecting
  on recent incidents
• Application of principles of Care Programme
  Approach to all Tier 3 4 CAMHS
• Adoption audit of Trust Risk Assessment
  Procedure, Zoning, with appropriate training
• Reconfiguration of adolescent services to provide
  adequate staffing to inpatient CAMHS support to
  young people and their families in crisis in the
  community 24/7
• Aquarius fit for purpose premises, user-friendly
  environment meeting particular needs of
  adolescent client group

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Looking to the future

• Evaluate review role of Clinical Team Leader
• Up to date, detailed, regularly reviewed
  summarised record keeping clinical team meeting
  minutes
• Regular, detailed documented mental state
  assessments
• Identified Lead Professional who can call
  multi-agency meetings
• Greater collaboration, integration joint
  working with other statutory private/voluntary
  sector services

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Conclusions

• We have much to be proud of much for other
  Child Adolescent Mental Health Services to
  model on learn from.
• We still have much to do in meeting the mental
  health needs of Children Young People,
  supporting them, their families carers.