Future of CAMHS: How best to support wellbeinguclpstorneuprod.blob.core.windows.net/cmsassets/Dr... · 2015-12-07 · 1. Anxious away from care givers (Separation anxiety) 11.Extremes

Future of CAMHS: How best to

support wellbeing

Dr Miranda Wolpert

Reader in Evidence Based Practice and Research, UCL

Director of the Evidence Based Practice Unit (EBPU), UCL and

Anna Freud Centre

Director of the Child Outcomes Research Consortium (CORC)

Director of Service Improvement and Evaluation, Anna Freud

Centre

Supporting wellbeing for those

in need

• What constitutes need for mental health input for

children?

• How have services been historically configured?

• Are they getting worse?

• What is the delivery context?

• What is the policy context?

• How can services work together to support

children young people and families?

Historical support for child

mental health needs

• From the 1920s

• Support child wellbeing

• Deal with problems before that become significant

The child guidance movement

• Focused on mental illness and severe mental health problems

Psychiatry

• More a recent perspective

• Focus on most troubling young people

• Risk to themselves or others

Management of risk

• Different languages: difficult cross-agency work

• Historically underfunded• Current austerity context resulted in cuts up to 25%

• The last UK epidemiological study (10 years ago) shows• Less than 25% of those deemed in need accessed support

Educational lexicon

Health lexicon

Social care lexicon

Categorising Mental Health problems 1. Anxious away from care givers

(Separation anxiety)

11.Extremes of mood (Bipolar

disorder)

21.Family relationship difficulties

2. Anxious in social situations

(Social anxiety/phobia)

12. Delusional beliefs and

hallucinations (Psychosis)

22. Problems in attachment to

parent/carer (Attachment problems)

3. General anxiety (generalised

anxiety)

13. Drug and alcohol difficulties

(Substance abuse)

23. Peer relationship difficulties

4. Compelled to do or think things

(OCD)

14. Difficulties sitting still or

concentrating

(ADHD/Hyperactivity)

24. Persistent difficulties managing

relationships with others (includes

emerging personality disorder)

5. Panics (Panic Disorder) 15. Behavioural difficulties (CD

or ODD)

25. Does not speak (selective

mutism)

6. Avoids going out (Agoraphobia) 16. Poses risk to others 26. Gender discomfort Issues (GID)

7. Avoids specific things (Specific

phobia)

17.Carer management of CYP

behaviour (e.g. management of

child)

27. Unexplained physical symptoms

8. Repetitive problematic

behaviours (Habit problems)

18. Doesn’t go to the toilet in

time (Elimination problems)

28. Unexplained developmental

difficulties

9. Depression/low mood

(Depression)

19. Disturbed by traumatic event

(PTSD)

29.Self-care issues (includes

medical care management, obesity)

10.Self-harm (Self injury or self-

harm)

20.Eating issues

(Anorexia/Bulimia)

30. Adjustment to health issues

See pages 15, 17 and 19 in Current view Tool Completion guide

1. Anxious away from care givers

(Separation anxiety)

11.Extremes of mood (Bipolar

disorder)

21.Family relationship difficulties

2. Anxious in social situations

(Social anxiety/phobia)

12. Delusional beliefs and

hallucinations (Psychosis)

22. Problems in attachment to

parent/carer (Attachment problems)

3. General anxiety (generalised

anxiety)

13. Drug and alcohol difficulties

(Substance abuse)

23. Peer relationship difficulties

4. Compelled to do or think things

(OCD)

14. Difficulties sitting still or

concentrating

(ADHD/Hyperactivity)

24. Persistent difficulties managing

relationships with others (includes

emerging personality disorder)

5. Panics (Panic Disorder) 15. Behavioural difficulties (CD

or ODD)

25. Does not speak (selective

mutism)

6. Avoids going out (Agoraphobia) 16. Poses risk to others 26. Gender discomfort Issues (GID)

7. Avoids specific things (Specific

phobia)

17.Carer management of CYP

behaviour (e.g. management of

child)

27. Unexplained physical

symptoms

8. Repetitive problematic

behaviours (Habit problems)

18. Doesn’t go to the toilet in

time (Elimination problems)

28. Unexplained developmental

difficulties

9. Depression/low mood

(Depression)

19. Disturbed by traumatic

event (PTSD)

29.Self-care issues (includes

medical care management, obesity)

10.Self-harm (Self injury or self-

harm)

20.Eating issues

(Anorexia/Bulimia)

30. Adjustment to health issues

Categorising Mental Health problems

Facing Shadows video

Evidence-based treatment for

Depression• NICE-recommended treatment:

• Watchful waiting

• Guided self-help e.g. sleep hygiene

– ‘Self-help’ for depression could include any activity or lifestyle

choice that an individual makes in the belief that it will confer

therapeutic benefit (e.g. taking more exercise, modifying diet,

reducing or increasing alcohol intake).

