The National Analysis of Regional Tier 4 Reviews What does it tell us

1. The National Analysis of Regional Tier 4 Reviews What does it tell us? Dr. Zarrina Kurtz

2. www.cypf.csip.org.uk/camhs/tier-4-camhs/ regional-reviews-of-tier-4-camhs.html

3. REFERENCES McDougall T, Worrall-Davies A, Hewson L, Richardson G, Cotgrove A. Tier 4 Child and Adolescent Mental Health Services (CAMHS) � Inpatient Care, Day Services and Alternatives: An Overview of Tier 4 CAMHS Provision in the UK. Child and Adolescent Mental Health, 2007:pp1-8 Green J, Worrall-Davies A. (2008) Provision of Intensive Treatment: In-patient Units, Day Units and Intensive Outreach. pp:1126-1142 In: Rutter�s Child and Adolescent Psychiatry, 5th edition. Edited by Rutter M, Bishop D, Pine D, Scott S, Stevenson J, Taylor E, Thapar A. Blackwell Publishing

4. REASONS WHY THE REGIONAL REVIEWS WERE UNDERTAKEN Increasing referrals to in-patient CAMH services, particularly significantly increased numbers of emergency referrals A national shortage of adolescent in-patient beds & a particular lack in developmentally appropriate provision for those aged 16 to 18 The inability of services always to respond in a timely way to requests for urgent admission & the consequent inappropriate usage of paediatric & adult psychiatry wards as an interim resource Regions wanting to study the findings & note the implications for commissioning in-patient care and community based services There were significant gaps in provision including long term therapeutic provision & post discharge services Significant problems in recruiting staff, especially nursing staff Much inter-agency confusion, in particular about the needs of children with conduct disorder & challenging behaviours

5. WHAT THE REGIONAL REVIEWS TELL US There is a major need for regularly updated & consistent data for use in provider management & service development & in commissioning & evaluation There is uneven distribution of, & access to (not necessarily the same thing) CAMHS in-patient beds In-patient beds are only part of the story about Tier 4 The extent & types of unmet need & some of the reasons for these The crucial relationship between Tier 4 & Tier 3 in effectively meeting needs The kinds of approaches that are likely to make significant improvements in meeting needs The importance of commissioning & its current under-development

6. Tier 4 CAMHS has recently come to be understood as multi-faceted, with multi-agency services that can include inreach, outreach, intensive & crisis community initiatives, day provision, therapeutic fostering & other services that may be described as �wrap around��

7. Tier 4 comprises very specialised services in residential, day patient or outpatient settings for children & adolescents with severe &/or complex problems requiring a combination or intensity of interventions that cannot be provided by Tier 3

8. THE NEED FOR TIERED APPROACH CAN BE DESCRIBED ACCORDING TO: the type of care required by the needs of the young person (covering a range with considerable variation in individual reviews): emergency/acute; intensive care; medium to long term; in-patient; day patient; community based (outreach, home treatment, post discharge, �wrap around�); low secure & high secure; the type of condition indicating certain needs: eating disorder; learning disability; dual diagnosis; conduct disorders; autistic spectrum disorder age group: children under secondary school age or thereabouts; older adolescents; those about to be classified as �adult�/transition; legal status: young offenders; sectioned under the Mental Health Act

9. UNMET TIER 4 NEEDS Emergency provision Conduct disorders/challenging behaviour Intensive care facilities Community based, as a �bridge� between tier 3 & tier 4 Low secure Young offenders Under 12s in-patient provision: In units that admit only children under the age of 14, there has been a 30% reduction in beds available (123 to 86)�. (O'Herlihy et al, 2007). Provision for older adolescents & transition Learning disability with mental health needs, severe learning disability with mental health problems Early intervention Dual diagnosis Eating disorders, in-patient provision �Low incidence needs�, also Autism, Aspergers, Attention Deficit Hyperactivity Disorder (ADHD)

