Self-perpetuation: What constitutes contemporary Child and Adolescent Mental Health Services?

Sally Hardy (@SallyHardys) and Dr Claire Gaskin from London South Bank University will be leading this week’s EBN Twitter chat on Wednesday 21st October between 8-9 pm UK time focusing on contemporary children and adolescent mental health services. Participating in the Twitter chat requires a Twitter account. If you do not already have one you can create an account at www.twitter.com. Once you have an account contributing is straightforward – follow the discussion by searching links to #ebnjc or @EBNursingBMJ, or better still, create a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN chat hash tag) at the end of your tweet – this allows everyone taking part to view your tweets.

In this Blog we will be focusing on whether Children and Adolescent Mental Health Services (CAMHS) are based on the specific needs of our children and young people, or whether the perspective of the adult professionals dominates how services are organised and delivered.

Adult opinion has dictated what is considered best for children and young people. We aim with this Blog to encourage discussion as to what some of the primary areas of concern are when considering what should constitute Child and Adolescent mental health services, and how these could be informed by our children and young people who are seeking help. The thoughts and ideas presented in this Blog are based on our personal parenting, professional clinical practice and academic experiences. This blog aims to provoke and allow us to explore and engage with each other’s thoughts and ideas.

CAMHS, for too long now, has been organised and delivered as a specialist service, defined by age limits and arranged by professionals who continue to extoll the virtues of their chosen therapeutic models (Wolpert, et al. 2014). Since the 1990s move towards community mental health service provision, academic writers such as Hopton (1997) and of course Foucault (1980; 2012) have been raising concerns that following the latest political directives or research trends continues to lead to exclusion rather than any substantive social change towards acceptance and individualised choice as a process for inclusion and improved wellbeing. Change is still required to ensure CAMHS can respond to the diversity and complexity our children and adolescents’ experience in their existential angst when experimenting and trying to understand their own place and personhood. Real change may only come about when focus shifts from rhetorical to insightful consideration of the implications and consequences of current practice on the next generation’s mental health and wellbeing, informed and driven by Children and Young People’s voices.

Young Minds (www.youngminds) identifies that over 850,000 children and young people in the UK have a diagnosed mental health problem. Children as young as two years are being diagnosed with mental health disorders.

Interest in the mental health of our children and young people has seen increasing television and media storylines, somewhat fixated with understanding the idiosyncrasies of human behaviour. We remain preoccupied with seeking a cause for mental illness or at least something to attribute (or to apportion blame). This is leading to an increased stressful existence and exposure of the significantly traumatic issues and encounters a young person’s life can often hold.

Young people and – increasingly – pre-school age (0-3 years) children are influenced by the media, spending many hours a day in the company of electronic and digitalised devices. Child minders are encouraged by their regulating body (Ofsted) to ensure electronic toys, digital devices and computerised games are available to pre-school and after school cared for children alongside other more traditional ‘sensory play equipment’ such as water, paint and cooking. School age (4-18 years) children have ready access to the world wide web and search engines that have already done much of the thinking and experimenting for them, and offer a quick fix, or direct access to sources of information that are again adult fixated. This has perhaps led to an increased use of online pornography sites for a young person’s introduction to sex education, with online gaming that focuses on warfare, mass murder, apocalyptic and zombie communities as our young person’s modern playground.

Reports reveal how many of our young people do not feel safe to explore or expose their sexual orientation (Yabarra & Mitchell, 2015). National statistics (http://www.england.nhs.uk/statistics/) continue to reveal a growing number of young people who feel unable to express their sexual preferences, for fear of losing friends, family and their home. Indeed a quarter of homeless young people in London identifying themselves as LGBT. A third of children in care are concerned about their sexual identity, many of whom have experienced abuse and neglect.

A British Broadcasting Corporation (BBC) report (25 September, 2015) identified how the number of young people at University seeking support from counselling and mental health services continues to expand, particularly during times of stressful change, such as experiencing the transition to independent living at University. Therefore, the demand for effective CAMHS is not going away. In fact the demand is growing, faster than innovative service delivery and effective outcomes can be identified and resourced.

CAMHS services, as discussed in our latest editorial (Gaskin & Hardy, 2015), have recently been taken through a governmental review process. The tiered service approach helps to clarify what level of services a person can expect, depending on what the professional adults think is the level of severity or need. Are we getting the perspective wrong when focusing on adults’ views of what is required, rather than focusing attention and interest on what the child, adolescent, or young person is asking for?

