National Assembly for Wales

Children, Young People and Education Committee

CAM 17

Inquiry into Child and Adolescent Mental Health Services(CAMHS)

Evidence from : Dr Penny Goss on behalf of Greenhill Special School, Bryn Y Deryn PRU and The Court Special School

1. I am a community paediatrician employed by Cardiff and Vale University Health Board.  I am responding to this enquiry on behalf of Greenhill Special School’s Team Around the School, and in my role as medical officer for Bryn Y Deryn Pupil Referral Unit.  I am also sending this on behalf of Dr. Narad Mathura, Consultant Community Paediatrician in his role as medical officer for The Court Special School.

2. All three establishments:  Greenhill Special School, Bryn Y Deryn PRU and The Court Special School provide specialist education for children identified as having Behavioural, Social and Emotional Disorders.  All children served by these establishments either have a statement of special educational need or are at School Action Plus of the Code of Practice for Special Educational Needs.

3. In considering the specific questions raised in the consultation letter (21^st January 2014) I have reviewed the following documents;

a. Child and Adolescent Mental Health Services -Everybody’s Business; strategy document 2001, with particular reference to the definitions of Mental Health Problems, and Mental Disorders(p14), and also the reference to the 4 Tier Strategic Concept (p24) of service provision

b. Thinking Positively – Emotional Health and Wellbeing in Schools and Early Years Settings, in which Behavioural Emotional and Social Disorders (BESD) are described as “a term to be understood within an educational context that describes a range of problems that children might experience as a result of adverse experiences in the early years, difficult family relationships or ineffective behaviour management or means of engaging children effectively within the school” (p11)

c. Together for Mental Health, The National Service Framework and Breaking the Barriers; the Implementation of the Mental Health (Wales) Measure 2010

1. Collectively these documents express an expectation that CAMHS will work with education to promote the emotional health of children and identify problems early. The strategies include the Healthy Schools Network, the School Health Nursing Service and the School Based counselling service. These fulfil a Tier 1 level of working. 

2. There is no recognition of the different populations served by different educational settings, and there is no mention of the level of correlation that is expected between children with BESD at different levels of the Code of Practice for special educational needs, and the prevalence of mental health problems that the children experience.

4. Our local experience is as follows:

a. Children in BESD provision have, by virtue of their statemented or school action plus status, problems that are both severe and enduring.

b. Their problems meet the defining criteria for ‘mental health problems’ and their severe and enduring nature imply ‘mental health disorders’ (Everybody’s Business)

c. Many children have diagnoses consistent with ICD 10 or DSM 4 criteria and are currently taking medications for these disorders, or have done in the past.

d. Of those who do not have ICD 10 or DSM 4 diagnoses, many have not been assessed by specialist community CAMHS because of the child’s / family’s inability to access the service

e. Of those children in specialist BESD provision, many cannot access primary care services including dentistry, optometry or general practice.

f. Where children are engaged with specialist community CAMHS there is no routine communication with the education establishment the pupil attends.  Liaison occurs on a case by case and occasion by occasion basis.

g. The children may come from recognised vulnerable groups, but most do not.

h. Children in specialist BESD provision have a high level of safeguarding needs.

i. Children in specialist BESD provision frequently exhibit challenging behaviour defined as “culturally abnormal behaviour of such intensity frequency or duration that the physical safety of the person or others is placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to the use of ordinary community facilities” Emerson, E. (1995) Challenging Behaviour. Analysis and Intervention in People with Learning Difficulties. Cambridge: Cambridge University Press.

j. In consequence not only are they unable to access services due to their own poor executive function, but are often actively shunned by services and individual professionals.

5. I have drawn the following conclusions that are relevant to the terms of the consultation:

a. The exclusive focus in schools of services at Tier 1 level jeopardises services for children with established severe or complex needs in specialist BESD provision.

b. Children in specialist BESD provision have a history of poor access to services, including specialist CAMHS and primary health care.

c. Education is the only service to which access is legally compulsory.  All other services, including Primary Care are accessed on a needs led basis initiated by the child’s family. Specialist BESD provision provides an opportunity to deliver Tier2 +/- Tier 3 services to a target population with a universal need

d. Teaching staff consider their duty of care to the child is undermined by their inability to refer directly to specialist CAMHS.

e. Specialist community CAMHS are configured to work around a primary care distribution without regard to education provision.

f. There is no clear expectation at commissioning level as to which agency is to provide what service or to what level of expertise in specialist BESD provision.  Specialist teachers and educational psychologists have a different skill set from psychiatrists, psychiatric nurses in CAMHS.

g. The lack of a reliable or consistent relationship with specialist CAMHS (or with other agencies) contributes to the ongoing risk to these most vulnerable children.

Penny Goss

Community Paediatrician

Cc            Gill James, Achievement Leader, Mynachdy

                Phil Norton, Head of Behaviour Support, Mynachdy

                Jane Counsell, Head Teacher, Greenhill Special School

                Fiona Simpson, Head Teacher, Bryn Y Deryn PRU

                Dr Jo Pike, Educational Psychologist, Mynachdy

                Angela Gregory, Attendance Officer, Mynachdy

                Dr Sadie Olson, Youth Offending Team, Penhill

                Dr Narad Mathura, Consultant Paediatrician, SDCC

                Peter Owen, Head Teacher, The Court School