Child and Adolescent Mental Health Services, They are a-changing

I started working in Child and Adolescent Mental Health Services (CAMHS) in 2007, which doesn’t sound like a long time ago in the scheme of things. Even so, I’ve noticed a lot of changes in what we do and how we do it. This post is an attempt to summarise those changes – some good, some bad.

 

 

CAMHS emerged out of what used to be known as child guidance clinics. These emerged in the early twentieth century to prevent “maladjustment” as it was then called, and to promote emotional wellbeing. There’s a potted history of them here – critics of the DSM-5 might wish to note that using psychiatric jargon to describe delinquent or even merely shy children has a longer heritage than they might think.

As a result, a lot of what was being brought to our doors back in 2007 could be viewed as psychosocial problems – angry kids, stressed-out young carers, family problems. Our service used to provide Webster-Stratton style behaviour management training for the parents, and anger management courses for the kids. Since then, I’ve noticed a steady shift away from us being a “child guidance” service, and much more of a mental health service. This isn’t so much down to waves of diagnosis mania coming over from the United States, more an effect of public sector cutbacks.

When the Credit Crunch hit, and it was clear that public services were going to be squeezed (and mental health services are always the first to get hit) there was a lot of talk among our higher-ups of “focusing on our core client base”. Who were the children who really need to see a mental health service?

Among the first things to go were the parenting classes. Other services outside of CAMHS offer them, and we can signpost parents to those services. The anger management courses are also offered less and less, but that’s for a different reason. Anger management for children is a waste of time. It’s vapid, shallow and doesn’t address the core question which is, “Why is this child getting angry?” Often it can be counter-productive, abdicating the responsibilities of parents, teachers and other adults to guide and support the child, in favour of handing that responsibility to someone too young to handle it.

Along with that has come a tightening of the referral criteria. We don’t accept referrals for “oppositional defiant disorder” (naughty kids) or “conduct disorder” (kids committing crimes) and have become stricter about this. We also don’t accept referrals any more for “school phobia” – if a child isn’t going to school, it’s the responsibility of parents and education services to get them there, not of CAMHS. This isn’t to say we won’t see kids who are becoming angry or avoiding school as a result of a mental health issue. It’s just that there has to be a mental health issue.

Perhaps I should say a few words about what happens when a child is referred to CAMHS by their GP. The referral letters are discussed. Depending on what the GP has written, these referrals then go either to a Primary Mental Health Team (PMHT) or to specialist CAMHS.

The PMHTs deal with those referrals that don’t contain any obvious indications of a psychiatric problem, or where another problem is clearly referenced. We get a lot of letters that go something like this.

Dear CAMHS

Thank you for seeing this 7 year old boy who is displaying aggressive and defiant behaviour. Getting into fights, destroying property, getting into trouble at school. Parents wonder if he has ADHD.

Yours Sincerely

Dr Geepee

Yep, sometimes the referral letters are as scanty as that! There’s nothing in this letter that suggests the child has ADHD, other than the parents’ query. Such referrals may well get a letter from the PMHT asking for more information. Have the parents attended a parenting class? What behavioural strategies are the school putting in? Has he seen the educational psychologist? What observations of the child has the GP made in his clinic? (Note: there’s nothing in the above referral letter to suggest that the GP has seen the child rather than just the parents.)

This is bringing us to an interesting example of the Law of Unintended Consequences – cutbacks in services are actually resulting in a more thorough assessment for ADHD, so that the only children who get given ADHD treatment are the ones for whom it’s genuinely indicated. This is only my anecdotal impression, but I wouldn’t be at all surprised if in the next couple of years we see a reversal of the steady rise in ADHD medication prescribing.

Sometimes the contents of a GP letter suggests another service would be more appropriate – say, a young person stressed out by living with a disabled family member. The PMHT may write back signposting them to a young carer service. On a couple of occasions, we’ve had a GP write asking us to treat the anxiety of a child who suddenly becomes distressed and agitated whenever he’s due to go to stay with a particular one of his estranged parents. Such letters tend to result in a hurried phone call back to the GP, telling him he needs to do a child protection referral at the double.

Some referrals can be a bit borderline as to whether they’re for us or not. Sometimes this might result in a member of the PMHT doing a joint consultation with a GP or a school nurse to try to identify a way forward.

And then there are those referrals which clearly indication the sort of problems that require a mental health service – depression, anxiety, self-harm, suicidal ideation, eating disorders and so on. These are the young people we need to focus our limited resources on, so we can give them the quality time that they need.

Contrary to what some have suggested in the media, I don’t think we’re currently seeing the whole range of childhood experience being colonised by psychiatry – at least not in Britain. On the contrary, we’re seeing a narrowing and focusing of CAMHS onto purely those who do need a psychiatric service. It’s not just that it shouldn’t be the realm of child psychiatry to make naughty children behave, or to make children go to school. My experience is that when we’ve tried we simply haven’t been successful. In some cases we’ve made it worse by allowing others to hand over their responsibilities to CAMHS rather than taking charge of it themselves (“You need to talk to my son about the fights he’s been getting into.”)

