8. Specialist Child and Adolescent Mental Health Services
Context
8.1 The primary function of specialist child and adolescent mental health services ( CAMHS) is to develop and deliver services for those children and young people (and their families and carers) who are experiencing the most serious mental health problems. These services are provided directly by specialist CAMHS teams in many cases, particularly to those children and young people whose difficulties are complex and severe.
8.2 As is clear throughout this Framework, specialist CAMHS staff also have a very important role in supporting what the SNAP report called the "mental health capacity" of the wider network of children's services. For example, paediatricians commonly support the mental health and wellbeing of children and young people who have mental health difficulties and a physical or learning disability, while residential social workers are often involved with children and young people with complex difficulties, including mental health problems. It is important to recognise the role and contribution of these practitioners.
8.3 Local arrangements are required to develop and sustain that contribution and the role of specialist CAMHS practitioners in supporting it, through liaison, consultation and training. However, wider initiatives to increase that capacity are also needed. These will include steps to establish awareness of mental health and wellbeing as a core item in the training of all professionals who work with children and young people. Also important are initiatives to develop skills in understanding and working with children and young people with mental health problems. Good examples of this are the training programme developed by YoungMinds for those working with looked after and accommodated children and young people, and the "Child in Mind" joint initiative between the Royal College of Psychiatrists and the Royal College of Paediatrics and Child Health.
8.4 Practitioners who contribute to specialist CAMHS include: psychiatric nurses, child and adolescent psychiatrists, clinical psychologists, forensic psychiatrists and psychologists, social workers, psychotherapists (including child, analytical, systemic/family, cognitive behavioural), creative therapists (including art, music and drama), play therapists, liaison teachers, speech and language therapists, occupational therapists and dieticians.
Overarching philosophy and culture
8.5 The English National Service Framework 77 has described the key elements of a child and adolescent mental health service that "works". It suggests that services need:
- "Strong inter-agency commitment over the medium to long-term, including a steering group or strategy group willing to tackle tricky issues, and a commitment to consulting with and acting on children's and families' views;
- Links with existing services within CAMHS, including the integration of the service within the CAMHS tiered framework and CAMHS development strategy;
- Links with other services and initiatives outside CAMHS, e.g. education, the voluntary sector and area-based initiatives;
- An ability to attract new sources of funding;
- Retention of a stable, multi-disciplinary staff group with opportunities for training and development;
- Positive commitment to continued evaluation and audit; and
- Balance between providing a direct service to users and influencing the broader network." ( Page 36)
8.6 This applies equally in Scotland. Services should also ensure compliance with professional and other guidelines such as those produced by the Royal College of Psychiatrists and the Mental Welfare Commission for Scotland.
A comprehensive range of services
8.7 It is important that children and young people in all parts of Scotland have access to the full range of mental health services, delivered locally through an appropriately planned and commissioned network of mental health services for children and young people.
8.8 Some more specialised services are more appropriately developed and delivered on a regional basis, as with the dedicated inpatient provision for young people, and some on a national basis, as with the dedicated inpatient provision for children. The Scottish Executive's Children and Young People's Health Support Group has published detailed recommendations 78 on the size, care models and commissioning arrangements for psychiatric inpatient services for children and young people in Scotland. The Framework cross-refers to the Inpatient Working Group's detailed recommendations, and should be read in conjunction with the detailed report.
8.9 Decisions about which services can be delivered locally and which should be delivered regionally and nationally should proceed from a presumption of local delivery, unless better care can only be made available on a regional or national basis. While such decisions will be informed by considerations of capacity within services, they should be governed primarily by considerations of quality of care.
A network of services
8.10 The SNAP report highlighted the importance of the connections between teams and agencies, advocating that they seek to operate as "intelligent networks" which are based on constructive and adaptable relationships between members. A particularly important quality of functioning as an intelligent network is that participants envisage the care pathways which children and young people may need to take, and then act with their partners in the network to make that pathway - and inter-agency transitions in particular - as smooth as possible.
8.11 Following publication of Building a Health Service Fit for the Future79 and the associated report on children's services, work is underway to identify those services for children and young people's health which can best be delivered using a formal Managed Clinical Network. Planning for services to address mental health problems should proceed in the same way. Proposals are already in development for a new Managed Clinical Network for children with severe and complex mental health problems. This is intended to improve opportunities for specialist staff across the country to support each other with the use of IT and other means, and is likely to be particularly beneficial for those in remote and rural areas.
