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8 - Multidisciplinary working
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- By Ian Partridge, Lime Trees CAMHS, York, Greg Richardson, North Yorkshire & York Primary Care Trust, Geraldine Casswell, North Yorkshire & York Primary Care Trust, Nick Jones, North Yorkshire & York Primary Care Trust
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- Child and Adolescent Mental Health Services
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- Royal College of Psychiatrists
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- 25 February 2017, pp 69-77
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29 - In-patient psychiatric care
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- By Angela Sergeant, Leigh House Hospital, Winchester, Greg Richardson, North Yorkshire & York Primary Care Trust, Ian Partridge, Lime Trees CAMHS, York, Tim McDougall, Cheshire & Wirral NHS Foundation Trust, Anne Worrall-Davies, University of Leeds, Lesley Hewson, Bradford District Care Trust
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- 25 February 2017, pp 270-283
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Summary
‘“It all comes”, said Pooh crossly, “of not having front doors big enough.”’
A. A. Milne, Winnie the PoohIntroduction
Despite the development of home treatment teams and early intervention psychosis services, the demand for in-patient child and adolescent beds remains. It is rare for young people with mental disorders to require inpatient services, but when they do, beds are few and far between. Reasons for admission include severity of illness, deterioration in psychological functioning despite community treatment, high risk to self or others, or family difficulties making treatment difficult, any of which may lead to the need for 24-hour care (Green & Worrall-Davies, 2008). In-patient care is a specialised field providing treatment for young people with serious psychiatric illness by skilled and experienced staff.
Who and what are in-patient units for?
There is a range of psychiatric, educational, social, criminal and societal indicators for admission to an in-patient service. It is usually impossible to separate the different aspects or contributors to the young person's disorder so that each can be provided by the different agencies responsible for it. Psychological disorders, because of adverse life experiences, are common and pure psychiatric disorders are rare, but they all have educational and social precursors and sequelae. Trying to compartmentalise children into unidisciplinary treatment pigeonholes is problematic as:
• admission to psychiatric in-patient units considerably disrupts education and the young person's functioning in the community
• education authorities have to meet young people's special educational needs but cannot isolate these from other social and mental health factors, which they often do not have the resources to address
• residential policies of Social Services departments tend to address young people's mental health and educational needs only as secondary considerations
• the Home Office and Ministry of Justice, which will provide care in a prison setting, have little investment in childhood preventative work for the large proportion of young people with conduct disorder and complex needs when they become adults.
Work on sharing residential responsibility and input requires considerable inter-departmental and inter-agency working, but each agency will be uncertain who is going to reap the most for investing in them, and the harvest is not guaranteed.
Contributors
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- 25 February 2017, pp xiii-xiv
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Frontmatter
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- 25 February 2017, pp i-vi
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22 - Bereavement services
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- By Barry Wright, North Yorkshire & York Primary Care Trust, Ian Partridge, Lime Trees CAMHS, York, Nick Jones, North Yorkshire & York Primary Care Trust
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- 25 February 2017, pp 207-213
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Summary
‘To the bereaved nothing but the return of the lost person can bring true comfort; should what we provide fall short of that it is felt almost as an insult.’
John BowlbyIntroduction
Bereavement is not a pathological process, but can lead to a significant mortality and morbidity. Some children may suffer significant psychological consequences (Pettle-Michael & Lansdown, 1986) but depression is rare (Pfeffer et al, 2000). The evidence for the efficacy or usefulness of therapeutic work is limited (Harrington & Harrison, 1999; Currier et al, 2007). Research suggests that positive outcomes from therapeutic work are more likely to be achieved if certain groups of children are selected and provided ‘timely’ treatment (Currier et al, 2007). The corollary of this is that many children do well with family and community support and never need to see child mental health services (Dyregov, 2008).
Indications for bereavement work
Children may need support at times of family bereavement. There are a number of reasons the impact of bereavement on the development of children might be more pronounced.
• Bereavement may be associated with circumstances in which the normal supportive family influences are severely hampered; such circumstances include parental mental illness (Van Eerdewegh et al, 1985), catastrophic parental bereavement responses, and emotionally abusive or neglecting parents (Elizur & Kaffman, 1983; Bifulco et al, 1987).
