National Assembly for Wales
Children, Young People and Education Committee
CAM 22
Inquiry into
Child and Adolescent Mental Health Services
(CAMHS)
Evidence
from : Llamau
1. Introduction
1.1 Llamau is a registered charity working across Wales with homeless young people and vulnerable women. Llamau seeks to resolve immediate homelessness and prevent future homelessness and vulnerability by supporting vulnerable people to gain the skills and confidence they will need to live independently within the community of their choice.
1.2 We currently operate a range of services across Wales that work with people who are experiencing homelessness or that help prevent homelessness, these include - supported housing projects, domestic abuse refuges, young person’s housing advice projects, family mediation, assertive outreach projects working with the most disadvantaged 14-19 year olds, a prevocational training programme that works with the most excluded NEET service users to gain qualifications and become work ready. We also have two YJB Cymru projects researching better outcomes for young people who are homeless. In addition we have two social businesses run with our service users and are working with Cardiff University researching the issues that young people who are homeless face to better understand these issues. We welcome the opportunity to respond to this consultation.
2. The availability of early intervention services for children and adolescents with mental health problems
2.1 Access to early intervention services for children and adolescents with mental health problems is dependent on the availability of these services and is primarily based on each child or young person’s GP’s knowledge of these services and their commitment to make sure referrals.
2.2 Llamau has recently concluded a 3 year Knowledge Transfer Partnership (KTP) between Llamau and Cardiff University Department of Psychology and the Neuroscience & Mental Health Research Institute. This research found that of the 121 young people who took part at the initial interview[1], 88% reported a current mental health condition and 93% reported previous experience of a mental health condition. This is considerably higher than the 32.3% reported for this age group in the general population[2] . 48% reported symptoms meeting criteria for two or more current co-occurring conditions. Comorbidity, the presence of two or more current psychiatric conditions, is a strong indicator of multiple vulnerability. Psychiatric comorbidity is associated with increased severity of symptoms, longer duration, greater functional disability and increased use of health services (Kessler et al., 2005). At the first follow up interview young people who took part 74% reported symptoms meeting criteria for a current mental health condition. At second follow up, 72% met criteria. This shows a slight reduction in mental health conditions over time. These significant findings have led Llamau to develop a Mental Health and Wellbeing Screening Questionnaire to allow us to better identify those young people we support who may need additional support either in managing or coping with any mental health issues or support in accessing Tier 2 and above services. We are currently piloting this in our Cardiff projects before rolling out across Llamau.
2.3 Frontline support staff and tutors report that access to services that can help young people better manage mental health issues, such as counselling services, have long waiting lists, causing frustration for young people and often meaning that the motivation to attend such services has gone by the time their name gets to the top of the list. In turn this can have a longer term need for Tier 2 and above services and their mental health deteriorates. Staff report poor communication from these services to young people while they are on the waiting list.
2.4 It is only in the past couple of years that some counselling services for young people up to the age of 18 have begun taking referrals for young people who are not in mainstream education. For example in the Vale of Glamorgan, formerly Barnardos and now Action for Children school’s counselling service run regular surgeries from Llamau’s young person’s multi-agency advice centre, @236.
2.5 Llamau would welcome more early intervention services for children and adolescents, particularly within the statutory sector. Often when this age group start to experience issues with their emotional wellbeing, they are not eligible for CAMHS services as they do not fit their criteria. Unfortunately due to the lack of early intervention support, these young people can go on to develop further problems with their mental health, leading to a mental health diagnosis. At this point, they could be eligible for CAMHS services however some of these young people may not have needed these services if they had received support earlier.