8.12 There is already a Forensic Mental Health Services Managed Care Network 80, with a number of working groups. The Network is developing advice on the provision of forensic mental health services for children and young people in Scotland. Planning for the development of forensic services for children and young people should take this advice into consideration.
Capacity and skill mix
8.13 The SNAP report discussed the contribution that specialist CAMHS can make across the continuum of mental health promotion, prevention, treatment and care, and this Framework has described this in some detail. The SNAP report also made clear that an enhanced role - with significant developments in liaison, training and consultation activities, as well as the range of direct work with children, young people, parents and carers - would not be achievable within services resourced as they were in 2002, when the SNAP review was undertaken.
8.14 The numbers and mix of specialist professions within a specialist CAMHS team will largely depend on local needs assessment and the priorities agreed within a local area. Where the configuration of services is informed by local need and developed in light of the particular patterns of strengths and weaknesses in partner services, local commissioners may be well placed to develop a view about the overall shape of the specialist CAMHS needed. However, there is a risk that in the absence of indicative figures, NHS Boards and their partners will not be well placed to make reasoned judgements about the scale of service.
8.15 The English National Service Framework81 states that:
"An analysis of a number of attempts to estimate staffing need has suggested the following: a generic multi-disciplinary CAMHS at Tier 3 with teaching responsibilities and providing evidence-based interventions for 0-17 year olds would need a minimum of 20 whole time equivalents ( WTEs) per 100,000 population, and a non-teaching service, a minimum of 15 WTEs." ( Page 28)
8.16 There are current shortages in available workforce which are impacting on service capacity. A CAMH Workforce Group has been working on a CAMH workforce profile to support planning for future workforce requirements. This is due to be published concurrently with this Framework.
Service elements and activities
Service Elements |
Activity |
Outcomes |
Planning and commissioning |
- Development of a multi-agency strategy for child and adolescent mental health services ( CAMHS) on the basis of local needs assessment (including the needs of particular groups of children and young people who are at higher risk of mental health difficulty).
- Use of the multi-agency CAMHS strategy to inform identification of priorities for investment across the care pathway.
- Multi-agency planning and commissioning which is informed by:
- the child and adolescent mental health strategy
- the views of users, carers and providers
- service use and outcome monitoring
- risk analysis
- strategies for workforce development, development of the estate (new and refurbished) and Information Management and Technology
- national policies and standards.
- Commissioning which ensures sufficient workforce capacity and skill mix within teams for a range of direct and indirect work to be undertaken across mental health promotion, prevention and care.
- Commissioning which ensures safe and appropriate environments for the provision of CAMHS.
- Commissioning of psychiatric inpatient services for young people on a regional basis with inter-regional liaison and co-operation, which implements the recommendations made in the Inpatient Working Group report.
- Collaboration with the independent sector to provide a range of services across the care pathway.
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- Strategic investment in sustainable services to meet need.
- Services are planned and resourced to provide a balance of direct and indirect work.
- The potential impact of local decisions on services in other areas is recognised and addressed.
- Multi-disciplinary CAMHS teams which have sufficient capacity and skill mix to function safely and effectively.
- Children and young people are cared for in comfortable and appropriate environments.
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Generic teams of mental health practitioners specialising in work with children and young people across the care pathway |
- Investment in and redesign of specialist CAMHS to enable staff to provide liaison, consultation and training for staff in universal services who are in contact with children and young people (sometimes called Tier 1 work).
- CAMHS practitioners working to support colleagues in primary care or directly with children and young people and their family (sometimes called Tier 2 work).
- Multi-disciplinary teams working with children and young people with more complex needs (sometimes called Tier 3 work).
- Provision of supervision, learning and audit for CAMHS practitioners.
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- Support and intervention is delivered as far as possible in the child's usual environments, and within universal children's services.
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Emergency and out of hours mental health arrangements |
- Multi-agency development of clear, well understood and well publicised arrangements for assessment and management of children and young people presenting with mental health emergencies on a 24-hour basis.
- Integration of emergency mental health arrangements with standard NHS arrangements for assessing and managing emergency presentations, and implemented in the same way: via primary care, NHS 24 and accident and emergency services, and including out of hours social work services, according to the circumstances.
- Development of locally agreed evidence-based multi-agency protocols for managing common mental health emergencies, for example, the assessment of deliberate self harm.