• CBT (individual and group)- e.g. behavioural activation, thought

challenging

• Interpersonal therapy (IPT)

• Individual psychodynamic psychotherapy

• Family therapy (NICE, 2015)

Supporting coping

1. Encourage some activity

Physical activity is particularly helpful. Try to encourage a student to walk, run, cycle, skip anything which begins to increase their activity and help improve how they feel.

2. Encourage them to talk to others

Try to encourage the student to tell people close to them how they are feeling. Having a cry can help relieve tension and let things move on.

3. Encourage them to look after themselves

Try to think about the ways they are coping and if this is helpful for example using drugs or drinking alcohol. This may give the students immediate relief but can also create further problems to cope with.

4. Challenge negative thinking

When someone is experiencing depression they often tend to think and expect the worst of themselves, their life and their future. Try to help a student write down their thoughts when feeling gloomy and try to counter these thoughts by writing down arguments against them.

(Northumberland. Tyne and Wear NHS Foundation Trust, 2015)

Delivery Context

• Rising need for girls with emotional problems though

plateau or improvement behaviour problems in boys

(Fink et al., 2015)

• Ongoing reduction in services- 25% (YoungMinds, 2013)

• Teachers most commonly contacted as point of advice

for mental health issues (Ford et al., 2007)

• Long-term challenges in relationship between schools

and CAMHS (Fazel et al., 2014)

Policy Context

• High interest and commitment to evidence based and outcomes focussed practice

• Aligned models of what good looks like creating transformed services building on children and young people accessing psychological therapies and allied initiatives

• Ring fenced funding to support ongoing transformation

• Increased collaborative working DH, Dfe, NHSE and PHE

Uncomfortable facts upfront

1. There are not enough resources to meet need.

2. Even if there were enough resources, at our current state of knowledge at least 1/3 of children with significant mental health problems will still have the same level of difficulties or worse, even after the most evidence-based and specialised input.

3. These two facts are unlikely to change in the near future.

(Warren et al., 2010)

Implications

• We must focus on how we can help

children within the limited resources that

we have

• Some of this work will involve supporting

people in managing ongoing mental health

difficulties.

• A key issue is how to help disparate

services work together

Understanding services

• Lack of data

• Payment system project

Project Findings and Final Report

CAMHS Payment System Project

June 2015

15

The prospective data collection pilot – 20 services participated

• Training late 2012 – early 2013

• Data collection until mid 2014 with focussed work on data quality

• Examples of services provided:

– Outreach & intensive community treatment

– Looked after children

– Neurodevelopmental disorders

– Learning disability

– Paediatric liaison

– Forensic

– Tier 2

– Tier 3

– Eating disorders

– Inpatient

• No. of sites in each region:

3

1

1

1

3

6

1

4

What does “clustering”

(“grouping”) mean?

Note: These images represent simulated illustrations only. No CAMHS data were used to make them.

Note: N = 4573. Forty periods of contact were recorded to have attended more than thirty appointments. These are not

shown in this graph, but are included in the analysis.

Approach 1: Regression Trees

Approach 2: K-medoids Cluster Analysis

Approach 3: Conceptually guided grouping

Grouping Development: Three approaches

Illustrative indication of relative grouping sizes based on analysis of Current View data collected Sep 2012-June 2014¶

Draft groupingsPercentage of periods of

contact in sample§

Getting Advice: Signposting and Self-management Advice [A1] 30 %

Getting Advice: Neurodevelopmental Assessment [A2] 3 %

Getting Help: Guided by NICE Guideline 16 and/or Guideline 133 (Self-harm) [H1] 6 %

Getting Help: Guided by NICE Guideline 26 (PTSD) [H2] 2 %

Getting Help: Guided by NICE Guideline 28 (Depression) [H3] 6 %

Getting Help: Guided by NICE Guideline 31 (OCD) [H4] 1 %

Getting Help: Guided by NICE Guideline 38 (Bipolar Disorder) [H5] 1 %

Getting Help: Guided by NICE Guideline 72 (ADHD) [H6] 6 %

Getting Help: Guided by NICE Guideline 113 (GAD and/or Panic Disorder) [H7] 4 %

Getting Help: Guided by NICE Guideline 158 (Antisocial Behaviour and/or Conduct

Disorders) [H8]

