Children and Young People ’ s Programme Professor Peter Fonagy National Clinical Advisor, CYP IAPT Kathryn Pugh Programme Lead, CYP IAPT Anne O’Herlihy Extended Scope Programme Manager with Faye Henney and Harriet Hamilton
Jul 02, 2015
Children and Young People’s Programme
Professor Peter Fonagy
National Clinical Advisor, CYP IAPT
Kathryn Pugh
Programme Lead, CYP IAPT
Anne O’Herlihy
Extended Scope Programme Managerwith Faye Henney and Harriet Hamilton
When we started on this
journey…
International Perspective on CAMHS• Alarms regarding the ineffectiveness and fragmentation of community-based mental health care for children and families (Bickman 2008; Kazak et al.,2010; Knitzer 1982; Warren et al. 2010; Warren et al. 2010, 2006).• majority of children receiving community-based ‘‘usual
care (UC)’’ do not show clinical improvement(Manteuffel et al. 2008; Warren et al. 2010).
• large meta-analytic review reported few differences between UC treatment and control groups, with reported effect sizes near zero (Weisz, 2004)
International Perspective on CAMHS: US studies
Summary of International Perspective on CAMHS
• No convincing evidence of a strong aggregate clinical impact of usual community-based care for children and families
• No consistent findings demonstrating a relationshipbetween provider characteristics (such as, discipline, education, or experience) and differential effectiveness(Beutler et al. 1994, 2004; Wampold 2001).
• Findings regarding child characteristics associated with effectiveness are also inconsistent
Fragmentation of services for children and young people
Current service provision: a snapshot
Fragmentation of services for young people aged 12-25
Artificial structural divisions in terms of
Under 18
Over 18
Age
Fragmentation of services for children & young people
Artificial structural divisions in terms of
Different lines of funding
DH DfE
DWPLA
Health
Social services
Education
Employment
Fragmentation of services for children & young people
Artificial structural divisions in terms of
Statutory vs voluntary providers
Fragmentation of services for children & young people
Artificial structural divisions in terms of
Separation of physical and mental health
Physical Mental
Many service designs are not young person friendly
Inaccessiblein terms of location, time,
criteria for access
Many service designs are not young person friendly
Problem centred not person centred
OCD CLINIC
Many current service designs are not young person friendly
Stigmatising; little YP involvement in decision making
OCD CLINIC
OCD OCD OCD OCD OCD
OCD OCD OCD OCD OCD
Many current service designs are not young person friendly
High dropout rates (40-60%)
OCD CLINIC
OCD OCD OCD OCD OCD
OCD OCD OCD OCD OCD
On top of these problems…
• There is massive unmet need: only 13% of adolescent males with a clinical diagnosis receive treatment
• Increased prevalence of at least some mental health problems in young people (e.g., self-harm)
• Inconsistent use of evidence-based interventions across services resulting in sub-optimal outcomes
• Missed opportunities for potential prevention, caused by delay in accessing services
• Lack of understanding about child mental health (mental health literacy) in services outside mental health care (GPs, education)
• In most services there is no routine outcome measurement and no requirement to monitor outcomes
Summary 2011 from CAMHS Perspective• Quality
• Significant shortages of trained professionals • Current level of CAMHS staff training is ‘poor and getting
worse’ with pressures on costs
• Access• Difficulties with access (very few services offer a self-referral
route)• Poor handling of transition between child and adult services• Inappropriate provision of adult services at T4 to young people
• Assurance and Safety• Data that could and should be used for performance
improvement, self-critical professional practice and commissioning is rarely collected
Template for appropriate CYP services: key components
Improving access & engagementAccess
Improving access & engagementAccess
AwarenessIncreasing MH
awareness & decreasing
stigmatisation
Template for appropriate CYP services: key components
Improving access & engagementAccess
AwarenessIncreasing MH
awareness & decreasing
stigmatisationParticipation
Enhancing youth, carer and community participation
Template for appropriate CYP services: key components
Improving access & engagementAccess
AwarenessIncreasing MH
awareness & decreasing
stigmatisationParticipation
EBPDelivery of evidence-based practices
Template for appropriate CYP services: key components
Enhancing youth, carer and community participation
Improving access & engagementAccess
AwarenessIncreasing MH
awareness & decreasing
stigmatisationParticipation
EBPDelivery of evidence-based practices
Accountability
Improving outcomes
accountability
Template for appropriate CYP services: key components
Enhancing youth, carer and community participation
CYP-IAPT
The book that has it all!!