- Establishment of clear and agreed arrangements to ensure that developmentally appropriate care environments are in place for children and young people requiring psychiatric inpatient care (in line with section 23 of the Mental Health (Care & Treatment) (Scotland) Act 2003).
- Designation of 1 place within each psychiatric inpatient facility for children or young people for emergency admissions.
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- Children and young people are able to access appropriate assessment, support and treatment quickly when they need it.
- Streamlined continuing care arrangements for children and young people presenting with common mental health emergencies.
- Children and young people requiring psychiatric inpatient care are admitted to developmentally appropriate care environments.
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Intensive outreach services |
- Development of specialist community "intensive outreach" CAMHS teams which provide intensive, flexible and rapidly accessible care for children and young people who present with severe mental health difficulties.
- Development of intensive outreach services in the context of other specialist CAMHS and ensuring particular links with psychiatric inpatient services for children and young people.
- Links to local secure accommodation and Young Offenders Institutes, to ensure integrated care and pre-discharge planning.
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- Intensive outreach services are available as part of the overall network of services for children and young people with mental health difficulties.
- Children and young people with severe mental health difficulties are managed in the community wherever possible.
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Inpatient psychiatric services |
- Inter-regional implementation of the recommendations made by the Child Health Support Group Inpatient Working Group.
- Compliance with the Mental Welfare Commission's good practice guidance on the admission of young people to adult mental health wards 82.
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- Children and young people in Scotland requiring psychiatric inpatient care are able to access developmentally appropriate services, provided consistently across Scotland.
- Psychiatric inpatient care is provided for children and young people on the best available evidence of effectiveness.
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Primary mental health work |
- Provision and promotion of direct contact between specialist CAMHS practitioners and staff working directly with children and young people in universal services, e.g. schools, children's homes or primary care. This could be achieved through appointment of designated primary mental health workers, school-based link workers or generic community CAMH practitioners adopting a particular role 83.
- Provision of supervision, training and support for those engaged in primary mental health work, with ongoing review of needs.
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- Children and young people receive support and care in their usual environments.
- Staff in universal and targeted services receive training, consultation and support in promoting mental health, preventing mental illness and supporting children and young people with mental health difficulties.
- Streamlined care pathways are in place for children and young people requiring access to specialist CAMHS.
- Those engaged in primary mental health work are supervised and supported by the CAMHS team.
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Early intervention |
- Investment in, and organisation of, CAMHS to promote opportunities for early identification and intervention. ("Early" in this respect refers both to early in the lifecycle and early in the problem cycle.)
- CAMHS teams review their criteria for accessing skilled support.
- CAMHS teams work closely with primary care, adult health and social work services to consider and address the impact of an adult's illness on their children.
- CAMHS teams work closely with primary care and childcare services to identify children and young people at risk of, or starting to experience, mental health difficulties.
- CAMHS teams develop explicit arrangements for early intervention for severe mental health problems and, in particular, for early onset psychosis.
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- Children and young people at risk of developing mental health difficulties are identified and supported.
- Children and young people are able to access skilled support, wherever possible, before their difficulties become severe.
- Children and young people who present with severe mental health problems have rapid access to appropriately skilled and supported teams of mental health practitioners.
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Liaison with secondary health care settings |
- Clear, negotiated and well publicised arrangements to ensure that CAMHS are accessible to all secondary health care settings providing services for children and young people, including:
- Accident and emergency departments
- Surgical and medical paediatric wards
- District General Hospitals
- Hospital services for children and young people with complex physical (especially neurodevelopmental) disorders.
- Planning in the longer term for the establishment of a dedicated CAMHS liaison service. This may be delivered by a generic, multi-disciplinary or single discipline CAMHS team and may require a regional approach.
- Implementation of the Child in Mind84 project in all secondary health care settings to promote awareness of mental health amongst paediatric practitioners.
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- Mental health awareness is promoted amongst paediatric, other secondary health care and social work practitioners.
- CAMHS staff contribute to work within paediatric, other secondary health care services and hospital-based social work teams to identify and address a child's or young person's global needs.
- Improved adjustment to, and coping with, physical health problems and treatment adherence.
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Children and young people with complex physical disorders |
- Development of clear links between CAMHS and paediatric and other medical services, and other children's services catering for children and young people with complex physical (particularly neurodevelopmental) disorders.
- Planning to ensure that arrangements include preventive activities, early intervention arrangements and the capacity to collaborate in the assessment and treatment of complex neuropsychological and neuropsychiatric disorders.
