July 2015 NHS Highland CAMHS
NHS Highland and the Highland Council currently provide Child & Adolescent Mental Health Services to children and young people from birth to eighteen years of age if in full time education. Young people aged 16 and over who are not in full time education should be referred to Adult Mental Health Services
Tier 2 CAMHS (Primary Mental Health Worker Service)
Requests for a service from the Primary Mental Health Worker Serviceare appropriate when focused targeted therapeutic intervention at an early stage is likely to have long term benefit to the well being of the young person and their family.
Referrals to the service are made through direct consultation with your local Primary Mental Health Worker. The purpose of consultation is to make information about children’s mental health accessible to all those professionals working with children within Highland. Requests for consultation are accepted from ALL child care professionals includingschool staff, specialist services, members of a Family Team, GPs, Voluntary Organisations etc. During consultation the PMHW may accept a request for a direct service with a child/young person. Additional guidance can be found here.
Tier 3CAMHS Referral
Referral to Tier 3 CAMHS at the Phoenix Centre is appropriate when a child or young person is experiencing severe, complex mental health difficulties. These are likely to have been present for some time, and/or to be having a significant impact on their daily functioning and well being.
Referrals to our service are considered urgent if:
- A child/young person is experiencing significant suicidal ideation, or has made a suicide attempt
- A child/young person has a suspected psychotic illness/symptoms
- A child/young person has experienced rapid recent weight loss, a concerning BMI and eating disorder cognitions.
- A child/young person is considered to be an immediate risk to themselves or others associated with mental health issues
- In the circumstance of medical non-compliance when this presents an immediate health risk
When there are concerns that a child or young person might need an urgent mental health assessment we would recommend referrals are discussed with a CAMHS clinician prior to referral submission. Referrals of an urgent nature out with normal working hours and at weekends should be directed to A&E.
All other referrals would be considered for routine appointments.
Tier 4 CAMHS Referral
Tier 4 referrals should also be directed to the Phoenix Centre and would be considered for young people with significant mental health difficulties which fulfil one or more of the following criteria;
- Too high risk to attempt to treat with usual out-patient resources for example immediate suicide risk, psychotic with disorganisation, significant self harm or violent behaviour.
- Requiring intensive assessment or treatment (equivalent to more than weekly out-patient contact and more than one CAMHS professional).
- Not responding to usual out-patient treatment – which may be because they need re-assessment or more intensive input.
Requesting a Service
Requesting a service fromTier 3/4 CAMH Service should be madeusingour referral formandthe most recent Child’s Plan if one is available.We require specific information to ensure that the correct intervention can be targeted to the right child/young person. If a referrer is not sure what information to include, s/he can contact us to discuss the referral. It is important that those referring have met with the parent(s)/carer(s) and the referred child/young personand that they are in agreement with the request for service.
Referrals can be sent by post to:Child and Adolescent Mental Health Service
The Phoenix Centre
RaigmoreHospital
Inverness
IV2 3UJ
By email:
Or via: SCI Gateway
We will respond to all referrals received, informing both referrer and the referred child/young person of the outcome.
We have our own webpage which includes details of what our service offers and what to expect when you come along.
The Royal College of Psychiatrists have also produced a helpful brochure on what to expect from CAMHS which can be downloaded from:
Introduction to this Guidance
This guidance document is intended to assist those in front line services to know when to refer to NHS Highland CAMHS, as well as offering suggestions for advice or where to go to get more information. The guidance is designed to improve access to CAMHS for those children and young people who need it most whilst at the same time making sure that other sources of help can be accessed where appropriate. Referrals are accepted from a number of professional groups including GPs, Public Health Nurses, Health Visitors, Paediatricians, Teaching Staff, Other Hospital Doctors (including Dentists), Allied Health Professionals, Educational Psychologists, Social Workers, Reporter to the Children’s Panel.
NHSHighland CAMHS
NHS Highland CAMHS operates within a tiered model of service delivery which includes both stepped care (as a problem becomes more severe in nature the type of help that is available becomes more specialised) and matched care (the idea that there should be an accurate and properly informed match of need to provision at the earliest stage of a child or young person’s presentation).
CAMHS 4 Tier Model of service delivery
Specialist Tier 4
Inpatient &
Intensive
Community outreach
Specialist CAMHS Tier 3
Team
PMHW – Training/consultation
to increase capacity & confidence. Tier 2
Consultation & direct work with children
& young people
Universal services have a role in promoting
children’s emotional health consisting of all primary Tier 1
care agencies including GP’s, school nursing, health
visitors, children’s service workers and schools
Problem / Description / Referral Pathway / AdviceADHD / Attention Deficit Hyper-activity Disorder is characterised by a pervasive lack of attention, impulsivity and hyperactivity across situations and settings – at home, school, and in public – which began before 7 years of age.