• Severe psychological trauma associated with the death, including parental suicide (Wright & Partridge, 1999; Pfeffer et al, 2000; Department of Health, 2008).
• Repeated bereavement.
• Prolonged disruption to the child's life.
• Family system changes (Wasserman, 1988).
• Extreme circumstances such as war (Goldstein et al, 1997).
Managing bereavement
Childhood bereavement services look at the effects of bereavement on children in a number of ways.
• Diagnostically: bereavement can lead to emotional or behavioural problems that have social or educational effects and that represent a diagnosable entity.
• Adult mental health: there may be effects on the parenting available to the child before or after the bereavement.
• Child protection: bereavement may upset parents’ emotional or physical care of a child.
• Systemically: there may be systemic effects that represent risk factors for the child.
• Developmentally: the circumstances surrounding the bereavement may damage the child's development.
• Attributionally: beliefs and attributions regarding the death, in either the child or the family, may be damaging.
5 - Evidence-based practice
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- By Jonathan Barrett, West Leeds CAMHS, NHS Leeds, Juliette Kennedy, Yorkshire and the Humber Postgraduate Deanery, Ian Partridge, Lime Trees CAMHS, York
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- Child and Adolescent Mental Health Services
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- 25 February 2017, pp 39-50
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Summary
‘The good educationalist works from within the material drawing it out, he does not impose the pattern he has chosen on “ungrateful material”.’
Cornelius CardewIntroduction
Evidence-based practice in CAMHS is epitomised by the conscientious, explicit and judicious use of current best evidence in decision-making about the care of young people and families (Sackett et al, 1997). Evidence-based practice therefore strives to:
• improve decision-making
• encourage cost-effective use of limited resources
• enhance knowledge among CAMHS practitioners
• assist in communication with families and facilitate collaborative, informed decision-making.
The underlying philosophy of evidence-based practice is that therapeutic interventions should be rational, measurable and observed to benefit their recipient (Laugharne, 1999). This leads to an attempt to standardise the way that all healthcare workers make clinical decisions, with a strong emphasis on using the best evidence available from research.
‘The aim is to see that Research and Development becomes an integral part of healthcare, so that managers and practitioners find it natural to rely on the results of research in their day to day decision making. … Strongly held views, based on belief rather than sound information, still exert too much influence in healthcare. In some instances knowledge is available but is not being used, in other situations additional knowledge needs to be generated from reliable sources.’
(Peckham, 1991)In this statement the government set an agenda that obliges all healthcare professionals to use evidence-based approaches to their clinical decision-making. A First Class Service (Department of Health, 1998) specifies that a quality organisation will ensure that evidence-based practice is in day-to-day use, with the infrastructure to support it. Evidence-based practice has been driven by the need for accountability to commissioners, families and those funding services. Standards for Better Health (Department of Health, 2006) states that healthcare organisations ensure that they conform to NICE technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care. Inertia can be induced when practitioners are required to work differently, which might present a barrier to the implementation of evidence-based practice. There are attendant risks of evidence-based nihilism, if professionals seek ‘perfect’ rather than the best-available evidence (Ramchandani et al, 2001). Research is provisional by nature, and will only provide definitive answers to specific populations.
1 - Introduction
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- By Ian Partridge, Lime Trees CAMHS, York, Greg Richardson, North Yorkshire & York Primary Care Trust
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- Book:
- Child and Adolescent Mental Health Services
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- 25 February 2017, pp 1-8
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Summary
‘The world is disgracefully managed, one hardly knows whom to complain to.’
Ronald Firbank, VaingloryPurpose and scope of the book
Child and adolescent mental health services (CAMHS) comprise a small, unusual specialty often ill understood by those who work within, those trying to use and those trying to commission them. In an attempt to make order out of the possible chaos, Together We Stand (NHS Health Advisory Service, 1995a) offered a review of and a strategic framework for, the organisation and management of CAMHS. This strategic approach was sanctioned by the House of Commons Health Committee (1997) and provided the benchmarks against which CAMHS have been measured (Audit Commission, 1999). Unfortunately, since the publication of the first edition of this book, the application of the principles and strategic approaches that informed Together We Stand has been subject to individualistic variation.