• ANXIETY DISORDERS
• DEPRESSIVE DISORDERS
• DISTURBANCE OF CONDUCT IN CHILDREN
• DISTURBANCE OF CONDUCT IN ADOLESCENTS
• ATTENTION DEFICIT HYPERACTIVITY DISORDER
• TOURETTE SYNDROME
• PSYCHOTIC DISORDERS
• PERVASIVE DEVELOPMENTAL DISORDERS
• SELF-INJURIOUS BEHAVIOR
• EATING DISORDERS
• SUBSTANCE USE DISORDERS
• CHILDREN WITH PHYSICAL SYMPTOMS
• SPECIFIC DEVELOPMENTAL DISORDERS
• CHILD MALTREATMENT
• SUMMARY OF FINDINGS AND DISCUSSION
• 4,060 References
We know what the evidence says
“Evidence Based Implementation ofEvidence Based Medicine”
“…implementation research needs to come into
its own to capitalize what is known and find
out what strategies work or do not work in
implementing changes in clinical practice.”Grol & Grimshaw (1999) Journal on Quality Improvement, 25 (10)
p. 503
‘The does it work in Grimsby test’Dr Peter Fuggle (2014) Personal communication
(with apologies to all who live in Grimsby)
What we need is…
Imbalance of “Design Time” and “Run Time”
Run TimeLocal conditions
Adaptation/reinvention
Aiming for at-least-equal effects
Design TimeDevelop & specify
Test feasibility and safety
Test efficacy/ effectiveness
Based on Chorpita & Daleiden, 2014
Run-Time Challenges: Why we needed the collaboratives
Managing uncertainties of intervention – context fit
o Unplanned adaptation of implementation parameters
o Unplanned adaptation of intervention itself
Intervention rejection
Implementation problems
Unequal outcomes
o Intervention failure?
o Implementation failure?
o How would we know?
Problem
Symptom or
Pressure
Symptom-Correcting
Process
Fix – Solution
that Works in
Short Run
Vicious cycle
Unintended
Consequences that
Make the Original
Problem Worse
Delay
We need to do
something
NOW!
CYP IAPT
Collaboratives
Evidence-Based Intervention: CYP IAPT
THE WHAT: Clinical interventions
Treatment model
Treatment component(e.g., exposure, fear ladder)
Diagnostic assessment
Treatment package(e.g., IY or PPP)
Classroom management programme
THE HOW: Context of interventions
Access to service
Leadership training
Clinical skills training
Feedback protocol for outcomes(e.g., service performance “report card”)
Partnership in decision making
A few achievements of
CYP-IAPT…
A simple evidence based implementation of EBP?
• CYP IAPT was conceived as a centrally initiated modification of CAMHS in the direction of EBP
• It is achieving remarkable degree of culture change in terms of the acceptability of principles of EBP interpreted broadly through a modest investment in:• service change• training service leads• supervisors and therapists
• Learning collaboratives made up of universities and local area partnerships offer mutual support, problem-solving and learning networks.
With permission from Scott Lunn
Why ROMs?The Derby experience
With thanks to Scott Lunn
Derby – Introducing ROMS • Encourages clinicians to be more focused on package of
care through use of ‘Goal Based Outcomes’.
• Time spent within the service is dramatically reduced, prevents therapeutic drift and allows the young person to have more control and say about the service which is being provided.
• Evidences to commissioners the level of service being provided and how effective it is.
With permission from Scott Lunn
With permission from Scott Lunn
Cases ceased to accumulate from June
INPUT=OUTPUT
Length of stay declines by 12%
With permission from Scott Lunn
How good is CYP-IAPT at integrating ROMs?
Mean percentage of CYP IAPT CAMHS staff using ROMs in 2014 in Year I, Year II & Year III partnerships
Source: Partnership annual report to central team.
Perc
ent
of clinic
ians u
sin
g R
OM
s
Year I0
Year II
20
40
60
80
Year of Recruitment
70.3% 75.6%
N=65
F(1,32)=27.4, p=0.00001
Year III
30.0%
CYP IAPT CAMHS staff using ROMs in 2013 and 2014 in Year I and Year II partnerships
Source: Partnership annual report to central team.
Perc
ent
of clinic
ians u
sin
g R
OM
s
20130
2014
20
40
60
80
Year of Report
31.1%
73.3%
N=41
F(1,32)=20.7, p=0.00001
Year I and Year II CYP IAPT partnership staff using ROMs in 2013 and 2014
Source: Partnership annual report to central team.
