1
CHILD AND ADOLESCENT
MENTAL HEALTH PROBLEMS
IN THE EMERGENCY DEPARTMENT
AND THE SERVICES TO DEAL WITH THEM.
THE ROYAL COLLEGE OF PSYCHIATRISTS
COUNCIL REPORT
BY
THE CHILD AND ADOLESCENT FACULTY OF THE ROYAL COLLEGE OF PSYCHIATRISTS,
THE ROYAL COLLEGE OF PAEDIATRICS AND CHILD HEALTH,
And
THE BRITISH ASSOCIATION OF EMERGENCY MEDICINE AND THE COLLEGE OF EMERGENCY MEDICINE
CONTRIBUTORS.
Editor: Dr. Tony Kaplan, RCPsych., CAP Faculty Exec.
Working Group Attendees.
Tony Kaplan (Chair),
Josie Brown
Lois Colling
Cathy Lavelle
Helen Stuart
Julie Waine
RCPsych.
Avril Washington,
Ian Maconochie
RCPCH
Diana Hulbert, BAEM (CEM)
Written Contributions were received from
DrsTony Kaplan
Josie Brown
Helen Stuart
Cathy Lavelle
Lois Colling
Mary Mitchell
Michael van Beinum
Julie Waine
Begum Maitra
- all of the Royal College of Psychiatrists Child and Adolescent Faculty
Dr. Paul Gill
- of the Royal College of Psychiatrists Liaison Psychiatry Faculty
Prof. Eric Taylor
- on behalf of The Paediatric Psychopharmacology Group
Dr. Avril Washington
Ian Maconochie
Tricia Brennan
- all of the Royal College of Paediatrics and Child Health
Ms.Diana Hulbert
- of the British Association of Emergency Medicine and the College of Emergency Medicine
Annie Souter, Specialist CAMHS Liaison Social Worker;
Acknowledgements.
Comments were received from
Sebastian Kraemer, Michael Morton, Ann York, Cleo Hart, Abhay Rathore, Adrian Sutton and Heather Gardiner (child psychiatry perspectives), and from Jane Shears, British Association of Social Workers representative, New Ways of Working for Psychiatrists (social work perspective) .
We took reference from existing Royal College of Psychiatrist Council Reports 64, 118 and 122, and the update of CR 64, currently a Child And Adolescent Psychiatry Faculty Document on Self-harm.
List of Contents.
- EXECUTIVE SUMMARY (pg.7)
- INTRODUCTION (pg. 8 – 13)
- CONTEXTS FOR THE ASSESSMENT OF CHILDREN AND ADOLESCENTS (pg.14 –19)
Presentations
Doing the assessment
Competence
Development and psychopathology
3.ORGANISATION OF SERVICES (pg.20 –38)
Introduction and terminology
Primary Care Staff referring in to the Emergency Department
Ambulance and Paramedical Staff
Emergency Department Staff
Paediatric First Line Staff
General (Adult) Mental Health First Line Staff
CAMHS
Social Services
Roles and Responsibilities
The Child and Adolescent Psychiatric Consultant
The Paediatric Consultant
The Consultant in Emergency Medicine
The (Adult) Liaison Psychiatrist
- INTERFACES BETWEEN DEPARTMENTS AND AGENCIES, RESOURCES, INFORMATION MANAGEMENT AND COMMISSIONING (pg. 39 – 50)
The Paediatric CAMHS Liaison Team
Working with other services
The Police
Social Services
Adult Mental Health
Medical ward staff
Management and Liaison
Resources
Information management, data bases and record keeping
Commissioning
- SPECIAL CONSIDERATIONS (pg. 51 –56)
Housing issues
Services for 16 and 17 year olds
‘Frequent attenders’
Young people who don’t wait to be seen
Dealing with violence and issues of restraining young patients
Rapid tranquillisation for children and young people
- CULTURAL DIVERSITY AND MENTAL HEALTH PROBLEMS IN CHILDREN ANDYOUNG PEOPLE (pg. 57 – 63)
7.RECOMMENDATIONS (pg. 64 –70)
- APPENDICES
APPENDIX 1. CHILD AND ADOLESCENT MENTAL HEALTH PRESENTATIONS IN THE EMERGENCY DEPARTMENT (pg. 71 –96)
Learning disabilities
Alcohol related problems
Substance misuse
Acute psychiatric disorders
Psychoses
Depression
Deliberate self-harm
Anxiety states
Phobic anxiety and Panic attacks
Generalised anxiety
Obsessive compulsive disorder
Acute and Post-traumatic stress disorders
Eating disorders
Medically unexplained symptoms
Altered consciousness/ ‘Altered mental status’ (AMS)
Side-effects of psychotropic medication
Abuse and neglect
Distressed children and adolescents
APPENDIX 2. CONSENT, CAPACITY AND THE LEGAL FRAMEWORK (pg.97 –105)
APPENDIX 3. CONFIDENTIALITY AND INFORMATION-SHARING (pg.106 – 114)
APPENDIX 4. CHILD PROTECTION (pg.115 118)
APPENDIX 5. PROTOCOLS AND SOME EXAMPLES OF GOOD PRACTICE IDEAS AND SERVICE ARRANGEMENTS (pg.119 –129)
APPENDIX 6. THE TEN ESSENTIAL SHARED CAPABILITIES FOR MENTAL HEALTH PRACTICE (pg.130)
APPENDIX 7. EMERGENCY DEPARTMENT RISK ASSESSMENT TOOL: AN EXAMPLE (pg.131)
APPENDIX 8. RESTRAINING CHILDREN AND YOUNG PEOPLE: GUIDELINES (pg.132 –133)
APPENDIX 9. RAPID TRANQUILLISATION GUIDELINES (pg.134 –140)
- REFERENCES (pg. 141 –143)
Articles and books
Policy documents and reports
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EXECUTIVE SUMMARY.
