Introduction to the executive committee of the
Adolescent Forensic Special Interest Group
Dr Philip Collins, Chair
Adolescent Forensic Psychiatry in Youth Offending Services (YOS)
Consultant in Child and Adolescent Forensic Mental Health at Lewisham CAMHS, London and at Lewisham YOS
Each local authority area across England is obliged by legislation to organise a multi-agency team to manage the delivery of a range of assessments and youth justice interventions to young people who have offended, or are at risk of offending (for further details see www.yjb.gov.uk )
One aspect of the services provided by these teams is the commitment to detecting and referring on significant mental health problems to the appropriate professionals in the locality. This is appropriate given the very high rates of mental health difficulty within the young offender population. This occurs when a basic mental health screening tool is used by the YOS worker who assesses the young person to alert the system to the possibility of disorders such as depression, hyperkinetic disorders or psychosis. When this happens, a further assessment by the YOS mental health worker is indicated.
The mental health worker, usually employed by the National Health Service and seconded into YOS, will then decide on the basis of the mental health assessment how to treat the problem. The local child and adolescent mental health service (CAMHS) may need to become involved in order to provide the necessary psychiatric expertise.
Each locality, in practice, organises itself differently on the basis of local inter-agency agreements and protocols. The level of adolescent forensic psychiatry input can differ greatly across localities depending on the availability of suitably trained psychiatrists. Most areas will have arrangements with a local child and adolescent psychiatrist to provide assessment of complex cases and to deliver the appropriate package of treatment.
A tension can arise when psychiatrists who are not specifically trained to deliver adolescent forensic assessments or interventions are required to provide a service to young offenders with complex risk and offending profiles linked to major mental health problems. It is rare to have full time psychiatric input into a youth offending service and many localities will have just one or two staff – often from a psychology or nursing background- within the YOS delivering mental health working to the young people. This can lead to very high levels of demand on the worker and can make it very difficult to deliver a comprehensive package of assessment or treatment to the young person and their families or carers.
YOS mental health workers can experience high stress levels given the enormity of need for mental health intervention in the absence of adequate resources locally to deal with the complex mental health problems presented by this high risk/high unmet needs group of young people. In greater London, the YOT Mental Health Worker Forum was established to provide a regular meeting point for those of us who work in this area. The group meets regularly at a central London location to discuss best practice, new developments within localities and to offer peer support to offset the isolation which single-handed mental health workers can experience.
In contrast, within Lewisham YOS and within a small number of other YOS across England, a full multidisciplinary specialist mental health team has been established to provide young people who offend and their families with a comprehensive CAMHS service. The team incorporates child and adolescent forensic psychiatry, psychology, child mental health forensic nursing, substance misuse nursing, mental health triage working and child mental health specialists and provides an enhanced range of specialist assessment and treatment programmes. For example, robust specialist outpatient based programmes for young people with sexually harmful behaviours have been established to provide a wider range of sentencing options to the courts in these cases. The team are also trained to provide specialist risk assessments to YOS and other agencies.
Dr Richard Church, Finance Officer
Specialty Registrar in Forensic Psychiatry, West London Mental Health Trust
I was first exposed to this field during my days of general SHO training. The opportunity arose to perform an assessment under the supervision of a local consultant adolescent forensic psychiatrist…eh?? What on earth do they do?!
I entered a fascinating area of psychiatry. I was rapidly exposed to a huge range of mental disorders including a range of neurodevelopmental disorders, psychoses, OCD and consequences of head injuries. I saw young people and families from all manner of ethnic and socioeconomic backgrounds, often faced with a form of psychosocial adversity such as poverty, illness, migration, family breakdown or abusive experiences. I conducted assessments at community CAMHS bases, on home visits, in prisons, in youth offending teams and in schools, and I have prepared assessment reports for GPs, CAMHS teams, youth court, criminal court and family court.
Based on my experience so far, I can say that adolescent forensic psychiatry really draws on my knowledge and skills as a general medical doctor, as well as a specialist psychiatrist. The young people and parents who come into contact with forensic CAMHS services often have (neglected) physical health problems, and general medical training also helps when faced with forensic scientific evidence which often features in court proceedings.
My route through psychiatric training has been unusual in that I embarked on CAMHS SpR training on one scheme and then, in my final year, applied for Forensic ST4-6 training on another scheme. During my CAMHS training I gained as much forensic experience as possible through generic adolescent CAMHS/YOT work, a specialist outpatient adolescent forensic service and a specialist adolescent forensic inpatient unit, whilst maintaining the breadth of CAMHS experience required for a CCT in child and adolescent psychiatry. In accordance with the subsequent letter published by the Dean of the College, I:
- justified the requirement for dual training in terms of career plans
- informed the deanery of my interest in dual training early during higher training
- applied for a second set of training within the same deanery
I persevered for several years in my quest to secure dual training and I am delighted with where I am today, as ST4 in forensic psychiatry. Already I see more clearly than ever how essential it is to be trained in both CAMHS and forensic psychiatry for work in the challenging field of adolescent forensic psychiatry. Dual training is supported by the overwhelming majority of consultants in the field and is something this Special Interest Group aims to protect and promote.
I would like to thank Dr Ekkehart Staufenberg for all his hard work over the last few years and I am honoured to take over from him as the new Financial Officer for the SIG. I will also be updating this website on behalf of the Executive - we look forward to keeping you informed!
Dr Ernest Gralton, Forensic Psychiatry of Developmental Disabilities
Adolescents with developmental disabilities who have forensic needs are a very complex population and present unique challenges to those who care for them. Those who are referred to secure psychiatric services often have a variety of co-morbid disorders, some unrecognised for long periods due to difficulties in carrying out comprehensive assessments (Barlow & Turk 2001) or because of the phenomenon described in amongst the developmentally disabled as 'diagnostic overshadowing' where abnormal behaviours are attributed to the presence of intellectual disability alone (Mason et al 2004).