The tiered system has been bastardised or ‘moved on’ over the past 10 years to an incomprehensible ‘lingo’ in which many writers assume all ‘specialist’ or ‘core’ CAMHS operate at Tier 3, and Tier 2 has been confined to limbo, beneath the dignity of so-called ‘senior professionals’ of whatever discipline. The differing interpretations have resulted in the very confusion about services that the tiers were intended to overcome, so the risk of the confusion that reigned prior to 1995 has reoccurred, indeed it has been amplified. There is a serious risk that CAMHS will again become marginalised as they cannot be understood and are subject to changes and targets from those in power who do not understand their functioning, as advisors to government ministers have no real understanding of what the tiers are about. The tiered system is an integrated approach in which CAMHS professionals work across tiers: it is not and cannot function as a hierarchical system in which ‘senior clinicians’ are seen to operate at Tiers 3 and 4 only. The creation of ‘Tier 2 teams’ is a contradiction in terms, and reinforces the hierarchical attitude that only senior staff work at Tier 3 and above, which undermines both an integrated approach and true multidisciplinary working. It is worth restating the following.
26 - Parenting risk assessment service
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- By Ian Partridge, Lime Trees CAMHS, York, Greg Richardson, North Yorkshire & York Primary Care Trust, Geraldine Casswell, North Yorkshire & York Primary Care Trust
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- Child and Adolescent Mental Health Services
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- Royal College of Psychiatrists
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- 25 February 2017, pp 242-247
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Summary
‘We may be excused for not caring much about other people's children, for there are many who care very little about their own.’
Samuel JohnsonIntroduction
Multi-agency cooperation and multidisciplinary perspectives are two prerequisites of the effective safeguarding of children (as per the Children Act 2004), and this has led to structural and organisational reform in safeguarding children with an emphasis on prevention rather than intervention (HM Government, 2004), but the least detrimental alternative for a child who has suffered significant harm will still need to be determined. The questions now asked of agencies are not about the establishment of the probability or certainty that a particular abusive act has taken place, but about whether the risks of return to parental care or the care of those responsible when the abuse took place outweigh the possible harm of statutory intervention.
Risk depends on the intra-personal characteristics of parents and children and their interpersonal interactions. Mental health input into risk assessment procedures has tended to centre on the psychiatric assessment of the parenting adult and a CAMHS role in the psychological/psychiatric assessment of the child. In addition, there is a role for CAMHS in looking at the parental ability to parent and the risk posed to the child's development, regardless of the absence or presence of psychiatric disturbance.
An independent multidisciplinary team within CAMHS that assesses forensic risks within a systemic and developmental context can contribute to the comprehensive assessment of risk and offer a valuable service to statutory agencies and the courts (Smith et al, 2001).
Risk assessment teams that advise the courts are incorporated in the chief medical officer's recommendations for providing reports to the courts in family law cases (Donaldson, 2006). There is a clear requirement to demonstrate the benefit to the child's welfare and well-being of any intervention.
Risk to children depends on the:
• intra-personal characteristics of each parent and carer
• intra-personal characteristics of the alleged abuser
• intra-personal characteristics of the child
• interpersonal relationships between the parents/carers
• interpersonal relationships between the parents/carers and the Abuser
• relationship between the parents/carers and potential supportive Agencies
• interpersonal relationships between each parent/carer and the child. Recently, the role of the ‘expert’ witness in cases concerning both harm and risk to children has become a topic of considerable debate.
Tables, boxes and figures
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14 - Structuring and managing treatment options
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- By Barry Wright, North Yorkshire & York Primary Care Trust, Sarah Bryan, Nick Jones, North Yorkshire & York Primary Care Trust, Ian Partridge, Lime Trees CAMHS, York, Greg Richardson, North Yorkshire & York Primary Care Trust
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- 25 February 2017, pp 127-137
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Summary
‘Life is short, the craft long to learn, opportunity fleeting, experiment deceptive and judgement difficult. Not only must the physician be ready to do his duty but the patient, the attendants, and external circumstances must all conduce to a cure.’
