Child and Adolescent MentalHealth:
The Strategic Framework and its implementation in Wales
DAWN ALLEN
A submission presented in partial fulfilment of the requirements of the University of Glamorgan/Prifysgol Morgannwg for the degree of Doctor of Philosophy
March 2010
Approval for Submission of a Thesis
Student: Dawn Allen
Award:Doctor of Philosophy
This is to confirm that a thesis entitled:
Child and Adolescent Mental Health:
The Strategic Framework and its implementation in Wales
has been approved for submission by the student's supervisory team and can therefore be forwarded to the examiners.
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Director of Studies
Date………………………………………
Certificate of Research
This is to certify that, except where specific reference is made, the work described in this thesis is the result of the candidate’s research. Neither this thesis, nor any part of it, has been presented, or is currently submitted, in candidature for any degree at any other University.
Signed………………………………………
Candidate
Date…………………………………......
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Director of Studies
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Acknowledgements
My grateful thanks go tomy husband Stuart for his love, patience, encouragement and technical assistance during this research. Thank youalso to my parents for theirlove and unwavering support, both financial and emotional.I wouldadditionally like to thank my colleague Philip Perkins for his advice and constructive feedback. Thank you to all the CAMHS stakeholders and other participants in this study for their generosity with their time and expertise.
Not least, my sincere appreciation extends to my fantastic Supervisors, Maggy McNorton and David Turner. Thanks David for all your words of wisdom and the perspectives you shared with me in your own unique way. Thank you both for your valuable guidance, support and continual encouragement throughout the ups and downs of this research. My unending gratitude goes especially to you, Maggy for all the times you picked me up and pointed me in the right direction again – I will always treasure the amazing journey we shared together - I couldn’t have done it without you!
Table of contents
Approval for Submission of a Thesis......
Certificate of Research......
Acknowledgements......
Glossary......
Preface......
Abstract......
Critical overview......
Introduction......
Project One......
Research methodology......
Ethical issues......
Conclusions of Project One......
Project Two......
Research methodology......
Conclusions of Project Two......
Project Three......
Research methodology......
Conclusions of Project Three......
Original contribution to knowledge......
PROJECT ONE - AN ANALYSIS OF THE NATURE OF LONG-TERM PUPIL ABSENCE FROM SCHOOL
Chapter summary......
Research aims......
Research objectives......
1An analysis of the nature of long-term pupil absence from school......
1.1Chapter 1 - An introduction to the research......
1.1.1Setting the context......
1.1.2Strategies and developments......
1.1.3Rationale and research questions......
1.2Chapter 2 - Literature review......
1.2.1What constitutes “long-term” absence?......
1.2.2What causes pupils to be absent from school “long-term”?......
1.2.2.1School Phobia......
1.2.2.2Truancy......
1.2.2.3Absenteeism and the curriculum......
1.2.2.4Cumulative deficit......
1.2.2.5Ill health......
1.2.2.6Domestic violence......
1.2.2.7Pregnancy......
1.2.2.8Holidays......
1.2.2.9Traveller children......
1.2.3What specific needs do long-term absentees have on returning to school and what can schools and other agencies do to aid the reintegration process?
1.2.3.1A sensitive welcoming back to school......
1.2.3.2Day care and sanctuaries......
1.2.3.3Alternative timetabling......
1.2.3.4Multi-agency approaches......
1.2.4Summary......
1.3Chapter 3 - Research methodology......
1.3.1An introduction to the research methodology......
1.3.2Ethical issues......
1.3.3Problems encountered during the research process......
1.4Chapter 4 - An analysis of the research findings......
1.4.1Emergent themes......
1.4.2What are the causes of “long-term” pupil absence from school?......
1.4.2.1Truancy......
1.4.2.2Bullying......
1.4.2.3Parentally-condoned absence......
1.4.2.4Exclusions and “soft” exclusions......
1.4.2.5Pregnancy......
1.4.2.6Mental Health Disorders......
1.4.2.6.1Depression......
