John, 17, has become isolated and withdrawn due to mental health issues leading him to thoughts of suicide, anxiety and panic attacks at the thought of going to school. Due to an incident of self-harm his GP referred him to Child and Adolescent Mental Health Service (CAMHS), Dundee. His allocated psychiatrist has prescribed anti-depressants to deal with his anxiety. For the past 4 weeks MACX Service, who are the emergency response team within CAMHS, have been working with John at home and in the school alongside his Guidance Teacher.
1.1 Explain the role of services in supporting the development of the young person.
CAMHS is a statutory, multidisciplinary mental health service which will identify and support John with his mental health issues. They recognise that every child/young person is unique and take the family centred approach to treatment. Johns GP referral was screened and accepted by a senior clinician, who directed his referral for a prioritised appointment due to his self-harm (see fig.1).
Mental Health Services are provided through a 4 tiered system:
Tier 1 is delivered through mental health trained primary care and partner agencies staff, e.g. GPs, who can make early identification of mental health issues and refer timeously.
Tier 2 is provided by CAMHS through specialist Primary Mental Health Workers.
Tier 3 is provided by CAMHS through specialist multidisciplinary secondary care service teams.
Tier 4 is provided by CAMHS through specialist, intensive, outpatient, outreach MACX teams who were set up to support young people aged 12-18 suffering from severe mental health difficulties to reduce the need for inpatient care. 2 of this team have a home appointment with John and his family where an assessment is made. John privately talks about his thoughts and fears. A safeguarding issue is discussed due to his self-harm and suicidal thoughts and a risk assessment is made as part of his care plan.
The use of the outreach MACX team is beneficial for John as due to previous bad experiences with CAMHS treatment he feels unsettled at Dudhope. Being able to talk at home or school is more relaxing, so he feels he can discuss his issues more openly and frankly. A personal safety plan is established, with details of persons to contact when Johns thoughts wander to self-harm and/or suicide. The team regularly review his needs and update his psychiatrist and core worker back at Dudhope.
High School is a statutory service funded by the Scottish Parliament. John has regular meetings with his guidance teacher who is his Named Person and she co-ordinates school visits made by MACX team. Using the GIRFEC (Getting it right for every child) framework she helps to support him in the most effective, sensitive but least invasive way possible whilst being mindful of his wellbeing according to the SHANARRI indicators – Safe, Healthy, Achieving, Nurtured, Active, Respected, Responsible and Included (see fig.2). The guidance teacher monitors his progress with a health assessment tool called a wellbeing web. If John has a really bad day and cannot cope with being in class he has the choice of going to a quiet place, e.g. the library or, due to his safeguarding issues, his parents are contacted for him to go home with one of them.
1.2 Analysing initiatives and/or strategies which influences these services
The Scottish Government: Suicide Prevention Strategy 2013-2016 sets out what measures it will take to continue to prevent and reduce the amount of suicides, suicidal behaviour and self-harm in Scotland. Male suicides counted for three quarters (1,112) of those who died in Scotland for the years 2011 and 2012. The target was to reduce male and female deaths by a further 20% by 2013. In order to meet this target the strategy focuses on:
Responding to people in distress, people in distress may have thoughts of self-harm or suicide and NHS staff should be aware of the source Scottish Patients at Risk of Readmission and Admission (SPARRA) in assessing those at risk.
Talking about suicide and reduce the stigma of mental illness, continued use of the Choose Life campaigns Suicide: Dont hide it. Talk about it and Read Between the Lines.
Improving the NHS response to suicide, making mental health services safer for those at risk. Many who die by suicide have previous had numerous contacts with health care services.
Developing the evidence base, continuing analysis and reviews of individual suicides to improve knowledge and outcomes.
Support change and development, continue with Choose Life campaigns, raising awareness across Multi-disciplinary, Multi-agency and partnerships of improving suicide prevention.