HippocratesIntroduction
The routine problems presenting to a CAMHS are likely to be addressed by those working at Tier 2 by an individual specialist mental health professional working with the problem. The demands of this everyday CAMHS work require all the specialist skills available in the service. No professional, unless at a very inexperienced stage, should not be available for Tier 2 work. To some extent the expenditure of energy on the development of the more high-profile ‘specialist’ Tier 3 teams is secondary and needs to be carefully managed to maintain availability of Tier 2 specialist provision. Treatments such as CBT are often offered by Tier 3 teams, although service members with relevant skills will do this as part of their Tier 2 work. The system needs to be coordinated and managed so that there is equity of access for required services at the most effective tier.
Requisites of Tier 2
‘Critical mass’ of staff
Meeting the needs of the community and providing a comprehensive range of services requires a critical mass of CAMHS staff with a multidisciplinary skill mix and a clear recognition of professional function.
Assessment
Assessment represents the first stage of any therapeutic relationship and professionals working at Tier 2 need a clear model of assessment.
Continuum of care
The Tier 2 professional, who may link up with Tier 1 workers, will also be in a position to access and make use of Tier 3 and Tier 4 provision where required. This highlights the importance of communication both within CAMHS and with other agencies, as well as underpinning the principle that all disciplines should be involved in this area of service provision.
Training and supervision
Staff of all disciplines require access to affordable and relevant training. Training budgets are limited and unequal in their distribution. It may be that units develop alternative funding strategies to support less well-resourced disciplines. In-house training initiatives and multi-agency and multidisciplinary training programmes are effective and keep costs down. Professional supervision is a prerequisite for effective professional functioning.
13 - Strategies for working with Tier 1
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- By Greg Richardson, North Yorkshire & York Primary Care Trust, Ashley Wyatt, Ian Partridge, Lime Trees CAMHS, York
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- 25 February 2017, pp 112-126
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Summary
‘In the beginning was the word and that word may well have been anxiety.’
Jules MassermanIntroduction
Mental health problems in children are best understood as being affected by and presenting in the children's constitutional functioning and in all areas of their interaction with their environment. Parents, families and teachers have a major role to play in the maintenance of mental health. Professionals such as childminders, teachers, school nurses, educational psychologists, social workers, GPs and health visitors make a substantial contribution to the promotion and maintenance of the mental health of children if they come in contact with them. They also play a role in the early identification of mental health problems, children's vulnerability thereto and in the management of those mental health problems once identified. However, Tier 1 professionals often feel at a loss as to how to manage children's mental health problems and all the emotional baggage that goes with them.
Mental health professionals, who provide a small part of the mental healthcare of children, classify the more serious mental health problems as mental disorders (World Health Organization, 1992). These disorders represent a small proportion of mental health problems produced by constitutional, family, educational, social and environmental factors, illness or developmental delay, all of which may impair future psychological functioning. The epidemiological evidence is that mental disorders affect about 10% of children (Ford et al, 2003), although estimates range from 10 to 20% (Fombonne, 2002). If all those children were referred to CAMHS, the service would be overwhelmed. Child and adolescent mental health services see only about 20% of these children. The alternative of providing support to Tier 1 professionals from primary mental health workers, or other CAMHS professionals ensures:
• children with mental health problems, and their families, are dealt with by those with whom they already have a relationship;
• more children than could be seen by individual mental health professionals have the benefit of mental health expertise;
• increased confidence and expertise among Tier 1 professionals dealing directly with young people and their families (Richardson & Partridge, 2000).
3 - CAMHS and the law
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- By Ian Partridge, Lime Trees CAMHS, York, Greg Richardson, North Yorkshire & York Primary Care Trust, Mary Mitchell, Leigh House Hospital Winchester
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- 25 February 2017, pp 21-33
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24 - CAMHS and looked-after children
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- By Fiona Gospel, North Yorkshire & York Primary Care Trust, Jackie Johnson, North Yorkshire & York Primary Care Trust, Ian Partridge, Lime Trees CAMHS, York
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- 25 February 2017, pp 226-233
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Summary
‘Change is not made without inconvenience, even from worse to better.’