1.4.2.6.2School phobia and anxiety disorders......
1.4.2.6.3Obsessive compulsive disorders......
1.4.2.6.4Eating disorders......
1.4.2.7Long-term physical illness......
1.4.2.8Domestic violence......
1.4.2.9Asylum seekers......
1.4.2.10Extended holidays for cultural or religious reasons......
1.4.2.11Traveller children......
1.4.3What strategies can be utilised to facilitate successful reintegration of “long-term” pupil absentees?
1.5Chapter 5 - Discussion/further work......
1.5.1Discussion......
1.5.2Further work as a result of Project One......
Project One Appendix 1 - Interview Timetable......
Project One Appendix Two – Interview Schedule
PROJECT TWO - AN ANALYSIS OF THE STRUCTURE OF THE 4-Tier CAMHS STRATEGIC FRAMEWORK AND LINKS BETWEEN STAKEHOLDERS
Chapter summary......
Research aim......
Objectives......
2An Analysis of the Structure of the 4-Tier CAMHS Strategic Framework and Links between Stakeholders
2.1Chapter One - Introduction......
2.1.1Research methodology
2.1.2CAMHS organization pre 2001......
2.1.3What do the 4 CAMHS Tiers mean?......
2.1.4How can CAMHS stakeholders be involved in several different CAMHS Tiers?
2.1.5How do referrals operate between CAMHS Tiers?......
2.1.6Is there a difference between Mental Health “Problems” and “Disorders”- are the terms interchangeable?
2.2Chapter Two - Literature review......
2.2.1Why are inter-agency links between stakeholders in Child and Adolescent Mental Health Services important?
2.2.2What problems occur with respect to inter-agency work?......
2.2.3How could problems with inter-agency working be overcome?......
2.3Chapter 3 - Research methodology......
2.3.1First actions......
2.3.2Next step - Questionnaire design and distribution......
2.3.3Problems encountered during the data collection stage of the research - a learning curve
2.3.4Modification in light of advice......
2.3.5Widening the research - stakeholders outside Cardiff......
2.4Chapter Four - Analysis......
2.4.1What kind of Mental Health Problems were encountered by the stakeholders?
2.4.2What CAMHS provision is there for children with Mental Health Disorders?
2.4.3For what reasons and how frequently do CAMHS stakeholders contact each other?
2.4.4What problems do stakeholders encounter with respect to inter-agency links?
2.4.4.1Lack of feedback/difficulties due to confidentiality......
2.4.4.2Lack of cohesion between Tiers......
2.4.4.3Problems caused by differing working practices......
2.4.4.4Timing of interventions......
2.4.4.5Resources......
2.4.4.6Miscellaneous issues......
2.4.5What do stakeholders think could be done to improve CAMHS links and provision?
2.4.5.1Resources......
2.4.5.2Joint working practices......
2.4.5.3Improvements in information sharing and communication......
2.4.5.4Improved training......
2.4.5.5Early identification......
2.5Chapter Five - Implications of emergent themes from the stakeholder questionnaires
2.5.1Resources......
2.5.2Joint working practices......
2.5.3Improvements in information and communication......
2.5.4Improved training......
2.5.5Early identification......
2.6Chapter Six -What next for CAMHS?......
2.6.1Enhanced explanation of CAMHS Strategic Framework (CAMHS Concept).
2.6.2Shared budgets for the development of common strategies......
2.6.3Early identification and intervention......
2.7Chapter Seven - Conclusions......
Project Two Appendix 1 - Questionnaire......
Project Two Appendix 2 – Background information attached to questionnaire......
Project Two Appendix 3 - List of contacts......
Project Two Appendix 4 – Sample introductory letter......
PROJECT THREE - CHILD AND ADOLESCENT MENTAL HEALTH: THE STRATEGIC FRAMEWORK & ITS IMPLEMENTATION IN WALES
Chapter summary......
Research Aim......
Objectives......
