Nottingham City Children and Young People’s Behaviour Emotional or Mental Health Pathway

1. Nottingham City Children and Young People’s Behaviour Emotional or Mental Health Pathway

2. Overview of the session • BEMH pathway including stage one & GP role • What makes a good referral • Recognising neurodevelopmental indicators for ASD/ADHD • When and how to make an urgent referral • Discussion

3. Warning: • This session does not train you in ASD/ADHD/mental health but will support you in thinking about behaviours and what to consider before making a referral • Free training session on understanding behaviours including indicators for neurodevelopmental concerns is available

5. The BEMH pathway

6. What should happen at stage 1 • Recognition of concern & early intervention by universal services withinput from targeted services if needed • Identification of a keyworker to develop support plan • Monitoring and review • Working with parents/families and other professionals • Gathering of information if concerns persist and it is felt that a specialist referral may be required Most children with behavioural concerns do not need to progress further along the pathway

7. Why might a child display behavioural concerns? CHILD Tired, hungry, unwell Sad/unhappy/upset, Worried/anxious Hearing/vision problems Developmental delay / learning difficulties LOW SELF ESTEEM Medical condition ASD/ADHD Not all concerning behaviour is ASD or ADHD! HOME Family disruption Chaotic lifestyle Parental illness /disability/mental health issues /alcohol or drug misuse Sibling illness/disability Safeguarding issues Domestic violence Bereavement SCHOOL Poor attendance Bullying/teasing Learning issues - struggling to keep up/work too hard or easy / inappropriate expectations Poor understanding about child’s needs

8. Discussion: Case Scenario 1 • 8 year old boy attends with mother at ‘wits end’ due his behaviour, issues include: • Temper tantrums and refusing to do as he is told • Aggressive towards mother and siblings • Not listening at school and school concerned about progress • Falling out with friends • Poor sleep • Prefers to spend time alone What should you do? Other than referring to BEHT or Community Paediatrics what might you consider ?

9. Feedback What should you do? Other than referring to BEHT or Community Paediatrics what might you consider ?

10. GP role • Review concerns with parents/child • Who is concerned • What are the concerns – are there any ASD/ADHD or mental health ‘symptoms or signs’ • How long have concerns been present • How is it impacting on the child/family • Who is involved and what has been done so far • Is there anything of relevance in background – family/birth or medical history? Any factors associated with increased risk of autism/ADHD?

11. GP role • Are there any ‘red flags’? • Are there any safeguarding concerns/concerns around vision/hearing or other medical issues • What are your observations of the CYP? • Where necessary • explore parents expectations - discuss that there are many and varied reasons for a child’s behaviour – not just ASD or ADHD • liaise with other professionals involved • consider further/longer consultation with family & YP • consider further training, such as SHARP sessions

12. Checklist for a good referral • Reason(s) for referral • Presenting needs in relation to the concerns incl. duration, triggers, frequency and impact on daily functioning • Who else is involved and what has already been done including current or previous assessments • Your own observations of the child • Positive indicators for neurodevelopmental or mental health issues • Safeguarding concerns/ family functioning / relevant family, birth and medical history

13. What is ASD? Persistent problems in social communication and social interaction with difficulties in all 3 of the following: social/emotional reciprocity eg initiating contact, sharing of emotions/interests, two way conversations non verbal communication eg eye contact, gesture, facial expression developing, maintaining and understanding relationships, lack of empathy/ awareness of others thoughts, feelings Restricted, repetitive patterns of behaviour, interests, activities with at least 2 out of the 4 following: stereotyped or repetitive speech/ motor movements/use of objects etc excessive adherence to routines, ritualised patterns of behaviour or excessive resistance to change highly restricted, fixated interests abnormal in intensity or focus sensory sensitivities or unusual interest in sensory aspects of environment

14. What is ADHD? Inattention Lacks attention to detail Difficulty sustaining attn Fails to finish tasks Poor organisation skills Avoids sustained effort Loses things, ‘forgetful’ Easily distracted Hyperactivity Fidgets Leaves seat in class Runs/climbs excessively Cannot play/work quietly Always ‘on the go’ Talks excessively Impulsivity Blurts out answers Cannot await turn Interrupts others Intrudes on others

15. For more information on ASD & ADHD • Signs and Symptoms of possible autism checklist • NICE Guidance CG128 Appendix C • NICE guidance on ASD and ADHD www.nice.org.uk • www.nhs.uk – basic information for parents and professionals on ASD and ADHD including videos • National Autistic Society www.autism.org.uk – excellent downloadable resources for parents on dealing with a huge range of challenges • ADDISS www.addiss.co.uk/information

16. When and how to make a direct Paediatric referral • RED FLAGS • Regression of skills in children under 3 years • Significant developmental delay in a pre-school child • Associated medical problems which need referral in their own right eg possible seizures • Complete e-referral on ERS choosing ‘Paediatric Developmental Concerns’

17. When to make a direct referral into the SPA • Suicidal thoughts or current self harming behaviours • Evidence of significant weight loss and skipping meals/possible eating disorders • Signs of distress, or the child or young person is experiencing worsening mental health symptoms

18. SHARP • The Self Harm Awareness and Resource Project • Offering support, guidance, training and direct work with children and young people who self harm, and their families. • A programme of training is available for GP’s from January 2016 (see flyer) • If you need advice and/or support around self harm/suicide behaviours please call the team on 0115 8764000

19. Safeguarding: • Referrals to social care should be made through Children and Families Direct http://www.nottinghamcity.gov.uk/article/26182/Children-and-Families-Direct  Telephone: 0115 876 4800 • When a child or young person or parent discloses abuse, (sexual, emotional, physical, neglect) including domestic abuse, either current or historic it is your responsibility to check that the child/YP is not at risk and to ensure they are safeguarded immediately

20. Self Referrals: • Patients and parents CAN make a self- referral where necessary BUT • It is preferable if they are seen in surgery, for the referral to be made via choose and book with your assessment of their behavioural, emotional or mental health issues This will ensure that referrals received into the SPA are directed to the right service in a timely manner.

21. Summary of GP role Do I have enough information? Is there any evidence of early intervention from Universal services? Is there any information from school/others to support concerns re ASD/ADHD? Are there mental health concerns/symptoms of distress? If YES to above – refer to Nottingham City SPA sending all relevant information If NO but evidence of red flags – refer directly to Community Paediatrics or the SPA as appropriate with as detailed a referral as possible If NO and no red flags – explain to family the need for further information / liaise with school/nursery either directly or via SN or HV and/or arrange further/longer consultation with family including the child/young person

22. Questions For more information please contact: SPA on 0115 8764000 BEH team 0115 8834760 www.bemhnottingham.co.uk.

23. Video - ‘It’s Good to talk and even better to be heard’ https://www.dropbox.com/s/j2g7lb16x6jhdyk/Main%20PPT%20Video.mp4?dl=0