The role of tier 4 children’s inpatient services in the

provision of a comprehensive CAMHS

Dr Steve Earnshaw, Dr Jon Goldin, Dr Marinos Kyriakopoulos, and Dr Gillian Rose on behalf of CHIPSIG Children’s Inpatient Specialist Interest Group

Initial discussion

• How many units nationally?

• Why would you refer?

• What do you want from a children’s unit?

Why Admit to In-Patient Units?

• For assessment and diagnosis of complex cases

• To relieve anxiety (parent , school, CAMHS)

• For treatment

• For respite/safety/at a time of crisis

• 24 hour mental health nursing care

• When CAMHS O.P. treatment inadequate

Principles

• Do no harm

• Least restrictive treatment

• Maximise access to scarce and costly resources

– single case evaluation

– evidence-based practice

– consider alternatives to I.P. admission

What Conditions? Children

• Children often multiply comorbid diagnoses and much wider spread of diagnoses than adolescents

Boys – Conduct disorder and mixed 23%

Hyperkinetic disorder 13%

Affective disorders 10%

Girls – Eating disorders 32%

Affective disorders 9%

Non organic enuresis or encopresis 8%

(NICAPS Census day)

What Conditions? Adolescents

Boys – Schizophrenia and psychosis 35%

Affective disorders 22%

Conduct disorders 6%

Eating disorders 6%

Girls – Eating disorders 33%

Affective disorders 19%

Schizophrenia and psychosis 14%

(NICAPS Census day)

Range of disorders seen

• Psychosis

• Eating disorders

• Affective disorders

• Anxiety and emotional disorders

• OCD

• Somatising disorders

• Self harm and Emotion regulation disorders

• Developmental disorders

• Primary diagnosis of mental illness with mild/borderline learning difficulties

• Child protection cases e.g. suspected FII

Referral thresholds

• We are not just a service who deals with core psychiatry (e.g. eating disorders, psychosis, depression, anxiety, OCD)

• We have broad experience working with the full range of CAMHS presentations

• We welcome timely referrals before difficulties become more entrenched but are used to working with very ‘stuck’ situations

What do we offer?

• Comprehensive inpatient/daypatient assessment and treatment packages

• Interventions based on goal-setting with families and referring teams

• Outpatient second opinions and consultations

• Emergency assessments and planned/urgent admissions

• Biopsychosocial MDT approach

• Range of evidence-based interventions

• Fixed term admissions and open-ended admissions

• CPA discharge planning involving referrers and other relevant stakeholders

The Assessment Process

• A detailed biopsychosocial assessment

• Appropriate investigations / liaison with paediatric team

• Naturalistic observations

• Structured interviews and observations

• Use of hospital school

• Risk assessment

• Consultation

Treatment (1)• Wide range of treatments offered by multi-

disciplinary team– family therapy– individual therapy– cognitive behavioural therapy– medication – education management– groups

• Liaison crucial during admission – with family – with external professional systems

Treatment (2)

• The effects of the ‘milieu’, i.e. provision of a therapeutic environment in a clinical setting, which aims to build on an individual child’s strengths, and encourages the child to examine their own behaviour, recognise and name distressing feelings, and find alternative ways of expressing these

• Behavioural programme • Case mix• Regular review/CPA meetings

Treatment (3)

• Key elements of ‘milieu therapy’– maintenance of a safe and containing

environment

– highly structured programme

– physical and emotional support

– collective involvement of the child, family and staff in the unit regimen

– continuous evaluation of all therapeutic interventions

Crouch, 1998

The Discharge Process

• Hand over to local services

– may need joint sessions

– contingency plans

• Links to family

• Education

• Social services

Age appropriate environment

Environment and FacilitiesStaff skills and training

Education Peer group

Environment & Facilities

• Child friendly

• Recreational Space

• Toys and books

• Bedrooms and communal space

• Access to age appropriate

leisure activities and media– assessment /therapeutic materials

• Security, managing visiting

• Age appropriate information

Staff skills and training

• Communication skills

• Training on competence

• Training on legal frameworks

• Consent, competence and capacity

• Advocacy accessible

• Staff numbers

• Skill mix

Education

• Access to the National Curriculum

• Staff with skill set to teach primary age children

• Access to full time education

Peer group

• Influence of peer group

• Exposure to age inappropriate language, behaviour, media

• Vulnerability to influence

• Vulnerability to bullying

Commissioning Arrangements

• Disparate arrangements currently

• Scotland National Commissioning

• England tier 4 inpatient units to be Nationally Commissioned from April 2013?