2.6 There is a need for proactive approaches supporting children and adolescent emotional wellbeing and mental health. Due to their stage of development, their emotional distress can often be misperceived and labelled as a behavioural problem and opportunities are missed. The development of early intervention services within both the statutory and voluntary sector could address issues such as raising awareness; identifying emotional and mental health issues; building resilience and problem solving skills; providing support that is appropriate to both age and developmental stage to individuals and their families / carers, which would help to reduce the development of long term issues such as diagnosable mental health problems; educational failure / disengagement from education; substance misuse; unhealthy relationships; unemployment; involvement in crime and homelessness. Llamau has two specialist mental health workers who provide training and support to staff as well as running workshops for young people to help them better manage and understand their emotional and mental health. For example these workshops help young people to recognise when their emotional and mental health may be deteriorating and help them understand and practice the steps they can take for themselves to help things improve.
3. Access to community specialist CAMHS at tier 2 and above for children and adolescents with mental health problems including access to psychological therapies.
3.1 The finding of Llamau’s joint research with Cardiff University showed that these high levels of mental ill health did not correlate with access to health services, as identified in the table below. Our research revealed very low numbers of people accessing mental health services and drug and alcohol services. This client group of young homeless people and care leavers seems to be underserved in terms of access to services that may help to reduce mental illness and substance misuse. However, the sample also appeared to be accessing health services more often than young people in the general population[3]. In the general population, the most often accessed health services for 16-24 year olds was recently reported to be the emergency department and outpatient hospital services with 19% having accessed each of these services within the previous twelve month period[4]. Emergency department services and other hospital services in particular appear to be much more commonly used by the young homeless group at 33% and 48% respectively.
|
Service type |
|
||
|
Mental Health Service |
29.2% |
||
|
General Practitioner |
64.6% |
||
|
Accident & Emergency |
32.9% |
||
|
Hospital Services |
47.6% |
||
|
Drug & Alcohol Services |
14.6% |
3.2 These findings also correlate with anecdotal evidence and case studies from Llamau’s front line staff. We have a number of examples of young people attending the GP for treatment/advice on their mental health issues who have received a prescription for 2 weeks’ worth of anti-depressants and told to go back in two weeks if this hasn't helped, rather than being referred to talking therapies or being given other strategies to help them cope.
3.3 One support worker cited her experience of accompanying a young person to her GP because she was feeling depressed, was in a very low mood and was self-medicating with alcohol, ‘street bought’ anti-depressants and cannabis. The appointment had been made as an emergency and therefore the Practice Nurse, rather than a GP was available. The Practice Nurse said her only option was to refer to the Practice Mental Health Nurse but that would take 4 - 6 weeks. Despite the support worker expressing concerns about keeping the young person safe until then, the only advice given was to stop taking the alcohol and drugs until the appointment. This advice failed to see the vulnerability of the young person and that her use of substances was a way of self-medicating.
3.4 In another case, a support worker accompanied a young person to see their GP because they had disclosed they were self-harming and having suicidal thoughts. In this case the GP was unwilling to allow the support worker to assist the young person in saying how they felt as the GP felt the young person should be able to explain himself. The recommendation was referral to a Mental Health Nurse in the Practice, which had a waiting list of two to three months.
3.5 As mentioned previously, often children and adolescents do not meet the criteria for CAMHS. Adolescence can be a turbulent time emotionally and developmentally which means there are vulnerabilities unique to this age group. For those who are engaged with CAMHS services, sometimes this age group feel that the service is not appropriate for their age. Feedback from the young people we support has been, for example, the environment is decorated for younger children; responses can be perceived as patronising or their needs misunderstood. In terms of psychological therapies, some of Llamau’s service users have reported that they feel therapies such as counselling have not been helpful. They can find it hard to engage in the process of counselling therefore do not benefit on a therapeutic level, this could be because the counsellor is not used to working with this age group or with someone with such complex needs. Interventions that may help to address their needs include the development of coping strategies; problem solving techniques; social skills training; improving self-esteem / confidence / developing assertiveness; conflict resolution and coping with relationships. Additionally the long waiting lists for interventions such as counselling can be a hindrance.
