Working formulation Description Initial intervention from other Tier 1 /2 services (Universal and Targeted services) prior to CAMHS involvement Service provided by & Adolescent Mental Health Service –Tier 3 Anxiety based disorders, generalised anxiety, social anxiety, panic attacks Anxiety is the feeling of fear or panic. It is quite normal to feel anxiety when faced with something stressful, or a problematic situation however once the difficult situation is over you usually feel better. Anxiety becomes a problem when the worry, fear and feelings of panic do not go away once the fearful situation is gone, where it leads to feelings of depression, poor sleep and eating difficulties. Physical symptoms of nausea, trembling, dry mouth etc are often associated with anxiety. Anxiety can be linked to a family history of anxiety, a trauma or a physical or additional mental health difficulty. Self help literature nfo www.youngminds.org.uk/ Guided Self help literature available from PMHLWs. Can be used by PFSAs or LSAs in schools to run groups. Mindful online counselling Support and intervention from PFSA, School nurse or School counsellor where one is available. Involvement of an Educational Psychologist. Professionals can discuss concerns with Primary Mental Health Linkworkers (PMHLWS). Where there are severe and persistent symptoms that have not responded to intervention at tier 2 or that are having a significant impact on the life of the young person, will be assessed by CAMHS and offered Cognitive behavioural therapy (CBT) based group interventions and individual therapy. Obsessive Compulsive Disorder and Body Dysmorphic disorder Many young people will have an “obsessive” interest in something or be compulsive in their behaviours. This may not be a problem but when this urge to do things repeatedly becomes a necessity and causes significant anxiety if they do not act on the obsession or compulsion then they may be developing OCD. The most common obsessions focus on contamination, disasters and symmetry. Self help literature nfo Guided Self help literature available from PMHLWs. Can be used by PFSAs or LSAs in schools to run groups. Mindful online counselling Support and intervention from PFSA, School nurse or School counsellor where one is available Where there is a moderate to severe impact on daily living, CAMHS will provide assessment and intervention as indicated.
informed. Self-harm / self injury Self-harm is a way of dealing with very difficult feelings that build up inside the child or young person and which they find hard to express or deal with in any other way. It can take a number of forms but most commonly presents as cutting or burning, bruising, taking an overdose of tablets, hair pulling or picking skin. Most school nurses, PFSAs and school counsellors provide support for children and young people who self-harm as a way of coping with strong emotions and difficult experiences, where the self harm is mild to moderate, there is limited risk, and no underlying mental health difficulty (i.e. depression). Training is provided to tier 2 professionals by the PMHLWs . training can be accessed via Self help literature nfo Any self-harm or self injury that presents an actual or possible risk to life should be referred immediately to the Accident and Emergency Department. The jointly agreed protocol for the management of self-harm will be followed. Where there is significant self harm or self injury related to moderate to severe depression or anxiety, refer to CAMHS. Useful websites: National self harm network Assessment & treatment will be offered as required
Suicidal behaviour Suicide is a relatively rare occurrence however all people are susceptible to thoughts and feelings that can place them at risk of suicide. Young people who are depressed and/ or who have strong feelings of hopelessness and anger can have thoughts of suicide. Professionals at tier 2 will talk with a child or young person experiencing suicidal thoughts and be able to support them if these thoughts are fleeting and not accompanied by an associated wish to die. Sometimes suicidal thoughts are expressed, particularly by younger children when they are angry and upset because they are not allowed to do something. When in doubt a professional should contact CAMHS directly or contact their primary mental health linkworker for advice. ASIST training (Applied Suicide Intervention Skills Training) is an internationally recognised suicide prevention training program available in Somerset. For details of how to apply contact: Where there is an expressed wish to take own life accompanied by corresponding risk taking behaviours and articulated plan and access to method this will require urgent assessment by CAMHS and may require a mental health act assessment. If there is felt to be an immediate risk to life then emergency services should be called. Bi-polar Affective Disorder Bi polar disorder is a serious condition associated with severe mood swings. These usually last several weeks or months and are far beyond what most people experience. It usually starts during the late teenage years or more often in adult hood. A person experiences feelings of intense depression or despair and feelings of extreme happiness and elation. It is not clear what causes bi polar disorder but it seems to be associated with genes. GP assessment to exclude medical causes and to assess whether symptoms are severe or rather the more common experience of fluctuating mood that is noticed by many adolescents. If significant numbers of indicators are present will provide assessment & intervention as appropriate. Emerging borderline personality disorder Borderline personality disorder is characterised by significant instability of interpersonal relationships, self-image and mood, and impulsive behaviour Please see sections relevant to clinical presentation such as self harm, suicidal behaviour, depression etc. Assessment and treatment of disorders will be undertaken by or where there is significant risk to life or others. co-
