LD-CAMHS in Norfolk Community Health Care

1. LD-CAMHS in Norfolk Community Health Care Dr Pippa Humphreys Clinical Psychologist Gill Jinkerson Lead Nurse / Systemic Psychotherapist ,,,,,,,,

2. Philosophy of Care Quality of life, and our ability to manage and adapt to changes and tolerate difficulties is dependent on the quality of the relationships we are able to build around us Our ability to build these relationships begins to develop in our very early experiences of being loved; the attachments we have to our parents. When these attachments are sensitive, warm, and responsive and attuned to who we are and what we need, we build positive and resilient internalised models of ourselves, others and the world. Central to our approach to working with children with learning disabilities is the aim to support, restore and improve the quality of the relationships between parents and their children. In order to foster resilience and positive self esteem. Children’s learning is optimised in the context of positive and sensitive inter-subjective experiences

3. Extra Challenges Children with learning disabilities and their families face extra challenges in their lives, challenges make them prone to poor mental health and persisting distress. This might be expressed though challenging behaviour, self-harm, insistence on sameness and routine, restricted environments.

4. Extra Challenges Child Cognitive impairment Communication difficulties Physical and medical difficulties Sensory difficulties Confusion and anxiety Sense of being different and the experience of being stigmatised Parents Anger loss and guilt Unusual and confused cues from your child Your child being difficult to understand Feeling deskilled and incompetent and stigmatised Being a Mum or Dad can become a professional job and the family can feel taken over by the difficulties and the disability

5. Linking Theory with Outcomes Positively engagement in family life. More secure attachment relationships help children to relax, accept themselves and feel accepted - despite their differences. They are more able to tolerate and adapt to changes. Caring for a more secure child means that the conflict caused by the competing needs of all the family members may be reduced.

6. Linking Theory with Outcomes Learning and achieving at school. Better relationships at school with teachers, means better communication between the teacher and the child. A greater sense of being understood (verbally and emotionally) can reduce a child’s anxiety, increases curiosity and the willingness to explore and experience new things.

7. Linking Theory with Outcomes Participating in consultation and decision making about issues that affect them Children who hold a secure sense of themselves and others will be more able to be patient when others find it difficult to understand them and be confident in participating in decision making. When adults are sensitive to a child’s experience and the way in which they communicate, we have the opportunity to enable children to express their thoughts and feelings about difficult choices without the child having to resort to maladaptive ways of communicating

8. Linking Theory with Outcomes Interacting with peers in inclusive leisure activities. Secure familial attachments fosters a child’s ability to make reciprocal and meaningful friendships and build social networks. Attending leisure activities with friends increases opportunities for life experiences without parents or carers, and is important for independence.

9. Linking Theory with Outcomes Having a positive emotional wellbeing as they enter adulthood and make the transition to adult LD services Positive internalised models of self and others enable children to adapt to developmental changes such as puberty and other life changes - new family members, leaving school, building appropriate relationships with new carers

10. Good Practice for Partnership Working From a client perspective time to build good working relationships with children and families, appropriate and timely assessment, clear care plans and treatment goals negotiated with families, regular reviews, flexibility with regard to how, where and with whom interventions are carried out, access to team around the child approach where multiple agencies are involved

11. Good Practice for Partnership Working From a provider perspective multi-disciplinary referral meetings, transparent decision making processes, good communication and links with wider professional networks, regular supervision and case review for professional, opportunities for continuing professional development that fits with the philosophy of care

12. Working Tier-3 in a Tier-2 service Consultation and access to LD/MH expertise and joint planning and co-working Investing in a broad skill base at Tier-3 Flexible working practice taking direct work into community settings Psycho-social model of health and treatment where specialist interventions contribute to wider care network

13. T-3 in T-2 Case example Steven Steven’s brother was referred into family therapy because of Steven’s behaviour. He was hitting and biting, breaking toys and attacking his brother’s and sister’s friends. From this the family accessed intervention and resources to begin to manage Steven who was confused, frightened and controlling, because of his severe learning disability and autistic and sensory difficulties and epilepsy. He was very difficult to understand and communicate with, only using a few words and signs and visual timetables. Communication work (home-school-respite), functional analysis, respite provision, systemic family therapy and parenting for autism, sensory assessment, medication. CWD, Paediatrician, Epilepsy Nursing, OT, Psychology (LD-CAHMS), Family therapy (LD-CAHMS), LD Nursing, Special School. Still living at home, Parents still engaged with making family changes.

14. Gaps and Better Practice As a team for children with communication difficulties, a gap in the current services is access to psychological therapies that are primarily non-verbal in their execution - play therapy, art therapy and drama therapy As yet respite for children with learning disabilities tends to be residential. With vulnerable children, family-based respite should be considered best practice as it is with children who do not have learning disabilities.

15. Gaps and Better Practice To reduce the need for respite, family breakdown and residential care, we would like to see an intensive support team who can create an intervention package that can either go into families homes who are in crises (as in adult mental health services) or the opportunity to bring families into a residential setting together (as in CAHMS services like The Croft). With such a service, you would additionally hope to reduce sibling distress and vulnerability to emerging mental health problems. For teenagers where there is evidence of emerging mental illness such as bi-polar disorder and psychosis, there may be some benefit in having an acute bed available locally so that cost for external placements is reduced, availability of specialists services is known and links with local professionals are maintained, and the disruption to the child’s local networks is minimised - ie accessing family and local friends when appropriate.