Perc
ent
of clinic
ians u
sin
g R
OM
s
20130
2014
20
40
60
80
Year I Partnerships
64.4%72.4%
2013 2014
11.1%
73.9%
Year II Partnerships
F(1,32)=23.0, p=0.00001
0
10
20
30
40
50
60
70
80
90
100
2013 2014
London and South East North West (Salford and Manchester)
Oxford and Reading (Reading University) North East
South West
Year II CYP IAPT partnership staff using ROMs in 2013 and 2014 by Collaborative
Percent of Clinicians
Year I CYP IAPT partnership staff using ROMs in 2013 and 2014 by Collaborative
0
10
20
30
40
50
60
70
80
90
100
2013 2014
London and South East North West (Salford and Manchester)
Oxford and Reading (Reading University)
Percent of Clinicians
0%
10%
20%
30%
40%50%
60%
70%
80%
90%
Therapists
discussin
supervision
meetings
Discuss outcome
data w ith service
Leads use to
inform service
planning
Managers discuss
service level
outcome
Review ed and
discussed w ith
partners
Year II
Year I
Significant increases in the contexts for the use of ROMs: Percentage of Year I & Year II Partnerships
using data from ROMs in 2014 for different purposes
Percent of Partnerships
What are ROMs for?
0%
20%
40%
60%
80%
100%
Outcome data in peer supervision Discuss service level outcome to
inform planinng
Report outcomes data to
comissioners
London and South East North East North West Oxford and Reading South West
Significant differences between collaboratives in the contexts where partnerships report using ROMs in
2014 for different purposes
Percent of Partnerships
Mean percentage of Year I and Year IIPartnerships accepting self referrals in 2013 and 2014
Source: Partnership annual report to central team.
Perc
ent
of Part
ners
hip
s
20130
2014
20
40
60
80
Year of Report
69.5% 75.3%
N=41
F(1,35)=1.59, p=0.20
Self-referrals:
Source: Partnership annual report to central team.
Perc
ent
of clinic
ians u
sin
g R
OM
s
20130
2014
20
40
60
80
86.2% 83.3%
2013 2014
76.3% 77.9%
N=41
Wilk’s L(2,37)=0.98,
p=0.63
Partnerships achieving participation milestones and including parents across years and collaboratives
Achieving milestones
Including Parents
100
Participation:
The Problems
&
The Future
Challenges with implementing CYP IAPT
Across year I, II and III CAMHS partnerships
• The bigger we get, the further trainees have to travel and the mentoring relationship becomes more challenging
• Increase in referrals and reduction in staffing (up to 20% reported)-demand outstripping capacity, impact on staff,
• Service re-tender or restructuring and leadership and management restructuring,
• Reductions or cuts in Tier 2 and LA provision. • IT and governance issues - time with data input and double
entry, local battles with IT departments and electronic patient record providers
• Data set for CYP IAPT is not mandated nationally
Improving access to
parenting training
“Training/education programmes are the first line of treatments for parents or carers of preschool children.”
“Group-based PT/education programmes are usually the first line of treatments for parents or
carers of children and young people with ADHD and moderate impairment.”
“Offer a group parent training programme to the parents of
children and young people aged between 3 and 11 years…”
NICE recommended parenting interventions
• Substance misuse among vulnerable young people• Parental skills training
• Parental monitoring
• At least 3 motivational interviews aimed at parents and carers each year
• Autism• Social-communication intervention: play strategies with parent and teachers
• Antisocial behaviour and Conduct Disorder• Aged 3-11: Group or individual parenting training programme
• Aged 11-17: Multisystemic Therapy, which has a strong parenting component
• ADHD• Pre-school children: Parent-training/education
• School-age: Group parent training + individual child intervention
(CBT, medication)
• Depression and Anxiety• Parental involvement is recommended. No specific parent intervention
REFERENCE LIST – INCREDIBLE YEARS
Axberg, U., Hansson, K., & Broberg, A. G. (2007). Evaluation of the Incredible Years Series - an open study of its effects when first introduced in Sweden. Nord J Psychiatry, 61(2), 143-151. doi: 10.1080/08039480701226120
Baker-Henningham, H., Walker, S., Powell, C., & Gardner, J. M. (2009). A pilot study of the Incredible Years Teacher Training programme and a curriculum unit on social and emotional skills in community pre-schools in Jamaica. Child Care Health Dev, 35(5), 624-631. doi: 10.1111/j.1365-2214.2009.00964.x
Evidence-base for:
REFERENCE LIST – TRIPLE P
Aghebati, A., Gharraee, B., Hakim Shoshtari, M., & Gohari, M. R. (2014). Triple p-positive parenting program for mothers of ADHD children. Iran J Psychiatry Behav Sci, 8(1), 59-65.