As to whether CAMHS should “promote emotional wellbeing” as was considered part of the role of the old child guidance clinic, here’s my take on it. If a child doesn’t have a mental health problem, but merely needs his emotional wellbeing to develop further, is it necessarily more effective to send him to a child psychiatrist than to, say, send him to Scouts or Air Cadets? I’m not sure that it is.

There’s another change which has affected both CAMHS and adult services up and down the country, which is that cash-strapped local authorities have started pulling their social workers out of mental health services. For years we talked about the importance of joined-up thinking between health and social care, and this was considered normal good practice. In times of austerity, this assumption has been cast aside because, to put it bluntly, normal good practice is too expensive. The NHS and social services are being torn asunder, with healthcare happening in one place and social care happening in another. This regularly results in unseemly battles between CAMHS and social services, with each service trying to persuade the other that a particular child is the other service’s responsibility not theirs. Collaborative multi-agency working in a spirit of mutual trust and cooperation? Whassat?

There’s also another change that’s come in. In 2008 we had a couple of young people with eating disorders being seen by the intensive outreach team, and virtually none with the outpatient clinic. Now, half the caseload for the intensive outreach team have an eating disorder. Meanwhile in the outpatient clinic, I have half a dozen young people with eating disorders on my personal caseload alone. This rise is worrying not least because of the risks involved – out of all the mental disorders, anorexia nervosa is the one that has the most capacity to kill you. While the number of young people with eating disorders is relatively small, they often need considerable amounts of time and effort just to keep them safe, never mind help them towards recovery.

While CAMHS in my part of the country still have relatively decent resources and expertise in eating disorders, the same sadly isn’t true in adult services. From talking to colleagues in adult mental health, it seems clear that there’s a will and a desire to improve eating disorder services for adults. Sadly, what there isn’t is any extra money. As this tragic case shows, sometimes young people with anorexia do well with CAMHS, and then it can catastrophically fall apart after they turn 18.

Melanie Lockett, a consultant gastroenterologist at Frenchay, told the inquest there was a change in the trust’s policy regarding eating disorder patients. “We were instructed that we had to … we used to keep patients longer than medically required,” she said. “The rationale for that was to give them a buffer so that when they went home they would not end up in crisis so very quickly. We applied for funding from the PCT for this service in 2009/10 and it was turned down. Therefore it was no longer offered. The PCT would not fund that. It was a PCT decision.”

You can almost hear the frustration in Dr Lockett’s voice, can’t you?

A while back I heard of a young woman with anorexia who recognised that her eating patterns were spiralling out of control, and begged to be admitted to hospital. She was told that services weren’t commissioned to provide inpatient care for anyone with a body mass index over 13. Can you guess what she did in response? If you feel sick in your stomach right now, you guessed right.

So, that’s roughly how CAMHS have changed over the last few years. A re-focusing onto its core client base, a disconnection from social services leading to an often-dysfunctional relationship with them, and a deeply concerning rise in eating disorders. As for what the future holds, who knows?

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About Zarathustra

Trained as a nurse, currently working in Child and Adolescent Mental Health Services (CAMHS). Co-editing the Not So Big Society blog. May possibly be an incorporeal being called Phil Dore. All views expressed are in a personal capacity and not necessarily the views of my employer.

17 Responses to “Child and Adolescent Mental Health Services, They are a-changing”

  1. I get a little bit angry every time i hear “Thats not part of our core business” we used to provide respite in NHS units which for the most part worked very well now it’s no longer funded we will have rehab units and crisis beds but no respite or any idea how we find it in the private sector.

    Quite a few LAs in this area have split from Trusts and it’s looking increasingly likely that we will be next all the years we have spent developing an integrated service offering a truly comprehensive assessment and holistic care wasted. Soon we will be back to the bad all days services arguing over what’s a health need or a social need with the most vulnerable losing out

  2. Good summary. So sad to hear of the young person who actually wanted inpatient ED support being put in that position. I was in a similar situation 20years ago as a 10yo, by the time I was admitted I had lost that crucial window of insight and no longer wanted help (cognition at BMI <13 can be very different from BMI 15) and required restraint, PEG (including anaesthesia without consent), 2 x resuscitation as inpatient and extended detention. That sort of interaction can make it very hard to work positively with services. I wonder if treatment had been available before it became so embedded if it could have been managed less restrictively. I'd hoped something would have changed for the better in terms of access for young people in that time, it makes me immensely sad that children are still put in that position. I'm in a similar situation again with adult ED services now. Where I live there is a BMI 18months. At current rate I’ll be below 12.5 before the 18months has elapsed. Even purely from an economic management of services standpoint, there’s something very inefficient about letting that happen.

  3. hmm, using less than and more than characters screwed the formatting there. Final part should have read: where I live there is a BMI cut off for adult inpatient of less than BMI 12.5. And the wait for low weight patients above BMI 12.5 for outpatient can be over 18months. At the current rate I’ll meet the inpatient criteria before the outpatient waiting list time has elapsed.. :(

    • The thing that strikes me most about the BMI cut-offs is (a) Who on earth thinks 12.6 is a healthy BMI? and (b) Who the hell thinks BMI is the only indicator of how well or badly a person with an eating disorder is doing? I once had a psychiatrist tell me that BMI is the last thing he looks at when assessing someone with anorexia.

