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? Courtesy of Zarathustra via The World of Mentalists