The National Analysis of Regional Tier 4 Reviews What does it tell us?

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The National Analysis of Regional Tier 4 Reviews
What does it tell us?

• Dr. Zarrina Kurtz

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• www.cypf.csip.org.uk/camhs/tier-4-camhs/
• regional-reviews-of-tier-4-camhs.html

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REFERENCES

• McDougall T, Worrall-Davies A, Hewson L,
  Richardson G, Cotgrove A.
• Tier 4 Child and Adolescent Mental Health
  Services (CAMHS) Inpatient Care, Day Services
  and Alternatives An Overview of Tier 4 CAMHS
  Provision in the UK. Child and Adolescent Mental
  Health, 2007pp1-8
• Green J, Worrall-Davies A. (2008) Provision
  of Intensive Treatment In-patient Units, Day
  Units and Intensive Outreach. pp1126-1142 In
  Rutters Child and Adolescent Psychiatry, 5th
  edition. Edited by Rutter M, Bishop D, Pine D,
  Scott S, Stevenson J, Taylor E, Thapar A.
  Blackwell Publishing

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REASONS WHY THE REGIONAL REVIEWS WERE UNDERTAKEN

• Increasing referrals to in-patient CAMH services,
  particularly significantly increased numbers of
  emergency referrals
• A national shortage of adolescent in-patient beds
  a particular lack in developmentally
  appropriate provision for those aged 16 to 18
• The inability of services always to respond in a
  timely way to requests for urgent admission the
  consequent inappropriate usage of paediatric
  adult psychiatry wards as an interim resource
• Regions wanting to study the findings note the
  implications for commissioning in-patient care
  and community based services
• There were significant gaps in provision
  including long term therapeutic provision post
  discharge services
• Significant problems in recruiting staff,
  especially nursing staff
• Much inter-agency confusion, in particular about
  the needs of children with conduct disorder
  challenging behaviours

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WHAT THE REGIONAL REVIEWS TELL US

• There is a major need for regularly updated
  consistent data for use in provider management
  service development in commissioning
  evaluation
• There is uneven distribution of, access to (not
  necessarily the same thing) CAMHS in-patient beds
• In-patient beds are only part of the story about
  Tier 4
• The extent types of unmet need some of the
  reasons for these
• The crucial relationship between Tier 4 Tier 3
  in effectively meeting needs
• The kinds of approaches that are likely to make
  significant improvements in meeting needs
• The importance of commissioning its current
  under-development

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• Tier 4 CAMHS has recently come to be understood
  as multi-faceted, with multi-agency services that
  can include inreach, outreach, intensive crisis
  community initiatives, day provision, therapeutic
  fostering other services that may be described
  as wrap around

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• Tier 4 comprises very specialised services in
  residential, day patient or outpatient settings
  for children adolescents with severe /or
  complex problems requiring a combination or
  intensity of interventions that cannot be
  provided by Tier 3

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THE NEED FOR TIERED APPROACH CAN BE DESCRIBED
ACCORDING TO

• the type of care required by the needs of the
  young person (covering a range with considerable
  variation in individual reviews)
  emergency/acute intensive care medium to long
  term in-patient day patient community based
  (outreach, home treatment, post discharge, wrap
  around) low secure high secure
• the type of condition indicating certain needs
  eating disorder learning disability dual
  diagnosis conduct disorders autistic spectrum
  disorder
• age group children under secondary school age or
  thereabouts older adolescents those about to be
  classified as adult/transition
• legal status young offenders sectioned under
  the Mental Health Act

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UNMET TIER 4 NEEDS

• Emergency provision
• Conduct disorders/challenging behaviour
• Intensive care facilities
• Community based, as a bridge between tier 3
  tier 4
• Low secure
• Young offenders
• Under 12s in-patient provision In units that
  admit only children under the age of 14, there
  has been a 30 reduction in beds available (123
  to 86). (O'Herlihy et al, 2007).

