Title: Whose crisis now?
Authors: Pamela Storey and June Statham
Institution: The research was carried out at the Thomas Coram Research Unit (TCRU), at the Institute of Education, University of London, the Mental Health Foundation and Young Minds.
Studies undertaken over the past seven years into the care that children and young people receive when they experience a mental health crisis indicate recurring themes around emergency assessment and provision. Partnership working between agencies may help resolve differing perceptions of the respective roles that child and adolescent mental health services (camhs) and social care services play in supporting those in crisis.
It was seven years ago that the Young Minds study Whose crisis? highlighted the issues that arose when children and young people experienced a mental health crisis that required professionals to provide an emergency response. The study identified three groups of young people who typically present as "emergencies", those with an identified mental disorder, those who had taken an overdose or self-harmed and those with conduct disorders who appeared out of control or with challenging behaviour. One of the difficulties highlighted by that study for social services departments was the range of settings where young people present in crisis. While the local A&E department was often the point to which young people took themselves or were taken by others, police custody and other areas of the youth justice system were recognised as likely places for emergencies to occur.
The report highlighted the wide variation in service provision and access to mental health assessments across the country. One of the key issues for social service staff was the difficulty they experienced in getting prompt responses and assessment from camhs colleagues, particularly for children and young people with conduct disorders and even more so for emergencies that occurred "out of hours", at evenings and weekends. The distress caused to children, their parents, carers and the professionals involved in accessing appropriate help was identified as an area of contention between many social services departments and camhs teams. A further barrier between the two related to those in care, with mental health professionals perceiving difficulties as reflecting a placement problem whereas social care staff viewed crises as reflecting a difficulty of the young person themselves.
In the light of those issues raised seven years ago, this article describes some of the results from a short study undertaken by the Thomas Coram Research Unit (TCRU) in 2006 to look at the emergency cover offered by camhs in England. The study undertook a short focused review of literature on the views of young people who had sought emergency support, and conducted telephone interviews with commissioners and providers in 14 camhs. The study also included a survey of all camhs providers in England asking about the cover they provided for emergency assessment, thus offering an opportunity to review changes in emergency cover since the Young Minds study in 2000.
The findings from the TCRU study offer a mixed picture in terms of progress since 2000. Some of the issues raised then still feature today, but the study also found positive examples of good practices addressing some of the difficulties that dog emergency referrals.
It suggested that over a quarter of camhs work with children's emergency duty teams when emergency referrals and assessments are required out of hours. Providers highlighted examples of services exploring a multi-agency approach as the way forward to appropriate and timely support in time of crisis. This strategy was based on an awareness of the range of problems that tend to surround emergency presentations and the frequent need for social care agencies to be involved as well as mental health services.
A pilot project under way to improve 24 hour emergency response described its key lesson as the value of partnership. The pilot provided the opportunity for the three agencies, represented by a mental health worker, a social worker and hospital ward staff to gain a better understanding of the part each played, and the challenges that each faced in terms of the resources they were able to access to support a young person in crisis. All agreed that whatever service was provided in the future, an understanding of each other's criteria, and the thresholds to support and responses each was able to muster was vital. A mutual understanding of what constituted a "crisis" for each agency and the threshold for involvement resulted in appropriate requests for response and support.
However, on other issues, there appeared to be little change. Providers and commissioners highlighted the difficulties of emergency mental health assessments that resulted in a young person being assessed as not having a mental health problem. These assessments often occurred in situations when a young person was behaving erratically or had misused alcohol or drugs. Looked-after young people, encountering difficulties in their placement, were perceived as psychiatric emergencies by the agencies involved but not so by the mental health team contacted to provide assessment. Mental health professionals were aware that assessments with this outcome tended to be unpopular with the other agencies, which were usually seeking support in managing a young person through a difficult experience. However, the assessors believed that adding the label of a psychiatric diagnosis might not be in the best interests of a young person already faced with a raft of other problems.
Again, the study found evidence that some services were working together to improve provision. A camhs provider described working with the local authority to review services for looked-after children, to establish a system of emergency foster care provision that had helped reduce the "Friday night crisis" when placements broke down. Training from camhs for staff in placement teams and care homes had helped them to see a potential crisis as a situation which they could handle and not an emergency that needed to be dealt with by mental health professionals.
While both the Young Minds report and the TCRU study focused on the views of service providers, the voice of those whose crisis it is remains more elusive. Few studies concentrate on the views and experiences of the children and young people involved. However, the strong message that comes through from studies such as that by the National Children's Bureau is that children and young people value help that is prompt, and that those who offer it are empathetic and prepared to listen. That timely response and those skills are more important to young people than the actual profession of the person who is there to help. A project by the Mental Health Foundation with young people aged 16-25 who had experienced mental health crises asked which aspects of a crisis service young people would consider most important if they were setting up or running such a service. The answers again focused on the way they were treated rather than on any particular model. Young people spoke of the "need to be understood, respected, acknowledged and supported rather than being patronised, smothered or blamed for their situation". The emphasis was on reassurance and the need to feel that there was someone there for them if they needed help.
So what has changed in seven years? To some extent, the target for 24 hour emergency cover that camhs were set would appear to have concentrated efforts into improving crisis response. Developing tools and skills and liaising with partner agencies has helped some to tease out the role each plays and led to a deeper understanding of what resources each partner can provide. Better still, there is evidence of services working to improve the identification of potential crises and to prevent a problem escalating into a major emergency. However, there are still widespread differences in practices so a clear cut answer everywhere to "whose crisis?" may still be a long way off.
IMPLICATIONS FOR PRACTICE
Anticipating a potential emergency
Very few presenting emergencies come out of the blue, without a deterioration in a situation being observed by those involved in day to day care. Training by camhs for partner agencies would help encourage the early identification of young people with potential problems in advance of crises occurring and help other agencies recognise when earlier interventions should be initiated. Developing the skills of other agencies, particularly those involved in social care would work to reduce the likelihood of problem behaviours presenting as mental health emergencies.
Initial assessment of needs
For those who find themselves with a young person in crisis, whether they be in social care, the criminal justice system or an A&E department, deciding which professionals to call is a vital step in ensuring that the child receives appropriate care as quickly as possible. Camhs can assist other professionals to develop those skills, by providing training and assessment tools to assist decision making around the need to call a substance misuse worker, the emergency duty team or a mental health professional.
Many services are working towards developing a multi-agency response to children and young people presenting in a crisis. Camhs that have worked to develop this, report that it has led to better links with other agencies, especially with social care teams and substance misuse services. For some, the experience of engaging the wider community of service providers within the emergency response has emphasised the appropriate and efficient management of young patients. While a psychiatric assessment may be the pre-eminent need within the emergency care pathway for some children and young people, there is a growing awareness that for many, this may not be the most pressing need.
Links and Resources
Smith K. and Leon L. (2001) Turned Upside Down: Developing community-based crisis services for 16-25 year olds experiencing a mental health crisis. London: Mental Health Foundation
Storey, P., Hurry, J., House, A., Owens, D. and Jowitt, S. (2005) A study of young people and mental health: Repeated use of Accident and Emergency clinics. Report to Department of Health, Thomas Coram Research Unit, unpublished.
Storey, P. and Statham, J., (2007) Meeting the Target: Providing on-call and 24-hour specialist cover in Child and Adolescent Mental Health Services. www.camhs.org.uk
Street C. (2000) Whose Crisis? Meeting the needs of children and young people with serious mental health problems. London: Young Minds
Street C. (2004) Mental Health Services - what children and young people want. Highlight 210. London: National Children's Bureau.
This article appeared in the 11 October issue under the headline "Emergency support"