Health Warning

Martin Smith is a clinical nurse specialist in child and
adolescent mental health who has been working for five years in
youth offending teams.  He
currently works for the North East London Mental Health NHS Trust
and is seconded to Havering youth offending team.

Regular audits of young people coming through the youth justice
system show that the reasons for offending behaviour are lifestyle,
abuse, poor parenting and social exclusion. These are similar to
the reasons for mental health and drugs problems among young
people. So addressing young people’s mental health problems
could help address their offending behaviour.

Research shows that one-third of 16 to 18 year olds sentenced by
courts have a primary mental disorder.(1) It also reveals that half
of males on remand and about one-third of sentenced young men have
a diagnosable disorder. Frequent drug use is recognised as a
problem in all these categories with 6 per cent of young people
experiencing psychotic symptoms. (2)

Waltham Forest youth offending team (Yot) in east London carried
out research that showed young people’s health needs were not
being met. (3) Many of these young people also had learning
difficulties, which made it difficult for them to access health
services while exacerbating problems of social exclusion and
alienation.

The question was: what resources could be brought in to help these
young people now that their mental and physical health needs were
identified?

I was seconded by the North East London Mental Health NHS Trust as
the clinical nurse specialist to Waltham Forest’s Yot so that
targets set by the Youth Justice Board could be met; namely, acute
mental health referrals should be seen within five days and
non-acute referrals within 15 days by a tier three service
(specialised multi-disciplinary teams).

The role meant that young people could be offered tier three mental
health assessments and referred on as appropriate, or have
interventions with a combination of clinical supervision and
structured clinical meetings within the child and adolescent mental
health services (Camhs).

But the enormity of the problem meant that not all young people
would receive mental health assessments. To address this, an
educational programme was carried out to develop skills within the
Yot so that more staff could perform basic screening. I could then
focus on fast-tracking the young people who needed help
most.

The educational programme was extended to other local agencies in
contact with young people including magistrates, primary care trust
school nurses and the fire brigade. The latter was keen to learn
about identifying and working with children with mental health
problems who might start fires. The programme resulted in earlier
detection of mental illness, which in turn would be better for
long-term prognosis.

A monthly interagency meeting was set up with Camhs to discuss the
young people who could not be sectioned under the Mental Health Act
1983, yet were deemed to have severe mental health and drug
problems, and who did not want to be referred to Camhs.

These meetings gave psychiatrists the chance to talk about managing
mental health problems and allowed Yot staff to share useful
information on court process with Camhs, as well as reporting on
some of their young people who may be offending.

My reports supported courts handing down community-based sentences
rather than custodial ones to young people with mental health
problems. And the work we were doing meant that more specialised
psychiatric reports could be obtained if custody was imminent and
mental health was a significant issue. Importantly this could
support an admission to a psychiatric facility either in custody or
the community.

General health assessments showed that many young people had never
seen a GP or a dentist and that many had missed out on
vaccinations. Measures were put in place to tackle the problem,
including registering with GPs which led on to them obtaining other
health services; talking to GPs about holding clinics at Yot
premises; developing links with local dentists; working with
primary care trust school nurses to set up clinics so that young
people could be brought to have vaccinations on Yot premises;
nurses also gave advice on contraception, diet, general hygiene and
health.

Addressing physical health problems acted as a catalyst to making
further progress in addressing young people’s mental health
problems, drug use and offending behaviours. It also conveyed the
message to clients that Yot staff were genuinely concerned about
them and the focus was not just on the offending aspect of their
lives.

Many young people and their families are not always motivated in
their desire to deal with their problems so identifying
opportunities to build therapeutic relationships and instigate
change are vital. To identify these, good communication with
colleagues is paramount to offer consultation, clinical supervision
and then take action with young offenders at the point of need.
These include: initial arrest; before attending court; when a
custodial sentence has been imposed; before release from custody;
when the young person has been a victim of crime themselves; crisis
in the family, for example parental separation or parental mental
illness.

Mental health assessments often show that other family members also
have severe mental health problems but are not known to local
services. I make the initial referrals for these individuals to the
appropriate service. Parenting and family work also helps to
address some of these problems.

When a young person has shown dangerous behaviour such as carrying
out arson or sexual abuse, it is difficult to find specialised
services and ones that are used can drain financially the referring
service.Pooling money and staff from Camhs and developing a
forensic mental health service for young people in North East
London Mental Health Trust is being looked at to resolve this
problem.

As well as addressing youth justice work, the model is an excellent
example of partnership working that could be tailored to other
agencies such as social services, education, and counselling
services. This also gives the Camhs tiers fluidity and a framework
for disseminating expertise through advice and education. The
benefits are accurate referrals to Camhs tier three.

Training and learning

The author has provided questions about this article to guide
discussion in teams. These can be viewed at
www.communitycare.co.uk/prtl and individuals’ learning from
the discussion can be registered on a free, password-protected
training log held on the site. This is a service from Community
Care for all GSCC-registered professionals.

Abstract

The article explains how the mental and physical health needs of
young clients are being addressed in a pioneering scheme in the
Waltham Forest youth offending team.

References

(1) Youth Offending and Health: The role of Yots, Nacro, June 1999
Briefings

(2) Deboarah Lader, Nicola Singleton, Howard Meltzer, Psychiatric
Morbidity among Youg Offenders in England and Wales, Office for
National Statistics, 2000

(3) M Smith, “An immunization programme”, Primary Care,
September, 13 (71): 22-23, 2003