Recently a Health Watch survey of young people reported that they do not want to get their health advice from a family based General Practitioner, as someone who knew their parents, knew them as a child and knows their personal history within the family context. Instead what the modern day young person prefers is to seek their health guidance from an anonymised source, such as a clinic, from an A & E department or most frequently, seeking information from an online information source.

So what should or could our CAMHS services be doing to enhance and help children and young people access services, to receive the evidence based effective early interventions required for improved recovery? How can our CAMHS be tailored services that are anonymised and adaptive enough to minimise the likelihood of removing the young person even further from their social setting?

In the diabetes field, many NHS clinics found it was the young people who failed to keep their regular (week day time) clinic appointments, so they surveyed young people and their families, to find they wanted a different service than the one in place, which at best was offering a slightly different approach from all other adult health care clinic provision. A Diabetes UK survey (www.diabetes.org.uk) identified it was in schools that much of the education and change was most effective, in providing information and advice to teachers and pupils that helped to stop children being excluded from sport, or field trips, on the basis of their diabetes. Cancer services are also developing treatment options that increase social engagement, rather than isolating the child in hospital to undergo their cancer treatments for months on end towards their recovery and reintroduction to their social network, that will have undoubtedly moved on, without them(Knott et al, 2013). The same should be said for children and young people with a mental health problem.

More research is being carried out into how to work alongside those children who have historically been excluded or become highly anxious school avoiders. Those children who struggle on alone, isolated in their experiences and emotional turmoil because, from an early age, adults have been their abuser, or have just not been reliable enough and consistent in caring adequately.

The self-help approaches of mindfulness, Dialectic Behavioural Therapy (DBT) and Children and Young Adults Improved Access to Psychological Therapy (CYA-IAPT) is beginning to show promise, with severe self-harming behaviours being worked with not further punished (see for example, ‘the butterfly project’ found on Facebook).

CAMHS services need to take into consideration the hearts and minds of our young people. Young people are struggling enough, as we have briefly outlined above. How then can CAMHS services embrace and contain that angst, distress and turmoil, rather than further exacerbate it?

Join us on Twitter to discuss some of the questions we have raised and of course to share your own experiences and raise further questions.

• Tell us about your CAMHS experience?

• How then can CAMHS services embrace and contain that angst, distress and turmoil, rather than further exacerbate it?

• Do you think CAMHS is adult –focused in its delivery and organisation?

• What do our Children and Young People want from services?

• How might we offer more age appropriate provision and what does that look like?

• How can the digital age be embraced to enable CAMHS to become easy access?

Sally Hardy, Professor of Mental Health Nursing & Practice Innovation and Head of Department for Mental Health and Learning Disabilities, School of Health and Social Care, London South Bank University

Claire Gaskin, Consultant Nurse/Senior Lecturer Mental Health and Learning Disabilities, North East London Foundation Trust and Department for Mental Health and Learning Disabilities, School of Health and Social Care, London South Bank University

References

Foucault, M. (1980). Language, counter-memory, practice: Selected essays and interviews. Cornell University Press.

Foucault, M. (2012). The birth of the clinic. Routledge.

Gaskin, C., & Hardy, S. (2015). The state of play in child and adolescent mental healthcare services (England): not in front of the children?. Evidence Based Nursing, ebnurs-2015.

Hopton, J. (1997). Towards anti-oppressive practice in mental health nursing. British Journal of Nursing, 6(15), 874-878.

Knott, C., Brown, L., & Hardy, S. (2013). Introducing a self-monitoring process in a teenage and young adult cancer ward: impact and implications for team culture and practice change. International Practice Development Journal, 3(2), 1-12.

Wolpert, M., Deighton, J., De Francesco, D., Martin, P., Fonagy, P., & Ford, T. (2014). From ‘reckless’ to ‘mindful’ in the use of outcome data to inform service-level performance management: perspectives from child mental health. BMJ quality & safety, bmjqs-2013.

Ybarra, M. L., & Mitchell, K. J. (2015). A National Study of Lesbian, Gay, Bisexual (LGB), and Non-LGB Youth Sexual Behavior Online and In-Person. Archives of Sexual Behavior, 1-16.

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