5 %

Getting Help: Guided by NICE Guideline 159 (Social Anxiety Disorder) [H9] 2 %

Getting Help: Guided by NICE Guideline 170 (Autism Spectrum) [H10] 2 %

Getting Help: With Co-occurring Behavioural* And Emotional** Difficulties [H21] 2 %

Getting Help: With Co-occurring Emotional** Difficulties [H22] 8 %

Getting Help: With a Difficulty or Co-occurring Difficulties Not Covered by H1-H10,

MH1-MH3 or H21-H22 [H23]

16 %

Getting More Help: Guided by NICE Guideline 9 (Eating Disorders) [MH1] 1 %

Getting More Help: Guided by NICE Guideline 155 (Psychosis) and/or Guideline 38

(Bipolar Disorder) [MH3]

1 %

Getting More Help: With Co-occurring Difficulties of Severe Impact [MH9] 8 %

¶ Total sample size: 4573 periods of contact in the community (i.e. does not include inpatient periods of contact) from 11 CAMH services. Data were collected between September 2012 and June 2014. Current View tools were usually completed after the first contact within a period of contact.§ Percentages sum to more than 100%, because each group has been rounded to the nearest whole percentage, and because a child can be in the grouping ‘Getting Advice: Neurodevelopmental Assessment’ (A2) at the same time as being in one of the other groupings. Apart from A2 all other groupings are mutually exclusive.* Behavioural difficulties (Conduct Disorder or Oppositional Defiant Disorder). ** For the purpose of grouping assignment emotional difficulties are defined as: Depression/low mood (Depression); Panics (Panic Disorder); Anxious generally (Generalized anxiety); Compelled to do or think things (OCD); Anxious in social situations (Social anxiety/phobia); Anxious away from caregivers (Separation anxiety); Avoids going out (Agoraphobia); Avoids specific things (Specific phobia).

Key to box plots

Illustrative indication of distributions of appointments by grouping based on analysis of Current View and appointments data collected Sep 2012-June 2014¶

Legend to grouping labelsA1: Getting Advice: Signposting and Self-management AdviceH1: Getting Help: Guided by NICE Guideline 16 and/or Guideline 133 (Self-harm)H2: Getting Help: Guided by NICE Guideline 26 (PTSD)H3: Getting Help: Guided by NICE Guideline 28 (Depression)H4: Getting Help: Guided by NICE Guideline 31 (OCD)H5: Getting Help: Guided by NICE Guideline 38 (Bipolar Disorder)H6: Getting Help: Guided by NICE Guideline 72 (ADHD)H7: Getting Help: Guided by NICE Guideline 113 (GAD and/or Panic Disorder)H8: Getting Help: Guided by NICE Guideline 158 (Antisocial Behaviour and/or Conduct Disorders)H9: Getting Help: Guided by NICE Guideline 159 (Social Anxiety Disorder)H10: Getting Help: Guided by NICE Guideline 170 (Autism Spectrum)

H21: Getting Help: With Co-occurring Behavioural* And Emotional** DifficultiesH22: Getting Help: With Co-occurring Emotional** DifficultiesH23: Getting Help: With a Difficulty or Co-occurring Difficulties Not Covered by H1-H10, MH1-MH3 or H21-H22MH1: Getting More Help: Guided by NICE Guideline 9 (Eating Disorders)MH3: Getting More Help: Guided by NICE Guideline 155 (Psychosis) and/or Guideline 38 (Bipolar Disorder)MH9: Getting More Help: With Co-occurring Difficulties of Severe Impact

* Behavioural difficulties (Conduct Disorder or Oppositional Defiant Disorder).** For the purpose of grouping assignment emotional difficulties are defined as: Depression/low mood (Depression); Panics (Panic Disorder); Anxious generally (Generalized anxiety); Compelled to do or think things (OCD); Anxious in social situations (Social anxiety/phobia); Anxious away from caregivers (Separation anxiety); Avoids going out (Agoraphobia); Avoids specific things (Specific phobia).

N.B. ‘Getting Advice: Neurodevelopmental Assessment’ (A2) is not shown as additional appointments that may be associated with this grouping cannot be discerned in this data set.