      It’s health economics at its most brutal and stupid. And as you say, it’s not even efficient on its own terms. Better to avoid the person getting to that stage in the first place rather than insist on their BMI plunging to catastrophic levels before they can be admitted.

      • Yes, BMI alone strikes me as a very lazy and inaccurate way to assess risk in anorexia, even if, as it seems sometimes, the only risk that is considered important in determining treatment thresholds is the risk of death from malnutrition. I’ve known a number of deaths in people with BMI 12.5-15. Even only using crude metrics and ignoring the impact of psychological state on risk rate of loss, HR, electrolytes, core temp, muscle weakness, visceral fat%.. might be better indicators.

        • Yes, this.

          I once saw a girl with a BMI of 19, which is barely even classed as underweight, but her periods had stopped, she was cold in her hands and feet, and her eyes looked like they sinking into their sockets. Which is the more important indicator?

          • it must be so frustrating to see people like that in evident clinical need of urgent help and be restricted in what you can do by criteria like BMI. :( I couldn’t do your job.

            When in treatment years ago, a friend who had concurrent AN and cancer was comparing and contrasting her experience in accessing help in mh and cancer services. It’s a clumsy comparison, but it struck me at the time that making ED patients wait for help until they are almost dead is in some ways similar to diagnosing cancer, then not offering any treatment until it is stage IV and well metastasised. You guarantee yourself poorer outcomes, increased mortality, increased long term morbidity. There are models for early intervention in eating disorders just as with other progressive disease processes. Not using these and has a big human cost as well as being economically irrational. Another friend with AN who became pregnant was deemed not sick enough to be expendited on the then 22mth waiting list for outpatient treatment as her BMI(!) was only just lower than 17.5, so by the local definition of AN here, she barely met ED service criteria. She received no specialist ED support through her pregnancy despite the pleadings of her family, GP and midwife. The baby was preterm, very low birthweight, and subsequently died. Access criteria for ED treatment and the resourcing of ED services make no sense to me. :(

  4. This mirrors my own experience of working in CAHMS. While agreeing in the focus on mental health problems the range of third sector and other agencies springing up is worrying.

  5. My experience as a parent with an AS child was that CAMHS competence was highly erratic and often worse than useless. Son had problems at school which were consistently characterized as disciplinary, he had rage attacks at home which in one case produced a restraint bruise and I was pulled in to a parenting class as a potential abuser. Further problems with bullying (being bullied) and truanting in middle school led to litigation threats from school enforcement officers. Asked CAMHS specifically to consider the possibility of Asperger’s, after a short interview they concluded there was a possibility of Asperger’s traits, but no diagnosis even after he had a series of chats with a counsellor which amounted to ‘pull your socks up’. Eventually self-harming and eating disorder forced us to take him to a private child psychiatrist who diagnosed an eating disorder and school phobia. The school’s response was that no specific reason was given why attendance was not mandatory and more threats of litigation. Eventually, after two suicide attempts and A&E, a competent psychiatric nurse referred him to an actual child psychiatrist at a different CAMHS who diagnosed Bipolar and AS, and the change since then has been enormous and constructive. Point being that the resource to NOT deal with the issue over several years was very substantial and utterly wasted. Most of it can be described as joined-up idiocy, some of it at a different CAMHS outpost was excellent. It has all the hallmarks of true believers trying their best to keep an unworkable system operational despite an incessant rain of obstacles from senior management and policy makers.

  6. School attendance issues are far, far more complex than is often acknowledged; they can also be an indicator of mental distress. There is zero support for a parent who is desperate to get their teenager to school but can’t. I used to invite the authorities to prosecute me, as a disabled widow, but of course they didn’t – and didn’t help in any other useful way either! My son was under CAMHS for 4 years!! In that time, the best thing they did was hold me together as much as possible whilst I fought social services for more help. In the end, it was a residential special school that did the trick, but only because I could start paying out of my late husband’s life insurance until I was able to prove its efficacy. CAMHS was the only organisation that supported my decision to start with, mainly because they took the time to listen to me and support unconditionally.

  7. I’ve been aware of this ridiculous BMI criteria for a while now, and although I’m critical of what EDU’s do I’m incensed that people [especially the young] are refused help when actually asking for it. Another long term consequences of having to reach lower and lower BMI’s before accessing support also include osteoporosis, it’s no joke seeing people in their 30’s with crumbling bones. Lowering the access threshold costs lives, but this is being played out across the whole of mental health care, you have to be practically running around with an axe as an adult to secure a service. I’m so cynical now, I don’t believe suicide registers much in political consciousness, but it’s clearly not pricking the conscious of service commissioners neither knowing the suicide rate is up in the community whilst down for inpatients – doesn’t say much for Home Treatment..

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