Mid and West Wales CAMHS Commissioning Network

1
Mid and West Wales CAMHS Commissioning Network

• May 2008

2
Establishment of the Network

• There are three CAMHS Networks across Wales.
• They are a requirement of of the Welsh Assembly
  Government.
• Established under circular WHC (2003)63

3
Areas Covered

• Bridgend
• Neath Port Talbot
• Swansea
• Carmarthen
• Pembrokeshire
• Ceredigion
• Powys

4
Membership

• Although the Network is LHB-led it has
  multiagency representation.
• LHBs
• NHS Trusts
• Childrens Social Services
• Education
• The independent Sector
• The National Public Health Service
• Health Commission Wales
• The Police
• Youth Offending
• Paediatrics

5
Organisation

• Powys LHB is the lead LHB for the Mid and West
  Wales CAMHS Commissioning Network.
• It receives non-recurrent funding from WAG to
  support the Network function.
• Powys provide the Chair, lead commissioner,financi
  al and administrative services.

6
Function of the Network

• Ensure a collaborative approach.
• Performance Manage AOF targets.
• Secure and manage resources.
• Conduct regional impact assessments.
• Validation of the CAMHS Mapping for the region.

7
Outcomes

• Recommended Core Business
• Telemedicine
• Bibliotherapy scheme for children and families
• Waiting time initiatives
• Strengthening IT systems
• Conferences and training

8
Specialist Child and Adolescent Mental Health
Services (CAMHS)

• Carmarthen,
• Ceredigion
• Pembrokeshire
• May 2008

9
Specialist CAMHS

• The Role
• Specialist Assessment
• Direct Clinical Work
• Advice to and consultation with other
  professionals
• Liaison
• Inter-agency case management
• 24 hour on call
• Urgent response through normal working hours
• Self harm assessment on paediatric wards
• Teaching and training
• Audit and Research

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Specialist CAMHS

• Populations (2001)

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Specialist CAMHS

• Age Boundary WHC (2002) 125

• Transition is flexible where possible to the need
  of the young person and will be initiated from 17
  years 6 months

Adult Services
12
Specialist CAMHS
13
Specialist CAMHS

• Delivery by location
• - Service base
• - Home
• - School
• - Range of hospital sites
• - Out-patient facilities
• - Pupil referral units
• - Child care facilities
• - youth work facilities and
  clubs
• - Other (e.g. Social Services, Childrens
  Home, General Practice)

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Specialist CAMHS

• Core Business -

• Serious self harm (eg overdose, cutting, hanging)
• Suicidal ideation/ intent
• Psychosis
• Eating disorders (nice guidance 2004)
• Severe OCD (nice guidance 2005)
• Severe Anxiety
• Mod/ Severe depression (nice guidance 2005)
• Post abuse (with mental health difficulties)
• PTSD (nice guidance 2005)
• Biploar disorder (nice guidance 2006)

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Specialist CAMHS

• Core Business (cont)
• The service will work as part of a multi-agency
  team but not as a lead
• agency where there is Autistic Spectrum Disorder
  or ADHD in line with
• an interagency local or nationally agreed pathway
  or where there are
• serious concerns about the childs mental health
• Severity, complexity and duration explains in
  what circumstances the
• service may be involved with other agencies
• Severe causing significant distress to the
  child/ family
• Complex exacerbated by other factors making
  change more difficult
• Enduring ongoing and has not been resolved
  despite input from tier 1 and 2 services

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Specialist CAMHS

• Urgent - Imminent risk of severe
  deliberate self harm or
  attempted suicide
• Severe mood disorder
• Severe depressive illness
• Severe Eating disorder
• Imminent risk associated with psychotic
  disorder
• imminent risk associated with Post Traumatic
• Stress Disorder
• - within 2 working days
• Routine - As above (with no urgency)
• - within 16 weeks

17
Specialist CAMHS
Referrers

• GPs
• Social Workers
• Health Visitors
• School Nurses
• Paediatricians
• Educational Psychologists

• Adult Mental Health Services
• Youth Offending Service
• Education Welfare Officers
• Behaviour Support Service
• Other Hospital Consultants

Normally a decision within a week
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Specialist CAMHS

• Interventions -
• Start of therapeutic process letter of
  appointment SDQCHI questionnaire
• Assessment - appropriate member(s) of team
  (uniform assessment procedure across all teams)
• - Utilising FACE Triage
  and Risk Assessment
• - may need one or more
  sessions
• - information from other
  agencies (school, Social Services, Ed. Psych,
  Paediatrician)
• Plan - participation of child and
  parents in formulation of plan of action

19
Specialist CAMHS

• Emergency On Call 5pm 9am
• Week days, weekends and bank holidays
• Carmarthenshire, Pembrokeshire, Ceredigion
  1st On Call Dedicated Nurse on call for
  support and guidance to professionals.
• Further support from adult services own on call
  team. Adult psychiatrist on call.