This document was initiated by the Child and Adolescent Faculty Executive of the Royal College of Psychiatrists. It is a companion document to the Royal College of Psychiatrists’ Council Report CR 118, which deals with mental health problems in adults and services to deal with them in the Emergency Department.
It has been co-written by and agreed with The Royal College of Paediatrics and Child Health and the College of and The British Association of Emergency Medicine.
It is primarily a policy document within the Royal College of Psychiatrists, but it is also written to provide information for both practitioners of various disciplines in and commissioners of Emergency Health Services for children and young people, and as an aid to teaching and training in this domain.
The diversity of service provision across the United Kingdom and Ireland is noted. The pressure to provide CAMH out of hours services has been formalised by the specifications within the National Service Framework for CAMHS in England and Wales, and in Scotland “The Children and Young People’s Mental Health: a Framework for Promotion, Prevention and Care.” Although examples of good practice are emerging, there are as yet no universal, evidence-based standards or models of care.
There is a paucity of literature on CAMHS in the Emergency Department to draw from. Crisis Intervention is rarely in the curriculum of training for CAMHS workers.
This document summarises the current level of knowledge and service provision, describes the contexts for assessment and intervention specific to children, young people and their families, and goes on to define the access points to emergency health services for children and young people in crisis, the competencies expected of practitioners at each stage of the patient’s journey, the roles and responsibilities of key professionals, and the resources, interaction and coordination required to provide a coherent, effective and safe service. Recommendations are made within each section.
We specifically endorse the Royal College of Psychiatrists’ Council Reports CR 64 and CR 118 to the extent that this later document applies to children’s services.
Areas of particular difficulty in providing for all children and young people and their families in crisis are highlighted. Appendices are provided as relevant background information for readers unfamiliar with children and young people’s mental health problems, and the statutory frameworks that surround them. Guidance is provided in areas of common difficulty to aid development of appropriate protocols and policies, and to aid teaching and training of new or less experienced members of the team dealing with the troubled young person and their family.
CHILD AND ADOLESCENT MENTAL HEALTH PROBLEMS
IN EMERGENCY DEPARTMENTS
AND THE SERVICES TO DEAL WITH THEM.
INTRODUCTION
This document is a companion to Council Report CR118: Psychiatric Services to Accident and Emergency Departments prepared by The Royal College of Psychiatrists and the British Association for Accident and Emergency Medicine, published in February 2004. Although there are many issues in common for children/young people and adults with mental problems in the Emergency Department, within CR118, the section on Child and Adolescents in the Emergency Department, on p.35, is very brief. It makes reference to CR64, dealing with deliberate self-harm in young people, but otherwise limits itself to reference to work being undertaken by the Child and Adolescent Faculty on the special problems for children and adolescents in the Emergency Department. This document fills that gap.
Five percent of adults attending the Emergency Department present with significant mental health problems. There are no comparable figures for children and adolescents in the UK and Ireland, but in the USA, studies show a similar proportion of children and adolescents present to emergency departments with mental health related problems. (Thomas 2003). They point to an increasing use of the Emergency Department for the emergency assessment and treatment of psycho-emotional and behaviour-related problems – between 1995 and 1999, while general paediatric attendance increased by 2%, child and adolescent mental health referrals increased by 60%. There is a suggestion that the increases are attributed to the greater knowledge of mental health problems in children and adolescents and hence a greater demand for services, and to the increase in self-harm.