Families with children who display difficulties in these categories should have already received significant advice and intervention from other professionals such as paediatricians, health visitors, social workers and educational support services before referral to Tier 3 CAMHS is made. / For all children the normal route to assessment would be through referral to Community Paediatrics. If the outcome is unclear or a severe/complex presentation is described a referral to Tier 3 CAMHS may be considered.
CAMHS would not normally assess a child for ADHD until they have completed at least one term within P1.
The PMHW Service may offer consultation to those adults supporting the child/young person when their behavioural needs are causing concern. /
Anxiety / Anxiety is a normal and common part of childhood. In most cases, anxiety in children is temporary, and may be triggered by a specific stressful event.
In some cases, anxiety in children can be persistent and intense, interfering with a child’s daily routines and activities.
Anxiety disorders include phobias, general anxiety, panic or persistent unexplained physical symptoms, such as headache or stomach-ache, where physical cause has been excluded. / Those with recently emerging, less severe difficulties may be directed to the PMHW Service via consultation.
Children who show persistent or severe symptoms of anxiety should be referred to Tier 3 CAMHS. These cases would include the following:
- Where the child’s development or level of functioning has been seriously affected or there has been a sudden deterioration.
- Where the anxiety appears to be out of proportion to the family circumstances.
- Where there is a significant impact on the parent/carer-child relationship - please describe in referral.
Bereavement: / Children’sresponse to grief will vary dependent on age, cognitive and developmental stage. Quite often it can be the subsequent change in circumstances or other family members’ reactions that can prove difficult for the child. / Consult with PMHW in the first instance describing what support has already been offered and how the difficulties are affecting the child’s day to day functioning. The PMHW may work directly with the child/young person or may signpost to other services that can provide bereavement support.
You may want to consider referral to Tier 3:
- When the loss has had an extreme impact on the child and their functioning, or when the child is experiencing difficulties after bereavement support.
- If the child is experiencing significant distress and / or difficulties following a bereavement / loss that has occurred in extreme circumstances (e.g. trauma, illness, suicide or accident).
You may wish to consider referral to CHAS at Home (the Highland outreach service for the Children’s Hospice Association of Scotland), where support is provided for children & parents who are bereaved.
Conduct/Behaviour problems / Challenging and defiant behaviour can present as a normal part of childhood development. Sometimes such behaviour can become out with parental control, impact on the child’s developmental progress and emotional well being and also on family functioning. / Initial presentations of defiant or challenging behaviour should be addressed by Tier 1 and consultation with PMHW if necessary. Early intervention is preferable in such cases and often leads to better outcomes.
Tier 3 CAMHS would consider referrals when conduct problems are a result of significant disruption to the parent-child relationship, are having a significant impact on a child’s emotional well being, and there is an indication that a mental health intervention could result in positive change.
We may in the first instance consult with the other professionals involved with a child/family. Referrals are best made via a Child’s Plan so we can be clear on what has already been offered.
Children who are out with parental control should be referred tothe Care and Protection Practice Lead within the local family team in the first instance. Young people whose behaviour has included offending should be referred to the Youth Action Team. /
Depression/Low Mood / Low mood is a normal part of childhood, in most cases is temporary and might well resolve on its own.
In order for referral to CAMHS to be appropriate difficulties should be more than age appropriate variation of mood. There should be a significant change from previous levels of functioning and an impact on daily living.
This may include disturbances of mood, sleeping, irritability, a decrease in energy, social isolation, school performance may be affected and thoughts of self-harm may be expressed.
Bipolar disorder is rare in children in adolescents. / GPs may advise and review prior to referral as often difficulties can resolve without intervention.
Where symptoms are mild or moderate in nature, a consultation with a PMHW will help clarify what support may be appropriate and whether they should provide some direct intervention to the child/young person.
For persistent and severe symptoms, or if concerns exist regarding significant suicidal thoughts then referral to Tier 3 CAMHS may be appropriate. / For more info:
www,beatingtheblues.co.uk
Eating Disorders / Anorexia is characterised by a refusal to maintain a minimally normal body weight or an intense fear of gaining weight.
Bulimia is characterised by binge-eating and purging and maintaining adequate body weight.
Where there is concern in relation to an eating disorder it is advisable to discuss with GP in the first instance to consider medical investigations (blood, weight, height, BMI etc) prior to referral. These assessments not only give us an indication of their BMI but assists with prioritisation as we would want to prioritise those children with low BMI.