Draft groupings

<- Upper quartile

<- Median

<- Lower quartile

A1 H6 H10 H5 H8 H3 H7 H4 H2 H1 H9 H21 H23 H22 MH1 MH9 MH3

Nu

mb

er

of

ap

po

intm

en

ts a

tte

nd

ed

be

twe

en

pe

rio

d o

f c

on

tac

t

sta

rt d

ate

an

d d

isc

ha

rge

da

te i

nc

lus

ive

(b

ina

ry l

og

sc

ale

)

¶ Total sample size: 4573 periods of contact in the community (i.e. does not include inpatient periods of contact) from 11 CAMH services. Data were collected between September 2012 and June 2014. Current View tools were usually completed after the first contact within a period of contact.

Testing the relevance of complexity

factors (etc.) for predicting resource use

Summary

The classification of CAMHS cases according to our

designed groupings provides a better and more reliable

prediction of resource use than “a-theoretical” models found

by statistical methods (cluster analysis, regression trees).

Once group membership was taken into account, there was

no strong evidence of an additional contribution by context

and complexity factors to the prediction of resource use.

This was regardless whether “number of appointments” or

“relative treatment cost” was used to estimate resource use.

Quality criteria• Clinical meaningfulness: The classification relates to NICE best

practice guidelines, takes into account frequent “comorbidities”, and

distinguishes groups of CYP that don’t appear to neatly fit into a

category. We recommend that allocation to a group is based on a

shared decision about treatment aims.

• Relation to resource use: Modest relationship to resource use (but

better than purely ‘data’ driven models).

• Reliability of identification: Unclear. Reliability will depend on

reliability of Current View Ratings, as well as reliability of

practitioners’ group allocation decisions (when overriding the

algorithm’s suggestion).

Note: This plot shows the same model as the previous plot, but this time the estimated effects of the 16 clusters are shown alongside the effects for complexity, context and EET factors. Clusters are identified by colour only: blue bars show clusters belonging to “Getting Help”, purple bars show clusters belonging to “Getting More Help”. The influence of each cluster or risk factor is shown compared to a POC in the “Coping” cluster without any risk factors. It can be seen that Cluster Membership is a more important predictor of “number of appointments” than any of the associated risk factors. See appendix for a legend to labels and for the model specification.

Useful Tools: Youth Wellbeing Directory

Table 1: Predicted resource use for needs-based

groupings, from payment systems project analysis

Needs-based

groupings

Predicted % in

grouping based

on application of

the algorithm

95%

confidence

interval of

group

percentage

Predicted

average no.

of sessions

95% confidence

interval of estimated

average

appointments

Predicted %

resource use

for a typical

service*

Informal

confidence

range for

predicted

resource use**

Getting

advice

28% 27%-29% 6.2 4.6-8.47 24% 20%-29%

Getting

help

61% 60%-62% 6.9 5.1-9.5 59% 53%-65%

Getting

more help

11% 11%-12% 10.4 7.5-14.5 16% 13%-22%

Total 100% -- 7.2 6.6-7.8 100% --

Table 2: Hypothetical resource use in NHS

outpatient CAMHS after implementing THRIVE

Needs-based

groupings

Hypothetical %

of episodes of

care in grouping

Hypothetical

average number

of sessions

Hypothetical %

resource use

(direct

appointments

only)

Hypothetical %

overall resource

use

Getting advice 30% 3 10% 8%

Getting help 60% 10 66% 56%

Getting more help 5% 30 16% 14%

Getting risk

support

5% 15 8% 7%

Thriving n/a n/a n/a 15%

Total 100% 9.2% 100% 100%

Initial thoughts on choosing outcome indicators

• Below are examples of indicators relating to the sort of goals agreed by children,

young people and families accessing services

• Goals Based Outcomes (GBO) may be useful in relation to bespoke goals agreed

Overarching theme Agreed goal Some possible outcome indicators that can be used

Relationship/

interpersonal

Make more friends

Have better family relationships

Have less fights

Better management of child’s behaviour by

parent

Strengths and Difficulties Questionnaire (SDQ); Child Outcome

Rating Scale (CORS)

SCORE Index of Family Function and Change-15 (SCORE-15)

Me and My School (M&MS)

Brief Parental Self-Efficacy Scale (BPSES)

Coping with specific

problems and symptoms

Less symptoms PTSD

Less low mood

Manage intrusive thoughts and compulsive

behaviours

Impact of Events Scale (IES)

Strengths and Difficulties Questionnaire (SDQ)

Revised Child Anxiety and Depression Scale (RCADS)

How are things: Depression/low mood (PHQ-9)

OCD subscale of Revised Child Anxiety and Depression Scale

(RCADS)

