Mid and West Wales CAMHS Commissioning Network

1. Mid and West Wales CAMHS Commissioning Network May 2008

3. Areas Covered Bridgend Neath Port Talbot Swansea Carmarthen Pembrokeshire Ceredigion Powys

4. Membership Although the Network is LHB-led it has multiagency representation. LHB�s NHS Trusts Children�s 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,financial 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

10. Specialist CAMHS Populations (2001)

11. Specialist CAMHS Age Boundary � WHC (2002) 125

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, Children�s Home, General Practice)

14. Specialist CAMHS Core Business -

15. 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 child�s 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

16. 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 Adult Mental Health Services Youth Offending Service Education Welfare Officers Behaviour Support Service Other Hospital Consultants GP�s Social Workers Health Visitors School Nurses Paediatricians Educational Psychologists

18. Specialist CAMHS Interventions - Start of therapeutic process: letter of appointment; SDQ;CHI 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 (PMHW�s) 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. Everybody�s 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: Everybody�s Business, 2001, p 22. WAG

24. Everybody�s 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: Everybody�s Business, 2001, p 7. WAG

25. Everybody�s 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: Everybody�s Business, 2001, p 22. WAG

26. 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: Everybody�s Business, 2001, p 24-27. WAG

27. 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

28. �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

29. 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

30. 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)?

31. 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 . . .

32. 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* Can�t 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/conceptualisation/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/conceptualisation/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 Don�t 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 People�s 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/conceptualisation/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)