In a 1995 paper by Behar and Shrier the most common diagnosis at presentation in an American sample was adjustment disorder (40%) followed by disruptive behaviour disorder (21%), psychotic disorders (12%) and mood disorders (8%). In what is the only recent UK study of CAMHS presentations to the emergency department, Healy and colleagues (2002) surveyed 107 consecutive emergency attenders at their inner-city emergency service (which included the Emergency Department of a London teaching hospital). Deliberate self-harm was the main presenting problem in one third. Most of these cases were young girls. After specialist assessment (and brief intervention), most were not admitted for further treatment, but were seen for urgent follow-up (75% within 2 weeks) in out-patients, where possible by the same assessing CAMHS professional who had done the emergency assessment. Of the non-DSH attenders, the most common problem was psychosis, including hypomania (a third of this group), followed by adjustment and other anxiety-related disorders, and problems related to learning difficulties. Also seen were problems related to conduct, drug and alcohol abuse, and depression (without self-harm). Five out of the thirty two in this non-DSH group had no psychiatric problems as such. Two third of cases presented out of hours, but no differences from those attending during normal working hours were discerned. Almost two third of all cases had had some previous involvement with CAMHS (48%) and/or Social Services. They advocate the development of a systematic clinical screening tool for emergency department clinicians to include known psycho-social risk factors (like domestic violence and parental mental illness, the two most common risk factors in their sample), a “treatment model” (Allen, 1996) for assessment and intervention, and the availability of urgent follow up, where possible by the same professional involved in the assessment and initial intervention (Greenfield,1995), and which is part of an integrated multi-agency approach. A review of the literature in the Lancet on self-harm in young people suggested that over 90% of young people presenting with deliberate self-harm at A&E departments fulfilled criteria for a mental health disorder with significant impairment (Skegg, 2005). However considering the prevalence of the problem, it is surprising that there is such a paucity of research and literature on child and adolescent mental health crises and emergency responses.
Nevertheless there is a requirement (in England, within the Children’s National Service framework (pp18 and 19 of the standards relating to CAMHS) (and in Scotland the recommendations set out in the policy document “Children and Young People’s Mental Health: a Framework for Promotion, Prevention and Care”) for commissioners and Local Authorities to ensure that policies and protocols for the management of children and young people with emergency mental health needs are developed in partnership, and to clarify the level of service provided and the criteria for referral. There is an expectation that arrangements are in place to ensure 24-hour cover to meet children’s urgent needs and that, where indicated, specialist mental health assessment is undertaken within 24 hours or the next working day, and that all staff likely to be called upon to carry out the initial social and mental health assessment receive specific training. There is a recognition that on-call and 24-hour specialist CAMHS are not yet provided in many areas. This lack of access and inequity needs short term and long term planning solutions.In Scotland, despite the recommendations laid out in the Framework document, no additional moneys have been earmarked for service developments. As a result, individual Trusts and Health Boards are expected to find resources within existing budgets to fund developments, and therefore little progress has been made in developing appropriate services. Services remain patchy and piecemeal.
Short term solutions include arrangements for Adult Mental Health Service colleague, specialist registrar rotations across several providers, collaborative arrangements for consultants on-call, and multidisciplinary on-call arrangements with psychiatric backup. CR 137, “Building and Sustaining specialist CAMHS” (2006) (pg. 40) recognises this diversity and inequity, and makes no specific recommendations for how emergency CAMHS provision should be configured. The CAMHS NSF (2004) declares, (6.11) “in the longer term, an expanded capacity within CAMHS will lead to an improved ability to respond to urgent need”. It is hoped that this report to Council will contribute to achieving this aim.
As was the case with adult colleagues, consultation with colleagues revealed a great diversity in the delivery of CAMHS emergency services across the UK and Ireland. Emergency departments are one of a range of provisions which address the needs of children, adolescents and families with acute bio-psycho-social problems. Some areas will have specialised paediatric emergency departments. Some will have primary care out of hours assessment centres. Others will have specialised mental health emergency and assessment centres, catering almost exclusively for adults, although some may see young people over the age of 16. There has been a growth in crisis intervention outreach/home visiting services in line with the NICE guidelines on early intervention. Some areas will have drop-in crisis services, largely provided by voluntary sector organisations. Although this document will deal only with hospital based services, the Executive of the Child and Adolescent Psychiatry Faculty has committed itself to looking at the wider delivery of crisis and emergency services for young people, as part of addressing the 24 hour, 7 day a week availability of CAMHS as specified within the Children’s National Service Framework (NSF) for England and Wales, and recommended in Scotland’s “Children and Young People’s Mental Health: a Framework for Promotion, Prevention and Care.”