Trauma and Post traumatic stress Disorder Young people may develop PTSD if they experience something where they feel very frightened, helpless and fear they might die. Many young people who experience horrible things recover without experiencing PTSD but some go on to experience some troubling symptoms including: flashbacks or nightmares, behaviour changes such that they keep busy or preoccupied with other things to avoid having to think about the traumatic event, poor sleep, anxiety, irritability and fearfulness, hyper- vigilance, loss of appetite and depression. Young children may repetitively re-enact the trauma in play, It is normal to experience symptoms of PTSD in the few weeks following a trauma. “Debriefing” immediately after the trauma can make things worse. However keeping things as normal as possible, maintaining the usual routines, engaging in relaxing activities, exercising and spending time with family and friends all help. Where symptoms are mild then professionals should “Watch and wait” offer support for 4-6 months before considering a referral. If symptoms increase and despite a period of time since the trauma, the problems persist, then refer to CAMHS. If related to domestic violence, consider involving the independent domestic violence advocate (for 16 and over) 0800 6949 999. If related to sexual consider referral to Somerset and Avon rape and sexual abuse support service 0117 9250680. Where symptoms persist and are having a significant impact on the young person’s life or mental state, or the young person is felt to be depressed or having strong suicidal thoughts, then CAMHS will assess and offer treatment as indicated. Feeding and Eating Difficulties and disordered eating Development al or Emotional based eating Difficulties Food Refusal, Restricted Eating or other developmental concerns Early intervention is key to the successful treatment of an eating disorder so, GPs, and parents play an important role in identifying an emerging eating disorder. If concerned about a possible eating disorder the GP should do a physical health check including a height, weight calculation as junior Marsipan guidelines See below ( CAMHS to provide CAMHS DO WITH THIS
Low weight as a result of other mental health difficulty (e.g. low mood, anxiety, vomit phobia) ARFID Anorexia Nervosa (AN) Bulimia Nervosa (BN) Eating Disorder Not Otherwise Specified (EDNOS) NB: CEDS does not treat Obesity unless there is a existing mental disorder that is specified Restriction of energy intake relative to requirement, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Intense fear of gaining weight or of becoming fat or persistent behaviour that interferes with weight gain, even though at a significantly low weight. Disturbance in the way in one's body weight or shape is experienced, undue influence of body weight or shape on or persistent lack of recognition of the seriousness of the current low body weight. Bulimia nervosa is characterised by a persistent pre-occupation with eating and periods of over eating in which large amounts of food are consumed in short periods of time. Associated symptoms include - self-induced vomiting, purgative abuse, alternating periods of starvation, and use of drugs such as appetite suppressants. intervention is key to the successful treatment of an eating disorder so, GPs, and parents play an important role in identifying an emerging eating disorder. If concerned about a possible eating disorder the GP should do a physical health check including a height, weight calculation as junior Marsipan guidelines See below ( sion/CR168.pdf) Possible referral to local paediatric service for medical review, which may result in short term admission on to paediatric ward if required, depending on concerns and severity. The young person will be offered a CEDS assessment and from this a care and treatment plan will be developed and implemented. A CEDS Care will be appointed who will carry out medical monitoring of weight and BP. Referral for appropriate psychological therapies. CAMHS CEDS Consultant involved for medical review. Referral to the CAMHS Outreach and Home Treatment Service if intensive home treatment is required inc medical monitoring, psycho education, meal planning and liaising with other service.
Psychosis Psychosis is a symptom of a serious mental illness. A person experiencing psychosis looses touch with what is accepted as reality, they may feel paranoid, hallucinate, hear voices or have delusions. It is associated with severe stress or depression, with a family history of serious mental illness and can be triggered by drug and/or alcohol use. People who develop psychosis usually have their first episode in their teens or early 20s. Professional concerned that a young person may be experiencing a psychosis can contact the Somerset Team for early intervention is Psychosis on 01823 368555. Young people with a first presentation of sustained psychotic symptoms, or symptoms causing severe distress, impacting on risk or associated with depression or manic symptoms can be referred to STEP or CAMHS and a joint assessment will be undertaken. CAMHS will assess jointly with STEP and involve the CAMHS Psychiatrist. They will formulate a care and treatment plan as a result.
