This project sought to identify the challenges encountered in the transition between CAMHS and AMHS for Looked after Children and consider what mental health and social care services can do to ensure it is a safe and successful transition

Ellis, K.

Jones, F.

South, R.

English

Canterbury Research and Theses Environment

Canterbury Christ Church University’s repository of research outputshttp://create.canterbury.ac.ukPlease cite this publication as follows: Ellis, K., South, R. and Jones, F. W. (2014) The transition between CAMHS and AMHS for looked after children: mind the gap. Clinical Psychology Forum (255). pp. 27-31. ISSN 1747-5732. Link to official URL (if available):http://www.bpsshop.org.uk/Clinical-Psychology-Forum-No-255-March-2014-P3735.aspxThis version is made available in accordance with publishers’ policies. All material made available by CReaTE is protected by intellectual property law, including copyright law. Any use made of the contents should comply with the relevant law.Contact: create.library@canterbury.ac.uk  Ellis, K., South, R. and Jones, F. W. (2014) The transition between CAMHS and AMHS for looked after children: mind the gap. Clinical Psychology Forum, 255. pp. 27-31.     -----------------------------------------   The transition between CAMHS and AMHS for Looked after Children: Mind the Gap      Kate Ellis Trainee Clinical Psychologist Canterbury Christ Church University  Rebecca South Highly Specialist Clinical Psychologist Oxleas NHS Trust  Fergal Jones Senior Lecturer Canterbury Christ Church University    Corresponding author: Kate Ellis, CCCU, Salomons Campus, Broomhill Road, Tunbridge Wells, TN3 0TG krhellis@googlemail.com                 2    Summary  This project sought to identify the challenges encountered in the transition between CAMHS and AMHS for Looked after Children and consider what mental health and social care services can do to ensure it is a safe and successful transition.  Introduction Managing transitions between Child and Adolescent Mental Health services (CAMHS) and Adult Mental Health Services (AMHS) is a recognised challenge worldwide (Street et al., 2011). Singh at al. (2010) evaluated the transition process between CAMHS and AMHS in London and the Midlands, tracking CAMHS clients across one-year, and found that many were not referred to AMHS due to CAMHS clinicians’ perceptions that they would not be accepted.  They identified the following factors as predictors of unsuccessful transitions: family history of mental illness, child protection, serious mental-health problems, emerging personality disorder, and medication use. Following transition, they reported concerning levels of non-attendance, drop-out after first appointment in AMHS, and discharges without being seen.    The report highlighted both facilitators and barriers to successful transitions. Facilitators included dedicated transition posts, joint CAHMS/adult appointments, co-working and early communication prior to transition.  Barriers were communication problems, variation in eligibility criteria, lack of confidence in adult services, a lack of understanding between CAMHS and AMHS about services, high workloads and a lack of funding for transitions posts.  An evaluation by the charity Rethink argues that the current transition system in England does not provide satisfactory support and that clearer transition protocols, earlier planning, a stepped down discharge process and training between CAMHS and AMHS are needed (Street et al., 2011). The transition from CAMHS to AMHS is particularly challenging for children who are looked after (British Association of Adoption and Fostering, 2010). These children are accommodated or looked after by a local authority subject to an Emergency Protection Order, Interim Care Order or Care  3 Order (DoH, 1989). In 2009, 60,900 children in the UK were looked after, of whom 73% were placed with foster carers, 13% in residential settings and the rest living with extended family or independently (Department for Children, Schools and Families, 2009a).   Research has consistently highlighted the poor outcomes for children in care with regard to the prevalence of mental health difficulties, under achievement in education, unemployment and heightened involvement with the criminal justice system (Department for Children, Schools, and Families, 2009a).  Clinical experience within an outer London CAMHS specialist Looked After Children service suggested that there are particular challenges in supporting these children to make the transition to AMHS, where this is needed.   Aims  To identify the perceptions of professionals working with children in care, concerning the challenges encountered in the transition between CAHMS and AMHS, and the services/supports that could overcome these.  Method Professionals working with children in care in one outer London local authority were invited to participate if they had experience of working with a young person who was currently transitioning or had transitioned in the last 18 months. Participants provided informed consent and included four professionals from a CAMHS looked after children team (consultant psychiatrist, family therapist, consultant clinical psychologist and team manager), two professionals from social care (a social worker and team manager), and one foster carer.  Following consultation with the CAMHS looked after children team, a semi-structured interview schedule was developed that aimed to explore participants’ perceptions of the challenges associated with transition, support requirements needed for safe transitioning, the unique difficulties experienced by children who are looked after in transition, and knowledge exchange with AMHS clinicians.  Interviews lasted approximately 20-30 minutes, and the subsequent transcripts were analysed using Braun and Clark’s (2006) version of thematic analysis. The themes and codes were  4 checked independently by the second author, and Elliot et al.’s (1999) quality assurance criteria were followed.  