An initiative that straddles both education and mental health services within the NHS is the Mental Health Foundations Make it count. Mental health is not extracurricular. This policy briefing was initiated on World Mental Health Day, 10th October 2018. The foundation wants schools to be mentally healthy places of learning, with mental health as part of the curriculum and SHANARRI indicators (see fig.2). School heads, teachers and peers to be trained in mental health and resilience so that By improving mental health in schools, we can dramatically improve the future mental health of the population as a whole.
In a recent strategy publication Delivering for today, investing for tomorrow: the Government’s programme for Scotland 2018-2019, chapter 2 A Healthy and Active Nation the Scottish Government sets out not only to reform how mental ill-health is treated by clinical services but also building new support networks from schools, communities and workplaces. It highlights that people should have information on how to keep themselves mentally fit with support on resilience. This would stop people reaching a critical state before getting access to mental health services.
In June 2018, a task force on Children and Young Peoples Mental Health Improvement was announced which listened to the views of young people, clinicians and service providers, as well as examining how other countries have had success in supporting good mental health.
The Scottish Government has used these views to set out 3 proposals:
1. to ensure that parents will know what and how to access help
2. children and young people will have a choice of a wider range of services
3. schools will have support with wellbeing concerns and trained to know when and what counselling services they direct children and young people into.
1.3 Explaining how legislation influences professional practice in these services and the impact this could have on the children or young people
Both CAMHS and high schools work within The Children and Young People (Scotland) Act 2014. Part 1 of this act deals with upholding the rights of the child as per the UN Convention on the Rights of the Child (UNCRC) e.g. Article 24 states (health and health services) Every child has the right to the best possible health. Governments must provide good quality health care, clean water, nutritious food, and a clean environment and education on health and well-being so that children can stay healthy. Richer countries must help poorer countries achieve this. Part 3 of the Act covers Childrens Services Planning, part 4 the Provision of Named Persons and part 18 General, subsection 96, Assessment of Wellbeing.
Using the key principles of GIRFEC to support the wellbeing of children, young people and their parent(s) by means of the SHANARRI well-being indicators, mental health issues can be highlighted earlier to prevent them worsening (see fig.2). Both CAMHS and high schools offer a single point of contact for discussion to assess, plan and access the correct support or advice. In school this is the Named Person and in CAMHS is the Primary Mental Health Worker.
Significantly, staff development within the GIRFEC framework gives them the skills to confidently and effectively support the child or young person in a sensitive way. Staff in schools can identify those in need of support with their mental health and have the abilities and knowledge when to make appropriate referrals to specialist services such as CAMHS. Reduced inappropriate referrals allows these services to focus and reduce waiting times for those who need their assistance more urgently (see fig.3).
1.4 Analysing an example of partnership working for children or young people
Partnerships protect and improve the quality of services and communication between agencies can keep children and young people safe from harm. All parties work together with common goals using one assessment with the same information, thus not leading to duplication in time and resources. This leads to better outcomes for the child or young person. Questions to be addressed from partnership meetings are:
What is getting in the way of this child or young persons wellbeing?
Do I have all the information I need to help this child or young person?
What can I do now to help this child or young person?
What can my agency do to help this child or young person?
What additional help, if any, may be needed from others?
Disadvantages of joint working are that all services must be simultaneously updated in their training, cuts in one budget can create demand in another service, not always enough time to share information and funding issues across the board leading to a lack of resources.
The MACX team are better equipped to meet the shared assessment of John and his familys
needs as it provides a coordinated service with his high school and outside agencies. This increases the understanding of Johns requirements and improves his service and results.
Following a Team Around the Child meeting between the Named Person at high school and MACX team to discuss John, a joint decision was made to involve 3rd Sector agencies such as Dundee Rep Theatre Drama Therapy and Art Angel, Dundee who hold young mens clubs (film, drama and art) to broaden Johns social groups and interests to occupy his mind and focus on positive experiences.