Sometimes the school nurse is also a good source of support in helping to assess a child you suspect may be of low weight. / If there has been a recent rapid weight loss (1kg+ per week with ED cognitions present) with no physical cause, request urgent Tier 3 CAMHS appointment.
If the symptoms are less severe but there is some concern that a young person has some distorted thinking or body image, consult with PMHW in the first instance.
The PMHW may work directly with the child/young person or may signpost other services that can provide support. / This is an example of the sort of screening questions that can be helpful however any decision on referral will be based on relevant history and clinical presentation:
- Do you make yourself sick because you feel uncomfortably full?
- Do you worry you have lost control over how much you eat?
- Have you recently lost more than 1 stone in a 3 month period?
- Do you believe yourself to be Fat when others say you are too thin?
- Would you say food dominates your life?
Early Years and Attachment Insecurities / Problems within this age range can take many forms and it would be usual for universal services to have had significant input to a family.
Difficulties would include significant emotional or behavioural difficulties in the age group 0 – 5 years, including difficulties within the parent-child relationship.
Additional guidance can be found in the NHS Highland Infant Mental Health Guidelines and NHS Highland Perinatal Mental Health Guidelines. / CAMHS involvement with this age range should be secondary not primary. Consequently, families should have already received significant advice and intervention from other named professionals such as paediatricians, health visitors, social workers and educational support services including within Nursery.
Therefore referrals should include information on what has been attempted and who is involved.
Consultation is available from the PMHW service in the first instance. For more complex difficulties, consultation from Tier 3 CAMHS may be sought and dyadic interventions would be considered. / PMHWs are committed to a programme of training and development for Tier 1 professionals and may be involved in direct work to support parents where issues arise (for example, delivering Video Interaction Guidance).
Often with these types of difficulties the relationship between the parent and child is the focus of intervention; therefore it is useful to know what has already been attempted.
Enuresis and Encopresis / Both are categorised as elimination disorders and involve the inability to control urination or soiling in those deemed old enough to exercise control.
Initial screening and treatment should be undertaken by paediatrician to rule out physical causes. / Refer to paediatrician in the first instance who will then refer to other specialist services if appropriate. / You may wish to find out more information from which includes a free downloadable toolkit for parents and professionals
Family Relationship Problems / Family relationship problems can result in emotional distress which presents in a variety of ways in children and young people.
Families may be struggling to communicate effectively or to understand why they are having problems within their relationships. / Concerns about a young person’s safety within a family should be immediately addressed tothe Care and Protection Practice Lead within the local family team.
Specialist CAMHS does not mediate residence and contact arrangements for a child/young person. Families could instead be advised to approach Family Mediation Highland or discuss with their solicitor, as appropriate.
Referral to Tier 3 CAMHS could be appropriate when difficulties are complex or entrenched and there is a clear mental health component.It would be advisable to contact the Phoenix Centre prior to making a referral. /
Feeding and Faltering Growth / Faltering growth is a common occurrence and health visitors play a key role. Most children with faltering growth will be detected by the primary health care team and supported within the community.
Feeding problems include:
- children with behavioural feeding problems in the context of chronic illness/medical problems;
- severe and chronic selective eaters;
- infant feeding problems and failure to thrive;
- Emotional eating difficulties (e.g. food phobias) or in the context of somatic problems such as chronic fatigue syndrome.
Initial screening and treatment should be undertaken by the paediatric team. CAMHS referrals often come via this route.
The PMHW can offer consultation to Health Visitors/ Public Health Nurses. /
Children / young people Looked After or Looked After Away from Home / Children are looked after and looked after away from home for many varied reasons. Their legal situations are also very varied and complex.
Referrals for children in this category need to identify whether a child or young person has a mental health difficulty or other condition that results in persistent symptoms of psychological distress, as well as an associated serious and persistent impairment of their day to day social functioning. OR, an associated risk that the child/young person may cause serious harm to themselves or others. / Referrals to specialist CAHMS are best made by the responsible social worker(Lead Professional).
LAC and LAAC young people can present with mental health needs of varying nature.
Where symptoms are mild or moderate in nature a consultation with a PMHW will help clarify what support may be appropriate and whether they should provide some direct intervention to the child/young person.
For persistent and severe symptoms, referral to Tier 3 CAMHS may be appropriate. / PMHWs offer training (see self-harming behaviours section) and consultation to foster parents and staff in residential units to support them.
If concerns exist they will have been discussed in multi agency groups. Local authority services and CAMHS aim to work together to provide a common, coordinated framework across all agencies that support the delivery of appropriate, proportionate and timely help to all children as they need it.