Child and Adolescent Mental Health Services: inpatient report

A4.8 Admissions to regional young people's units (YPUs)

Summary of characteristics of patients admitted to YPU wards:

• Level of learning disability: 8 no learning disability, 9 mild learning disability, 13 moderate learning disability, 0 severe/profound learning disability
• Autism spectrum disorder: no autism spectrum disorder ratio: 1.5:1
• Age: 63% were 16-17 years, 30% were 14-15 years

A4.8.1 Positive aspects of care

It was generally felt by clinicians that the YPUs were able to appropriately manage the vast majority of admissions for young people with autism spectrum disorder without learning disability, or with mild learning disability. There were good outcomes for most of these young people. However, when YPU beds were unavailable, it was hard to manage the complex needs of these young people in the community or in local adult mental health wards. Some families were relieved when their young person was admitted or transferred from adult mental health units to YPUs. A number of clinicians reported families being happy with care provided. There was more developmentally appropriate activity than on adult LD wards. Clinicians reported that YPU staff were more confident managing young people with mild learning disability and/or autism spectrum disorder when the main presentation was of severe mental illness. To support one young person, they were able to up-skill themselves with help from LD CAMH community clinicians in communication needs, the use of visual timetables and in how to support self-help skills.

A4.8.2 Patient groups with less access to YPUs

Of those with mild or no learning disability in the study, it was mostly children and young people with forensic/secure needs who could not be admitted to YPUs. Generally, YPUs were not considered 'a good fit' for patients with moderate to severe learning disability and a number were not admitted, even if beds were available. Good outcomes for those with more severe levels of learning disability tended to be gained only with extremely high levels of support from local LD CAMH community services. One of the YPUs had been supported in this way to successfully manage a number of young people with moderate learning disability. In that YPU, there was also learning disability expertise in the inpatient staff group itself, with one post-split between the unit and the LD CAMH team.

Clinicians commented that the lack of specialist learning disability input into the Regional YPUs for those outside the Health Board where that YPU is located was a difficulty. In Greater Glasgow and Clyde and in Lothian, there are specialist LD CAMH community services and in Lothian an Intensive LD CAMH service. These services could provide support for their own community patients when admitted to the regional YPU situated in their Health Board, but not usually for those admitted from other regional Boards. This meant unequal access to the regional YPUs for those with learning disability, particularly with moderate learning disability who had more complex presentations and more severe challenging behaviour.

A4.8.3 Parental concerns/relationships with services

Distance was an issue for some families, even to regional units. As well as making travel difficult, it also affected liaison with local services. Families who may have been relieved when an admission was arranged became concerned that staff were not trained on the YPU to meet their young person's needs with respect to their learning disability.

Clinicians reported at least one family had a number of concerns about the patient's care and there were difficult relationships between them and the inpatient team and community Services. Another was critical of social work services such that a patient ended up in hospital due to a lack of other resources. Concern was raised about lack of education arrangements appropriate to a young person with autism spectrum disorder.

A4.8.4 Staff expertise and experience

YPU staff struggled to manage and understand the behaviour of some young people with learning disability, assess the relevance of their symptoms and to cater for their level of need. Staff lacked confidence in working with those with more severe communication difficulties and had difficulty managing high levels of aggression.

This was a highly complex presentation which the adolescent unit struggled with. It was difficult for them to work out the role of the obsessions and the anxiety in a patient with learning disability, autism and psychosis.

Several clinicians were concerned that YPU staff misattributed behaviour that was due to young people's learning disability and mental illness as them exhibiting 'oppositional' or 'teenagery' behaviour.

In one YPU, the local LD CAMH community team had given intensive support and training to staff over a number of years around several admissions. Their expertise and confidence noticeably improved over that time, reducing the need for community team input. An LD CAMH clinician working as part of the ward team also contributed to improved care and led to greater recognition of undiagnosed learning disability and autism spectrum disorder in patients.

Contrasting views of the YPUs expertise on autism spectrum disorder were given, with one clinician noting that they have moved on hugely in recent years in an understanding and management of people with autism spectrum disorder. However, a parent reported that the YPU their child was admitted to had little knowledge about young people with autism spectrum disorder and " the staff were inconsistent in their approach, it seemed to be about who was on duty and that isn't really good enough. You need to feel there is a shared understanding and a consistent approach being taken". Another setting was reported as " being fully aware of my child's needs and how her autism affected her behaviour. We had long conversations so did the consultant. They offered a place in the knowledge of the challenges she presented. Two weeks in they announced they couldn't manage her."

A4.8.5 The physical ward environment

Few young people with more severe levels of learning disability and highly challenging behaviour were admitted to YPU beds. One major limiting factor to their admission was the lack of availability of a separate, quiet part of the ward on which they could be nursed separately from other patients for safety reasons. This was also a problem for those of all degrees of learning disability and none whose autism spectrum disorder meant they could not cope with being around other patients. However, a small number admitted to one YPU used a secured segregated area with extensive reinforcement of all fittings and doors. This was built to accommodate one specific patient, who was nursed in isolation with staff sitting outside the door. One young person with autism spectrum disorder but no learning disability also required this area, due to their sensory needs and need for containment. This was too restricted for their overall care and a specialist secure autism spectrum disorder unit was required.