Bodenmann, G., Cina, A., Ledermann, T., & Sanders, M. R. (2008). The efficacy of the Triple P-Positive
Evidence-base for:
Evidence-base for:
Other parenting programmes,
the best of the rest
Evaluation of other parenting programmes
Cotton, Daphne; Reynolds, Jenny and Apps, Joanna. Training for parenting support: Qualitative research with
employers, managers, providers and practitioners in ten local authorities in England. London: Family and Parenting
Institute, 2009.
Allen, J. L., Faulkner, N., Legge, K., Chivers, C., Wormald, C., Oliver, B., & Dadds, M. Talking and Listening with your
Child (TLC): An Innovative Parent-Child Emotion Conversation-Based Adjunct to Parent Training. Paper in symposium
titled: “National Academy for Parenting Research: A Collection of Papers presenting Parent-Focused Resources and
Programmes.” British Association for Behavioural and Cognitive Psychotherapy, Manchester, United Kingdom, July,
2010.
Salmon, K., Dadds, M.R., Allen, J., & Hawes, D.M. ‘Can emotional language skills be taught during parent training for
conduct problem children?’ Child Psychiatry and Human Development 40.4 (2009): 485-498.
Van Bergen, P., Salmon, K., Dadds, M. R., & Allen, J. L. ‘Training mothers in emotion-rich reminiscing.’ Journal of
Cognition and Development, 10.3 (2009): 162-187.
Scott, S, Sylva, K, Doolan, M, Price, J, Jacobs, B, Crook, C and Landau, S. (2010) Randomized controlled trial of parent
groups for child antisocial behaviour targeting multiple risk factors: the SPOKES project. Journal of Child Psychology and
Psychiatry 51, 48-57
Scott, S, O’Connor T, Futh A, Price J, Matias C & Doolan M. (in press) Impact of a parenting program in a high-risk,
multi-ethnic community: The PALS trial Journal of Child Psychology and Psychiatry
Professor Stephen Scott, CBE BSc, MB Bchir (Cantab), FRCP, FRCPsychDirector of the National Academy for Parenting Research
Body of evidence
Less evidence does not necessarily mean less effective
Other programmesMost frequently used programmes
How should parenting interventions be judged?
Parent training
Support from RCTs
Clear manual permitting training
Instrument to assess fidelity
Practice-based evidence
0
2
4
6
8
10
12
14
Before After
Parent training versus control
Intervention Control
Other things I would still like to see:
Make CYP-IAPY even more young person-centred
Make services (young) person centred
Covering transition from adolescence
to young adulthood
Integrating MH provision with other services
Youth-orientated
access point
Young person controlled
referral process
Shared decision-making
Empowering children, young people and carers
Participate in service design
Participate in training of practitioners & managers
Understand and modify treatment
progress via PROMs
Empowering young people enables them to….
1. Take control of their care
2. Establishtreatment goals
3. Choose the route to health that’s best for them
4. Improve their own health
Reduce access barriers caused by stigma & lack of knowledge
Improve mental health literacy through activities at local and national levels we should be educators
Policy makers, commissioners and providers need a better understanding of
Natural history of mental disorder: likelihood of natural recovery, need for maximal resources at age of peak onset, need for continuity of services at this age
Massive impact of social context on the course of disorder
Resilience as well as risk factors
Too little is known about availability of effective evidence-based services; more needs to be done to promote good experiences of care (Layard & Clark, 2014)
CYP-IAPT and integration initiatives
Close ties with other Tier 1 to Tier 3 programmes
YP MH services
Provide a platform for early identification and intervention
Interface/integrate with early psychosis youth services
Establish strong links with school counselling
programmes
Professor Mick Cooper, DPhil (Psych),
CPSY, Dip Counselling, AvDip
Psychotherapy,
Prevent social exclusion by integrating services
Mental health
services
Housing
EmploymentSocial
support
What is required for a better service for CYPs?
An integrated, youth-centred, outcomes-oriented system
Joined up care and multiagency cooperation
• No young person should have to deal with gaps in their care.