Results  The results are presented by the themes identified.  Multiple simultaneous losses  Professionals felt that timing was a challenge both in relation to when to make the referral but also the amount of things changing simultaneously for children who are looked after as they approach their 18th birthday. They cease to receive support from CAMHS and Social Care at the same time as leaving the foster placement/residential unit, and hence are negotiating numerous difficult transitions at the same time.   “Because leaving care is quite traumatic for them, before 18 there is a lot of intervention going on for them and then suddenly at 18 it is not a lot of intervention”.   Systems not joining up Professionals also identified challenges inherent in CAMHS and AMHS being two different systems that do not dovetail, e.g. having different referral criteria, and reported a poor flow of information between the systems. In particular, reference was made to procedures in place for looked after children who are placed out of borough but who return at 18. Participants reported difficulties in making referrals to AMHS for out of borough looked after children because, although they will be returning to borough on their 18th birthday, the receiving adult team is determined by the GP address, which at the time of referral is not within borough.  Professionals identified the need to bridge the gap between services and suggested the development of a specialist transitions role to support looked after children through the transition.   “It is a vulnerable group, I think looked after children by a specialised team if possible, at least the first year after transfer a specialised team would be good as an extra intervention and support”   5 They also suggested the need for greater understanding between CAMHS and AMHS about how each service works, better communication with and involvement of young people and earlier involvement of AMHS with a longer period of joint working for looked after children.     It was also identified that clinicians in AMHS would benefit from receiving clear information about the young person’s history, knowledge of the care system and how attachment related difficulties may present in early adulthood.  Limited understanding about the transition process A further theme identified was the need for a clearer understanding of the transition process to AMHS, by both CAMHS and Social Care. Professionals requested clarification of the referral criteria, pathway and operational policies currently in place.  Vulnerability Professionals identified that there is an enforced sense of independence for children who are looked after at 18, as they try to negotiate numerous significant transitions at the same time, such as independent living, finding employment or further education  and leaving foster care. Professionals identified that looked after children often report feeling lonely making these transitions in the absence of family/carers support, and questioned how they would be able to act as a responsible adult, if they have not experienced a functional and safe family environment themselves.   “Remember these children have been abandoned already or taken from their families and they are expected disproportionately to share degrees of independence most other young people of that age do not show and if actually you looked carefully at their development psychology they are not capable of exhibiting”   The analysis revealed that professionals believed this in turn makes young people vulnerable to both returning to a dysfunctional family and being exploited by others.    Understanding how a looked after young person may present to AMHS Professionals identified that it was important for adult services to understand how a  6 looked after young person may present in the context of all the changes taking place in their life.  For example, they may present with a lot of bravado but are in fact very scared, due to having to become independent before they may feel emotionally equipped for independence. They may also be very testing or rejecting of a new professional.    “I think understanding the ongoing effects of attachment could be key.  Understanding how that presents itself in an older child that it is rubbishing of authority, the inability to keep appointments and things and that you need to keep hold of them to keep trying even though they are running in the opposite direction”   Engagement  Following on from the last theme, a key challenge identified was that of engagement, both the young person’s reluctance to engage with a new service and to recognise the need for mental heath services.   Discussion Professionals described numerous challenges that had been encountered in supporting young people leaving care to transition from CAMHS to AMHS. The challenges broadly related to difficulties in the young person’s willingness to engage with a new service coupled with the loss of previous services and relationships with professionals (e.g. CAMHS and social worker), multiple changes occurring at the same time for the young person and a gap between CAMHS and AMHS regarding service provision.  In relation to the CAMHS and AMHS ‘gap’, concern was expressed not only that the services are not joint working efficiently together but that they have different referral criteria and place a different onus on who is responsible for supporting the client to engage.  For young people leaving care, who may struggle to form a new relationship, additional support may be needed to increase the likelihood of engagement and for this to be sustained. A particular challenge was also raised regarding looked after children who have been in a foster/residential placement outside of the borough but who, once they are no longer ‘looked after’ on their 18th birthday, typically return to their borough of origin to seek housing. At the time of the referral to AMHS the young person does not have a GP within the local borough.  