Richard Hooker, Of The Lawes of Ecclesiastical PolitieIntroduction
There are assorted reasons for children being ‘looked after’. A proportion will have suffered physical, sexual or emotional abuse, and parental mental illness. Marital violence, relationship breakdown and parental imprisonment are not uncommon experiences. These children can be seen as enmeshed in a matrix of developmental disadvantage, and have a higher number of risk factors predisposing them to mental health problems. They may already have significant mental health problems as they enter care (Dimigen et al, 1999).
The care system presents these young people with further challenges and difficulties, particularly frequent moves and placement breakdowns (Quinton & Rutter, 1984; Minty, 1999), which may influence their already vulnerable state, interacting with and interrelated to social, educational and relationship difficulties. A cycle evolves whereby children with mental health problems are less likely to achieve placement stability, and therefore become more vulnerable (Barber et al, 2001).
‘Upon rereading my old diaries, I realised how hard foster care was and what a detrimental effect it had on me at that time. Before my first foster placement broke down, I thought foster care was a relatively positive experience, apart from the usual problem of occasionally feeling a bit awkward around the family, but when my foster care placement did breakdown, literally overnight, I realised why some young people in care do have the problems they do. I became very defensive and was determined to never let anyone ever hurt me ever again. I developed a very hard exterior to protect me at that time.’
(Cuckston, 2004: p. 24)A study in Oxfordshire, which looked at the mental health needs of looked-after children, found that 97% of children living within residential care and 57% of children living in foster care were found to have significant mental health problems (McCann et al, 1996). In their research on the mental health of looked-after children aged 5–17 years of age in England, Meltzer et al (2003) discovered that 45% of these children had a mental disorder, 36% a conduct disorder, 12% an emotional disorder and 7% were rated as hyperactive.
Preface
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- By Ian Partridge, Lime Trees CAMHS, York, Greg Richardson, North Yorkshire & York Primary Care Trust
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- Book:
- Child and Adolescent Mental Health Services
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- Royal College of Psychiatrists
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- 25 February 2017, pp xvii-xxiv
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Summary
‘“Lucky we know the forest so well, or we might get lost,” said Rabbit ... and he gave the careless laugh which you give when you know the Forest so well that you can't get lost.’
A. A. Milne, The House at Pooh CornerThis second edition is a ‘how to do’ text and an update of the evidential and operational base for child and adolescent mental health services (CAMHS) delivery, and about organising intervention into the lives of children and their families, into their functioning and relationships. It is a parochial rather than a universal text – it addresses CAMHS in a particular country, the UK and primarily England, at a particular time, although we hope the principles of service delivery will have a more universal resonance. Service delivery is bound by the interacting contexts of healthcare delivery, attitudes to mental health, attitudes to children and broader social mores, locally and regionally, and the wider social, political and economic context as well as the tension between a demand for and supply of clinical provision. This book describes ways of delivering services to young people and their families within, and with full awareness of, those contexts.
This book is about the operation of services for children and young people who have been identified as having mental disorders or psychological problems. It is not about the emotional well-being of all children, although it recognises and acknowledges factors in our society that influence that emotional well-being. The difference between treating mental disorder and ensuring emotional well-being are clarified by the two questions those of us interested in the welfare of children need to address.
How do we as a society support, respect and develop self-esteem in those who in turn will do the same for their children? This question belongs in the arena of nurturing the mental health of the community, of society.
How do those of us working in CAMHS assess and manage those children and their families who are suffering because of their mental disorder or psychological difficulties?
Unfortunately, the answers to these two questions have become confused.
4 - Structure, organisation and management of CAMHS
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- By Ian Partridge, Lime Trees CAMHS, York, Greg Richardson, North Yorkshire & York Primary Care Trust
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- 25 February 2017, pp 34-38
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Contents
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11 - Referral management
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- By Sophie Roberts, North Yorkshire & York Primary Care Trust, Ian Partridge, Lime Trees CAMHS, York
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- 25 February 2017, pp 96-103
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Summary
‘I'm playing all the right notes, but not necessarily in the right order.’