Personal functioning Doing better at school

Feeling happier

Number of days attending school; academic achievement

Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS)

Young people’s strategies

(13-14 year old self report)

• Long baths

• Physical activity

• Eating chocolate

• Sleeping

• Talking with friends (more true of young

women than young men)

Project GroupDr Miranda Wolpert, Director, Evidence Based Practice

Unit and Child Outcomes Research Consortium, UCL

and the Anna Freud Centre (Project Co-Director)

Professor Panos Vostanis, Professor of Child

Psychiatry, University of Leicester (Project Co-Director)

Simon Young, Finance Director, Tavistock and Portman

NHS FT (Chair of Project Steering Group)

Dr Bruce Clark, Clinical Director of CAMHS and Child

and Adolescent Psychiatrist, South London and

Maudsley NHS FT

Dr Roger Davies, Clinical Psychologist, East London

NHS FT

Dr Isobel Fleming, Deputy Director, Child Outcomes

Research Consortium, UCL and the Anna Freud Centre

Dr Lynne Howey, Consultant Clinical Psychologist,

Tees, Esk and Wear Valleys NHS FT

Pat Howley, Assistant Director of Contracts (Sexual

Health and Children’s Services), NEL Commissioning

Support Unit

Amy Macdougall, Statistician, Child Outcomes

Research Consortium, UCL and the Anna Freud Centre

Dr Peter Martin, Statistics Professional Lead, Evidence

Based Practice Unit, UCL and the Anna Freud Centre

Tony Martin, Chartered Accountant, Project Finance

Lead

Charlotte Payne, Project Support Officer, Child

Outcomes Research Consortium, UCL and the Anna

Freud Centre

Benjamin Ritchie, Pilot Site Manager, Evidence Based

Practice Unit, UCL and the Anna Freud Centre

Dr Rob Senior, Medical Director, Tavistock and Portman

NHS FT

Dr Ann York, Consultant Child and Adolescent

Psychiatrist, Chair of Project Advisory Group

Dr Andy Whale, Statistician, Evidence Based Practice

Unit, UCL and the Anna Freud Centre

References

• Fink et al., 2015. Mental Health Difficulties in Early Adolescence: A Comparison

of Two Cross-Sectional Studies in England From 2009 to 2014. Journal of Adolescent

Health. http://dx.doi.org/10.1016/j.jadohealth.2015.01.023

• Fazel et al, 2014. Mental health interventions in schools in low-income and middle-

income countries. Lancet Psychiatry.

http://dx.doi.org/10.1016/S2215-0366(14)70357-8

• Ford et al., 2007. Child Mental Health is Everybody's Business: The Prevalence of

Contact with Public Sector Services by Type of Disorder Among British School

Children in a Three-Year Period. Child and Adolescent Mental Health.

http://dx.doi.org/10.1111/j.1475-3588.2006.00414.x

• YoungMinds, 2013. Local authorities and CAMHS budgets 2012/2013. London:

YoungMinds.

The THRIVE ModelAttempts at drawing a clearer distinction than before between:• treatment and support

• self-management and intervention

Service Profile Completion

Percentage of services that

have completed ACE-V

ACE-V Quality standards

30% (92/305) Basic Information

12% (37/305) Basic Information and Accountability

9% (29/305) Basic Information, Accountability and Compliance

13% (41/305) Basic Information, Accountability, Compliance and

Empowerment

13% (40/305) Basic Information, Accountability, Compliance,

Empowerment and Value

User Journey on NHS Choices Young

People Mental Health Hub1. Enter

http://www.nhs.uk/pages/hom

e.aspx into search engine

2. Click on Youth Mental Health

Link

Youth Mental Health

3. Use widget to select mental

health support for young

people in your area.

Search for CAMHS, mental health

support for young people or alcohol

services for young people

Map of results

Distance from location

Export all

data as an Excel

file or print

Age range

4. The results page

displays 139

mental health

services for young

people in Croydon

NB. The search covers a 35

mile radius – results are

displayed in order of

proximity to the search

location

NB. Distances are given in a

straight line, but NHS choices

does note that travel

distances may be longer

Save location for future visits

Narrow your search

5. A service page

Service details

Age Range

Information Supplied by

Get directions by car, walk, cycle

or train.

You can also print this page

NB You can report an issue with this

page

User Journey on NHS Choices

Young People Mental Health Hub

Service name, distance and age

range

Search by location and/or issue

Service webpage visible

Relatable resources

Testimonials

Service Standards

Map of Coverage