4. The extent to which CAMHS are embedded within broader health and social care services.
4.1 Llamau’s experience is that this is patchy across Wales and staff felt that although it was not as good as it should be, there were examples of positive work, including:
· Last year Careers Wales Youth Gateway in Cardiff had their own CAMHS Healthy Mind Worker, which was a really positive step. It helped to tackle stigma and young people were more relaxed about referrals seeing it as part of a joined up provision. Llamau staff felt this model should be rolled out, although unfortunately this provision has not continued due to inconsistent delivery and the funding ceased.
· Llamau’s Learning 4 Life in the Vale has had a very productive relationship with CAMHS which has led to the development of the Anger Management Agored Cymru OCN workbook. This has been piloted successfully amongst Llamau learners and has led to the development of a second workbook “Understanding Feelings” also accredited by Agored Cymru. This course was introduced as some young people were not at the stage where they were recognising their feelings including anger. It has proved successful and a useful tool for Learning 4 Life.
4.2 Llamau has been commissioned by YJB Cymru to provide two resettlement broker projects, one in North Wales and one in South Wales. The findings from the South Wales Mapping Report of Service provision highlighted issues and some positive examples. The Health Section from this report is included as Appendix 1. In North Wales, the Resettlement Broker project has identified that although every YOT has a nominated NHS secondee in the team, who is usually a nurse with CAMHS speciality, able to conduct initial assessments, giving ‘expedited’ access to CAMHS, workers in YOTs have reported that if a young person self-harms, the only way to get quick attention is to attend A&E, as there doesn’t seem to be any protocol for dealing with this type of situation. Another issue notes is that there is also only one Child Psychologist for ‘forensic’ referral (from YOTs) in the whole of Wales.
4.3 We have a positive case study of a young child being given an excellent service from CAMHS following her experiences of a witnessing a severe and violent assault on her mother by her father. In this case as well as working with the child the CAMHS service gave her mother positive coping strategies and advice on how to help her child manage her emotions and feelings.
5. Whether CAMHS is given sufficient priority within broader mental health and social care services, including allocation of resources to CAMHS.
5.1 Whilst we have little knowledge of budgetary configurations within Health, it would certainly appear, from the examples cited, such as geographical variation, waiting list for services and case studies that CAMHS not given the priority needed.
6. Whether there is significant regional variation in access to CAMHS across Wales
6.1 From the examples cited this certainly seems to be the case. Frequent issues of regional variation we have come across include waiting list, accessibility, gatekeeping of services, i.e. the definition of the criteria in order to receive a service from CAMHS. A young person needs to have a diagnosed condition to gain referral and some areas use dual diagnosis, behavioural issues as a way of refusing gatekeeping access, whilst in other areas a young person may fall below the threshold of having not a mental health issue, but rather an emotional well-being issue. The problem with these approaches is that young people end up being denied access to services that can help them manage conditions, conditions which will escalate into adulthood if left unmanaged and will end up having a life time effect on a person, not just in terms of mental health, but in social and economic terms also.
7. The effectiveness of the arrangements for children and young people with mental health problems who need emergency services.
7.1 This is a particularly significant issue for children and young people who are exceedingly vulnerable and in crisis. Our experience is that it is extremely difficult to get appropriate emergency or crisis support for a young person and this becomes even harder for a young person who is not currently linked into services. In one case a young person whose self-harm and deterioration in their mental health was leading to frequent and traumatic access to A&E involving the ambulance service and Police, we were told a crisis appointment would take two months. Other recent examples include two incidents of significant self-harm which in both cases have required medical treatment at the local hospital. On both occasions Llamau staff have been required to repeatedly request a Mental Health assessment being completed as there was a reluctance to do so by the hospital. These cases highlight that young people are not having their mental health needs met by health services and that they are not receiving the appropriate referral or follow on support necessary for them to manage their mental health needs. The question should be asked that for every young person who is eventually given a mental health assessment, how many slip through the net?
7.2 Issues that Llamau have experienced in this area tend to arise when service users who require emergency services are under the influence of alcohol or drugs. For instance, service users may be at a high risk of suicide and are refused an urgent mental health assessment or hospital admission due to having consumed alcohol and/or drugs. We understand that there can be barriers to obtaining a comprehensive assessment in such circumstances, however there is a need for a holistic dual diagnosis approach which doesn’t exclude young people from accessing emergency mental health care due to their substance misuse issues, particularly as their use is a self-medicating coping strategy.
