The NHS CAMHS & Attachment Disorder
The previous report to the Committee needs to be understood in the context of 3 key Welsh Government documents:
The 4 Tier model of service mapping was developed by the Health Advisory Service and described in their document “Together We Stand” in the early 1990’s. It has subsequently been the basis of CAMHS service planning across the majority of the western CAMHS services. It is described in more detail in the Welsh CAMHS strategy “Everybody’s Business” (2001) which also emphasises the multiagency responsibility for provision of mental health services for Children & Adolescents throughout the Tiers.
Children do not so much move through the Tiers but rather access additional support and interventions from each Tier as complexity increases.
Tier 1 are the universal/primary care services that all children access from health, local authority and third sector. The professionals involved do not have specific specialist mental health training but should have basic capacity to identify normal and abnormal behaviours and offer services that promote positive mental health. The commissioning and planning for these services is normally at a local authority level often through Child and Young person plans.
Tier 2 are the services that provide interventions from individual Professionals specifically trained in child & adolescent mental health providing direct specific psychotherapy, medication or specialist consultation and liaison. This may and indeed should be provided by all agencies (see Everybody’s Business) but the largest currently is the NHS. These NHS services have been planned at an LHB level.
Tier 3 are the services provided by teams of specially trained professionals, (sometimes those working individually in tier 2) to individual families and children. This may include day hospitals, specialist eating disorder teams etc. These are planned at an LHB level but often, in the NHS, with the all Wales Welsh Specialist Health Care Committee (WSHCC) resources
Tier 4 are the highly specialised specially trained CAMH professionals working at a national/regional level delivery highly specialised interventions or to very high risk or complex groups. This includes forensic and inpatient services. These are planned and delivered at a national level through WSHCC.
It was recognised at the outset of this model that there was a potential chasm between Tiers 1 & 2 due to the low (and potentially decreasing) level of understanding regarding emotional wellbeing and mental health at Tier 1. Hence the idea of a Primary Mental Health worker/Team was proposed and developed. This is a skilled, CAMH trained professional who has the full time role of assessing alongside, advising, signposting and training Tier 1 professionals. The NHS AOF and the new Mental Health Measure for Wales sets specific targets for minimum numbers.
Attachment disorder can require interventions from services at all Tiers over the course of the child’s life. The 3 main groups of children who are at high risk of requiring services are:
At Tier 1 interventions regarding early bonding, parenting classes, management of parental mental illness, training for foster or prospective adopters, teachers, social workers regarding expectations and attachment. Monmouthshire CYPP has developed funding for training of health visitors and social workers in identifying early attachment disorders and giving ameliorating advice to families. In Caerphilly a PMH Worker post has been developed to offer specialist training and support to carers and looked after children with potential attachment disorders. Funded through Caerphilly LHB and CYPP.
At Tier 2 specialist staff offer more direct work to children, carers and Tier 1 professionals working with young people with attachment disorder. This may come to light when the young person is referred suspecting Autistic spectrum disorder or Attention Deficit Disorder. Newport Social Services have created a psychology post for consultation; liaison and identification of those looked after children that require direct work from the NHS specialist CAMHS services, normally provided by a senior psychologist.
At Tier 3 teams work with families and children with attachment disorder. This may be for the purpose of a more intensive needs assessment, particularly in children with other needs such as a learning disability or autistic traits. This may include the Team around the Family initiative or multidisciplinary assessment teams provided by Pollards Well day unit in Aneurin Bevan Health Board. Aneurin Bevan HB, in collaboration with local authority partners have also funded 2 days per week of a specialist psychotherapist offering direct attachment focussed psychotherapy for those in care and with the highest degree of need working with social work partners and generic NHS CAMHS workers as required.
Tier 4 provision is generally residential based multi system care that provides specialist care, education and individual or family work as described by Dr Mike Davis, often provided by the independent sector and funded by joint continuing care packages.
There are also projects such as the MIST service in Torfaen and Skills for Living hosted by Action for Children across Gwent that work with troubled older adolescents frequently with attachment problems, housing issues and self harm who employ psychologists as part of the team and work across the transition age
As the Welsh Audit Office indicated in its 2009 report into services for children with emotional and mental health problems, services are variable across Wales for all children. The capacity for such attachment work small as small services seek to ensure all children are able to access some service proportional to the immediate risk and the availability of evidence based health therapies for the issues faced.
The Welsh Government has an extensive work plan in place addressing the huge issues across CAMHS looking at planning, service priorities and service delivery across Wales. The new mental health strategy, with a focus on prevention and resilience will hopefully be looking at attachment as a major issue.
Looked after children have a larger slice of the cake as LA’s and HB’s pool resources effectively in some areas, the examples I give are exclusively from Gwent as it is the area I have the most knowledge of especially those not hosted by the NHS CAMHS.
As indicated I have previously worked with Dr Mike Davis and share many of his concerns and views of future direction and look forward to giving this area of work greater profile, improved coordinated multiagency treatment and support plans for adopted children and all those with attachment disorders.
Dr David Williams