Primary Child and Adolescent Mental Health

A Practical Guide, Volume 1

Quentin Spender, Judith Barnsley, Alison Davies, Jenny Murphy

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315346175
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Rewritten with the new primary care environment in mind, this greatly expanded and updated edition of Child Mental Health in Primary Care extends the structured approach of the first edition to adoelscent mental health. As in the first edition, Primary Child and Adolescent Mental Health covers each problem in a uniform way, offering definitions, assessment outlines, detailed management options and indications for referral. Numerous case examples further illuminate aspects of many conditions. Comprehensive and practical, the forty-eight chapters of Primary Child and Adolescent Mental Health cover the full range of difficulties and disabilities affecting the mental health of children and young people. The book is divided into three volumes, and can either be read from cover to cover or used as a resource to be consulted for guidance on specific problems. This book is vital for all healthcare professionals including general practitioners, health visitors and other staff working in primary care to assess, manage and refer children and adolescents with mental health problems. School medical officers, social workers and educational psychologists, many of whom are in the front line of mental health provision for children and young people, will also find it extremely useful. Reviews of the first edition: 'This very comprehensive and detailed book provides the tools for primary care health professionals not only to assess a child's needs but in many cases also to implement an initial package of care.' JUST FOR NURSES 'I have no reservation in recommending the book to all people working with children and families in any capacity. An important training text for a variety of professions. A very effective text to be used in daily practice for quick reference.' CHILD AND ADOLESCENT MENTAL HEALTH 'This book is well produced and clearly written. A useful book for anyone interested or involved with children.' FAMILY PRACTICE 'I looked through the book again and again but could not find anything missing.' NURSING TIMES

PART 1

Overview

CHAPTER 1

The context for provision of Child and Adolescent Mental Health Services

A Definition of Child Mental Health

Mental health in children and young people has been defined as having the following components:¹

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  a capacity to enter into and sustain mutually satisfying personal relationships
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  a continuing progression of psychological development
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  an ability to play and to learn so that attainments are appropriate for age and intellectual level
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  a developing moral sense of right and wrong
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  the degree of psychological distress and maladaptive behaviour is within normal limits for the child’s age and context.

Additional aspects of emotional well-being include the following:

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  a capacity to use and enjoy solitude
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  empathy and awareness of others’ feelings
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  continuing emotional, intellectual and spiritual development
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  becoming able to learn and benefit from setbacks or problems.

In the words of one young person reporting to the 2008 UK Child and Adolescent Mental Health Services (CAMHS) review panel, which will be quoted extensively in this chapter: ‘It doesn’t mean being happy all the time but it does mean being able to cope with things’.²

Child mental health problems are therefore difficulties or disabilities in these areas that may arise from any number of congenital, constitutional, environmental, family or illness factors. Such problems have two components: firstly, the presenting features are outside the normal range for the child’s developmental age, intellectual level and culture (‘deviance’ – with a statistical more than a sociological meaning); and secondly, the child or others are suffering from the dysfunction (‘impairment’). Or to put it in a nutshell:

Disorder = deviance plus impairment.

There is no mental health disorder unless both aspects are present.

The Organisation of Services

Children’s mental health needs, in the broadest sense, are met by a multitude of people: firstly, and most obviously, by their parents (or carers), other relatives and friends; but also by a variety of professionals, from those who look after the baby in hospital, the toddler in nursery, the child in school and the adolescent in youth clubs to the various professionals working in multidisciplinary teams that we will call ‘specialist CAMHS’.

The Four-Tier model

This broad approach to service delivery was the basis for the Health Advisory Service Report ‘Together We Stand’,³ which provided a new way of thinking about how CAMHS can be organised. The authors of the report⁴ proposed two new concepts: the Four-Tier system and the primary mental health worker (PMHW or PCAMHW). These concepts can still give rise to endless confusion and debate, although their description in the original document is fairly clear. Part of the reason for the confusion is that services have developed in very different ways in different parts of the United Kingdom, so that people whose job titles are the same may do very different things, and the same service may be provided in different areas by people with different training or job titles. Teams of people working together to help children, young people and their families may have a variety of different names. Examples include:

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  ‘Team Around the Child’
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  ‘Behavioural and Educational Support Team’
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  ‘Multi-Agency Support Team’
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  ‘Social Inclusion Team’
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  ‘Integrated Service Delivery Areas’
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  ‘Primary Care Behaviour Service’
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  ‘Children’s Emotional Health and Wellbeing Service’
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  ‘Targeted Mental Health in Schools’ team
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  and many others.

Our attempts in this book to explain these concepts will inevitably fall foul of such geographical variability in the way that services and teams are named – as well as the frequent major changes that are made to the ways in which services are delivered, particularly with each new government.

Figure 1.1 attempts to clarify the Four-Tier model, but with the strong caveat that the exact placement within the diagram of each profession may seem appropriate only in some areas.

The traditional threefold division of services was into primary care (who refer onto) secondary or specialist care (who refer onto) tertiary care – even more specialist care – traditionally in the local teaching hospital.

In the fourfold model, Tier 1 practitioners are those working in universal services, such as primary care, schools or youth clubs. These professionals are not primarily trained as mental health specialists – but mental health and emotional well-being is increasingly seen as everyone’s business. Their role includes: promoting mental health; providing general advice, support and treatment for less severe problems; helping to identify problems early; and referring on to more specialised services.⁵ An example of this sort of work is given in Box 1.1.

FIGURE 1.1 The four tier model of child and adolescent mental health provision. The oval represents specialist CAMHS

BOX 1.1 Case Example

Sandra, aged four years, is referred to her health visitor by her nursery school because she is having episodes of rage during which she goes blue and appears to stop breathing. The health visitor checks that Sandra’s mother, Janet, has given consent to the referral and then visits her at home, while Sandra is there, to discuss the concerns. She then visits the nursery school to talk to the staff and following this she reviews the situation with a local primary mental health worker.

The health visitor and primary mental health worker have little difficulty establishing that these episodes, which happen at home as well as at the nursery school, are blue breath-holding attacks. Although there are no concerning features in the history, Janet remains anxious about the breath-holding attacks and so the health visitor arranges for a general practitioner’s appointment, where a thorough history, examination and explanation provides Janet with some reassurance.

The health visitor then gives Janet the behavioural management advice contained in Chapter 18 of this book on Breath-holding. She reinforces this advice with further telephone support and a home visit six weeks later.

At this follow-up, the attacks have substantially reduced and Janet is much more confident about managing the behaviour.

Tiers 2 and 3 include the traditional narrowly defined ‘specialist CAMHS’ service in the oval, which is part of secondary care. A referral from Tier 1 is usually necessary to allow a child or family to have access to it. Tier 2 is uni-disciplinary and Tier 3 multi-disciplinary. Tier 2 professionals have specific mental health training. They may support service delivery at Tier 1 by carrying out assessment, treatment, consultation or training. Tier 3 teams usually offer a specialised service to those with more severe, complex and persistent disorders. Confusion sometimes arises with this model because the same professional may work in Tier 2 and Tier 3 in the same day: she may be working in isolation in the morning, but in collaboration with others in the afternoon. The nature of multidisciplinary working is also a little ambiguous: does it require the young person or family to be ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Preface to the second edition
• About the authors
• Acknowledgements
• Part 1: Overview
• Part 2: General issues
• Index