8. The extent to which the current provision of CAMHS is promoting safeguarding, children’s rights and the engagement of children and young people
8.1 Whilst Llamau cannot comment on what CAMHS teams do to promote safeguarding, children’s rights and the engagement of children and young people there are a number of examples in this response which indicate that the time delays between referral and access into CAMHS does not promote this, nor does the attitude of some professions to vulnerable young people who may also have challenging or multiple needs. There are also some examples of staff who do not take a young person’s condition seriously, which better training may address. Equally there are some examples here of good practice.
9. Any other key issues identified by stakeholders
9.1 As well as the issues raised in access to services, we have noted issues relating to transition between children’s and adults services, where in adult services the threshold to access services is often much higher. The case study below highlights a positive example of support around transition:
9.2 The above example also highlights the issue many vulnerable young people face when they miss appointments. In this case there was a positive outcome, however for many young people we work with, particularly those with additional behavioural or substance misuse issues, their chaotic lifestyle can mean that key appointments are missed. In these cases, mental health professionals need to show more understanding of how difficult it can be to keep appointments.
9.3 Other issues include using behavioural or substance misuse issues as a way of gatekeeping access to services. In Llamau and Cardiff University’s research, co-morbidity (including substance misuse) was extremely high, with 80% of the sample meeting diagnosis for two or more forms of current psychiatric condition, yet only 17% identified as currently having a psychiatric condition were currently receiving any kind of mental health care. Additionally 7% of young people who were not identified as having a mental health condition using the Mini Neuro Psychiatric Interview, were receiving some form of mental health care.
Sam Austin
Operational Director
Llamau
Appendix 1: Health Section of Llamau’s Mapping Report of Services in the South Wales Consortium for Youth Justice Board Cymru
The definitive area of concern identified by YOT practitioner interviewees is the lack of speech and language provision. In the Secure Estate it is not available and there are long waiting lists for such services in the community.
Stakeholders identified numerous issues as being problematic with the service provided from the Child and Adolescent Mental Health Service (CAMHS). These issues run throughout the consortium area. A rigid approach to referral practices is prevalent thus risking the young person’s continuum of care, mental health and continued engagement in the service. In order to receive a service from CAMHS, the young person needs to have a diagnosed condition and as many young people have problems with emotional well-being they fall below this threshold and depending on their need, services may be lacking.
Education providers are failing to highlight early enough the need for specialist health support services. For those that are in mainstream education there is a good school based counselling service. However many of this cohort are not and have no access to the service. The need for schools to have Nurture Groups has been identified– i.e. working in very small intensively staffed groups within an educational setting with a view to providing short term and focussed intervention strategies which seek to overcome barriers to learning caused by deep rooted social and / or emotional difficulties.
There are limited Family Therapeutic services available which provide early identification and intervention for pre18’s. There is llimited assertive outreach provision and no community based supervisory support for those leaving custody who require medication.
One stakeholder group identified that CAMHS will class any young person with both mental health issues and YOT involvement as a forensic case. This will deny access to inpatient bedspaces making accurate assessment problematic.
Some areas have lost in house health specialists due to cuts in funding. This has resulted in some young people in the prevention service not being assessed due to the high numbers of young people travelling through the service and the need to prioritise provision for those on statutory orders. Areas of good practice include:
· Specialist in house staff for general physical health
· Joined up service for CAMHS and substance misuse
· Links to school nurses for immunization
· SLA with CAMHS
· Attendance at YOT from Community Psychiatric Nurse (CPN)
· CAMHS advisory service
· CAMHS present at YOT’s are able to offer timely short interventions
· Referrals to CAMHS acted upon in a timely manner.
· School based counselling
· Community based services for Domestic Abuse and Bereavement
· Full comprehensive service in Hillside SCH.