Psychiatric disorders are up to four times more prevalent in adolescents with intellectual impairment than adolescents without impairment, however only a small minority young people receive any form of specialist service (Emerson 2003, Tonge et al 2001). Diagnoses amongst this population frequently include developmental problems including Autism and Attention Deficit Hyperactivity Disorder, Developmental Dyspraxia/Developmental Coordination Disorder, Tourettes and Tic disorders.
In addition to this a number of environmental insults notably
developmental trauma (including neglect and physical and sexual abuse), head injury and substance misuse are extremely common. Some have also gone on to develop a variety of formal mental illness including atypical affective disorders, anxiety disorders (including complex PTSD or Developmental Trauma Disorder) and a range of psychoses, although these are not always easy to recognise.
Dr Ollie White, Higher Specialist Training
SpR in Child & Adolescent Forensic Psychiatry, Oxford
As adolescent forensic services continue to develop, their success will in part depend on the expertise of consultant psychiatrists who have the necessary training to work in this specialist area of psychiatry. As of 2007, only 17 members of the College were registered as having dual CCT qualifications in Child & Adolescent Psychiatry and Forensic Psychiatry. There is, therefore, an ongoing need to dual train psychiatrists in order to meet service demand, albeit at relatively small numbers.
Despite this service need and the desire from some trainees to dual train in child & adolescent and forensic psychiatry, training opportunities have become extremely limited over the past 2 years. There are a number of reasons for this, the greatest being the introduction of Modernising Medical Careers (MMC). Although there continues to be the scope to provide dual training under the MMC framework, it is unclear how this will be facilitated. Access to dual training will continue to be at the deanery level but it seems likely that it will be increasingly linked to service provision. The lead-time of 5 years for higher dual training means that trusts and deaneries will require long-term vision. Alongside these changes, the College is continuing to consider how best to accommodate the increasing specialisation within psychiatry training. Options include increasing the number specific curricula (either via more CCTs or more sub-speciality endorsements) and it is possible that adolescent forensic psychiatry may become an individual speciality in the future. The move to competency-based training may facilitate this development, as it is likely to become easier for doctors to demonstrate achieved competencies across psychiatric specialties.
It is at present unclear to what extent dual training opportunities will exist within the new structure of MMC. Indeed, it appears that there are very few specific dual training schemes being offered at ST4 level at present, and none to my knowledge in child & adolescent and forensic psychiatry. It has been suggested that training in a second psychiatric specialty may occur after the first CCT has been achieved and I am aware of one trainee with a CCT in child and adolescent psychiatry who has been appointed on a forensic psychiatry training scheme at ST4 level. It is unclear at present whether this will be the solution to the lack of specific dual training schemes, and raises a number of issues, most crucially surrounding the funding of additional post-CCT training. Deaneries would have fulfilled their responsibility to provide training to CCT and may be reluctant to fund training beyond this. An alternative solution is that special interest sessions could be used to obtain competencies in a specialty other than that in which the trainee will obtain their CCT. This would require careful planning and cooperation between trusts and training programme directors and it is unlikely to be a sufficient alternative to full dual training.
It is clear that the combination of child & adolescent and forensic psychiatry remains crucial to the provision of adolescent forensic services and appropriate training must therefore exist to ensure that there are specialists in this area. However, traditional dual training appears to be under threat and adaptations need to be made to the new structure of postgraduate training to allow trainees to develop the necessary competencies across specialties. The rhetoric surrounding MMC promised greater flexibility of training and it is of paramount importance that this is developed in order for trainees to achieve the broad and diverse range of competencies that are required by these developing services. This will allow us to meet the needs of our patients and deliver the best possible care.
The SIG are keen to hear from any trainee interested in training in Adolescent Forensic Psychiatry – please feel free to contact us via these webpages.
For more information please see the following article published in the Psychiatric Bulletin:
Oakley C, White OG & Bailey S (2009). Dual Training in Psychiatry: Which way now? Psychiatric Bulletin 33: 231-234.
http://pb.rcpsych.org/cgi/content/full/33/6/231
Dr Nick Hindley, Community and Prisons
At present there is no clear countrywide network of community forensic CAMH services. We (members of the Special Interest Group) are however aware that a number of services across the UK do consider themselves to fulfil the functions of a community forensic mental health service for young people.
The SIG would be interested in forming a directory of community forensic CAMH services and we would be happy to coordinate this via this website.
As a first step towards this I am providing a link to an information document for referrers which outlines the organisation and functions fulfilled by our team in Oxford. Key issues relating to the service include:
· Regional specialist commissioning agreements and funding
· A dedicated service for a catchment population of 2.2million
· A strong emphasis on liaison work and support for other services working with young people
· Strong local, regional and national links within CAMHS, YOS and other agencies
Dr Heidi Hales, Independent Sector
The independent sector provision for adolescent forensic psychiatry continually has to reinvent itself as the NHS provision catches up with the need which is being provided by the independent sector. Prior to the NCA funded NHS medium secure beds, much of the independent sector provision was for mentally disordered young offenders who had major mental illnesses. There was also provision for adolescent females (and less so males) who were self harming to such a degree that they required the levels of nursing care that are provided in secure settings.
With the advent of the NCA NHS medium secure beds, the greater need now is for provision of secure beds for mentally disordered offenders with emergent personality disorders (male and female). There are ongoing ethical and moral debates with the adolescent and child and adolescent fraternity about whether these young people should receive care within the context of mental health provision and whether there is evidence based effective care that can be offered.