3Child and Adolescent Mental Health: The Strategic Framework & its implementation in Wales
3.1Chapter One - Introduction......
3.2Chapter Two - Research methodology......
3.3Chapter Three - Literature review......
3.3.1What is Policy implementation?......
3.3.2How is successful implementation measured?......
3.3.3A brief history of policy implementation......
3.3.4Implementation gaps – The difference between expected and achieved.....
3.3.5Policy adaptation......
3.3.6Who instigates and actions these adaptations?......
3.3.7Networks & interdependencies......
3.3.8Top-down v Bottom-up implementation & Strategic Planning......
3.4Chapter Four - Interview feedback......
3.5Chapter Five - How does research findings compare with the literature?......
3.5.1Background to the implementation......
3.5.2The cog metaphor......
3.5.3Top-down v Bottom-up models......
3.5.4Diffusionalism model......
3.5.5Street-Level Bureaucrats......
3.5.6Homophilly and networks......
3.5.7CAMHS in schools......
3.6Chapter Six - Evaluation of the implementation process......
3.6.1Improved understanding of the role and position of CAMHS stakeholders...
3.6.2Improved joined up working and links between CAMHS providers......
3.6.3Reducing inappropriate CAMHS referrals and waiting lists......
3.6.4How could this implementation process have been improved?......
3.7Chapter Seven - Conclusions......
Postscript......
Bibliography......
Glossary
AHAArea Health Authority
BDDBody Dysmorphic Disorder
BDPBehaviour Desensitization Programmes
CAQDASComputer Aided Qualitative Data Analysis Software
CAMHSChild and Adolescent Mental Health Service
CBTCognitive Behavioural Therapy
CBWCognitive Behavioural Work
CCAPCommunity Child & Adolescent Psychiatrist
CCPConsultant Community Paediatrician
CFSChronic Fatigue Syndrome
CGPCommunity & General Paediatrician
CITTCommunity Intensive Therapy Team
CNSClinical Nurse Specialist
CPChild Psychologist
CPNCommunity Psychiatric Nurse
CPTChild Psychiatry Team
DFEDepartment for Education
DFEEDepartment for Education and Employment
DFESDepartment for Education and Skills
DHSSDepartment for Health and Social Security
DHTDeputy Head Teacher
DHMDayHospital Manager
DoHDepartment of Health
EALEnglish as an Additional Language
EBDEmotional & Behavioural Difficulties
EDEating Disorders
EOPEarly Onset Psychosis
EMIEEducation Management Information Exchange
EPEducational Psychologist
ESMHPExpanded School Mental Health Programmes
EWOEducation Welfare Officer
EWS Education Welfare Service
FTFamily Therapy
FTTFamily Therapy Team
GSPGenuine School Phobia
GPGeneral Practitioner
HAS(NHS) Health Advisory Service
HMSOHer Majesty’s Stationery Office
HOFHead of Faculty
HOYHead of Year
ILEAInner London Education Authority
INSETIn Service Training
KS3Key Stage 3 (Year 7-9)
KS4Key Stage 4 (Years 10 & 11)
LALocal Authority
LACLooked After Children
LEA`Local Education Authority
LMHWLead Mental Health Worker
MHCMental Health Clinician
MHDMental Health Disorders
MHPMental Health Problems
NAWNational Assembly of Wales (Now Welsh Assembly Government – WAG)
NHSNational Health Service
NFERNational Foundation for Educational Research
NSPCCNational Society for the Prevention of Cruelty to Children
NVQsNational Vocational Qualifications
OCDObsessive Compulsive Disorder
OFSTEDOffice for Standards in Education
OTOccupational Therapist
PEPractice Educator
PMHWPrimary Mental Health Worker
PRUPupil Referral Unit
PSSPupil Support Service
PTSDPost-Traumatic Stress Disorder
SASeparation Anxiety
SCSchool Counsellor
SCMHSainsbury Centre for Mental Health
SCREScottish Centre for Research in Education
SCUTREAStanding Conference on University Teaching and Research in the Education of Adults
SDQStrengths & Difficulties Questionnaire
SEDScottish Education Department
SENCOSpecial Educational Needs Coordinator
SEUSocial Exclusion Unit
SFTSolution Focused Therapy
SLBsStreet-LevelBureaucrats
SNSchool Nurse
SoASocial Anxiety
SoCSSchool of Care Sciences
SRBSchool Refusal Behaviour
SWSocial Worker
TATeaching Assistant
UKUnited Kingdom
WAGWelsh Assembly Government
YOTYouth Offending Team
YPUYoung Person’s Unit
YPWYoung Person’s Worker
YTYear Tutor
Preface