The provision of specialist services within the Emergency Department is also variable. A recent review of children’s hospital services by the Health Care Commission for England found that 28% of services were performing poorly with regards to emergency provision (Health Care Commission, 2006). This diversity and inequity, and the discrepancy between national policy documents, like the NSF which applies to England only, and the differences in the statutory framework in the different jurisdictions, makes it impossible to have a set of prescriptions which will apply to all services. Rather we have chosen to identify the components of different provisions, and identify principles, issues and recommendations within each of these, with some overarching principles and recommendations. Ultimately local provision will be a compromise between best practice and the pragmatics of current resources and the service development trajectory.
Children and young people present to the Emergency Department when the way they are being is intolerable to the people who feel responsible for caring for them. Their behaviour becomes intolerable when it is too upsetting, too frightening, or too confusing to be coped with by the physical and emotional resources of the supporting system. The problems which bring children and young people to the Emergency Department may have arisen suddenly and surprisingly, or may be the culmination of a gradual accretion of dysfunction with a final precipitant, or the recurrence of known problems.
Children and young people may present to the Emergency Department through a number of referral routes. Often they will be brought by parents, although in some cases they will be brought by non-parental carers and/or friends. Older teenagers may refer themselves. They may be referred by a professional referrer, most commonly the GP or primary care practitioner. They may also be referred by their schools and colleges (including school nurses), Social Services community or residential teams, and other Tier 1 professionals. They may be brought to the Emergency Department by the police, as the gateway for what may be seen as benign social control through mental health services. Children and young people may be referred to the Emergency Department by Tier 2 or Tier 3 CAMHS Services, who cannot manage aspects of the presentation and are referring to the Emergency Department for assessment with a view to admission into an inpatient setting.
It is still the case in many parts of the UK, that 16 and 17 year old young people, referred with mental health emergencies to the Emergency Department, will, at least in the first instance, be seen by adult services, although, with the NSF requirements, this will change eventually. Many generally trained junior doctors and emergency assessment mental health nurses have not had training to deal with young people and their families. They will usually not have specialist knowledge of the laws relating to children and their applications, and may not be familiar with child protection procedures.
The biggest differences in considering the needs of children and young people with mental health/emotional and behavioural difficulties presenting to the Emergency Department, compared to adults presenting with psychiatric disorder, are the statutory and social care responsibilities which surround them. Thus understanding the nature of parental responsibility, the child protection framework, issues of competency to give consent or to withhold treatment, the rights to confidentiality and consideration and understanding of the family and social support environment into which the young person may be discharged, are vital. All of these are informed by the child’s development. The younger the child the more likely they are to be influenced by changes in the family relationships and atmosphere. Children’s emotional and behavioural problems may exceed the parents’ capacity to cope as a consequence of impairments in the adults’ functioning rather than an escalation in the child’s behaviour. These things often go together, interacting in a mutually reinforcing circular causality. (Pumariega and Winters 2003) (Gutterman et al, 1998). And “while the child’s ecological context influences the time, nature and severity of the crisis, the organisation of emergency mental health services in the ecology of a health care system may influence the outcome of the crisis”; “psychiatric emergency services are brief windows of time in which the child or adolescent and the family are coming for the first time, ready to receive help and engage in change” (Thomas, 2003). Unlike the expectation for general paediatric patients, that attendance at the Emergency Department is as likely to lead to brief treatment and discharge to outpatients as to inpatient care, the expectation with mental health presentations in crisis is that separation from their care-giving environment (usually their families) is the desirable solution, in the short term at least. To some extent this is because professional staff who see children, young people and their families for mental health crisis in the Emergency Department are relatively untrained in being able to include in their assessment an understanding of cognitive and emotional development, family/systemic dynamic influences of the child and even the significance of certain symptoms in the child. Thus the tendency to admit children and young people for further assessment by a suitably qualified CAMHS professional within the next working day. The tendency is to assess for admission or discharge, “screening” patients, with an emphasis on examining for pathognomonic indicators and overt presenting symptoms, all with regard to risk management. It is easier in that context to admit than to discharge. It is probably safe to say that little attention is given to crisis intervention to produce change which would limit risk, de-escalate crisis, enhance support and may even produce dramatic and fundamental change in the young person’s support structures.