10. REASONS GIVEN FOR LIMITED TIER 4 RESPONSES TO UNMET NEEDS In-patient case mix: young people with psychosis & with conduct disorder Poor service capacity � shortage of key staff & skills high turnover of staff poor retention of staff poor staff supervision & development opportunities Poor integration between service components at tier 4 Poor integration with tier 3

11. APPROACHES TO ENHANCE MEETING TIER 4 NEEDS EFFECTIVELY Assertive Outreach teams Early Intervention in Psychosis services Crisis Intervention/Home Treatment teams Multi-disciplinary Referral Panel On call with specialist back-up Peripatetic Specialist Assessment team Community based delivery of new treatment modalities, such as Dialectical Behaviour Therapy (DBT)

12. INPATIENT CARE Advantages Acute risk management Allows detailed assessment in a controlled environment and away from the family Intensive specialist treatment Can lead to more effective use of other services post discharge The ward as a therapeutic milieu Can produce rapid gains in functioning (socialization and academic achievement) and self-esteem 

13. INPATIENT CARE Disadvantages Loss of support from the child�s local environment Presence of adverse effects within the inpatient environment Effects of admission on family life

14. DAY UNITS Advantages Relate to the flexibility of care that can be provided Management of younger children Work with the family and foster parental care Emphasis on education 

15. EFFECTIVENESS OF INPATIENT AND DAY PATIENT TREATMENT Overall efficacy of inpatient care across a range of disorders, with the following predictors of outcome: High levels of aggressive antisocial behaviour and organic symptoms, as in schizophrenia predict poor outcome; emotional disorders do better Intelligence, measured as IQ shows a moderate positive effect but functional achievement may be more critical Pretreatment family functioning is a key predictor of outcome Longer treatment stays are, in general, associated with improved outcome For eating disorders-widely differing results

16. EFFECTIVENESS OF INPATIENT AND DAY PATIENT TREATMENT (continued) Depression and suicidality and psychosis � little beneficial effects of IP psychiatric care Conduct disorder - multimodal day treatment for children with disruptive disorders produced significantly greater improvement in behaviour than in a control group Substance misuse � additional benefits from community treatment Obsessive-compulsive disorder � poorer outcome among those needing admission compared with those treated as outpatients 

17. MODELS OF OUT-OF-HOSPITAL CARE Family preservation Home Treatment Case Management: assertive outreach, assertive community treatment, wraparound and intensive community treatments Multi-systemic Therapy Treatment Foster Care

18. Well known examples can be referred to on the National CAMHS Support Service (NCSS) website www.cypf.csip.org.uk/camhs & the CSIP Knowledge Community http://kc.csip.org.uk/ Massie L, (2008) Right Time, Right Place: Learning from the Children�s National Service Framework development initiatives for psychological well-being and mental health, 2005-2007. http://www.cypf.csip.org.uk/camhs/childrens-nsf-initiatives--development-projects.html Kurtz Z, James C. (2005) Creative practice and innovation in child and adolescent mental health services, pp 534-544 In: Williams R, Kerfoot M (eds). Strategic Approaches to Planning and Delivering Child and Adolescent Mental Health Services. Oxford: Oxford Medical Publications. Kurtz Z, James C. (2002) What�s New: Learning from the CAMHS Innovation Projects. London: Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006011 SUGGESTED READING

19. THE EFFECTIVENESS OF INTERVENTIONS TO MEET THE COMPLEX AND OFTEN ENTRENCHED MENTAL HEALTH NEEDS OF CHILDREN AND YOUNG PEOPLE This depends upon: Access, and engagement, often over the long-term Intervening at the earliest stage and avoiding crisis situations Full understanding of the needs of each individual child Attention to problems that are not diagnosable mental health disorders Promoting the child�s strengths, self-efficacy and resilience Outcomes that are �measured� across a number of domains Staff are appropriately skilled, valued and supported Agencies working together in full collaboration