When I began this research I was a classroom teacher with 7 years’ experience, teaching Chemistry in a school which was quite socially deprived and had issues with attendance. I had previously been an Assistant Year Tutor and also Pupil Mentor. Three years ago I changed jobs, gaining a promotion to Head of Science in a school with a similar demographic in a nearby town. This put a high demand on my time and meant that it was often a challenge to achieve a balance between my work demands and my research. During the period of this research there have been many changes in both my work life and personal circumstances. I am now in charge of a department comprising 11 teaching staff and have matured both personally and professionally as a result of this. Since the initial writing of this preface, I have been promoted to the position of Assistant Principal at an Academy in England.
This research took me on a journey from day one when I considered myself as “only a classroom teacher” to the present where I have grown in confidence in my own abilities as a researcher and am now secure in the knowledge that I can make a valid contribution to the research community. During the last 6 ½ years, there have been many ups and downs, times when I didn’t know what to do next and times whenlateral thinking had to be applied to overcome obstacles in my path. I learned the lesson of how to gracefully accept constructive criticism and throughout all this, both my research and my research persona went from strength to strength. The last 6 ½ years has been an extremely important part of my life - an experience which I value tremendously and probably will never experience in quite the same way again. During this time I have learned a great many things, meeting professional people I would have possibly never have otherwise encountered. I have immersed myself in fantastic professional dialogues with people who were, initially to my surprise, taking my work seriously, enthusiastic and supportive and what is more, were interested in setting up joint working projects based upon the final outcomes of this research.The support and encouragement I received from the CAMHS stakeholders and their genuine interest in my work gave me a huge boost and the drive to continue on this journey even when times were tough.
Undertaking this PhD via a portfolio of 3 linked projects has led me into new experiences, and research in areas that would otherwise have been beyond my normal working practice. Had I undertaken a more traditional PhD and written my thesis on just one subject, it is highly likely that, based upon my initial project, my entire research are would have been in the fairly familiar area of pupil absence from school. However, due to the nature of a PhD by portfolio, my research led me into unknown and mysterious territories as each project funnelled into the next one. This has at times caused me a great deal of anxiety, yet in doing so, provided me with opportunities for new professional dialogues and a rich personal learning experience.Both the second and third projects ventured completely out of my comfort zone and into unexplored territory as far as I was concerned. In addition to working outside my comfort zone, this research led me into working in a way which was also quite alien to me. As a scientist, my ‘internal wiring’ is used to working in a mainly quantitative way, generally with black and white answers and few grey areas. I am happiest when everything can be put into neat categories or boxes. As projects 2 and 3 progressed I began to realise that I could not apply this kind of scientific ‘neatness’ to this research. One of the biggest shocks for me was the emergence of what is now fondly referred to by both myself and my supervisors as “the messy diagram” (see page 154). It took me quite a considerable amount of time to get my head around the fact that this diagram, which could be thought of as a kind of communication map, was not well ordered, or highly structured. In the beginning, my scientific brain found this hard to deal with, but as the research progressed I began to accept that this is what the qualitative research, in the area I had chosen to study, looked like. I also had more than a few sleepless nights and moments of anxiety struggling with the idea of validity and reliability in my research. Again, my scientific brain was trying to go through the usual ‘plan, develop, reflect’ cycle, testing hypotheses via experiments and control groups, and aiming to be able to answer every possible criticism with a black and white answer. I have since learned that with qualitative research such as this, as long as the research is undertaken with sufficient rigour, transferability is a more appropriate aim than scientifically rigid terms such as reliability and validity – it took me some time to be comfortable and self-assured enough to be able to let go of these issues.