For diagnosis discuss with your GP who may refer to a paediatrician to ensure there is no other underlying physical cause and would give a diagnosis if appropriate. Severe tic disorders may need medication which may be prescribed by a CAMHS Consultant. Complex Tourettes with a co-morbidity will be assesses and treated by CAMHS. Mild Emotional and Behavioural difficulties Generalised emotional and behavioural difficulties that are causing concern or distress or are impacting on health, development and welfare. Universal and Targeted Services to offer assessment and support and access to Triple p or other parenting training program. Access through Get Set services. Moderate – Severe disturbance of mental health and/or significantly challenging behaviour associated with intellectual impairment, genetic conditions or acquired brain injury Learning disability is a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence); with a reduced ability to cope independently (impaired social functioning); which started before adulthood, with a lasting effect on development. Challenging behaviour (including self-injurious behaviour) - culturally abnormal behaviours of such intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities. Assessment and intervention by specialist/allocated school nurses Where there are concerns that there is a significant mental health difficulty as well as the learning disability and/or challenging behaviour then a referral to CAMHS should be made. Sexually harmful Behaviour (SHB) Sexually harmful behaviour can be described as persistent sexual behaviour that infringes the rights of others. the police have taken action in response to SHB YOT will lead on assessment and intervention planning and provision. Where co-existing mental health difficulties are present, CAMHS practitioner or YOT psychologist may joint work with service leading on response to SHB.
consuming preoccupations with restricted subjects. Where the conditions below have been identified there would also need to be a coexisting mental health problem as listed above for a referral to CAMHS to be appropriate. Working formulation Brief Description Interventions available from Tier 1 /2 Child & Adolescent Mental Health Service –Tier 3 Oppositional Defiant Disorder, (ODD) Conduct Disorder & Challenging behaviour ODD is characterised by behaviours such as: a child or young person loses their temper, argues with adults, defies adult requests, deliberately annoys others, shifts to others, touchy, easily annoyed, resentful, spiteful or vindictive. Conduct disorder and Challenging behaviour in this context can include: self-injurious behaviour, culturally abnormal behaviours of such intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities. Children aged 7-11 can be referred to the Incredible Years parenting programme being piloted in the Health Visiting service. Refer to a parent training course via the Get Set services. For younger children Paediatric assessment may be indicated. In complex cases, including those where the challenging behaviour is linked to cognitive impairment, consultation for children and young people aged 11 – 18 PMHLW can be sought to determine whether the client meets the referral to CAMHS due to the presence of a mental health difficulty or because the behaviour is believed to be the way in which the client demonstrates mental distress. GPs and social workers can seek advice via the advice line. Behaviours believed to be primarily the result of a learning disability or a social communication difficulty will not warrant a referral in themselves. Enuresis and Faecal Enuresis: A disorder characterised by uncontrolled urinating, by day and/or by night, which is abnormal in relation to the child or young person’s developmental stage and which is not a consequence of a neurological disorder, epileptic attacks or to structural abnormality of the urinary tract. Initial physical screen by GP, Early stage of presentation should be signposted to Health Visitor or School Nurse for intervention. Referral to paediatrics and via them to the continence team.
soiling In primary enuresis children have acquired normal bladder control, whereas a child who acquires bladder control for at least 6 months and then loses it again is said to have secondary enuresis. Faecal soiling: Repeated voluntary or involuntary passage of faeces, in places not appropriate for that purpose in the child’s own social cultural setting. Soiling more than once a month after the age of 4 is generally regarded as an elimination disorder. Chronic Fatigue Syndrome (or ME) An of unexplained, persistent fatigue unrelated to exertion and not substantially relieved by rest that causes a significant reduction in previous activity levels. All suspected cases of CFS initially to be referred to General Paediatrics for medical physical assessment. This may result in referral on to the specialist CFS service and the involvement of the specialist OT. Issues related to sleep and diet to be addressed by specialist OT. For treatment of a coexisting mental health difficulty a baseline minimum of 4 hours needs to have been achieved for young person to be able to access treatment. Substance Misuse Problematic drug and alcohol use. people presenting with drug or alcohol intoxication refer to substance misuse service SDAS ory/2014/02/03/making-a-referral- to-sdas/17/ If the substance misuse is co-existing with a possible mental health difficulty, CAMHS will provide assessment and intervention as appropriate and with specialist substance worker.