Eric MorecambeIntroduction
In CAMHS provision, managing referrals is perhaps the one area that illustrates most clearly the failure to understand and implement the principles of the tiered model of working. If there is one type of problem that generates concern and anxiety in families, commissioners and service providers, it is the management of the demand placed upon the service and how this demand is met.
Waiting lists in CAMHS are a common cause of distress to children's families, referrers and professionals within the service, and have been shown to increase rates of non-attendance (Subotski & Berelowitz, 1990). To avoid waiting lists and to provide an efficient service, a CAMHS must have an overt prioritisation and allocation process for its referrals. The process of allocation must be based upon managerially realistic and clinically relevant principles. As discussed previously, in the future, CAMHS should move away from a system based upon referrals, to one in which tiers are interacting and mutually supporting each other in such a fashion that the notion of referral becomes redundant and working together is integral. The effective functioning of the primary mental health worker will greatly facilitate this process. In the interim, the process of referral and allocation will be the first test of the efficiency of a CAMHS.
Where GPs have access to mental health professionals of different disciplines in adult psychiatric services, they tend to refer different patient groups to each professional (O'Neill-Byrne & Browning, 1996). It is uncertain whether these specific referrals are always geared to meeting the patients’ needs. Studies have shown that there is a poor level of understanding among GPs (Markantonakis & Mathai, 1990; Thompson & Place, 1995; Jones et al, 2000; Foreman, 2001) and paediatricians (Oke & Mayer, 1991) of the different roles of disciplines within a CAMHS. General practitioners identify quick access to services as a top priority for them when they refer children and families with mental health issues (Weeramanthri & Keaney, 2000).
All systems of referral management, however labelled, should be based upon the principles of working together, working efficiently and working in a fashion that is informed by the best evidentially substantiated clinical practice.
Index
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- 25 February 2017, pp 315-323
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Abbreviations
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21 - Eating disorder teams
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- By Ruth Norton, Oakwood Young People's Centre, Sheffield, Ian Partridge, Lime Trees CAMHS, York, Greg Richardson, North Yorkshire & York Primary Care Trust
- Edited by Greg Richardson, Ian Partridge, Jonathan Barrett
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- 25 February 2017, pp 200-206
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Summary
‘How disenchanting in the female character is a manifestation of relish for the pleasures of the table!’
William Charles MacreadyIntroduction
What causes eating disorders and how they are best treated remains the subject of much debate (Royal College of Psychiatrists, 1992; Ward et al, 1995; Shoebridge & Gowers, 2000; Gowers & Shore, 2001; Steinhausen, 2002; Gowers et al, 2007). However, referral to CAMHS continues and the need for an effective service remains. The NICE guidelines (National Collaborating Centre for Mental Health, 2004) recommend psychological interventions primarily in an out-patient setting, naming CBT for bulimia nervosa and family involvement including siblings in the treatment of young people with eating disorders. Specialist services for these young people are increasing, particularly in the independent in-patient sector. The establishment of a Tier 3 team within a CAMHS makes effective use of resources, in terms of both personnel and time (Roberts et al, 1998). The principles that underpin the workings of such a team are set out in Box 21.1.
Eating disorders can present in a number of forms: anorexia nervosa; bulimia nervosa; atypical variations of both; eating disorders not otherwise specified; and other feeding problems or disorders in childhood, described by Nicholls & Bryant-Waugh (2009) as food avoidance emotional disorder, selective eating, food phobias, functional dysphagia and food refusal. Obesity, ironically, remains the result of the major eating disorder of our time – eating too much and exercising too little, but its management is not usually the province of an eating disorder team.
Anorexia nervosa is characterised by a fear of fatness and a preoccupation with food, in which reduction of caloric intake (vomiting may be used) and increase in energy output via exercise and/or forms of purging results in serious weight loss. It may commence prior to puberty, although this is unusual, and affects up to 1% of 15- to 20-year-olds, of whom 10% are male.
Bulimia nervosa is characterised by a fear of loss of control with regard to eating. It results in episodes of binging and vomiting, and a preoccupation with weight and diet. It is more common than anorexia nervosa but tends to develop later in adolescence.