This can lead to referrals  7 being rejected or delayed, causing distress and confusion for the young person which may ultimately reduce the likelihood of them engaging with a new service.  Professionals also identified multiple changes happening simultaneously as a key challenge. Unlike young people who live with their birth parents, for young people in care the18th birthday often denotes leaving foster care, seeking independent accommodation and employment, saying goodbye to their social worker and also CAMHS professionals. In this way, young people leaving care who are also referred to AMHS are often trying to negotiate multiple and demanding challenges simultaneously. This is synonymous with guidance that suggests that the transition between CAMHS and AMHS should occur at a time of stability for the young person and the need to avoid multiple simultaneous transitions (Singh et al., 2010; NICE, 2010). Earlier joint working may also serve to ameliorate the number of transitions coinciding and support the young person to engage with the new service (Singh et al., 2010).  This project also sought to consider what mental health and social care services can do to ensure it is a safe and successful transition. The recommendations that emerged are detailed below.   1. Specialist looked after children transitions role.  There was broad consensus amongst professionals that there was a need for a specialist ‘transitions’ role to work across CAMHS and AMHS with care leavers.  A dedicated role would enable there to be a single point of contact for sharing information across teams and engaging with the young person. This clinician would be able to facilitate the transition process and support the young person in engaging with AMHS.  2. A clear referral pathway for looked after children placed out of borough.  Professionals identified that a policy is needed to detail the pathway for referrals where the young person is placed out of borough at the time of referral. It was suggested that one adult team could receive all such referrals until the young person is within borough or the same procedures could be applied as for people who are  8 homeless. This supports the recommendation by Street et al. (2011) that clearer protocols are needed to avoid leaving young people without support.    3. Specialist training between CAHMS and AMHS. Professionals also suggested that training provided by CAMHS for clinicians in AMHS regarding looked after children, the care system, and attachment may be beneficial. This level of joint working may be particularly useful in thinking about how child and adult focused services may differ in the language used regarding diagnoses, for example regarding attachment related difficulties and personality disorder.   4. Involvement of the young person. An additional suggestion that emerged from the findings was the need for greater involvement of the young person in the transition process. One participant highlighted that a booklet outlining the transition process (e.g. what to expect and who is involved) may be of utility.   Conclusions This project sought to identify the challenges encountered in the transition between CAMHS and AMHS for looked after children and consider what mental health and social care services can do to ensure it is a safe and successful transition.  The key challenges identified were the young person engaging with AMHS, a lack of joined up services, multiple changes occurring at 18 years old, and the loss of existing support including CAMHS, social workers and foster carers.  A number of constructive suggestions were made as to how mental heath and social care services could improve the transition process for young people in care, including a specialist transition worker, earlier and more effective joint working between services, training provision between CAMHS and AMHS, a protocol regarding referrals of young people living out of borough at the time of referral, and greater involvement of the young person.   References   9 Braun, V.,  & Clark, V.  (2006).  Using thematic analysis.  Qualitative Research in Psychology, 3, 77-101.  British Associaion of Adoption and Fostering, (2010). Children in Public Care. Retrieved from www.baaf.org.uk/res/statengland#pc  Department for Children, Schools and Families (2009a). Resource accounts. Retrieved from https://www.education.gov.uk/publications/eOrderingDownload/HC-256.pdf  Department for Education (2010). Children looked after by local authorities in England (including adoption and care leavers) - year ending 31 March 2010. Retrieved from http://www.education.gov.uk/rsgateway/DB/SFR/s000960/index.shtml  Elliott, R., Fischer, C. T., & Rennie, D. L. (1999). Evolving guidelines for   publication of qualitative research studies in psychology and related fields. British Journal of Clinical Psychology, 38, 215–229 NICE (2010). Looked after children, draft guidance.  The physical and emotional well being of looked after children and young people.  Retrieved from www.nice.org.uk/guidance/PH28   Singh, S., Paul, M., Ford, T., Kramer, T., Hovish, K., Islam, Z., & Weaver, T. (2010). Lost in Transition: A multi-perspective study of process, outcome and experience of transition from child to adult mental health care (TRACK). British Journal of Psychiatry,197, 305-312.  Singh, S., Paul, M., Islam, Z., Weaver, T., Kramer, T., McLaren, S., Belling, et al (2009). Transition from CAMHS to Adult Mental Health Services (TRACK): A study of service organisation, policies, process and user and carer perspectives. Southampton: NIHR SDO programme.   10 Street, C., Smith, J., Shiers, D., Tummey, F., & Pinfold, V.  (2011).  Joint working at the interface: Early intervention in psychosis and specialist child and adolescent mental health services. London: Rethink.   Word Count: 2484.              

The transition between CAMHS and AMHS for looked after children: mind the gap

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The transition between CAMHS and AMHS for looked after children: mind the gap

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