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- The mental health needs of children and young people with complex physical disorders are identified and addressed within a holistic approach.
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Children and young people with learning disability and mental health problems |
- Arrangements to ensure that children and young people with a learning disability and mental health difficulties are able to access and benefit from mainstream health services wherever possible.
- Planning for the development of specialist CAMHS which include members who have training both in relation to children's and young people's mental health and learning disability, such as has been described by the Royal College of Psychiatrists 85.
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- Children and young people with mental health difficulties and a learning disability are able to access appropriate care and treatment.
- Staff in generic CAMHS teams and wider children's services are able to access training and consultation.
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Forensic services |
- Planning for the development of forensic capacity within local specialist CAMHS, taking into account the work of the national Forensic Mental Health Services Managed Care Network ( MCN) 86.
- Work with local youth justice and social work teams to address the mental health needs of children and young people involved in the youth justice system.
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- The needs of children and young people requiring forensic mental health services are met.
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Substance misuse |
- Provision of CAMHS input to services for children and young people misusing drugs and alcohol.
- Planning for the development of specialist CAMHS which include members who have training both in relation to children's and young people's mental health and substance misuse issues.
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- The mental health needs of substance misusing children and young people are addressed.
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Liaison with services for looked after and accommodated children and young people |
- Multi-agency planning and commissioning to ensure the development and delivery of appropriate and accessible CAMHS for children and young people in the care of their local authority, including those in residential and secure settings.
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- The mental health needs of children and young people in local authority care are identified and addressed.
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Therapeutic services |
- Planning to ensure capacity within CAMHS to deliver a full range of high quality therapeutic interventions covering a spectrum from psychosocial interventions and psychotherapeutic therapies to the skilled use of the range of medications of proven effectiveness.
- Ongoing training for CAMHS staff in therapeutic interventions.
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- CAMHS are able to offer a range of therapeutic interventions.
- CAMHS staff are able to offer training and supervision to other professionals within children's services in developing therapeutic skills and delivering therapeutic interventions.
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Staff training and development |
- Recruitment of, and training for, new CAMHS staff to ensure skills and knowledge in both working with children and young people and in mental health.
- Continuing professional development arrangements, with associated training budgets, for all CAMHS staff in areas such as:
- Learning disability
- Working with children and young people with additional and specific support needs
- Supporting universal services in "mainstreaming" mental health
- Use of psychoactive medication, cognitive behavioural therapy, child psychotherapy, family therapy
- Research skills.
- CAMHS staff provide advice and training for commissioners and managers about the service needs of children and young people across the continuum of mental health promotion, prevention and care.
- Input to training in mental health as part of ongoing continuing professional development arrangements for professionals such as:
- Paediatricians with a special interest in child mental health
- GPs with a special interest in child mental health
- Childcare staff
- Education staff.
- Provision of adequate staff supervision arrangements and mentoring opportunities for staff when dealing with children and young people with additional requirements.
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- Staff are appropriately skilled and qualified in mental health issues and working with children and young people.
- Staff in universal services are supported to promote mental health and wellbeing, and to provide direct support for children and young people experiencing mental health problems.
- Service commissioners and managers are aware of the specific service needs of children and young people.
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Clinical effectiveness |
- Establishment of routine audit and evaluation mechanisms in line with clinical governance requirements.
- Evaluation of any new developments, whether translating research findings into practice or seeking new forms of service delivery to address previously unmet need.
- Development and adoption of reliable systems for evaluating outcomes in CAMHS practice 87.
- Consultation with service users on their experiences as an integral part of all service evaluation processes.
- Provision of appropriate administrative and IT support to facilitate evaluation.
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- Audit and evaluation is a routine element of CAMHS practice.
- Outcomes are monitored and evaluated to support service planning and delivery.
- Service planning, commissioning and delivery is informed by accurate data and robust evaluation.
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Research and development |
- Use of this Framework to stimulate research activity, as well as to provide opportunities for implementation of research findings.
- Provision of appropriate training and supervision for practitioners within NHS specialist CAMHS to engage in research activity.
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- Academics and practitioners in specialist CAMHS are supported to engage in research activity.
- Research in specialist CAMHS extends across the full range of issues relevant to a strategy of promotion, prevention and care, including epidemiology, developing effective interventions, and developing innovative methods of capacity building.
- Service development is informed by research.
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