20
Specialist (PMHW)

• Specialist (PMHWs) 7.96 to provide support to
  three counties providing
• Advice and consultation
• Support and supervision
• Training advice on packages specific to emotional
  health and well being
• Gate Keeping
• Joint working

21
Future needs for Specialist CAMHS

• Additional resource for PMHWs team
• Utilise money from retirement and promotion to
  develop SECOND TEAM with additional support
  workers, psychology assistant and nursing staff
  to develop community based support
• Seek additional resource to provide extra
  community based support
• Create flexible workforce to meet need
• Develop specialist services to meet need

22
Specialist Child and Adolescent Mental Health
Service

• a.k.a. Child and Family Consultation Service

23
Everybodys Business?

• Our concept of CAMHS is inclusive. That is, we
  take the term CAMHS to mean all of the services
  provided by all the sectors that impinge on the
  mental well-being, mental health, mental health
  problems and mental disorders of children and
  young people before their majority.
• Child Adolescent Mental Health Everybodys
  Business, 2001, p 22. WAG

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Everybodys Business

• Aims
• Relief from current suffering and problems with
  the intention of improving, as soon as possible,
  the mental health of children, adolescents and
  their families.
• Longer-term interventions to improve the mental
  health of young people as they grow up and when
  they become adults and, thereby, to positively
  influence the mental health of future
  generations
• Partnership with families, substitute families
  and all those who care for young people
• Child Adolescent Mental Health Everybodys
  Business, 2001, p 7. WAG

25
Everybodys Business cont.

• Putting Principles into Practice
• No sector can be absolved from the duty to play a
  full part in CAMHS and to co-operate across
  professional boundaries
• Child Adolescent Mental Health Everybodys
  Business, 2001, p 22. WAG

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Four Tier Strategic Concept

• Tier 1 Primary or Direct Contact Services
  GPs, HVs, School Nurses, Teachers etc.
• Tier 2 Services Provided by Individual
  Specialist CAMHS Professionals Specialist CAMHS
  Clinicians, EPs, Spec Child SW etc.
• Tier 3 Services provided by Teams of Staff from
  Specialist CAMHS hub and spoke, specialised
  clinics, day-care
• Tier 4 Very Specialised Interventions and Care
  Regional/National specialised clinics,
  inpatient psychiatric services.
• Child Adolescent Mental Health Everybodys
  Business, 2001, p 24-27. WAG

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Children seen and heard!

• West Wales Specialist Child and Adolescent Mental
  Health Service (spec. CAMHS) aims to promote and
  provide a non-stigmatising mental health service
  to children, adolescents, their families and
  carers that is accessible, comprehensive and
  informed by evidence of best practice.
• Children and Adolescents should be Seen and
  Heard The Strategy for West Wales Specialist
  CAMHS. February 2003

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Client Groups

• Children and adolescents for whom there is
  evidence of mental health disorder
• Children and adolescents with mental health
  problems who are at risk of developing a more
  serious mental health disorder
• Children and adolescents identified through
  liaison or consultation with other disciplines or
  agencies who are suffering a level of distress
  sufficient to cause a significant concern to
  themselves, their families or the context of
  another caring environment
• The promotion of positive mental health for all
  children in West Wales

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Core Business

• Severe anxiety
• Severe OCD
• Depression (moderate to severe)
• PTSD/Post-trauma
• Psychosis
• Self-harm (moderate to severe)
• Suicidal thoughts and intent
• Eating disorders

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Not Core Business

• AD/HD
• Challenging behaviour
• Bereavement
• Tantrums
• Oppositionality
• Failure to comply with medical regimens
• Emotional Consequences of Divorce
• Access arrangements
• Chronic Fatigue (NICE CBT)?

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Better Business?

• Clients who are experiencing mental health
  difficulties that are manifest in the form of
  significant psychological distress that is
• Severe psychiatric conditions, high impact on
  their functioning . . .
• Enduring - chronic in nature, beyond normal
  (developmentally appropriate) expectation
• Complex LAC, children of parents with M/H
  difficulties, multiple difficulties . . .

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Multi-disciplinary

• Psychiatry
• Psychology
• Family/systemic therapy
• Specialist Social Work
• CPN

• Specialist CPNs
• Child Psychotherapy
• Non-specific support

33
Number of referrals to the Service

• During a 7 month period there were 632
  referrals to CAMHS. These were spread across the
  teams as follows
• Carmarthen 163 (26)
• Llanelli 145 (23)
• Pembrokeshire 219 (35)
• Ceredigion 105 (17)

34
Referral patterns across the 7 months
35
Referrals accepted into CAMHS

• Of the 632 referrals, 238 were accepted into
  CAMHS (38).
• 365 referrals (62) were not accepted into CAMHS.
• Of these 365 referrals, 51 were signposted.