• We can expand and build on the CAMHS transformation partnership
model through effective commissioning and sufficient resourcing.
• We need a deepening of relationships with commissioners and the
encouragement of joint commissioning with partner agencies in order to
improve integrated care pathways and achieve a thorough understanding
of evidence-based practice.
• We need to create a single information system for young people (e.g.,
CYP IAPT) – IT problems compromise many service improvement initiatives
CYP-IAPT and physical health
Involve physical healthcare in mental healthcare and vice versa
Physical healthcare
Mental healthcare
Involve physical healthcare in mental healthcare and vice versa
Integrated healthcare
Strong co-occurrence between mental and physical health problems Integration makes economic and health care sense
and is likely to be destigmatizing
CYP-IAPT and prevention
Involve the educational system in MH education
Mental
Health
Education
Anti
Bullying
Workshop
There is mandated physical health, sex (relationship) and drug abuse education in schools
Few secondary schools include mental health literacy in their syllabi
Despite the known high prevalence of MH difficulties, young people are not effectively signposted to services
Education is an effective form of prevention (e.g. suicide attempts and suicidal ideation)
Schools are an ideal platform for the delivery of prevention services in relation to
Bullying including cyberbullying
The sequelae of acute mental health problems (e.g. suicide)
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
Incident suicide attempts Severe suicidal ideation
12 months follow-up
Youth Mental Health Awareness Programme (YMHAP)
Question, Persuade and Refer (QPR)
Screening by Professionals
Controls
OR: 0.52
[0.29 - 0.94]OR: 0.53
[0.29 - 0.96]
• 11,110 adolescents
• Average age= 14.8
• 168 schools
• 10 European countriesAustria, Estonia, France, Germany, Hungary,
Ireland, Israel, Italy, Romania, Slovenia & Spain
Three suicide prevention programmes (RCT)
Wasserman et al., in press. The Lancet
At 12 months follow up, the only programme better than controls
was the Youth Mental Health Awareness
Reduction of suicide attemptsOR: 0.52 [0.29 - 0.94]Reduction of severe suicidal ideationOR: 0.53 [0.29 - 0.96]
Question, Persuade and Refer (QPR): Gatekeeper training for teachers and school staff
Youth Mental Health Awareness:Aimed at pupils
Screening by Professionals with referral of at-risk pupils
Control: No intervention
CYP-IAPT and resilience enhancement
“Differential sensitivity”
Self-regulationpredicts resilience
Peer influenceprotective against risk-promoting environments
Involvement in community and extracurricular activitiesimpact on biological stress response system
better overall adjustment
Family resourcesprotective against ACEs
Racial socialisationpositive outcomes in school, overall wellbeing,
less depression, higher self-concept
The Chicago Center for Family Health Resilience FrameworkCCFH
Parent-Child Interactive TherapyPCIT
Families OverComing Under StressFOCUS
HomeFront StrongMSPAN
The Child Illness and Resilience ProgramCHiRP
The Penn Resilience ProgramPRP
Steps Toward Effective and Enjoyable ParentingProject STEEP
Nurse-Family Partnership (US)NFP
Toddler-Parent PsychotherapyOklahoma State University Center for Family Resilience
University of IllinoisFamily Resilience Center
CorStone Family Resilience ProgramFRP
University of WisconsinFamily Resilience Program
Inner Resilience ProgramIRP
Open Doors’ Resilient KidsCCFH Bounce Back and Thrive!
BBT
Potential resilience enhancing
programmes for CYP-IAPT
CYP-IAPT, quality control
and the future
What the future should bring
• Incorporating a public health framework of prevention and health promotion with treatment
• Mental health promotion may be woven into the lives of our children
• Innovative methods for early detection and manipulation of neurobiological risk and protective factors
• Technological and communication advances may enable entirely new psychosocial assessment and intervention.
What needs to happen?
We cannot wait complacently for new discoveriesMillions of children often languish in suboptimal mental health services
We do not need a further reorganisation We just need to reform the practice within them
Collaboration between professionals and agencies is essentialAnd this is not something that can be created only by throwing money at it
We need a client-focused, outcome-oriented approach to all aspects of working with families
This is less about organisations:Not about organising 15 professionals around a family
It’s about empowering and supporting each otherfor each of us to carry out our work
We need to mobilise all the individuals and organisations that have astake in YP’s future
To make changes to the current system to improve care for YPs