• Provision for older adolescents transition
• Learning disability with mental health needs,
  severe learning disability with mental health
  problems
• Early intervention
• Dual diagnosis
• Eating disorders, in-patient provision
• Low incidence needs, also Autism, Aspergers,
  Attention Deficit Hyperactivity Disorder (ADHD)

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REASONS GIVEN FOR LIMITED TIER 4 RESPONSES TO
UNMET NEEDS

• In-patient case mix young people with psychosis
  with conduct disorder
• Poor service capacity shortage of key staff
  skills
• high turnover of staff
• poor retention of staff
• poor staff supervision development
  opportunities
• Poor integration between service components at
  tier 4
• Poor integration with tier 3

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APPROACHES TO ENHANCE MEETING TIER 4 NEEDS
EFFECTIVELY

• Assertive Outreach teams
• Early Intervention in Psychosis services
• Crisis Intervention/Home Treatment teams
• Multi-disciplinary Referral Panel
• On call with specialist back-up
• Peripatetic Specialist Assessment team
• Community based delivery of new treatment
  modalities, such as Dialectical Behaviour Therapy
  (DBT)

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INPATIENT CARE

• Advantages
• Acute risk management
• Allows detailed assessment in a controlled
  environment and away from the family
• Intensive specialist treatment
• Can lead to more effective use of other services
  post discharge
• The ward as a therapeutic milieu
• Can produce rapid gains in functioning
  (socialization and academic achievement) and
  self-esteem

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INPATIENT CARE

• Disadvantages
• Loss of support from the childs local
  environment
• Presence of adverse effects within the inpatient
  environment
• Effects of admission on family life

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DAY UNITS

• Advantages
• Relate to the flexibility of care that can be
  provided
• Management of younger children
• Work with the family and foster parental care
• Emphasis on education

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EFFECTIVENESS OF INPATIENT AND DAY PATIENT
TREATMENT

• Overall efficacy of inpatient care across a range
  of disorders, with the following predictors of
  outcome
• High levels of aggressive antisocial behaviour
  and organic symptoms, as in schizophrenia predict
  poor outcome emotional disorders do better
• Intelligence, measured as IQ shows a moderate
  positive effect but functional achievement may be
  more critical
• Pretreatment family functioning is a key
  predictor of outcome
• Longer treatment stays are, in general,
  associated with improved outcome
• For eating disorders-widely differing results

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EFFECTIVENESS OF INPATIENT AND DAY PATIENT
TREATMENT (continued)

• Depression and suicidality and psychosis little
  beneficial effects of IP psychiatric care
• Conduct disorder - multimodal day treatment for
  children with disruptive disorders produced
  significantly greater improvement in behaviour
  than in a control group
• Substance misuse additional benefits from
  community treatment
• Obsessive-compulsive disorder poorer outcome
  among those needing admission compared with those
  treated as outpatients

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MODELS OF OUT-OF-HOSPITAL CARE

• Family preservation
• Home Treatment
• Case Management assertive outreach, assertive
  community treatment, wraparound and intensive
  community treatments
• Multi-systemic Therapy
• Treatment Foster Care

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SUGGESTED READING

• Well known examples can be referred to on the
  National CAMHS Support Service (NCSS) website
  www.cypf.csip.org.uk/camhs the CSIP Knowledge
  Community http//kc.csip.org.uk/
• Massie L, (2008) Right Time, Right Place
  Learning from the Childrens National Service
  Framework development initiatives for
  psychological well-being and mental health,
  2005-2007. http//www.cypf.csip.org.uk/camhs/child
  rens-nsf-initiatives--development-projects.html
• Kurtz Z, James C. (2005) Creative practice and
  innovation in child and adolescent mental health
  services, pp 534-544 In Williams R, Kerfoot M
  (eds). Strategic Approaches to Planning and
  Delivering Child and Adolescent Mental Health
  Services. Oxford Oxford Medical Publications.
• Kurtz Z, James C. (2002) Whats New Learning
  from the CAMHS Innovation Projects. London
  Department of Health. http//www.dh.gov.uk/en/Publ
  icationsandstatistics/Publications/PublicationsPol
  icyAndGuidance/DH_4006011

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THE EFFECTIVENESS OF INTERVENTIONS TO MEET THE
COMPLEX AND OFTEN ENTRENCHED MENTAL HEALTH NEEDS
OF CHILDREN AND YOUNG PEOPLE

• This depends upon
• Access, and engagement, often over the long-term
• Intervening at the earliest stage and avoiding
  crisis situations
• Full understanding of the needs of each
  individual child
• Attention to problems that are not diagnosable
  mental health disorders
• Promoting the childs strengths, self-efficacy
  and resilience
• Outcomes that are measured across a number of
  domains
• Staff are appropriately skilled, valued and
  supported
• Agencies working together in full collaboration