36
Total referrals accepted by team
37
Total referrals accepted by referring source
38
Total referrals accepted by referring concern
39
Total referrals by gender
40
Total referrals accepted by gender
41
Total referrals accepted by age
42
Total referrals accepted by referring source
43
Referrals involving self-harm

• How many referrals to the service involved
  self-harm?
• 90 (14)
• How many of these referrals did we accept into
  CAMHS?
• 66 (73)
• What proportion of the referrals accepted into
  CAMHS involved self-harm?
• 28 (66)

44
Referrers

• Can
• General Practitioners
• Paediatricians
• School Nurses
• Social Workers
• Health Visitors
• Educational Psychologists
• YOT

• Cant
• Schools (teachers)
• Special Schools
• Education Welfare Officers
• Parents/Clients
• Non-professionals e.g. welfare assistants

45
Initial Consultation

• Referral to team
• Emergency referrals intercepted
• Weekly referrals meeting
• If valid, routine or rapid response
• If routine, waiting list
• Taken from list on first come, first served basis
• Back to team for onward allocation

46
IC process

• Clinician meets family and/or YP for 90min
  session
• Measures taken
• FACE assessment completed
• Shared understanding of difficulties
• Communicated to family (GP and referrer)
• Discussed with team for onward allocation

47
Psychology

• Develop an understanding (formulation/conceptualis
  ation/hypothesis) based on the particular
  psychological model/orientation being used
  (psychodynamic, behavioural, cognitive, systemic,
  personal construct . . .)
• Considers Predisposing factors
• Precipitating factors
• Maintaining factors
• Protective factors
• (c.f. Personal Construing)

48
Psychology

• (Applied) Psychology tries to understand why this
  particular person/group behaves in this
  particular way, in this particular context
• It emphasises the why, not just the what

49
Psychology

• Develop an understanding (formulation/conceptualis
  ation/hypothesis) based on the particular
  psychological model/orientation being used
  (psychodynamic, behavioural, cognitive, systemic,
  personal construct . . .)
• Considers Predisposing factors
• Precipitating factors
• Maintaining factors
• Protective factors
• (c.f. Personal Construing)

50
My Practice

• Therapeutic intervention
• Personal Construct Psychotherapy
• Solution Focused Brief Therapy (Systemic)
• Cognitive Behavioural Therapy (REBT)
• Hypnotherapy
• Comprehensive psychological assessment
• Psychometrics
• Questionnaires
• Assessment through intervention Observation

51
SFBT

• Assumptions
• Dont need to understand cause to find solution
• Success depends on knowing where client wants to
  get to
• There are always exceptions
• Problems do not represent pathology
• Small change ripple effect
• Unique ways of cooperating

52
SFBT Techniques

• Problem Free Talk
• Pre-session Change
• Goal Setting
• Exception Finding
• Rating Scales

53
CBT

• Biological tendency to irrational thinking
• Awfulising
• Automatic thoughts
• Musterbations sic
• Low frustration tolerance

54
CBT Techniques

• A Activating event
• B Beliefs (rational and irrational)
• C Consequences (emotional sic,
  physiological, behavioural)
• D Dispute. (evidence? so what)
• E new Effect

55
PCP

• Peoples processes are psychologically
  channelised by the ways in which they anticipate
  events
• Constructive alternativism
• People are scientists
• Behaviour is an experiment
• No dualism (th-f, m-b)
• Constructs are bi-polar

56
PCP Techniques

• Self-characterisation sketch
• Fixed-role therapy
• Rep. grid
• Loosening tightening (technical eclectism)
• ABC analysis
• Laddering
• Pyramiding

57
Cases

• Lee OCD, alien abduction (CBT)
• Kathy Bulimia (PCP CBT)
• Martin psychosis, depression (PCP)
• Angela eating disorder, BDD (Int.)
• Laura ADHD, low self-esteem . . .(SFBT)
• Lionel Psychiatry vs. Psychology (Int.)

58
Psychology

• (Applied) Psychology tries to understand why this
  particular person/group behaves in this
  particular way, in this particular context
• It emphasises the why, not just the what

59
Psychology

• Develop an understanding (formulation/conceptualis
  ation/hypothesis) based on the particular
  psychological model/orientation being used
  (psychodynamic, behavioural, cognitive, systemic,
  personal construct . . .)
• Considers Predisposing factors
• Precipitating factors
• Maintaining factors
• Protective factors
• (c.f. Personal Construing)