• National Commissioning Board

• Tier 4 CAMHS Clinical Reference Group

National PictureCaledonia Ward

9 beds7 – day + Emergency bed

Dewi Jones9 beds5 - day

Ocean Ward10 beds7 - day

Collingham 14 beds5 - day

Acorn Lodge10 beds

7 – day + Emergency

Galaxy House5-7 beds7 - day

Emerald Lodge3 beds5 - day

The Croft12 beds5 - day

Mildred Creak10 beds7 - day

Innovation and Research

Children’s Inpatient Units as Centres of Excellence

• Clinical, teaching/training, research

• Strong multidisciplinary ethos

• Engaging with the most challenging of children and families

• Contributing in the national scene through publications, conference presentations and workshops

• Peer-reviewed yearly by QNIC

• Overall rated and commended very positively by children and families

Selected recent publications

Basic Research Projects

Clinical Research Projects

Psychotherapy contributions

Reviews and Case Reports

Surveys

Books

Selected current projects

Evaluation of emergency admissions

020

40

60

80

100

120

140

160

180

20092010

2011

LOS in days

0

5

10

15

20

25

30 Emergency AdmissionsN= 45

Planned AdmissionsN=36

0

10

20

30

40

50

60

CGAS admission

CGAS discharge

CGAS change

Emergency

Planned0 1 2

34

5

Satisfaction Parents

Satisfaction Children

ASD and PsychosisNutritional status of children in an

inpatient unit

Developing a new measure of

complexity

Evaluating the use of sensory

strategies

Investigation of the effect of total energy intake on the physiological recovery rate during refeeding

children/ adolescents with anorexia nervosa: Develop evidence based refeeding guidelines

• National multi-centre clinical trial• Recruitment target n= 40 (complete April 2013)• Children randomised into 2 groups: 500 Kcal or

1200Kcal starting meal plan• Preliminary results unexpectedly suggest higher

meal plan is safer• Aim is to develop international refeeding

guidelines for malnourished children with anorexia nervosa.

Service User feedback

Qualitative outcome measures

How would you compare your child’s current difficulties with his/her difficulties

on admission?

• Huge difference

• She doesn’t get as angry or out of control as she used to

• She’s eating and drinking now and she’s a healthy weight

• Some difficulties completely overcome, some still there

Comparison of difficulties?

• From where she was to where she’s grown to 1000% difference

• Listening more and not running away

• More confidence

• Much calmer

• Enormous improvement

• You’ve given us our son back

What do you think of the outcome of your child’s treatment?

• Brilliant, that within 3 weeks you had him up and on a frame, and so well now

• Very pleased – H is a different girl now

• We couldn’t have asked for anything more

• Exceptional

• Extremely pleased that Z is better and back home

How would you describe treatment to another parent?

• It’s hard but stick with it, because the outcome is very positive

• It may seem like you’re not getting anywhere at all but that is short term – overtime all the skills developed here come together and make you a whole new person (13 year old girl)

• The video illustrates it well

How would you describe the inpatient treatment to another parent?

• Feeling able to let go – handing over elements of care…and getting the balance right

• A structured programme with the families involved

• Tough at times but would thoroughly recommend it

• The whole team was wonderful and helped us through a very difficult period in our lives

• The bottom line is that the unit saves lives

Discussion

• In pairs talk with a partner re a case you would consider referring – advantages/disadvantages of referral

• Your experience of making a referral – what went well/not so well

• What you would like from a nationally commissioned service

• Please email gillian.rose@nhs.net if any suggestions/comments re commissioning process