This research was begun over 6 ½ years ago so it was important to ensure that it was still as up to date and relevant at the end as it was at the beginning. Project One was started in at the end of 2003 and took approximately 1 ½ years to complete. Project Two followed in mid 2005, taking around 2 ½ years, while the final project began in early 2008 and was completed in March 2010.As I have progressed on this journey my experiences and viewpoints have altered and I have revisited my research on many occasions, reflecting on what has occurred and what I have learned. I have thought long and hard about my experiences and the way I have presented this research. After reading texts by both Jennifer Moon (1999) and Donald Schön (1983) on reflective practice, I decided to overtly incorporate this into my thesis. The sections which are written in italics show my thoughts and ideas since the individual projects were written and are my recent reflections on the original comments.
Abstract
This research comprises three linked projects stemming from the first project which aimed to define “long-term” pupil absence from school and discover the principal reasons for such absence. The second project focussed on the area of Child and Adolescent Mental Health Services (CAMHS), an issue emerging from the first project. The CAMHS 4-Tier Strategic Framework (or “CAMHS Concept”), including links between CAMHS providers were examined and referral pathways investigated and measured against published criteria. The thirdproject explored the new CAMHS Strategic Framework and considered whether implementation problems were to blame for its lack of transformational impact.
All three projects utilised qualitative research methodologies. In ProjectsOne and Three semi-structured interviews were conducted, while the second project relied on postal questionnaires. All interviews were transcribed then sent back to the interviewees for the purpose of ensuring accuracy.The “Snowball Sampling” (Heckathorn, 2004), or “Chain Referral” (Portney & Walkins, 1993) method was used throughout this research to select participants. The initial “seeds” for the sampling were chosen by convenience, that being they were stakeholders known to the author by virtue of the institution she worked in or the social circle she moved in.
The principal outcomes of the first project were that “long-term” absence from school was defined as ten school days or two full weeks.It was discovered that a range of Mental Health Disorders (MHD) in children and adolescents could be the cause of such a period of absence. Project Two subsequently investigated provision for children with Mental Health Problems (MHP) and Mental Health Disorders (MHD) (it was discovered that there was a distinct difference between the terms) and links between CAMHS stakeholders were explored. Finally, through Project Three, strategies used to implement the CAMHS Concept were scrutinised using several implementation models. These models were then used to consider whether the type and method of implementation of the CAMHS Concept were a contributing factor to it having failed to have transformed CAMHS in Wales.
The major recommendations of this research are that ten school days or two full weeks should be accepted as a standard definition for “long-term” absence from school and that “long-term” absentees should be treated individually and with sensitivity on their return. Phased attendance programmes may prove an effective way to successfully reintegrate pupils, but above all it is essential that the pupil themselves feel fully involved in their own reintegration programmes. It was also recognised that reintegration into school may not be suitable for all long-term absentees and that alternative provision may be moreappropriate. Key areas for improving the everyday working practices of CAMHS in Wales were identified from the third study. Communication between CAMHS providers needs to be improved with a common language developed between Health and Education. Inter-agency collaboration also needs to be increased to reduce wastage of time and financial resources due to duplication. Recommendations emerging from Project Three mainly concentrated on improving the implementation of the CAMHS Strategic Framework. Since the Strategic Framework has been changed (unnecessarily in the view of the author), simple flow charts or diagrams should be designed, explaining the structure of CAMHS and clearly illustrating where each type of stakeholder fits in. Increased training, particularly for Tier One and Two stakeholders in Education, would help clarify roles and responsibilities and could reduce inappropriate referrals to higher CAMHSTiers, allowing the provision ofeffective, timely interventions for children and adolescents in need of more specialised skills.